Documentof The World Bank FOR OFFICIAL USEONLY ReportNo: 36413-IN PROJECTAPPRAISAL DOCUMENT ONA PROPOSEDCREDIT INTHEAMOUNT OFSDR 167.9MILLION (US$250MILLIONEQUIVALENT) TO THE REPUBLIC OF INDIA FORA THIRD NATIONAL HIV/AIDS CONTROL PROJECT March22, 2007 ' Human DevelopmentUnit South Asia Region This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not otherwisebe disclosedwithout World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective January 31,2007) Currency Unit = Rupees (Rs) Rs44.20 = US$l.OO US$l.OO = SDR.6716 FISCAL YEAR April 1 - March31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immuno-Deficiency Syndrome ANC Ante-natal Care ART Anti-Retroviral Treatment AWP Annual Work Plan BCC Behavior Change Communication BMGF Bill& MelindaGates Foundation BSS Behavioral Surveillance Survey C&AG Comptroller andAuditor General CAS Country Assistance Strategy CF William Jefferson ClintonFoundation CBO Community-Based Organization CMIS Computerized Management Information System CPMS csw Computerized Program Management System Commercial Sex Worker DAPCU District AIDS Program Control Unit DFID Departmentfor International Development DIR Detailed Implementation Review DP Development Partner(s) EPW Empowered ProcurementWing FSW Female Sex Workers GAAP Governance and Accountability Action Plan GFATM Global Fundto Fight AIDS, Tuberculosis and Malaria GO1 Government of India HIV HumanImmuno-DeficiencyVirus HRG HighRisk Groups IBRD International Bank for Reconstructionand Development IBBS Integrated Bio-Behavioral Surveillance ICB International Competitive Bidding ICTC Integrated Counseling andTesting Centers IC-WMPlan InfectionControl and Waste ManagementPlan IDA International Development Association IDU InjectingDrugUser(s) IEC Information, Education and Communication IFR InterimFinancial Report ITDA Integrated Tribal Development Authorities FOROFFICIAL USE ONLY ABBREVIATIONS AND ACRONYMS (continued) L O U Letter of Undertaking M&E Monitoring and Evaluation MDG MillenniumDevelopment Goal(s) MOHFW MinistryofHealthandFamilyWelfare MSM MenHaving Sex WithMen MSW Male Sex Worker NACB NationalAIDS Control Board NACO National AIDS Control Organization NACP National AIDS Control Program NCA National Council on AIDS NGO Non-Governmental Organization NNCC NACP NFWMCoordination Committee NRHM National Rural Health Mission 01 Opportunistic Infections PEP Post-exposure Prophylaxis PIC Public Information Center PID Project Information Document PIP ProgramImplementationPlan PLHIV People Living with HIV PPTCT Preventiono f Parent to Child Transmission RCH Reproductive and Child Health RTI Reproductive Tract Infection SACS State AIDS Control Society SBD Standard BiddingDocuments SIMU Strategic Information Management Unit SIS State Implementing Society STD Sexually TransmittedDisease STI Sexually TransmittedInfection TB Tuberculosis TI Targeted Intervention uc TSU Technical Support Unit Utilization Certificate UN UnitedNations UNAIDS Joint UnitedNations Programon HIVIAIDS UNOPS UnitedNations Office for Project Services USAID United States Agency for International Development VCTC Voluntary Counseling and Testing Center WHO World Health Organization Vice President: Praful C. Pate1 Country Director: Isabel M.Guerrero Sector Manager: Anabela Abreu Co-Task Team Leaders: Kees Kostermans & Suneeta Singh a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may notbe otherwise disclosed without WorldBank authorization. INDIA Third NationalHIV/AIDS ControlProject CONTENTS Page A. STRATEGIC CONTEXT AND RATIONALE ............................................................. 1 1. Country and Sector Issues................................................................................................... 1 2. Rationale for Bank Involvement......................................................................................... 2 3 B .3. Higher Level Objectives to which the Project Contributes ................................................ PROJECT DESCRIPTION ............................................................................................. 3 1. Lending Instrument............................................................................................................. 3 2. Program Objective and Phases............................................................................................ 4 3. Project Development Objective and Key Indicators........................................................... 4 4. Project Components............................................................................................................ 4 5. Lessons Learnedand Reflected inthe Project Design........................................................ 6 7 C .6. Alternatives Considered and Reasonsfor Rejection........................................................... IMPLEMENTATION ...................................................................................................... 8 1. PartnershipArrangements................................................................................................... 8 2. Institutional and ImplementationArrangements ................................................................ 8 3. Monitoring and Evaluation of Outcomes/Results............................................................. 10 4. Sustainability . . . ..................................................................................................................... 11 5. Critical Risksand Possible Controversial Aspects ........................................................... 12 14 D .6. Credit Conditions and Covenants APPRAISAL SUMMARY ............................................................................................. ..................................................................................... 14 1. Economic and Financial Analyses.................................................................................... 14 2. Technical ........................................................................................................................... 15 3. Fiduciary ........................................................................................................................... 16 4. Social................................................................................................................................. 19 5. Environment...................................................................................................................... 19 6. SafeguardPolicies............................................................................................................. 20 7. Policy Exceptions and Readiness...................................................................................... 21 Annex 1: Country and Sector or Program Background ......................................................... 22 Annex 2: Major Related Projects Financed by IDA and/or other Agencies ......................... 25 Annex 3: Results Framework and Monitoring ........................................................................ 26 Annex 4: DetailedProject Description 35 Annex 5: Project Costs ............................................................................................................... ...................................................................................... 40 Annex 6: Implementation Arrangements ................................................................................. 44 Annex 7: Financial Management and DisbursementArrangements ..................................... 50 Annex 8: Procurement Arrangements ...................................................................................... 62 Annex 9: Governance and Accountability Action Plan (GAAP) ............................................ 74 Annex 10: Economic and Financial Analysis 80 Annex 11: SafeguardPolicy Issues ............................................................................................ ........................................................................... 84 Annex 12: Project Preparation and Supervision ..................................................................... 93 Annex 13: Classification of States and Districts ................................................................................. ....................................................................... 95 Annex 14: Documents inthe Project File 98 Annex 15: Statement of Loans and Credits .............................................................................. ....................................................... 99 Annex 17: MultiSector Mainstreaming-A Strategic Approach Annex 16: Summary of Research Studies for NACP I11 103 113 Annex 18: Country at a Glance ............................................................................................... ........................................ 116 INDIA THIRD NATIONALHIV/AIDS CONTROL PROJECT PROJECT APPRAISAL DOCUMENT SOUTHASIA HumanDevelopment Unit Date: March21,2007 Co-TeamLeaders: Kees Kostermansand Suneeta Singh Country Director: Isabel M.Guerrero Sectors: Health (100%) Sector ManagedDirector: Themes: Health systemperformance (P); HIV/AIDS Anabela Abreu/Julian Schweitzer (P); Population and reproductive health (P); Other communicable diseases (S); Child health (S) Project ID: PO78538 Environmental screening category: Partial Assessment Lending Instrument: SDecifii Investment ~ o a n [ ] Loan [XI Credit [ 3 Grant [ ] Guarantee [ 3 Other: Borrower ResponsibleAgency Governmento f India National AIDS Control Organization Departmentof Economic Affairs 9th Floor Chandralok Building 36 Ministry o f Finance Janpath New Delhi, India New Delhi, India 110001 Tel: 91.11.2335.1700 Fax: 91.11.2332.5331 Tel: 91-11-23092500 nacoasdg@gmail.com Project implementationperiod: Start April 1,2007 End:March31,2012 Expected effectiveness date: August 15,2007 Expected closing date: September 30, 2012 Does the project depart from the CAS incontent or other significant respects? [ ]Yes [XINo Does the project require any exceptions from Bank policies? [ ]Yes [XINO Have these beenapproved by Bank management? [[ ]Yes [XINO ]Yes [ IN0 I s approval for any policy exception sought from the Board? Does the project include any critical risks rated "substantial" or "high"? [XIYes [ ]No Does the project meet the Regional criteria for readiness for implementation? [XIYes [ ] No Project development objective: The objective of World Bank support i s to contribute to the NACP I11goal o f halting and reversing the AIDS epidemic by attaining the following project development objectives in accordance with two o f the national program's strategic objectives: 1) achievingbehavior change by scaling up prevention o f new infections inhighrisk groups and general population; and 2) increased care, support and treatment o f PLHIV. Project description: Component 1: Scaling up preventionefforts. Component 2: Strengtheningcare, support andtreatment. Component 3: Augmenting capacity at district, state and national level. Component 4: Strengtheningstrategic informationmanagement. Which safeguard policies are triggered, ifany? 1). Environmental Assessment (OP/BP/GP 4.01)-Category B project. 2). Indigenous Peoples (OD 4.20, beingrevisedas OP 4.10) Significant, non-standard conditions, ifany, for: Boardpresentation: There is no policy exception requiredfor the program support. Loadcredit effectiveness: NIA. Covenants applicable to project implementation: The GO1shall cause the MOHFW to ensure that eachproject state and State Implementing Agency carry out their respective activities under the project inaccordance with a Letter o f Undertaking (LOU) satisfactory to IDA to be signedby eachproject state and its respective . State ImplementingAgency (SIA), i.e., expendituresfrom a given state would not be eligible for reimbursementunless the corresponding LOU has been signed. The GO1shall cause the MOHFW to ensure adequate managementcapacity inNACO, to reviewthe number and composition o f staff and requirementsfor technical assistance annually; to revise the staffing norms and composition if found necessary during the mid term review: to strendhen and maintain a financial management unit and a mocurement supply and logistics unitwithinNACO and maintainthese units throughout project implementation; to maintain a unified strategic information monitoring unit which reports on activities and outcomes o f all partners o fNACP I11and ensure timely reports inan agreed format satisfactory to IDA for the six monthly review missions. The GOI, through MOHFW, shall causeNACO to implement the financial management reform. NACO shall carry out a management audit as per TOR satisfactory to the Association within three months o f effectiveness o f the project. NACO will upgrade its computerizedprogram management system and maintainand support the system duringimplementationoftheproject. The GO1shall cause audits o fvarious project executing agencies to be conducted inatimely manner inaccordance with the terms o freference set out inthe Financial Management Manual and inthe Procurement Manual for NACP 111. The GO1shall cause MOHFW to ensure that all NGOs/CBOs with whom NACO shall enter into a contractual arrangementfor provision of targeted interventions, testing and counseling services, STI and 01diagnosis andtreatment and ART provision are regularly supervised and outputs monitored andthat this information is usedto form the basis o f their continuation of contract. The GO1shall cause the MOHFW and the project states to implement, ina manner satisfactory to IDA, the Tribal Action Plan and the interventions targeted towards other socially deprivedgroups set forth therein, as well as the agreed Infection Control and Waste Management Plan, and ensure that relevant manuals and guidelines are at all times consistently and satisfactorily applied. The GOI, throughout the duration of the program, shall cause the executing agenciesto implementthe GAAP, refrain from taking any action which shall prevent or interfere with the implementation o ftheir Plan, not waive, amendor abrogate the Planand, providea writtenreport onprogress achieved inthe implementation o fthe Plansemi-annually. A. STRATEGIC CONTEXT AND RATIONALE 1. Country and Sector Issues 1. The Problem: Acquired Immuno-Deficiency Syndrome (AIDS) poses a serious threat to India's health gains as well as its economic growth. Given the evidence from other countries o f the potentially devastating impact o f a Human Immuno-Deficiency Virus (HIV) epidemic, efforts must continue to respond to the epidemic ina significant and appropriate manner inorder to prevent it from spreading further to the general population, and to provide treatment, care and support to People Living with HIV (PLHIV). 2. Worldwide, a quarter of a century into the epidemic, the number of people infected with the Human Immunodeficiency Virus (HIV) which leads to AIDS is 38.6 million. Joint United Nations Program on HIV/AIDS (UNAIDS) estimates that 4.1 million became newly infected with HIV and an estimated 2.8 million lost their lives to AIDS in 2005. InIndia, 20 years after the first case was identifiedin 1986, HIV infection has grown to 5.2 million cases by 2005 or a prevalence o f about 0.9% inthe adult population (15- 49 years), according to estimates based on data o f the national surveillance system. 3. The HIV Epidemic inIndia: While the Indianepidemic continues to be concentrated, to a large extent, in populations engaging in high risk behaviors such as unprotected sexual intercourse with multiple partners, unprotected anal sex, and injecting drug use with shared needles, both rural prevalence and HIV prevalence among women i s increasing leading to generalizing epidemics in some states. The low rate o f concurrent sexual relationships with multiplepartners seems to have, so far, protected the other 99% o f the adult Indian population. Changing economic structures and accompanying demographic shifts may affect the sexual behavior o f the society at large and thus the potential o f the virus to spread further among the general population. An environment where power dynamics, gender imbalance, poverty, harmful traditions and discriminatory legal frameworks and practices reinforce vulnerability further enhances the chances for the virus to spread and hampers opportunities to fight the epidemic effectively. 4. Six states, representing 30% o f India's populationalready have what is considered to be a highprevalence of HIV accordingto UNAIDS criteria (>1% inante-natal care (ANC) attendees and >5% in High Risk Groups High Risk Groups-HRG). Three additional states have been characterized as moderate prevalence states (HIV prevalence i s >5% inthe HRG, but <1% inthe ANC population) but contain several districts with highprevalence. The remaining states, which were previously classified as low prevalence, have been reclassified as "highly vulnerable" or "vulnerable" to guard against complacency and reflect the increasing threat o f the epidemic and the presenceof structural factors o frisk andvulnerability. 5. People Livingwith HIV: As the infection insuccessively larger cohorts of HIV infected persons expresses its natural history, India i s also discovering the visible face o f the epidemic with a significant number of PLHIV. This group has special issues to be dealt with including reported stigma and discrimination in the workplace, medical settings and from society at large. A comprehensive response to the epidemic must also provide appropriate care, treatment and supportto these populations. 6. GovernmentResponse: Over the last two decades, the GO1has developed and gradually enhanced its response to the epidemic. The National AIDS Control Program(NACP) established in 1986, received support from the World Bank in 1992 with an IDA credit of US$84 million, and a second IDA credit o f US$191 million in 1999. This sustained commitment has yielded benefits, including an effective blood safety program, increased number o f sexually transmitted disease clinics, voluntary counseling and testing centers, and an expansion o f prevention o f parentto child transmission services delivered through a quasi-autonomous NACO supported by a strengthened state level implementation structure. In addition, NACP began providing free anti-retroviral therapy inhighprevalence states inApril 2004 andnow have over 47,000 persons on treatment. 7. In 2005, GO1 launched the National Rural Health Mission (NRHM) with a strong commitment to reduce maternal and infant mortality, provide universal access to public health services, prevent and control communicable and non-communicable diseases, ensure population stabilization, maintain gender balance and revitalize local health traditions. NACP I11will link closely with the broad operational frameworkprovidedfor the Health sector byNRHM. 8. Challengeof Coordination:The past few years have seena greater involvement of other Development Partners (DPs). Those who provide significant financing to the program include the Global Fund to Fight AIDS, TB and Malaria (GFATM), the Department for International Development (DFID) and the United States Agency for International Development (USAID). The Bill & Melinda Gates Foundation (BMGF) and the William Jefferson Clinton Foundation (CF) also fund HIV interventions in the country. While this has increased the overall funding envelope, it has also resulted in a fragmentation of the response, a competition among partners, sometimes a deviation from national priorities, and an insufficient focus on vulnerable and low prevalence states. GO1has responded to the challenge o f coordination by preparing its plans for the ThirdNational AIDS Control Project (NACP 111) inan exemplary consultative and inclusive process at the national and state level, and i s looking to the development community for funding and technical support to accomplish the goals which it has defined for this period. With IDA support, GO1 proposes to implement the "Three Ones" approach espoused by the Joint United Nations Program on AIDS (UNAIDS)' and the internationalcommunity at large. 2. Rationalefor BankInvolvement 9. GO1 has requested continued IDA support to help ensure adequate, flexible and continuous financing for a comprehensive program o f HIV control to be funded by GO1 and the large number o f DPs now active in India. While there has been a significant increase in the financial resources available for HIV/AIDS as other development partners and donors have supported the program over the past 3-5 years (such as GFATM and BMGF), financial requirements for different activities are also increasing as the epidemic evolves. Preventive IThe "Three Ones" approachpromotedby UNAIDSrefers to: "one agreedHIV-AIDSaction framework that providesthe basis for coordinating the work o f all partners; one National AIDS Coordinating Authority, with a broadbasedmulti-sectoral mandate; and one agreedcountry level Monitoring and Evaluation System". 2 services need a higher coverage than has thus far been achieved. There is an urgent need to strategically scale up prevention, care and treatment interventions nationwide. 10. In addition, IDA also brings added value to the program, through: (i)its convening power, which would assist the NACO/GOI in implementing the "Three Ones" approach; (ii) its worldwide experience and technical expertise on HIV/AIDS programs; (iii) ability to work its with other sectors receiving Bank support to foster a more sustainable multi-sector response; (iv) the possibility of supporting GOI's efforts to increase convergence with other healthprograms through our ongoing health operations, including health sector reform projects and centrally sponsored schemes such as the Reproductive and Child Health (RCH) and Tuberculosis Control Programs; and (v) its experience gained under NACP Iand 11. 3. HigherLevelObjectivesto whichthe ProjectContributes 11. The proposed operation i s inline with the strategic principles of the CAS, which include a "focus on outcomes" by directly supporting the 6th Millennium Development Goal (MDG) to combat infectious diseases, including HIV/AIDS, and "applying selectivity" through targeted activities that are highimpact and that will bring greater synergy with the financing o f other DPs. As recommended by the CAS, co-financing with other partners under common arrangementsfor national programs i s being considered through a programmatic approach. The project i s also in line with the World Bank South Asia Regional Strategy for which HIV i s a thematic priority. Finally, the project focuses mainly on prevention amongst HRG, which is in line with the South Asia HIV strategy. 12. The importance of this project was underscored in the address by the Prime Minister of India on the 2005 IndependenceDay celebration, when he stated that "AIDS is now becoming a major national problem and we need to tackle this on a war-footing. We need to have a mass movement to ensure that this disease i s rapidly checked and its growth arrested."2 B. PROJECTDESCRIPTION 1. LendingInstrument 13. IDA proposes to provide a Sector InvestmentandMaintenance Loanwhich itwould pool with DFID, to fund a programmatic approach in order to flexibly support the government's program. As a financier o f last resort, IDA will channel its support to areas o f the agreed program not receiving adequate support from other financiers. This approach would be the most appropriate and relevant since it would facilitate: (a) joint support by DP and GO1for an overall program ensuring close coordination o f inputs; (b) assistance for a program o f work developed annually in support o f a five year results oriented program rather than for specific investments; (c) performance-based support; (d) adherence to the "Three Ones" framework; and, (e) building in-house capacity to plan, execute and monitor the program. 2"Prime Minister ManmohanSingh's IndependenceDay address" The Hindu, August 15,2005 3 2. ProgramObjective and Phases 14. As the name NACP I11indicates, this constitutes the third phase o f a program to which the Bank has provided support since 1992. NACP I11 has the ambitious goal of halting and reversing India's HIV/AIDS epidemic by 2011, ahead o f the 2015 target o f the 6* MDG. The program i s seen as part o f a longer term plan to realize the MDG and complete the long term reform agenda. The Bank i s likely to be requested to provide support to a later phase o f the program, however, the format o fthis future support will depend on evolving government policies inthe healthsector and the Bank's policytowards more integratedstate-wise support. 3. ProjectDevelopmentObjective and Key Indicators 15. The objective o f World Bank support is to contribute to the NACP I11goal o f haltingand reversing the AIDS epidemic by attaining the following project development objectives in accordance with two o f the national program's strategic objectives: R achieving behavior change by scaling up prevention o f new infections in HRG and the generalpopulation; and 8 increased care, support and treatment o fPLHIV. 16. The key indicators which will be used to track the project development objectives o f World Bank supportto NACP I11are: (( percentage o f female sex workers who report using a condom with their most recent client; R percentage o f male sex workers who report using a condom with their most recent client; R percentage o f injecting drug users who have adopted behaviors that reduce transmission o f HIV, that i s who avoid both sharing injecting equipment during the last month AND who report using a condom with their most recent sexual partner; and (( number of people with advanced HIV infection receiving anti-retroviral combination therapy. 4. Project Components 17. IDA will provide flexible funding for the implementation o f NACP I11 based on an analysis o f support from other DPs and specific government needs. The project has the following four components: Component 1: Scaling up Prevention Efforts. With 99% o f the population uninfected, prevention remains the top priority o f the project, which aims to reduce new infections through saturation of coverage (>80%) o f HRG over a five year period. This would be implemented through 2100 Targeted Interventions (TI) targeting one million Female Sex Workers (FSW) and their partners; 1.15 million MenHavingSex With Men(MSM) including but not limitedto Male Sexual Workers (MSW), and 190,000 injecting drug users and their partners. In addition, this 4 component would support scaling up o f interventions inhighly vulnerable sub-sections o f society identified as long distance truckers (3 million) and short duration migrant workers (8.9 million). Finally this component would also put in place strategies to address the most vulnerable among the general population, namely youth between the ages o f 15-29 years, women inthe age group of 15-49 years, children (age 0-18 years), and socio-economically disadvantaged people, including tribal people. 19. These groups would be addressedthrough a variety o f means including through targeted plans for condom promotion and provisioning through Non-Governmental Organizations (NGO) and where possible or necessary, Community-Based Organizations (CBO); promotion o f counseling and testing for HIV; better availability, testing and assurance o f blood and blood products; deployment o f a cadre o f Link Workers and establishment o f Red Ribbon Clubs to spread awareness and provide counseling for HIV; fostering an enabling environment to change the legal, policy and structural barriers; and campaigns through bothmass media as well as more local and direct forms o f Behavior Change Communication (BCC) to raise awareness and facilitate public dialogue. The component also focuses on mainstreaming o f HIV activities inkey sectors beyond the health sector, such as education, defence, justice, tribal affairs, transport and labor. Component 2: Strengthening Care, Support and Treatment. GO1 plans to expand care, support and treatment opportunities for people affected by HIV through a comprehensive strategy to strengthen family and community care, provide psycho-social support for PLHIV (especially marginalized women and children), and ensure accessible, affordable and sustainable treatment services. It i s estimated that duringthe project period, care and support services will be providedto 380,000 PLHIV with AIDS; ART to 340,000 o f which 40,000 children (inthe public sector); 0 1treatment to 330,000 persons; and TB treatment to 2.8 millionpersons. 21. This component will support the strengthening o f PLHIV networks, linking them to service centers and risk reduction programs; developing and implementing standard 01 management guidelines; establishing community care and support centers which would act as a hub for HIV services in the community; and advocacy and social mobilization to integrate PLHIV into society. Component 3: Augmenting Capacity at District, State and National Level. The planned decentralization and scaling-up o f activities will require new and additional capacity at various levels. It i s recognized under the program that systems to manage the relationships that NACO must develop with the State AIDS Control Society (SACS), and also with private sector providers o f essential service support both for HRG and the general population, i s going to be critical to the success o f this phase o f the program. Likewise, it i s clear that capacities within NACO need to upgraded and improved accountability frameworks established that respond to the revisedrole o fNACO as a catalyst and steward ofHIV control activities inthe country. 23. This component will support the collaborative development o f standard operating procedures for crucial HIV services; setting up o f internal and external quality assurance systems; establishment of improved and performance-based contracting arrangements with private providers; upgrading capacity to extend the program to socio-economically vulnerable 5 people, including tribal people (in the North-East, other Tribal Sub-Plan areas and mixed populations); and strengthening o f both training and technical support capacities linked to core HIV control structures withingovernment andNGO/CBO community. Component 4: Strengthening Strategic Information Management. The NACP I11proposes a significant change in the purpose and effectiveness o f data collection and analysis. A Strategic Information Management Unit (SIMU) will be supported in order to maximize the effectiveness o f available information and implement evidence-based planning. This will be set up at the national and state levels to address strategic planning, monitoring and evaluation, surveillance, and research. In addition, all program officers will be trained on evidence-based strategic planningmethodologies, informationuse, and program management. 25. This component will include strengthening of the monitoring framework to provide more accessible and ready-to-use information across program content and management functions; enhanced surveillance systems to provide HIV related epidemiological, clinical and behavioral data, especially for specific high-risk behaviors, at a state and sub-state level, including for vulnerable populations where relevant; and independent evaluation and research to inform and support program implementation. The models used to generate national and state estimates on the basis of surveillance data will be reviewed. 5. Lessons Learned and Reflected in the Project Design 26. NACP I11 takes into account key lessons from international, national, and other IDA project experiences. 27. Key lessons from international experience include: (a) targeted interventions for marginalized groups at high risk o f infection, within a broader population-wide campaign, are the most effective ways to reduce transmission of HIV; (b) working through NGOs/CBOs, especially peer-based groups, i s one o f the most effective HIV prevention strategies; and (c) convergence o f HIV programs with programs which deal with other health related issues such as STI, TB and reproductive health is beneficial for the effectiveness o fall programs. 28. Key lessons from national experience o f the first two phases o f NACP include: (a) at the state level a combination o f strong political commitment, focus on high impact interventions, good management with continuity o f trained staff, strong surveillance and technical assistance, and adequate financial resources, can increase coverage among high-risk groups and lead to improvement inHIV prevalence rates; (b) successful planning o f TISinclude micro-site mapping that i s repeated periodically, since high-risk groups are mobile and dynamically changing populations, helps in identifying coverage gaps; (c) participatory mapping involving CBOs i s an example o f good practice; (d) surveillance i s the back bone o f a successful program; (e) decentralized management i s an efficient strategy so staff capacity o fthe SACS should be further strengthened; (f) strong partnerships with donors and with NGOs/CBOs are successful means to respond to the epidemic and will be further developed. However, NGO selection mechanisms needto be strengthenedand streamlined,inorder to improve accountabilities and decrease unfair competition for NGO services amongst donor agencies; (g) multi-sector involvement can address some o f the underlying determinants o f the epidemic, create an enabling environment, reduce 6 stigma and discrimination, increase awareness, and increase access and use of prevention and treatment services; and (g) enhancing awareness in the general population can contribute to a reduction instigma and discrimination and an increase incoverage. 29. Kev lessons from other IDA pro-iectexperiences inIndia include: (a) the needto focus on links betweenthe disease specific programs, such as TB, RCH, Vector-borne Diseases for better integration and effectiveness; (b) an important lesson from the R C H program i s that for successful project implementation, management capacities o f the MOHFW should be strengthened; (c) there i s a need to focus on creating a robust procurement system; and (d) the Bankand other DPs should ensure the availability ofmoreresources for effective supervision. 30. Inresponse to these lessons, the project design provides that NACO will work closely together with the National Program Coordination Committee for R C H chaired by an Additional Secretary which has been established for providing oversight to the program. The Additional Secretary i s assisted by financial management and program management groups responsible for financial management and technical guidance respectively. An Empowered Procurement Wing has beenestablished to effectively implementsome o f the agreed actions under the government's GAAP (see Annex 9), while remaining actions shall be implementedby NACO. The Bank and GO1would ensure an adequate budget for implementingthis plan. 6. Alternatives Considered and Reasons for Rejection 3 1. Three project designalternatives were considered andrejected. (a) Continuing present level of interventions with HRG and adding ART. Present coverage of HRG with prevention efforts i s insufficient to keep the epidemic under control. Therefore, the number o f new infections would continue to rise. (b) Creating an explicit multisector set-up for NACP 111. Under the previous phases of NACP, the government had established NACO and SACS, under the MOHFW. Given the successful performance of the Borrower, according to the ICR and the Bank's IndependentEvaluations Group, this arrangement is apparently working well. Inits present design the program is capable to work with other Ministries. During NACP I1a high level multi-sectoral National Council on AIDS (NCA) chaired by the Prime Minister was also established. (c) Providing support for a general health program. Given the specificities o f HIV and the support to it from the development community, it was decided to keep NACP 111 as a separate program which will providethe focus needed for an enhanced response and is in line with GO1 organizational structure. The government intends to bring greater convergence between the NACP and disease specific programs such as the TB control program and broad programs like RCH through the NRHM. This allows for a convergence o f relevant activities as opposed to the support o f a general program. 32. Because o f the above choices, a Sector Investment and Maintenance Loan seems to be the better fitting lending instrument, as it keeps the middle between a narrowly defined traditional investmentproject andthe budget support o f a DPL. 7 C. IMPLEMENTATION 1. PartnershipArrangements 33. Support to NACP I11will be provided in accordance with the "Three Ones" approach. This approach applies the Monterrey Consensus and Rome Declaration on the Harmonization o f Development Assistance to a specific area o f development - HIV. N A C O will establish a clear joint working relationship with DPs at both the national and state levels through the establishment o f a coordination framework enjoining each to the spirit o f "Three Ones". NACO would form with a select group o f DPs (including the UN, DFID, USAID, and the World Bank) a Steering Committee for Donor Coordination to: (a) prevent duplication o f DP efforts; (b) share information on action plans; and (c) review program performance during quarterly reviews. Besides this, all DPs providing support to NACP I11are meetingregularly as a Thematic Group to coordinate their support. 34. DFIDintendsto poolits support to NACP I11with IDA and GOI. 2. Institutionaland ImplementationArrangements 31. While health is a state subject under the Indian Constitution, issues of national public health concern fall within the purview o f the Centre. Therefore from its inception in 1992, the NACP has been a centrally sponsored scheme receiving 100% financing from GOI. 32. The NACP is managed by NACO which is an integral unit o f the MOHFW. Under NACP 111, NACO would consolidate the decentralized model of implementation established under the prior two phases and provide direction and stewardship to the national program, while institutionalizing coordination with partners within and outside government. NACO intends to constitute Technical Advisory Groups comprising o f leading experts to provide guidance and review of the program's thematic areas. Coordination o f the program with the NRHM will be facilitated by the NACP NRHM Coordination Committee (NNCC) headed by the Secretary, MOHFW. 33. NACO reports to the National AIDS Control Board (NACB) chaired by the Secretary, MOHFW, which also has oversight o f activities carried out by partners whose programs do not pass through the national budget. InJune 2005, the N C A was constituted under the chairmanship o f the Prime Minister and with membership o f 31 central ministers, six state chief ministersand civil society. This body will provide the highest political oversight and support to the implementation o f the national HIV control framework especially to mainstream HIV control into the work o f all organs o f government, private sector and civil society and lead a multi-sector responseto HIV/AIDS inthe country. The states will establish State Councils on AIDS along the pattern o f the N C A to be chaired by the Chief Ministerand having the Minister o f Health as Vice Chair. 34. Civil society partnership fora will be established at national, state and district level with membership of active civil society partners representing the various constituencies that are stakeholders inHIV control. Their inputs will be sought for planningpurposes and duringannual 8 program reviews. A wide range o f stakeholders -public sector managers and service providers; private sector partners in the program, especially NGOs; other civil society groups, some businesses; researchers; international development partners - have been involved in project preparation in a variety o f ways including 14 topic-based working groups, consultations with civil society and HIV-positive people, e-consultations, national and state-level meetings, and a social assessment. Many will continue to be involved in implementation, monitoring and evaluation. For example, NGOs and private sector agencies are widely involved in prevention and care, and support activities; public sector providers will be sensitized and trained to increase the reach of Integrated Counseling and Testing Centers (ICTC) and treatment facilities; and social marketing firms are integral to condom distribution under the program. Periodic consultations will be held with civil society organizations including women's groups, organizations o f the socio-economically vulnerable, and organizations of HRG and PLHIV. The NACP i s among the few governmental programs in India that are substantially implementedby non-governmental organizations, and inwhich `public voice' i s central. The social impacts o f the project will be monitored within its overall monitoring framework and through special studies contracted from time to time. 35. Responsibilities and core functions at the national and state levels: Inaccordance with its stewardship role, NACO i s responsible for: (a) setting the program framework and establishing accountability systems; (b) carrying out broad advocacy and social mobilization in support o f normative behavior change; (c) establishing technical support capacities; (d) facilitating the mainstreaming o f HIV control into the work o f other ministries, the private sector and civil society; (e) institutingpartnerships with significant stakeholders who are vested with capabilities for HIV control; (f) requiring and using regular monitoring, surveillance, and evaluations o f NACP I11at every level; (h) setting standards and puttinginplace a system to assure the quality o f laboratory and treatment facilities; and (i)establishing robust, transparent and efficient systems for procurement o f pharmaceuticals, medical supplies and equipment, goods, works and services. NACO i s headed by an officer o f the Indian Administrative Service at the level o f Additional Secretary to the GOI. These functions will be distributed among four strengthened core units each led by a Joint DirectorDirector. In addition, NACO will establish a sub-office withintheNRHM'sNorthEasternunit. 36. Implementation o f HIV control activities vests primarily with the states. SACS, established under NACP 11, are expected to assume a leadership role and coordinate the work o f all partners in each state. In states where Municipal AIDS Control Societies or other societies have been established, their work plans would be subsumed under the overall workplan for the state. In a few states, SACS have been merged into an overarching State Health Society and in some, this may happen during the life o f the project, however, characteristics o f SACS will continue to be maintained. The SACS or State Health Society would be responsible for: (a) planning and implementing interventions with high risk, bridge and general populations; (b) undertaking state level advocacy, Information, Education and Communication (IEC), social mobilization and youth campaigns; (c) providing technical support to partnerswithin and outside the health department in respect of program components; (d) supporting intersectoral collaboration with significant stakeholders; and (e) undertaking essential procurement as per the agreed procurement arrangement. SACS staffing decisions will be based on the size o f the state 9 and disease burden. Similarly Technical Support Units (TSUs), established in response to problem size, will assist inthe managemento fthe TI programs with HRG. 37. A key feature o fthe effective implementationo fHIV interventions with some ofthe most marginalised groups in society i s the use o f NGOs and CBOs. Guidelines on their involvement have been reviewed in detail during the formulation o f NACP I11 and will be finalized after consultation withNGO partnerspresently providing services under the program. 38. With regardsto the flow o f funds at the GO1level, the project's funding requirements are budgeted within the budget o f the MOHFW and the NACP I11 program will have a separate budget head operated by NACO. The annual budget o f the project would be allocated as per national Program Implementation Plan (PIP) and take into account the actual pace o f implementation. At the state level, the budget would be allocated to each state based on the approved state Annual Work Plan (AWP). The annual budget allocated to each state would be released only in two installments during the 1st and 3rd quarters of each fiscal year. Funds required to implement the Project will be released by NACO to the SACS. The SACS in turn would release necessary funds to various implementing units (NGOs, ICTCs, blood banks, district units, etc.) based either on contractual obligations (NGOs) or sanctioned amount for the specific activity. A shift to electronic transfer o f funds (to beginwith from GO1to states) will be institutedduringprogram implementation by buildingon the experience inRCHI1(see Annex 7 for further details). 3. MonitoringandEvaluationof OutcornesDtesults 31. India has many o f the elements o f an effective monitoring and evaluation system. These elements need to be integrated into a cohesive and coherent national monitoring and evaluation systemto assist with progress measurement, accountability, learning andplanning. 32. DuringNACP 111, India will strengthen: (a) the overall system; (b) program monitoring, which will be based on several sources: (i) health services will be tracked using data from the Health Management Information Systems and episodic health facility surveys; (ii) intervention coverage, particularly o f HRG, will be assessed using coverage modules in behavioral surveys; and (iii) reporting forms and systems will be developed to track services provided outside the health sector; (c) surveillance, which will be strengthened in the following ways: (i)existing surveillance data from numerous sources, including ANC sentinel sites, Prevention o f Parent to Child Transmission (PPTCT), blood donors, population-based surveys and targeted surveys, will be rigorously analyzed and synthesized; (ii) National Family Health Survey will undertake a national household bio-behavioral survey; (iii) ANC surveillance will be strengthened; and (iv) national integrated bio-behavioral surveillance (IBBS) o f HRG will be undertaken at yearly intervals; (d) data analysis and use to improve policies and programs will receive major emphasis. Data from each o f the above sources will be analyzed in an integrated manner, to produce a holistic understanding of India's HIV epidemic and responses. Important findings will be shared widely through numerous dissemination fora and usedto strengthen national and state planning and programming; (e) financial tracking, financial monitoringand expendituretracking will be used to monitor resource use and needs; and (Q procurement tracking for the physical and financial progress o f the contracts issued; and (g) essential research. In addition to surveillance, 10 essential research will be commissioned to better understand HIV incidence, risk factors, HIV transmission dynamics and interventioneffectiveness. 33. The intention of the proposed framework is to move from a traditional "monitoring and evaluation" system to a strategic information management approach. The system will produce a clearly defined set o f products on a quarterly, annual or periodic basis to allow information to be used strategically. 34. It is expected that progress could be tracked using an approach that recognizes the implementation plans o f the program both in terms o f their ability to cover sufficiently large sections o f the HRG, as well as their ability to influence outcome indicators over time. Thus it i s proposed that IDA would apply a "ladder approach" to incrementally measure program progress, outputs and outcomes over the period o f support. The achievement o f these measures could also provide confidence in assessing the ability o f the program to absorb funds. See Annex 3 for further details onthe "ladder". 35. Supervision: The infrastructure and systems put inplace by GO1will be used to measure the actual performance o f states andNACO and the program's achievements. The tools produced by the system - monthly program reports, quarterly dashboard (see Annex 3), annual state o f the epidemic report, external program evaluations, and periodic published reports - have been developedto measure improvements inthe performance o f SACS and NACO. The Bank will use a subset of data from this system to track progress o f the program (see Annex 3). NACO and pooling DPs will carry out joint annual performance reviews o f the program. A Steering Committee for Donor Coordination will be formed by NACO at the national level and this group will meet quarterly for program review. A similar forum will be formed inthe states and will be convened by the SACS. The Bank and DFID will carry out semi-annual review missions to monitor and supportprogram implementation. 36. The project will require extra supervision in the initial year especially for ensuring successful implementation o f the state level financial management and fund flow arrangements. A mid-term review would be conducted after two and a half years of the project to comprehensively review the overall performance o f the project in achieving its targets and maintaining strong fiduciary mechanisms, and the requirement for additional financing (see Annex 5). 4. Sustainability 37. Political sustainabilitv: GO1 has demonstrated significant commitment to containing the HIV epidemic through the establishment of NACP in 1986 and its continued actions, funded through its own budget and international funds. The program has formed an integral part o f successive five year plans, including the ongoing loth five year plan. In June 2005, GO1 established the N C A under the chairmanship o f the Prime Minister (see paragraph 2 on "Institutional and Implementation Arrangements" for further details). With a few states in India now showing stabilization o f HIV prevalence rates, India i s set to scale-up its control efforts throughout the country by leveragingthe important experiences it has gained. 11 38. Institutional sustainabilitv: While NACP I1focused on targeted interventions for highrisk marginalized groups, the third phase o f the program seeks to maintain this focus while also mainstreaming and scaling up a number o f HIV control activities in the health department's routine activities (see paragraph 2 on "Institutional and Implementation Arrangements" for further details). Further, NACP I11 also proposes to partner with private sector players in important areas such as testing and counseling services, Sexually Transmitted disease (STD) services and continued provision o f TI, and establishing systems that support quality services made available through them. The repositioning o f the SACS as the nodal agency for all HIV/AIDS activities in the state and the operationalization of the "Three Ones" principle will ensure greater institutional stability inthe program. 39. Financial sustainability. See Section D.1 "Economic and Financial Analyses" 5. Critical Risks and Possible Controversial Aspects Risk RiskMitigation Measure Risk Rating Toprojects development objective Decline inpolitical 8 AgreedNational Strategic Framework and Program commitment ImplementationPlan 88 Prime Ministerchairing N C A L Involvement of NGOs, PLHIV networks and civil society inthe N C A Pressureto shift 8 National Strategic Frameworkand Program focus toward ImplementationPlan agreed betweenGOI, state treatment services governments and partners at the cost o f 8 Use of common Monitoring andEvaluation (M&E) prevention systems to determine project focus and results M 8 Project would finance broad social mobilization and informed advocacy with significant pressure groups to -~ keepfocus on prevention agenda Scaled up targeted 8 Performance based monitoring o f non-government sector interventions not deliveredbehavior change strategy will be put inplace effective in 8 Supervisiono f TI programs will be decentralized to modifying behavior dedicated support units at state level with appropriate M sufficiently to halt oversight by peer based organizations and reverse the 8 Operational researchfor bestpractice models epidemic Toproject's outputs Managerial 18 Significant capacity buildingis proposed to strengthen capacity and/or the systemto deliver and supervise activities staffing not 8 Institutional framework o fHIV control program being expanded and revisedandupgraded to reflect the new roles necessary M upgraded to deliver for intendedoutputs project outputs 12 Risk RiskMitigationMeasure Risk Rating Linkages to R Program implementationplan sufficiently recognizes the ongoing GO1 need to integrate medical services with ongoing public programs e.g., sector service delivery as well as interventions with the NRHM,Revised private sector as necessary National TB I( Implementationplanto take this into account inorder to M Control Program ensure accountability for these program components so not fully that it i s adequately integrated into the M&E systems established R Convergence o f various disease-specific healthprograms and RCHunder the NRHM Mainstreamingand I( AgreedNational Strategic Framework istakenas the partnershipsnot basis for the work by the N C A fully developed fi Special institutional arrangements established within NACO to engage with, support and monitor L mainstreaming and partnershipdevelopment activities duringprogramperiod Monitoring and XR Maintaining strong DP coordination mechanisms Quarterly dashboard will be usedto track data on key evaluation not used indicators ina regular manner; annual indicator to as a basis o f measure whether states are submittingtheir dashboards to programming NACO ina timely manner decisions R Behavioral Surveillance Survey (BSS) at the state level on an annual basis M R Special research studies and external evaluations will be commissioned duringthe project to generate new research for programming decisions. Results will be widely disseminatedto the appropriate audiences Procurement and 8 Capacity buildingofprogram staff at central and state financial levels to manage these functions effectively management show R Supervisiono f these functions to be integral to the M&E weakness system which would be usedfor evidence based programming R Strengthened contracting arrangementsfor contracts with private sector, including NGOs and CBOs. S R Agreement on a GAAP which would be supervised closely as part of program supervision during Joint Review Missions R Procurement and financial management carried out in accordance with strict fiduciary arrangements (see Annexes 7 and 8) Overall risks M .isk Rating:L (Low or N ligible); S (Substantial);M(Modest) 13 6. Credit Conditionsand Covenants R GO1 shall cause the MOHFW to ensure that each project state and State Implementing Agency carry out their respective activities under the project in accordance with a L O U satisfactory to IDA to be signed by each project state and its respective State Implementing Agency (SIA), Le., expenditures from a given state would not be eligible for reimbursement unless the corresponding L O U has been signed. R The GO1 shall cause the MOHFW to ensure adequate management capacity in NACO, to review the number and composition o f staff and requirements for technical assistance annually; to revise the staffing norms and composition if found necessary during the mid- term review; to strengthen and maintain a financial management unit and a procurement supply and logistics unit within NACO and maintain these units throughout project implementation; to maintain a unified strategic information monitoring unit which reports on activities and outcomes o f all partners o f NACP I11and ensure timely reports in an agreed format satisfactory to IDA for the six monthly review missions. R The GOI, through MOHFW, shall cause NACO to implementthe financial management reform. R NACO shall establish a system o f management audit as per TOR satisfactory to the Association withinthree months o f effectiveness of the project. R NACO will upgrade its computerized program management system and maintain and support the systemduringimplementationo fthe project. R The GO1 shall cause audits of various project executing agencies to be conducted in a timely manner in accordance with the terms o f reference set out in the Financial Management Manual and inthe Procurement Manual for NACP 111. 8 The GO1shall cause MOHFW to ensure that all NGOs/CBOs with whom NACO shall enter into a contractual arrangement for provision of targeted interventions, testing and counseling services, STI and 01diagnosis and treatment and ART provision are regularly supervised and outputs monitored and that this information i s used to form the basis o f their continuation o f contract. R The GO1 shall cause the MOHFW and the project states to implement, in a manner satisfactory to IDA, the Tribal Action Plan and the interventions targeted towards other socially deprived groups set forth therein, as well as the agreed Infection Control and Waste Management Plan, and ensure that relevant manuals and guidelines are at all times consistently and satisfactorily applied. R The GOI, throughout the duration of the program, shall cause the executing agencies to implement the GAAP, refrain from taking any action which shall prevent or interfere with the implementation o fthe Plan, not waive, amend or abrogate the Plan and, provide awritten report on progress achieved inthe implementation o f the Plan semi-annually. D. APPRAISAL SUMMARY 1. Economic and FinancialAnalyses 40. The AIDS epidemic generates significant externalities, and therefore necessitates public intervention regarding policy and allocation o f resources. The focus o f NACP I11on targeted interventions for the high-risk groups and "bridge" populations will mitigate these externalities 14 to a large extent. AIDS also causes significant loss o f income. This ranges from 10 percent o f household income where PLHIV i s still working, to 66 percent inthe case o f incapacitation due to HIV/AIDS.3 Public expenditure on mitigating the costs o f care and treatment i s justified especially for disadvantaged or discriminated-against high-risk groups, and given the unusually large burden that HIV/AIDS poses on households. NACP I11 therefore incorporates both externality and equity considerations in the design o f the program, in line with the recommendations o f the World Bank OED Report on improving the effectiveness o f HIV/AIDS as~istance.~ 41. Increasing the efficiency and coverage o f targeted interventions will help prevent new infections that will reduce the long-run cost to the health system and mitigate income loss for the general population. Achieving NACP I11 prevention objective would reduce the number o f PLHIV by 0.94 million at the end of the project period as compared to continuing with NACP I1 ~trategy.~ As per the proposed NACP I11budget, the cost per infection prevented is around US$500. In comparison, the average cost o f ART i s $250 per PLHIV per year for medication alone, or US$1250 over the five years o f the program. The focus on preventingnew infections through TIS i s a cost-effective strategy especially considering the proposed scale-up o f ART, both inthe mediumand long term.6 42. Given the threat of the epidemic to India, the proposed scale-up o f NACP I11i s justified inorder to reduce long-run costs to the economy and the country's development. Assumingthat GOI's share covers 30 percent of total program cost o f about US$2.5 billion, there is a need to mobilize considerable resources from external sources - institutional, private foundations, international NGOs etc. Therefore, bridgingany resource gap by domestic (both government and private sector contribution) and external donor agencies would be critical for the success o f the program. Financing plans shared with IDA indicate that such a gap exists at the present time, and GO1 proposes to seek additional DP support. However, if such support i s not received and the achievement o f program objectives becomes critically dependent on additional financing, GO1 may approach the Bank for such funding. The Bank would consider supplemental financing (in the region of US$250 million) only when satisfied that implementation of the project, including disbursement and substantial compliance with loan covenants, is satisfactory. Performance would be measured interms o f program and financial/disbursement indicators. Further details o f project financing can be found inAnnex 5. 2. Technical 43. The HIV/AIDS epidemic in India remains highly concentrated in key populations at higher risk of infection. Therefore, priority given to prevention efforts and increase o f coverage Socio-economicImpactofHIV/AIDS inIndia.NACO-NCAER-UNDPStudy, 2006. 4Committingto Results:Improvingthe Effectiveness ofHIVIAIDS Assistance.OperationsEvaluationDepartment, 'WorldBank,2005.Sudhakar, Rao, Kurienand ModellingHIV Epidemic inIndia, BackgroundPaper for NACP 111.July 19,2006 version. MeadOver et.al., IntegratingHIV preventionandanti-retroviraltherapy inIndia:Costs andConsequencesof Policy Options.2004 15 o f these groups with high quality targeted interventions inNACP I11i s appropriate.' Since the virus penetrates only slowly from these groups into the general population, the rising prevalence in both rural and female populations is worrying. The epidemic is also clustered in certain geographical areas. 44. It is appreciated that NACP I11is broadening the scope o f the fight by including issues such as the rights o f the affected groups; that it looks at the enabling environment o f the planned interventions; and that it focuses on mainstreaming o f efforts through multiple ministries, including the MOHFW, and partnerships with civil society including PLHIV, and the private sector. Individuals' vulnerability to HIV and the extent to which they are affectedwill depend on a variety o f social, cultural and economic constructs. The ability for anyone to protect him or herself from infection i s influenced by the ability to negotiate safer sexual practice and access appropriate information, services and commodities. The expected outcomes o fNACP I11will not be reached ifindividuals are to live inan environment where power dynamics, gender imbalance, poverty, harmful traditions and discriminatory legal frameworks and practices reinforce vulnerability. Therefore, this National Strategic Framework for Action assumes that the underlying constructs o f vulnerability will be challenged and changed through the implementation o f the strategies laid out in the document, moving from criminalization to regulation o f Commercial Sex Workers (CSW) and MSM.Providing more attention for care and treatment i s also appropriate and several treatment options are now well withinthe means o f the Government. 3. Fiduciary 45. Financial Management: The project has a financial management system that i s adequate to account for and report on project expenditures in a timely manner as well as satisfying the fiduciary requirements of 1DA.This i s a follow on project from NACP 11, under which a Computerized Program Management System (CPMS) was developed and successfully implemented. In addition, uniform accounting policies and financial reporting (internal and external) by project components were achieved during implementation. However the financial management arrangements (staffing, accounting internal control processes etc) did not keep pace with the increased resource allocation and increasing number of sources of funding, leading to parallel systems and procedures for various development partners. 46. Accordingly an independent assessment o f the effectiveness o f the financial management arrangements under NACP I1and the modifications required inresponse to: (i) growth o f the the program; (ii) changes envisaged in the institutional arrangements such as creation o f District AIDS Program Control Units (DAPCU); and (iii)change in the nature o f interventions, was carried out by NACO as part o f the preparation o fNACP 111. 47. Based on the study's recommendations NACO has taken the following actions: (i) initiated action to award a contract for upgrading the CPMS and aligning the chart o f accounts and financial reports in line with the new interventions; (ii) updated the financial management manual incorporating the annual work planrequirements/ timelines, good practices identifiedin 'Successfulprevention efforts amongst highrisk groups will cause a decrease inHIV incidence, while infections and AIDS cases amongst the general population will increase us aproportion of all infections and AIDS cases. 16 the assessment and the process o f selection o f external audit firms by the SACS and incorporating financial management aspects in the manual for NGO/CBO selection and monitoring; (iii) contracted additional finance consultants in N A C O and proposal to strengthen the finance function in identified large states and TSU responsible for NGO/CBOs; and (iv) instituteda system o f management audit with specific TOR. In addition, NACO developed a financial management improvement plan with timelines which focuses on further enhancing the systems and processes such as regulartraining of finance staff, electronic transfer o f funds etc 48. The external audit will be carried out by the Comptroller and Auditor General (C&AG) for expenditures at NACO and by independent firms o f chartered accounts at the SACS level. This will be based on TOR approved by the Bank and consented to by the C&AG. 49. Public Disclosure & Transparency: With greater functional autonomy and delegation to the SACS it is important to build mechanisms whereby the financial (audited financial statements) and physical performances and shortfalls, if any, are reported and made available in the public domain. The annual program report will be prepared at the individual SACS level and also at the overall program level and made available on the websites o f NACO and the SACS. This is also inline with the Output Budgetingand Rightto Information Act o fthe Govt of India. 50. The disbursement arrangements and the detailed financial management arrangements are giveninAnnex 7. 51. Procurement: NACP I11 would involve the procurement o f minor civil works, pharmaceuticals, goods, equipment, services and other miscellaneous items to be procured by NACO and SIS levels. A review (funded by DFID) o f existing procurement policies and procedures was carried out through a consulting firm inrespect o fNACO and a sample o f SIS to identify areas for strengthening,to allow their use for procurement under the program. Based on the findings of the national and state level procurement assessments, and the irregularities observed inR C HI,the procurement risk i s considered to be High. 52. The issues relating to improving Good Manufacturing Practice (GMP) certification process, increasing competition and mitigating collusion, strengthening procurement implementation including supply chain management and contract monitoring, handling procurement complaints, and disclosing information have been discussed with NACO and MOHFW at a senior level, which along with the agreements reached on proposed actions, are summarized inthe GAAP. The GAAP shall be further strengthenedbased on the risks identified and the recommendations o f the ongoing DIR, the procurement review by international consultants supporting Empowered Procurement Wing (EPW) o f the MOHFW, and the report on the assessment of quality and quantity o f pharmaceuticals and medical goods/supplies under Banksupported healthsector projects. 53. Until such time that the capacities of the EPW, NACO and SIS are strengthened satisfactorily to pooling partners, all ICB/LIB procurement, the N C B contracts estimated to cost more than US$l00,000 for goods and works, Consultancy services contracts for firms estimated to cost more than US$150,000, and individual consultants costing more than US$50,000 will be carried out by a qualified procurement agent or through a UN agency hired to do so. In this 17 regard, the MOHFW i s in advanced stage o f negotiations with UNOPS to act as procurement agent for central health sector projects including NACP 111. NACO/SIS may also procure pharmaceuticals and medical supplies directly from UNagencies with the Bank's prior approval. The procurement agent (commercial or UNagency acting as procurement agent) will follow the World Bank Guidelines dated May 2004 and other procurement arrangements agreed for the project. For the interim period (until the procurement agent i s appointed and becomes operational), EPW will be allowed to handle the urgent procurement under an oversight arrangement satisfactory to the pooling partners. 54. NACO has traditionally been procuring services without involving PSAs, and has developed in-house capacity for handling service procurement. These services include IEC, specialized studies and training activities, operational and epidemiological research and other services. NACO has also provided assurances that a dedicated procurement staffkonsultant will be recruited by March 31, 2007 to handle procurement o f services. Based on these factors, NACO has been permitted to handle the procurement of services on its own, without the involvement o f either EPW or the procurement agent. However this arrangement will be reviewed once the results o f DIR are available. 55. NACO, inconsultation with the pooling partners, has prepared a procurement manual for guidance o f the procuring agencies at all levels under the project. Goods and works contracts above US$lOO,OOO and consulting services above US$50,000 will follow the World Bank's procurementlconsultant guidelines respectively. All other methods will follow the procedures as per the NACO Procurement Manual for NACP 111. 56. Condoms for NACP I11 will continue to be procured by MOHFW under existing arrangements and will be financed by Government o f India outside the pool. NACO will however set-up an arrangementsatisfactory to the pooling partners regarding timely delivery and quality assurance o f condom supplies. The entire procurement for Care, Support and Treatment i s likely to be hnded by GFATM outside the pooling arrangement. 57. The pooling partners will support procurement o f pharmaceuticals and medical supplies through NCB,shopping and direct contracting only after concerns regardingrevised Schedule M have been addressed in a way that i s satisfactory to the Bank and the recommendations o f the detailed implementation review (DIR) o f the health sector projects are incorporated in to the GAAP. The exception to this will be the small procurement o f pharmaceuticals and medical supplies by NGO/CBO under the Targeted Interventions and Care, Support, Treatment (TI and CST) service contracts issued to them by SIS, with a maximumvalue o f USD 75,000 per year, subject to an aggregate o f USD 150,000. Under such contracts procurement o f pharmaceuticals and medical supplies manufactured by WHO GMP-certified manufacturers (as per the list available on MOHFW website) shall be allowed up to 5% o f the value o f the TI and CST service contract or USD 3500 per annum, whichever i s higher. However this arrangement will be reviewed once the results o f DIR are available. 58. All contracts below prior review threshold procured will be subject to periodic post review on sample basis. A multi-stage stratified random sampling is proposed for the periodic post reviews. For states, this sampling takes in to consideration the potential risk as well as 18 volume o f procurement. Monitoring the implementation o f the GAAP would be an integral part o f the project review and supervision plan. In addition to regular monitoring and prior reviews, the designated procurementspecialist will beparticipating inthe six monthly review missions. 59. NACO will ensure that the key procurement related posts as identified in proposed organograms for NACO are filled up by October 31, 2007 in addition to the dedicated procurement staff/consultant for handling the service contracts who will be in place by March 3 1,2007. SIS will be requiredto fill up the key procurement related posts by October 31,2007. 60. Detailed procurement arrangements for the project are described inAnnex 8. 4. Social 61. In the socio-cultural and political contexts o f India, the project presents a number of important opportunities, constraints, potential impacts and risks. The key opportunity i s to address current inequities inaccess to information and condoms to preventHIV infection, and in treatment, care and support o f those infected. The inequities are related to geographical location and socio-economic status, including income levels, literacy and gender. As the NACP has been largely urban based to date, residents o f rural and tribal areas have had less access to services (except in a few areas o f the country). However, during this third phase o f the program it will expand into these areas, thus increasing the likelihood o f benefits to rural and tribal people. However, the ability to address these inequities i s constrained inter alia by the lack of infrastructure (e.g., health centers, roads, NGOs) inunder-developed areas, and by social barriers to providing information and influencing attitudes and behaviors related to sex and use o f health care. 62. The project proposes to address these constraints directly by expanding communications and services indifficult areas and to people who come into contact with the highrisk and bridge groups. It will achieve this through a better communications strategy, increasing the number o f non-governmental partners, sensitizing public service providers and planners, social marketing, and other means. These activities would also address the important social issues o f stigma and discrimination. The main risks are that: (a) all these means together may not be adequate to safeguard a population the size o f India's from continued transmission o f infection; and (b) social barriers may prove intractable as overcoming them involves changing the power dynamics related to sex (and drug use), i.e., that between males and females, rich and poor, informed- unaware, provider-client, young-old, and so on. 5. Environment 63. The proposed project has been classified as category B for environmental screening purposes, given the risks associated with the handling and disposal o f infectious wastes resulting from AIDS related preventative and treatment activities. Such wastes are sharps (infected needles and syringes, surgical equipment, IV sets) infected blood, HIV test kits used in VCT centers, blood banks and laboratories and pharmaceutical wastes. Proper management o f such wastes is integral to prevention o f further infection and control o f the epidemic. 19 64. An Infection Control and Waste Management (IC-WM) Plan has been developed by NACO which focuses on the establishment o f a sound management system for the treatment and disposal o f the waste related to the treatment and prevention o f HIV/AIDS and STI and includes generic guidance and protocols and alternative technologies for treatment, transportation and disposal in accordance with the size o f healthcare facilities. The IC-WM Plan includes an Addendum which details national building rules and regulations related to construction, site selection, facility design and waste management. The IC-WM Plan was discussed at a stakeholder consultation workshop and after finalization was disclosed in-country and through the Bank's Infoshop. 65. NACO plans only minor civil works under NACP 111, such as rehabilitation and remodeling o f existing buildings. The Infection Control and Waste Management Plan includes guidelines and instructions to mitigate adverse environmental impacts from the proposed minor construction activities. The Plan also mentions the steps NACO will need to take if major construction i s planned inthe future. 6. Safeguard Policies 66. This project has triggered OP 4.01 Environmental Assessment due to the potential negative environmental impacts o f healthcare waste as discussed in the previous section. The safeguard screening category i s S2. An environmental assessment was undertaken in a sample selection o f 33 facilities in three states, which included field visits and consultations. The key findings were that SACS run facilities had high levels o f awareness regarding infection control and universal precautions practices but were dependent on conditions intheir host facilities. The IC-WM Plan addresses these issues and also provides guidance on mainstreaming integration of environmental and infection control activities in various health programs. NACO and the SACS may not have the necessary institutional capacity to implementthe IC-WM Plan and would need to obtain appropriate support for components such as training, IEC and monitoring. An external independentevaluation is recommended before the mid term review o fthe program to ensure all activities are on track. 67. The project triggers the Indigenous Peoples' safeguard as there is the need to ensure that India's tribal populations receive culturally-appropriate benefits to prevent HIV/AIDS infections and to treat and care for those infected. A social assessment was carried out during project preparation to identify the main issues related to reaching tribal people for these purposes, and how these could be addressed. Key findings o f the tribal assessment include: (a) very low awareness and knowledge o f HIV/AIDS and STIs among tribal people; (b) highvulnerability in areas where they come into frequent contact with non-tribal populations, especially among migrant groups; and (c) low access to health facilities and high recourse to faith healers and unqualified health practitioners. These and other findings have been addressed through a Tribal Action Plan for the program (see Annex 11) which includes actions to improve: (i) participation o f tribal people in program design, implementation and monitoring; (ii)program planning (especially at the district level) to ensure attention to tribal areas; (iii) institutional capacity to address tribal needs, including inter-governmental coordination and private sector involvement; (iv) communication and services to tribal areas; and (v) informationabout tribal areas andpeople to further increase understandingo f needs, constraints and opportunities relevant to HIV/AIDS. 20 68. NACO andthe SACS currently have limited capacity to implement the tribal action plan. Capacity will be built by: (a) increasing the involvement o f tribal people themselves, as well as their representatives and specialists who are knowledgeable about tribal issues inthe program, at the national, state and district levels; and (b) sensitizing andtraining non-tribal people inrelevant locations and agencies in the needs, constraints and opportunities o f tribal areas, especially service providers. 69. The social assessment involved consultations at the field level ina sample of districts and states across the country. Tribal people, NGOs working with them and/or on HIVIAIDS, opinion leaders and health officials at local, state and national levels were consulted on the specific needs o f tribal people, relevant practices, and how these could be addressed to provide appropriate services to them through the NACP 111. As described above, the assessment led to the formulation o f the program's Tribal Action Plan. The assessment report was made available in draft form on the UNAIDS website in early May 2006, and was the basis for a national consultation held inJune. The final version, revised inkeepingwith comments received through the website, consultation and reviewers, was sent to the World Bank InfoShop in November 2006 and reposted on the website. SafeguardPolicies Triggeredby the Project Yes N o Environmental Assessment (OP/BP/GP 4.01) X Natural Habitats (OP/BP 4.04) X Pest Management (OP 4.09) X Cultural Property (OPN 11.03, being revisedas OP 4.11) X Involuntary Resettlement (OP/BP 4.12) X Indigenous Peoples (OD 4.20, beingrevised as OP 4.10) X Forests (OP/BP 4.36) X Safety o f Dams (OP/BP 4.37) X Projects inDisputedAreas (OP/BP/GP 7.60)* X Projects on International Waterways (OP/BP/GP 7.50) X 7. PolicyExceptionsand Readiness 70. There is no policy exception requiredfor the program support. Safeguard clearances have been obtained. The program is ready for implementation as evidenced by the following: (a) the NACP I11Program Implementation Plan has been prepared and found to be o f sound quality; (b) the procurement plans for ICB contracts have been developed and shared with IDA; (c) the IC- WM Planhave beenfinalized, cleared with IDA and disclosed to the public by the Borrower; (d) adequate allocations for the program have been included in GOI's budget for 2006/07; and (e) indicators for results monitoring have been specified and will be collectedroutinely. * By supporting the proposedproject, the Bank does not intend to prejudice the final determination o f the parties` claims on the disputedareas 21 Annex 1:Country and Sector or ProgramBackground Third NationalHIV/AIDS ControlProject With a population o f over 1100 million people, India is a country o f great diversity and sub- cultures which have an important bearing on the AIDS epidemic that it presently faces. The first case o f HIV infection inIndia was detected in 1986 inChennai, Tamil Nadu. India i s today home to the largest number o f HIV infected persons (approximately 5.7 million) andthe second largest number of adults (approximately 5.2 million) living with HIV infection inthe world. India i s experiencing a significant, complex and heterogeneous HIV/AIDS epidemic. Within the country, the epidemic has important regional variations. Six states, representing30% o f India's population have a high prevalence o f HIV according to UNAIDS standards (>1% in ANC attendees and >5% in HRG). Three additional states have been characterized as moderate prevalence states (HIV prevalence i s >5% inthe HRG, but <1% inthe A N C population) but have high prevalence in several districts. The remaining states, which were previously classified as low prevalence, have been reclassified as "highly vulnerable" or "vulnerable" to guard against complacency and reflect the increasing threat o f the epidemic. However in all these states, HIV infection remains largely concentrated in population groups routinely practicing high risk behavior, i.e., IDUs, MSM and CSW - male, transgender and female. In some North Eastern states, sharing needles among seems to be the main risk factor, while in the Southern states sexual transmission i s the main factor. Further, certain population groups likely to have frequent interaction with these groups have likewise been identified, and hence act as a "bridge" between these and the population-at-large. These are the truckers and transport community, and the migrant workers' community. Further it is recognized that youth, more generally, are also at risk. If HIV continues to spread widely among those with high risk behaviors and their immediatesexual partners, several million new infections will result. The country has displayed commitment at the highest level and the national leadership has repeatedly emphasized the need to respond to the threat posed to public health by the HIV/AIDS epidemic. Following the identification o fthe first few cases, a National AIDS Committee was set upto carry out national surveillance to track the course ofthe epidemic. In 1990 a MediumTerm Plan was launched focus on the drivers o f the evolving epidemic. Subsequently, the GOI, in association with IDA and the World Health Organization (WHO) began the National AIDS Control Project in 1992 focusing on blood safety issues and the establishment o f an autonomous NACO among other areas. NACP 11, which began in 1997, broadened the response and was successful in the creation of SACS, which allowed for more decentralized planning and implementation including through the establishment o f a Central Management Information System (CMIS) and a fully functional CPMS. Another major achievement was the setting up o f an HIV Sentinel Surveillance with 670 sites and behavioral sentinel surveillance system, but which i s probablythe best inthe developing world and has the largest coverage inthe world. The NACP I1has led to developing national and state level capacity in government, private sector, NGOs, communities and PLHIV. Targeted Interventions involving over 1,000 NGOs, national coverage o f the Blood Safety Program, establishment o f 848 Voluntary Counseling and Testing Centers (VCTC), a successful PPTCT program through 312 centers, upgrading o f 845 STD 22 clinics, a successful condom promotion program including social marketing, establishment of 135 Community Care Centers and drop-in centers, and ART made available through 75 centers are other significant achievements. While the current stage o f the epidemic raises formidable challenges, India has the commitment and capacity to mount an effective response. The response to the epidemic varies across India. In many parts, prevention efforts to reduce HIV prevalence among groups with highrisk behavior seemnot yet fully effective and coverage, especially for MSM, i s low. As a result an increasing number o f monogamous women, including inrural areas, have become HIV positive. Inother areas, such as TamilNadu, prevention efforts have borne fruit and HIV prevalence rates in the general population and in several o f the HRG are on the decline. NACP I11 aims to shift from project to program mode, using principles o f the sector-wide approach. NACO will change its role from implementation agency to a program catalystlsteward o f the program, while implementation responsibilities will be consolidated at the SACS. This will require an organizational restructuring (NACO & SACS) and capacity building at all levels for a strengthened state and district level response, including planning exercises which reflect programs and resources o f all international and local development partners. Local planning will be evidence based and the monitoring o f implementation will focus on results. Preventionefforts through TI o f HRG will continue to have the highest priority. HIV interventions will be mainstreamed into sectoral programs and partnerships including the private sector, and will be further expanded. NACP I11will have an increased focus on vulnerable and North Eastern states, and there will be more attention for adolescents, youth and women. Prevention efforts will also be better integrated with care, support andtreatment. NACO has undertaken the preparation o f NACP I11through an intensive participatory process which involved wide-ranging consultations with other government departments and various sections o f society. To do this, NACO put together a planningteam to orchestrate a process for preparation o f the Strategic Framework which included: meetings o f 14 Working groups; an e- consultation; a civil society consultation; consultation with positive people; two state level and one national level "Three Ones" consultations; and state level meetings. Fourteen working groups met to discuss key evidence and strategies for 14 thematic areas; representatives of government, and national and international development partners participated actively in the groups. Specific studies and critical assessments were commissioned and results used in developing the PIP along with the reports o f five assessments related to procurement, financial management, social aspects, and the environment (see Annex 16 for a full listing). An e- consultation was organized with the assistance o f UN Solutions Exchange to which over 800 people subscribed and hundreds o f reactions/comments were received. The site is, until today, a very lively forum for discussion. Inaddition to these initiatives, a consultation with civil society was undertaken which led to further cooptation o f civil society in the development and implementation o fNACP 111.Reports are available summarizing these consultations. By seeking the participation o f the people-at-large inthe design o f the program, the government i s setting an example and a new standard for other sectors. We expect that this greater involvement will be carried throughout implementation and evaluationo fthe program. 23 There are also clear signs that at the highest level o f government, political support for the fight against HIV/AIDS is increasing. The Prime Minister inhis Independence Day address urged the people to initiate a mass movement to check and arrest the spread of HIV on a war footing. The Common MinimumProgramme established by the present government makes special mention of their leadership in the response to HIV/AIDS.An NCA has been formed, presided over by the Prime Minister, and the Council will mainstream HIV control into the work of all organs of government, private sector and civil society and lead a multisector response to HIV/AIDS inthe country. 24 Annex 2: Major RelatedProjectsFinancedby IDA and/or otherAgencies Third NationalHIV/AIDS ControlProject Sector: Cr. PSWOED Ratings Health, Project No. (IDA-financedprojectsonly) Nutritionand As ofApril 1,2006 Population Implementation Development OED Progress (IP) Objective Rating IDA-financed Uttar PradeshHealth Systems 3338 MU MU Ongoing UttaranchalHealth Systems 3338 S S Foodand Drugs CapacityBuilding 3777 S S RajasthanHealth Systems 3867 MU MS IntegratedDisease Surveillance 3952 MS MS Tamil NaduHealth 4018 MS S Reproductive& Child HealthProject I1 4227 S S SecondNational Tuberculosis Control 4228 S S KarnatakaHealth SystemDevelopment 4229 S S and Reform IDA-financed Immunization Strengthening 3340 MS MS Closed SecondNational LeprosyElimination 3482 S S 2ndHIV/AIDS 3242 S S MaharashtraHealth Systems 3149 MS MS OrissaHealth Systems NO17 MS MS TuberculosisControl 2936 S S MalariaControl 2964 S S Woman and Child Development NO42 MS MS State Health Systems I1 2833 S S Population VI11 2394 S Population IX 2630 S National AIDS Control 2350 S AP First Referral 2663 S CataractBlindness 2611 S ICDS I1 9977 HS Reproductiveand ChildHealth I N-018 S APERP (Andhra PradeshEconomic RestructuringProgram) -Primary Health Component 3103 S S -Nutrition Component 3103 S S GFATM Grant support inselectedstates USAID, Grant support in selectedstates as well AUSAID, as national DFID and other donor supported projects 25 Annex 3: ResultsFrameworkandMonitoring Third NationalHIV/AIDS ControlProject ResultsFramework Safer sexual and injecting Percentage o f FSW who report Assess risk reduction practices inorder to usinga condom with their most contribute to the national recent client goal o f reduced HIV transmission Percentage o f MSW who report ReviewandstrengthenIEC usinga condom withtheir most and TI inorder to achieve recent client safer sexual and injecting practices Percentage o f IDUs who have adopted behaviors that reduce the transmission of HIV (defined as: who avoid both sharing injecting equipment duringthe last monthAND who report usinga condomwiththeir most recent sexual partner) Increased care, support and Number ofpeople withadvanced Assess and improve progress treatment for PLHIV HIV infection receiving anti- o f treatment program retroviral combination therapy IntermediateOutcomes New infections inHRGand Percentage o f FSW reached Assess coverage vulnerable populations through TI inthe last 12 months prevented Percentage o f IDUsreached Review and strengthen through TI inthe last 12 months program reach Percentage o f MSW reached through TI inthe last 12months Numberof TI implementedby Assess scale-up o f TI target group The infrastructure, systems Percentage o f SACS who Assess and improve program ~~~ andhumanresources in achieve at least 80% o fplanned expenditure prevention andtreatment expenditure targets programs at the district, state and national levels strengthened 26 Strategic Information Percentageof districts which Assess decentralization of key Monitoring and Evaluation have done highriskmapping element of strategic Systems enhanced information for intervention Percentageof SACS that submit planning their most recentdashboardsto NACO on time Percentageo f relevant' districts which have mappedHRGsin tribal areas and developedTribal Action Plans. i.e. indesignatedtribal districts with ITDAs. 27 l- 0 2z 84z 84z 842 0 2z 84z t s s 0 0 g g 0 0 00 \o 8 d \o W m s g 0 10 m t The GO1 proposes a significant strengthening and rationalization of the M&E systems that service the project in order to make them more user friendly on the one hand, and more product oriented on the other. The SIMU which will have units at the national and state levels, will maximize the effectiveness of available informationand implement evidence basedplanning. In addition, all program officers will be trained on evidence based strategic planning methodologies, informationuse, and program management. Thus the program would have a strengthened monitoring framework to provide more accessible and ready-to-use information across program content and management functions; enhanced surveillance systems to provide HIV related epidemiological, clinical and behavioral data at a state and sub-state level; and independentevaluation and researchto inform and support program implementation. A number of reports will be produced by the system which support the various functions ofthe program and canbe summarized as follows: Levels di ProgramReports National Program managementof specific CMIS (Monthly/Quarterly) State areas e.g., ART, blood safety for District program managers at the national, state and district levels National UsedbyNACBto monitorNACO & CMIS State NACO to monitor SACS Management tool for NACO and State dashboards partners State of the National Strategic managementand CMIS Epidemicand State accountability tool for NCA, NACB, Surveillance Response NACO, SACS, partners, GOI, public Special surveys (Annual) and DPs Research 8 Planning CPMS Monitoring RRR Accountability Quality Dissemination ExternalProgram National Measurementofprogress against Annual reports, EvaluationReports State and objectives for NCA, NACB, NACO, special surveys, (Mid-term; Endof District SACS and DPs evaluation process NACO, SACS, partners, wider Researchstudies Other Reports audience Surveys During NACP 111, monthly and quarterly program routine reporting will be captured by the CMIS which will comprise a set of input and output information. While this will provide useful inputsfor program managersat the facility and district level, it may be somewhattoo detailed for 29 management review on a quarterly basis. Hence a "dashboard" o f crucial information will be distilled from these reports to provide a set of largely process and hence operational indicators. These indicators will act as reference points to inform managers whether the program is on course and will provide early warnings o f weaknesses or failing processes. NACO will use the "dashboard" as its key tool for program management at the national and state levels. The NACB which is tasked with meeting quarterly to oversee program management of NACO will use national level "dashboard" as its tool, and NACO will use state "dashboards" to track and monitor performance o f SACS. Percentage o f states which submittheir dashboards to NACO regularly Percentageo f due procurement contracts awarded duringthe original bid validity period Percentageo f ICTC centers with test kit stock-outs duringquarter Percentageo f ART centers with ART stock-outs duringquarter Percentage o f SACS where governing body met at least once during reporting quarter Numberof district units established, staffed and reporting, relative to targets 30 This will be complemented with a set of Annual Core Indicators which will form the basis of the "State of the Epidemic and Response" report which will be produced on an annual basis to describethe HIV situation inthe country. These indicators are as follows: Outcomes/Outputs I Indicator Source 1 Target Goal To halt and reverse t ;epidemic over the next five years BehaviorChange New infections in 1.1 Percentageof FSW reporting 1.1- 1.6 HRG and consistentuse of condomswith IBBS/BSS vulnerable clients inthe last 12months Baseline from populations increasedfrom X to 80% 2006 National prevented 1.2 Percentageof IDUswho have BSS HRG adoptedbehaviors that reduce survey. Mid- transmission o f HIV inthe last 30 line BSS in days from X to 80% 2009. End-line 1.3 Percentageof menreporting use of BSS in2011. condom the last time they had anal sex with amale partner from X to 80% 1.4 Percentageofpopulation aged 15-49 reporting condom use inlast sex with non-regular partners(disaggregated by sex and age sub-group) 1.5 Percentageof menreporting they are clients of sex workers 1.6 Percentageof population aged 15-49 with accurateknowledge on HIV/AIDS(recall three modes of transmission, two modes of prevention andwho reject major misconceptions about HIV transmission) increasedfrom X to 100% disaggregatedby gender and age InterventionCoverage 1.7 Percentageof sex workers report 1.7- 1.9 CMIS, 80% beingreachedby TISincreasesfrom reports and 44% to 80% special studies 1.8 Percentageof IDUsreportingbeing 80% reachedby TISincreased from 20% to 80% 1.9 Percentageof MSM(high as defined by NACO) reportingbeing reached bv TISincreasedfrom X to 80% 31 Outcomes/Outputs Indicator Source Target InterventionPlanning 1.10 Percentageof districts which have 1.10 CMIS, done high risk mapping increased Consultant from 10%to 100% reports Services/Coverage Proportion of 2.1 Numberof ICTC (PPTCTNCT) 2.1 CMIS 4995 personsliving with facilities increasedfrom 3919 to HIV/AIDS receiving 4995by2011 care, support and 2.2 Numberof ICTC clients tested and 2.2 CMIS 22,000,000 treatment increased. receiving result increased from 3,000,000 to 22,000,000 by 2011 (disaggregatedby sex and age) 2.3 Percentageof districts with at least 2.3 CMIS, 40% one functioning PLHA networks special studies increasedfrom 10%to 40% Treatmentand Care 2.4 Numberof HIV positive pregnant 2.4 CMIS and 76,500 women (mother and baby) receiving PPTCT records a complete course of ART prophylaxis increased from 8,000 to 76,500 by 2011. 2.5 Number of eligible people including 2.5 CMIS 340,000 childrenwith advancedHIV infection receiving ART (disaggregatedby sex and age) increasedfrom 60,000 to 340,000 by 2011 2.6 Number of affected and vulnerable 2.6 CMIS childrenreceiving care and support through programs annually is 170.000 Infrastructure, 3.1 Annual increasesinresources 3.1 SACS systems and human (financial and other) for HIV/AIDS records, resourcesin inother ministrieddepartments interviewswith prevention and according to plan key staff treatmentprograms 3.2 Percentageof SACS which achieved 100% at the district, state at least 80% of plannedexpenditure andnational levels targets strengthened 3.3 Percentageof audit reports 100% completedand forwarded within time limitsto NACO 3.4 Percentageof TIs runby CBOs from 50% 5% to 50% 32 Outcomes/Outputs Indicator Source Target Strategic 4.1 Percentage o f states with at least 4.1- 4.2 CMIS 95% information 80% CMIS reporting monitoring and 4.2 Percentage o f states which prepare 90% evaluation systems dashboards, submit themto NACO enhanced. anduse them intheir own review meetings 4.3 Percentage o f states whose annual 4.3 State PIPS, 95% plans demonstrate effective use o f State BSS, M&Edata and other strategic household information. survey data, program reports, interviews with key stakeholders. IDA will monitor the performance of the program on the basis of a subset of these indicators which will act as proxies for the overall achievement of objectives of the program. This will take into account the phasing in o f various activities and the likely time lag before outcome can be expected to be measurable. Thus IDA would apply the following "ladder approach" to measuring outputs and outcomes over the period o f support. The achievement o f these measures could also provide confidence inassessingthe ability o fthe programto absorb funds. 33 Ladder of Achievement for NACP I11 Year 1 Year 2 4 an Program Coverage + Behavioral HIV impact (national level) outcomes Program + + Behavioral outcomes (PDOlevel) Coverage + + Coverage Program + Program Indicators HIV impact HIV impact Stabilized HIV Stabilized HIV prevalence prevalence among sex among sex workers, IDU, workers, IDU, MSMand MSMand antenatal clients antenatal clients Behavioral Behavioral Behavioral outcomes outcomes outcomes Increased safe Increased safe Increased safe sexual and sexual and sexual and injecting injecting injecting Dractices mactices mactices Coverage Coverage Coverage Coverage Percentage o f Percentage o f Percentage o f Percentage o f sex workers, sex workers, sex workers, sex workers, IDU,MSMand IDU,MSMand IDU,MSMand IDU,MSMand clients reached clients reached clients reached clients reached by TI by TI by TI Program Program Program Program Program Percent Percent Percent Percent Percent resources spent. resources spent resources spent. Number TI Number TI Number TI NumberTI Number TI supported supported supported 34 Annex 4: DetailedProjectDescription Third NationalHIV/AIDS ControlProject The overall goal o f the NACP I11program is to halt and reverse the epidemic in India over the next five years by institutinggood quality, scale interventions with HRGand integrate programs for prevention, and care, support and treatment for the wider population. This is proposed to be achieved through four strategic objectives namely: The objective o f World Bank support will be to contribute to the NACP I11goal o f halting and reversing the AIDS epidemic by attaining the following project development objectives in accordance with two of the national program's strategic objectives: % achieving behavior change by scaling up prevention o f new infections in HRG and the general population; and % increased care, support and treatment o f PLHIV. The goal, objectives and strategies will be informed by a set o f tenets that include the "Three Ones" principle; equity and universal access in both prevention and impact mitigation; respect for legal, ethical and human rights o f PLHIV; creation o f an enabling environment; and civil society participation inplanning and implementation o fNACP 111. The program will place the highest priority on preventive efforts amongst those at the highest risk of acquiring or transmitting the infection. Thus sex workers, MSMand IDUswould receive priority attention, while long distance truck drivers, prisoners, migrants and street children would also be an important focus o f prevention programs. All persons, including children, who require testing and treatment will be assured access andtreatment for 01and first line ART. NACO will collaborate with agencies providing specialized services such as nutritional support child care etc. and will support community care centres to provide outreach, support and palliative care. Mainstreaming and partnerships will be a key approach to facilitate a multi-sector response engaging a wide range of stakeholders including the private sector, civil society, PLHIV networks and government departments. The program intends to leverage the financial and technical resources o f the development partnersto achieve the objectives o f the program. The objective o f World Bank support will be to contribute to the NACP I11goal by attaining the following project development objectives in accordance with the first two national strategic objectives: % promotion o f behavior change by scaling up prevention o f new infections in HRG and THE general population; and % increased care, support and treatment o f PLHIV including through support to infrastructure and systems strengthening which form the last two strategic objectives o f the NACP 111. ProjectComponents Project activities are grouped into four components. All components reflect activities at the national, state, and municipal levels. 35 Component1: ScalingUpPreventionEfforts Programcost US$1,652 million (i) SaturatingcoverageinHRG: Theprojectaimstoreduceinfectionsbyreachingahigh coverage o f HRG over a five year period. This i s to be implementedthrough 2100 TI targeting one million FSW and their partners, 1.15 million MSM including but not limited to those practicing sex work, and 190,000 IDU and their partners. It i s expected that NACP I11would focus significantly on groups that were not well covered duringthe last phase o f the program viz. IDUs and MSM. The activities listed below are expected to be delivered through NGOs and if possible, about half o f these would be delivered through CBOs by year five o fthe program. This component will include: an effective BCC interventionwith high-risktarget groups to increase demand for products and services- this will include a variety o f interventions such as education o f individuals innegotiation skills, andtraining on use o f condoms for personal protection; provisiono f STI services including counseling at service provision centers to increase compliance o f patients to treatment regiments, risk reductiontraining, and a focus on partner referral; both promotion and provisioning o f condoms to HRGto promote their use, anduse by clients, o f condoms inevery sexual encounter; creation o f an enabling environment to facilitate dialogue with relevant stakeholders such as the police, community leaders, local public functionaries and introduce changes inthe social, structural, andpolicy environment to motivate the community to practice safer behaviors; community organizing and ownership buildingto empower HRGto create CBOs to implement the program intheir communities this i s an important new area of - attentionduringNACP I11to promote sustainability o f the program; and linking HIV relatedcare, support andtreatment with other services so that HRGcan access them without stigma or discrimination. (ii) Scalingupof interventionsinhighlyvulnerablepopulations:Thesegroupshavebeen identifiedas being long distance truckers andmainly temporary migrants. There are an estimated three millionlong distance truckers o f which about 20% are thought to be HIV positive. There are another 8.9 milliontemporary short duration migrantswho are thought to be particularly vulnerable to infection. Inbothcases, further information, mapping o f peer networks that can be usedto approach and influence their choices and improving their access to preventative services, i s o f importance. This component would include: R BCC through peer led interventionso f either individuals or groups to create awareness o f their vulnerability and increase demand for products and services; R the promotion andprovisioning o f condoms through both free supplies and social marketing; 36 R development o f linkages with local institutions, bothpublic and NGO owned, for testing, counseling and STItreatment services this will be an important area of - public-private partnerships withinthe program; and R inthe case of migrants, creation o f "peer support groups" and "safe spaces" for migrantsat destination. (iii) Interventions in the generalpopulation: Strategies for the general populationwill take into account the specific riskfactors andvulnerabilities ofpopulation groups such as youth (age 15-29 years); women (age 15-49 years) and children (age 0-18 years). This component will include: the deployment o f a cadre o f link workers to reach young people including women, in villages with BCC, condom provision -both free and through social marketing and - linkages to health services; enhancing access to testing facilities for HIV infection which have links to associated programs, and to counseling and treatment services by the establishment o f ICTC; establishing Red Ribbon Clubs where `youth friendly information services' will be provided; improving access to testing and treatment for PPTCT; improving availability, testing and assurance o f blood and blood products; providing STItreatment inpublic and private health facilities for easy access to the community; and undertakingeffective communication programs to encourage normative changes aimed at stigma and discrimination reduction insociety at large. (iv) Multi sector mainstreaming: This component envisages that work will be carried out with relevant ministries, government departments and private players to establish programs to minimize infections and mitigate effects on vulnerable populations; key sectors make HIV and AIDS their core business; and incorporate HIV and AIDS as an integral part of their policies, products and processes. They will be encouraged to identify their added value, roles and responsibilities; develop plans and allocate budgets to contribute to the development objectives ofthe national program; and coordinate their activities within one common national framework Component 2: Strengthening Services for Care, Support and Treatment Program costs: US$414 million This component aims to adopt a comprehensive strategy to strengthen family and community care, provide psycho-social support for PLHIV (especially marginalized women and children), and ensure accessible, affordable and sustainable treatment services. It i s estimated that during the project period, care and support services will be provided to 380,000 PLHIV; ART to 340,000 o f which 40,000 children (in the public sector); 01treatment to 330,000 persons; and TB treatment to 2.8 million persons. Socio-economically disadvantaged people would be reimbursed the cost o f transportation and other costs related to access o f ICTC and ART facilities (for both the affected person and an attendant); and costs o f CD4 testing and treatment 37 with ART would be waived for tribal people. Especially for this component, networks of health professionals must be involved inthe planningand implementation. This component will include: strengthening PLHIV and other networks o f vulnerable populations with enhanced linkages with service centres andrisk reduction strategies; developing standard HIV and 01management guidelines including improvedreferral to the RevisedNational Tuberculosis Control Program for TB treatment begununder the NACP 11; establishing community care centres which will provide outreach, referral, counseling and treatment, and patient management services - this will be an important innovation underNACP I11which will be takento scale duringthe program; and undertakingadvocacy, social mobilization and BCC to integrate HIV positive persons into the society at large while reducing stigma and discrimination. Component3: AugmentingCapacity at District,State and National Level Program costs: US$254 million The component aims to undertake strengthening and skills development within NACO and the SACS to better carry out the task o f institutinggood quality, greatly scaled up interventions in MOHFW and other ministries;while at the same time, recruiting private sector systems to public health goals. It i s proposed that this would be carried out through a streamlining of NACO and SACS' form, function and accountability framework on the one hand, and systems to manage the relationship with private sector entities recruitedto provide HIV related services on the other. This component will include: collaborating with partners on developing standard operating procedures in respect o f crucial HIV services, as well as the establishment o f internal and external quality control systems; adopting standard, performance based contractual arrangements linked to delivery o f HIV-related services; providing high quality, operational training in areas critical to the scaling up needs o f the program such as support to establishment o f CBOs, ART training etc. within and outside the government sector; establishing such technical support instruments as necessary, linked to HIV control structures within the government. These could range from TSGs at the level o f NACO or TSUs at the level o fthe SACS; and engaging the services o f a procurement agent for carrying out procurement o f pharmaceuticals, medical supplies, and other goods and works required under the project 38 Component 4: StrengtheningStrategicInformationManagement Programcosts: US$76 million The NACP I11proposes a significant change inthe purpose andeffectiveness o f data collection and analysis. A SIMUwill be established inorder to maximize the effectiveness o f available information and implement evidence-based planning.This will be set up at the national and state levels to address strategic planning, monitoring and evaluation, surveillance, and research. In addition, all program officers will be trained on evidence based strategic planning methodologies, information use, and program management. This component will include: a review o f the appropriateness o f the information gathered, inorder to generate specific informationon highrisk behavior, andproject related impact on behavior change; strengthening o f the monitoring framework to provide more accessible and ready-to-use information across program content and management functions through review and revision o f existingNACP I1frameworks; enhancing the surveillance systems to provide HIV related epidemiological, clinical and behavioral data at a state and sub-state level; a review o f the models usedfor the generation o f various state and national estimates on the basis of surveillance data; and undertaking independent evaluation and research to inform and support program implementation. 39 Annex 5: ProjectCosts Third NationalHIV/AIDS ControlProject GO1 estimates that the total country program costs o f NACP I11will be approximately US$2.5 billion. Taking into account the financing o f condoms and direct funding of NACO's program, the domestic budget o f GO1contributes a quarter of these estimated costs. The program is also supported by a variety o f players including the BMGF and Clinton Foundation (international NGOs), GFATM and local private sector, US government, UN family, and other development partners. Table 1 presents: (a) country program cost by components; (b) the funding from sources outside the government, i.e. the private sector; (c) others, which includes mainly the UN agencies, BMGFetc.; (d) funds tied up from Non-Pooling DPs (GFATMandUS government); (e) condom procurement; (f) STD pharmaceuticals from NRHM sources; (g) contribution to GFATM and (h)the residuewhich needs to be funded by GO1andpart financed by the poolingpartners, Le., the World Bank and DFID. DFID and WB would finance part of GOI's investment in the programby contributingto a Pool o fresources referredto incolumn (g) of Table 1. GO1funding represents 16% o f the Pooled Financing available for the Project, while its overall contribution to the Program is 42% of committed funding. See Table 2. The data provided are obtained from NACO. The Bank team's appraisal o f the PIP supports the approach proposed and the estimates o f total program costs provided by the GOI. Project performance (through M&E arrangements and indicators used) will measure progress o f the entire country program includinginterventions by all player^.^ Based on currently committed resources and projected annual expenditure, a financing gap o f US$390 million is possible inyears 4 and 5 of the plan. GO1plans to seek additional financing for these years o f the program from its development partners. Such additional financing would among others depend upon budget cycles o f donors, availability o f donor resources, as also their readiness to provide additional resources as the program scales up its effective implementation. This gap has specifically been discussed with development partners at joint review missions duringprogrampreparation. Additional funding from the Bank could be required if other funding for the program doesn't materialize or is delayed. Program performance would be closely monitored through a detailed Mid-Term Review including likelihood of achievement o f program objectives through performance indicators, utilization o f resources and review o f further commitments to the program by various partners. Additional financing in the region o f US$250 million would be considered only if performance indicators and disbursements under the Project are satisfactory and that it i s clear that achievement o f development objectives i s critically dependent on such additional financing. Should the financing not be forthcoming or if the program does not scale up as envisaged, project objectives and targets would be reviewed to reflect the expectations fromthe program at that time. 9Fiduciaryoversightby the WB will be limitedto the Pooledfundingcolumn(8) inTable 1, while M& Ewill cover the entire country plan. 40 4 M l- VId VI w m La W El 0 0 0 .I m z 0 z"aB El LI 0 Y m u A m b VI d VI I 0 a B .. Y M (d cc, ktj .. c4) s0 P m d Annex 6: ImplementationArrangements Third NationalHIV/AIDSControlProject Under the Constitution of India, responsibility for health care provision is a state subject. However, issues o f national public health concern fall within the purview o f the central government. Therefore, in view o f the importance assigned to the epidemic o f HIV, the NACP has been a centrally sponsored scheme receiving 100% financing from the GO1 from its inception in 1992. The NACP is managed by NACO established within the MOHFW. The present location and structure o f NACO is an outcome o f the history o f the HIV response in India. Inthe years since the first case was discovered in 1986, India has responded to the perceived risks posed by transmission o f the virus in the community and the opportunities inherent in the health architecture o f the country, by establishing a decentralized public health program which combines interventions deliveredthrough the public health system as well as NGOs. Under NACP 111, NACO intends to consolidate the decentralized model of implementation established under NACP I& I1and provide direction and stewardship to the national program. Recent changes inthe health architecture afforded by the initiation o f the NRHMwill strengthen the delivery o f health system interventions such as ICTC, STD care, PPTCT and 01 and ART provision. The program intendsto institute a policy o frecruiting the private sector to the delivery o f public ends o f HIV control. The program will continue to provide prevention services to HRG through NGOs, while building long term sustainability through facilitation o f both CBO development as well as PLHIV networks. The program also plans to greatly expand its reach to the population-at-large through the involvement o f crucial government departments and the corporate sector. NACO will constitute Technical Advisory Groups comprising o f leading experts in the country to provide guidance and review o f the program's thematic areas. In the same vein, NACO would establish a Technical Advisory Group on Tribal Issues to advise on necessary and possible actions to strengthen the program for tribal populations and to provide inputsfor implementation. A key feature of the implementation of effective interventions with some o f the most marginalised groups in society has been the use o f NGOs and CBOs. The transfer of public funds to these groups has always been a matter of some unease. Guidelines for NGO involvement were revised during the life o f NACP I1 in response to widespread concerns that funds were not being transferred with sufficient transparency, efficiency and attention to performance. Accordingly, this has formed an important aspect o f deliberations duringNACP I11 formulation, with attention to this on the part o f the thematic working group on NGO participation, a consultancy by an international consulting firm, and discussions within NACO and the MOHFW. In view o f the scaling up o f NGO/CBO provided services in NACP 111, NACO has put together an approach paper on contracting with the private not-for-profit sector, and has revisedits guidelines for NGO/CBO contracting. Responsibilities and core functions at national level: The functions o f NACO would be distributed among four strengthened core units each led by a Joint Director/Director. NACO would continue to be headed by an officer o f the IndianAdministrative Service at the level o f 44 Additional Secretary to the GOI. The proposed organogram i s attached as Figure 2 inthis Annex. While NACO will maintain staff to execute all core functions, several functions that are better outsourced, will be contracted to private entities usingperformance-based contracts. The technical and institutional needs o f the five North Eastern states are unlike those of India, due to the geographic location o f the region and differing capacity o f the states. Thus there is a need for sustained technical support for all the states to address the specific needs o f the eight states and the regional strategy. NACO will establish a sub-office - the Regional AIDS Control Unit - within the NRHM North Eastern Regional Resource Unit which would provide implementation support to the states o f this region. There will be a NNCC chaired by the Secretary, MOHFW, which would ensure the full cooperation between programs such as the RCH and TB programs on the one hand, andthe NACP on the other. Inaccordance with its stewardshiprole, NACO would be responsible for: (a) settingthe program framework and establishing accountability systems; (b) carrying out broad advocacy and social mobilization in support o f normative behavior change; (c) establishing technical support capacities; (d) facilitating the mainstreaming o f HIV control into the work o f other ministries, private sector and civil society; (e) institutingpartnerships with significant stakeholders who are vested with capabilities for HIV control; (f) requiringand usingregular monitoring, surveillance, and evaluations o f the HIV control program at every level; (h) setting standards and putting in place a system to assure the quality o f laboratory and treatment facilities; and (i) establishing robust, transparent and efficient systems for procurement o f pharmaceuticals and equipment, goods, works and services. Responsibilities and core functions at state and sub-state level: At the commencement o f NACP phase 11, autonomous decentralized societies called SACS were set up giving states more functional autonomy than available to the State AIDS Cells set up under phase I. Implementation o f HIV control activities would vest primarily with the states. SACS established under NACP I1 are expected to assume a leadership role and coordinate the work o f all partnersineach state. In states where Municipal AIDS Control Societies or other societies have been established, their workplans would be subsumed under the overall workplan for the state. In a few states, SACS have beenmergedinto an overarching State Health Society and insome, this may happen during the life of the project, however, characteristics of SACS will continue to be maintained. SACS staffing decisions will be based on size o f state and disease burden. Similarly TSUs, established in response to problem size, will assist in the management o f the TI programs with HRG.The government proposes to gradually set updedicated implementationunits at the district level called DAPCU, strengthening the ability to implement various components o f the program. NACP I11provides for capacity development o fthe SACS and DAPCU as an important output o f the program which would support the major scaling up o f program interventions. However, where states fail to take adequate ownership o f the program, NACO intends to institute special measuresto ensure implementation o fthe program. The SACS or State Health Society would be responsible for: (a) planning and implementing interventions with high risk, bridge and general populations; (b) undertaking state level advocacy, IEC, social mobilization and youth campaigns; (c) providing technical support to 45 partners within and outside the health department in respect o f program components; (d) supporting intersectoral collaboration with significant stakeholders; and (e) undertakingessential procurement per the agreed procurement arrangements. The DAPCUs will gradually be established and when fully functional, will have their own action plans and budget with a separate account. These will be closely linked to the institutional arrangements for the NRHM at the district level. All medical functions at the district level will be supervised by the Chief District Medical Officer under the aegis o f the District Health Society. The Hospital Safety Units o f district hospitals will be in charge o f managing hospital waste and ensuring hospital safety under the district health society. All non-medical functions, Le., preventive services, IEC, social mobilization, outreach services and facilitation o f TI will be discharged by the DAPCU. For proper planning and management o f activities both by NACO and SACS, a "dashboard" has been developed by which both NACO and the SACS can monitor progress o f the program per state and compare states inperformance (see Annex 3). Oversight arrangements: NACO would report to the N A C B chaired by the Secretary, MOHFW, which would also have oversight o f work carried out by partners whose programs do not pass through the national budget. The N A C B will consist o f the Secretary o f Health, Secretary o f Family Welfare, Director General o f Health Services, Director General o f the Indian Council o f Medical Research, Joint Secretary & Finance Advisor, a representative from the Ministry o f Finance (Department o f Expenditure), Project Director and Additional Secretary, NACO and representatives o f civil society including NGOs, national trade unions, private sector, and AIDS experts. InJune 2005, the NCA was constituted under the chairmanship of the Prime Minister and with membership of 31 central ministers, six state chief ministers and civil society. This body will provide the highest political oversight and support to the implementation o f the national HIV control framework especially in order to mainstream HIV control into the work o f all organs of government, private sector and civil society and lead a multi-sector response to HIV/AIDS inthe country. States will establish State Councils on AIDS along the pattern o f the National Council on AIDS to be chaired by the Chief Ministerand having the Ministero f Health as Vice Chair. Partnership with the civil society at national, state and district levels: Civil society organisations have beenactive partners o fthe national response to HIV/AIDS. Civil society partnership forums will be established at national, state and gradually at district levels with membership o f active civil society partners and representing the various constituencies that are stakeholders in HIV control. District forums of civil society whose membershipwould include any civil society organisation e.g., NGOs, CBOs, PLHIV networks, tribal people/organizations (in predominantly tribal districts), private sector organisations and academic institutions working in the area o f HIV are proposed. The district forum will pay special attention to the needs o f socio-economically vulnerable (including tribal people), develop collaborative district implementation plans, and review progress. These will be federated to the 46 state level forum through elected representatives o f the district level, not exceeding two per district. The national forum will have representatives from the state level forums. Partnership arrangements with development partners: Support to NACP I11will be provided in accordance with the "Three Ones" approach. This approach applies the Monterrey Consensus and Rome Declaration on the Harmonization of Development Assistance to a specific area o f development - HIV. NACO will establish a clear joint working relationship with DPs at both national and state levels through the establishment o f a coordination framework enjoining each to the spirit o f "Three Ones." NACO would form with a selected group o f DPs (including the UN, DFID, USAID, BMGF, CF and WB), a Steering Committee to: (a) prevent duplication of DP efforts; (b) share information on action plans; and (c) review program performance. Joint annual program reviews will be carried out. IDA will work closely together with DFID, which intendsto pool resources with IDA. The program will require intensive supervision, especially inthe first year o f operation. 47 Annex 7: FinancialManagementand DisbursementArrangements Third NationalHIV/AIDS ControlProject Background The project has a financial management system that is adequate to account for and report on project expenditures in a timely manner, as well as satisfying the fiduciary requirementsof IDA. TheNACP I11program ofthe GO1builds onthe lessons learnt underthe NACP I1project which closed on March 31,2006. A programmatic approach i s proposed to be followed under NACP I11 with all development partners expected to support and align their activities and finances behindGOI's programframework for the next five years. The total program size (level o f investment from all sources form within and outside GO1budget) has been determined at US$ 2.5 billion. This i s expected to be financed by: (i) private the sector, independent agencies such as BMGF, various UNagencies (all these funds will be outside GO1 NACP I11 budget for the program); (ii) provisions in other line budget ministriedprograms; and (iii) budget provision within MOHFWNACO for the NACP I11program. The Bank (along with DFID as pooling partner)will finance part o fNACO's expenditure on the program, which are not financed by other non-pooling development partners such as GFATM, USAID, etc. FinancialManagementCapacityAssessment This is a follow on project from the NACP Iand NACP I1projects. In NACP I1the implementation arrangements and consequently the financial management arrangements changed with the creation o f SACS. Under NACP I1 a CPMS was developed and successfully implemented. In addition uniform accounting policies and financial reporting (internal and external) by project components was achieved during implementation. However the financial management arrangements (staffing, accounting systems, internal controls etc.) did not keep pace with the increased resource allocation and the increasing number of sources of funding leading to parallel systems and procedures for various development partners. A study o f the financial management arrangements was carried out. The assessment covered six SACS and NACO. Inaddition NACO circulated and obtained completed financial management checklist for other states which also fed into the assessment. The key issuesemergingfrom the study are the needfor: 8 Improvement (timeliness and quality of review) of the AWP preparation and reduce the budget cycle time which in turn impacts the fund release from NACO. 8 Regular assessment o f the project financial management arrangements and compliance with internal control procedures through a system o f management audit. 50 R Updating the financial management manual and develop consistent accounting policies applicable for all donors. The study confirmed that under NACP 11, the accounting policies were uniformly & consistently followed only in case o f the World Bank fundedproject. R Updating the CPMS to ensure that it is able to account for all funds instead of only World Bank financed project. R Extending the TSU for monitoring NGOs (which were in existence in seven states) to all the SACS. A Regular and periodic training for financial managementstaff. The study also identified various "good practices" adopted in many states, which are capable o f being replicated across the states. The above issues including the identified good practices have beenbuilt into the updated FinancialManagement Manual. Country Issues Generic country level issues and specific resolutions under the project are discussed further. 8 GOI's existing accounting system concentrates mainly on book keeping and transactional control over expenditures and there is little inthe way o f a concept o f financial management information being used for decision making.Also GO1 considers all releases as expenditure: a separate CPMS has been developed and i s in use by the project under NACP I1which enables the generation o f reliable financial reports. This i s beingupdatedto facilitate accounting and reporting for all donor funds which flow through the budget o f MOHFW (NACO). R Quality and timeliness o f audit reports: the audit o f N A C O will be conducted by C&AG, India: 1 the project financial statements (sources and uses o f funds) generated by the CPMS for the expenditure incurred at N A C O would be audited in accordance with TORapproved by the Bank and consented to by the C & AG's office - consent to be obtained. The audit o f the financial statements of the SACS would be carried out by independent chartered accountants firms empanelled with the CAG. (as per TOR approvedby the Bank) R The following country issue with respect to non-availability o f the project financial statements does not apply: The SACS are requiredto prepare financial statements which will be audited by an independent chartered accountants firm. NACO will also maintain books o f accounts based on which a statement o f sources and applications o f funds will be prepared for the expenses incurred at the central level. 51 The issue of availability of funds on a timely basis to the project implementing entity does not apply to this project as the funds to meet the expenditure at the states will be remitted directly to the SACS. RiskAnalysis Risk Rating RiskMitigationMeasure While the number o f accounting S Many states have adopted innovative practices to centers are limitedto approx 45, address the issue o f unsettled advances which have funds are advancedto a large beenidentifiedinthe FMstudy. Therehave been number ofperipheralunits such built into the updated FMmanual for replication as NGOs, blood banks, VCTCs, across the program. Inaddition a DAPCUi s being schools, hospitals, district created inapprox. 200 highincidence districts. agencies (withmany beingone The DAPCUwill have one to two finance staff, time activities),settlement of which would be responsible for district level advances i s time consuming planningand financial monitoring including resultingindelays inbooking o f collection o f financial reports andutilization expenditureandmismatchis certificates from various institutions to whom physical and financial targets. funds flow inthe district. Monthly cut-off procedures and financial management indicators are being built as part o f CPMS upgradingwhich will help track buildup o f advances The project proposes to A separate study onNGO contractingand capacity implement a significant part o f has beencompleted. A guideline onNGO/CBO the project through NGOs/CBOs selection, contracting and FMarrangements has and scale up the number of S been developed. A separate TSU i s proposed inall NGO contracts to approx 2100. states for dealingwith NGOs/CBOs which will The capacity o fthe NGOs to use have a full time finance staff. Inaddition andreport on the project funds accounting handbook to help build capacity o f i s limited. Inaddition there i s NGOs developed by some states will also be rolled the risk ofvarious donors out across the program chasing a limitednumber o f A systemofputtinginformation inthe public NGOs and possibility o f same domain and sharing o f information amongst financial reports being donors will be instituted. submittedto various donors. Overall risk rating S Strengthsand Weaknesses Strengths The project has the following strengthsinthe area o ffinancial management: The financial management unit i s inplace inNACO headed by Director Finance and supportedby five finance staff/consultants who are well versed with the GO1 financial regulations as well as World Bank requirements. This will be further 52 strengthened with finance staff/ qualified finance consultants in line with the PIP. R The CPMS is operational in the SACS'*. A contract for upgrading the CFMS and continuous system support has been awarded by NACO. The upgrade is expected to be completed by October 31,2007. Weaknesses Significantweaknesses Mitigation Incentrally sponsored projectsthe flow Ithasbeenagreedandincludedinthe Finance of funds from the center to the states Manual that flow o f funds will be linkedto andthe district is not normally linked to adherenceto financial reporting conditions. The meetingfinancial reporting targets (i.e,, new General Finance Rule o f GO1(July 2005) timely submission o f SOE, FMR's and now requirethat the second installment canbe auditreports). releasedonly on receipt o f audited financial statements. Inadequate use o f financial information A set o f financial management indicators has for planning& decision making. been developed and included inthe financial management manual which will help finance andprogram managers inNACO/SACS to monitor the financial progress and controls. ImplementingEntities The project will be implemented by the NACO at the central level and by the SACS at the state level. NACO is responsible for overall management o f the project, its financial management, central level procurement, review and approval o f AWPs, management and technical support to the states and for annual progress review o f the program. The DG o f NACO would have overall responsibility for the proposed project. The DG i s supported by various technical specialists including a Joint Secretary in charge of Administration, Procurement, IEC and Social Mobilization; and a finance unit headed by a Director Finance, a senior Indian Administrative Service (IAS) officer, responsible for financial management. At the state and district levels SACS have been in existence under the NACP I1project and have beenimplementing the program. The project director o f the SACS supportedby a financial controller i s responsible for financial management o f the project within the state, state level procurement, annual work plans management and technical support to the districts and annual progress reviewofthe programinthe state. Under NACP I11it is proposed to create district level units -DAPCU which will be responsible for district level planning and monitoring. N o funds are expected to flow to these units except to meet its operational costs. 12Some SACS have reverted to manual systems in2006-07 due to lack of continued IT support fiom the consultants following the close o f the NACP I1project. 53 Budgeting& AnnualWork Plans At GO1 level the project's funding requirements are provided within the budget of the MOHFW and NACP I11program will have a separate budget head (minor head). At the national level, the budget would be operated by NACO. Annual budget o f the project would be allocated as per national PIP and the actual pace o f implementation. At the state level the budget would be allocated to each state based on the approved state AWP. As this is 100%centrally sponsored scheme, funds would be made available to the states, on a full grant basis. The existing scheme guidelines/ FM manual have been reviewed and updated to incorporate the revised cost norms, the timelines for preparation o f AWP by SACS and review and approval by NACO. Timelines have been incorporated to ensure that all AWPs are reviewed and approved by NACO before the start o f the financial year. In addition NACO will carry out a mid-year review o f the SACS AWP and implementationperformance. FundFlow Arrangement The annual budget allocated to each state would be released in two installments during the 1st and 3rd quarters of each fiscal year. Fundsrequired to implementthe Project will be released by NACO to the SACS. The SACS in turn would release necessary funds to various implementingunits (NGOs, VCTCs, blood banks, district units,etc.) based either on contractual obligations (NGOs) or sanctioned amount for the specific activity. The release o f the first installment by NACO to the SACS would be determined on the basis o f the approved AWP and will be subject to receipt o f provisional Utilization Certificates (UC) from the states. A shift to electronic transfer o f funds (to begin with from NACO to states) will be instituted during program implementation by buildingon the experience in RCH 11. Release o f second installment funds from NACO to the SACS would be incumbent on the receipt of the audit certificates and UC for the previous year. Under NACP I1there were instances o f delayed funds flow to NGOs. This aspect has been addressed by de- linking the financial reporting from the funds flow to ensure that there is a float (working capital o f approx 2/3 months)available with the NGOs. Books of Accounts and AccountingPolicies The project costs incurred at NACO (grogram management, IEC, etc.) and costs incurred on central procurement o f pharmaceuticals and test kits etc would be recorded in the books o f NACO at MOHFW in accordance with procedures and policies prescribed in the General Financial Rules (GFR). As the GO1 follows a cash accounting system, all funds either transferred to the states and to central level implementing units are recorded as expenditure in the books o f the GOI. For the purpose o f the project however the accounting policies as documentedbelow will be followed. 54 Level Activity Mainstream GO1 For Proiect At the Centralized Will becarried out by The NACO (Finance central procurement independent procurement Cell) will monitor ministry including ICB, agent, empowered advances/ settlement level training, procurement wing in to the procurement WAC01 monitoring, MOHFW andMedia agents and other evaluation and Agencies (for IEC contracts) consultants. For the IEC. who receive advances from purpose o f financial NACO. The books o f account reportingto the Bank for this are maintainedby the only the actual Chief Controller o f Accounts. expenditure as Advances to the procurement reported by the agencies are recorded as various agents and expenses (Non plan) and institutes will be transferredto Plan recognized as expenditureonce the expenditureandthe procurement process i s balance will be completed, i.e. proofo f recognized as delivery is provided by the advance. agents. The advances for IEC are recorded as expenditure when funds are released and U C are requiredto be provided by such agencies. State All activities Fundreleasesto State The actual Society fundedas per Societies are also recorded as expenditure incurred (SACS) AWP expenditureinGOI's books & reportedbythe with a requirement the U C are State & District submittedwithin 9 months Society (based on from the end of the financial accounting policies year. prescribed inthe Financial Management Manual) will be the basis both for reporting and for the financial statements A CPMS for the project has been inuse by the project at the SACS level to account for the expenditures under the World Bank assisted project (see section on information systems below for improvement in the CPMS). Expenses would be recorded on a cash basis and would follow broadly the project activities for ease in reporting to various stakeholders. Standardbooks o f accounts on a double entry basis (cash and bank books, journals, fixed assets register, advance registers are available in the CPMS and will continue to be maintained under the project by NACO/SACS. 55 Internal Control UnderNACP I1project internal controls (financial & operational) controls were found to be weak ina few states with issues such as delays insettlement o f advances by peripheral units/NGOs, lack o f timely bank reconciliations and inadequate arrangements for financial review o f NGO activities. These have been addressed by updating the NGO/CBO guidelines (which includes financial management aspects) and the FM Manual which provides the overall internal control framework for the project. The finance manual laying down the financial policies and procedures, periodic & annual reporting formats including financial statements, flow o f information and methodology o f compilation, budgeting & flow o f funds, format o f books o f accounts, chart o f accounts, information systems, disbursement arrangements, internal control mechanisms, internal and external audit for the project has been updated to incorporate various guidelines, circulars and amendments issued during the implementation and to also reflect `better practices' adopted by certain states. In order to improve the internal controls a set o f checklists, year end cut off procedures and financial management indicators have been developed for monitoring purposes. NACO has also developed a time bound financial management reform plan which has process improvement measures such as electronic transfer, web-enabling o f the CFMS and its interface with the Computerized Management Information System and regular training plans for finance staff etc. The training manual developed for NGOs in Tamil Nadu will be extended to all states. The timely implementation o f this reform plan i s a legal covenant and will be monitored during project supervision. Finance Staffing and Training The Finance Unit inNACO is headedby a Director -Finance and supported by 5 finance staff/ consultants. In view o f the increased scale o f operations the finance unit will be further strengthened by deputatiodcontracting additional qualified consultants by October 31, 2007. The finance cell i s responsible for establishment o f the agreed financial management arrangements, providing timely financial reports to the stakeholders including the Bank, ensuring smooth and timely flow o f funds andproviding overall guidance inrespect o f the financial management issues for the project. At the state level depending on the size of the program the finance unit is headed by a Finance Controller/Finance Officer. The FM assessment study has suggested strengthening the finance units in larger states and a focus on regular and periodic training. The additional finance staff has been built into the national PIP, the states will hire additional staff as required to strengthen the finance units by October 31, 2007. Some o f the constraints relating to finance staffing and training under the NACP I1 project was the lack o f regular training to finance staff and vacancy in the position o f Director (Finance) for one year and qualified finance consultant -for two years inNACO which led to a lack o f adequate oversight/ monitoring o f the financial management arrangements in the SACS. This i s being addressed by building in regular & periodic training as part o f the FM reform plan and the need for continuity in the position o f Director (Finance) as a legal covenant. 56 InformationSystems The project implemented a CPMS system under NACP I1 which is functional in the SACS. This system however only accounted for World Bank project and while the funds from other donors where accounted for in parallel systems. A contract to upgrade the CPMS has been awarded and i s expected to be completed by October 31, 2007. The upgrade inter alia includes (a) facilitate accounting and reporting multiple donor funding; (b) amending the chart o f accounts to facilitate reporting in line with the proposed activities; (c) web enabling of the CPMS; (d), development of a budget module with interface with the accounting module; and (e) ageing o f advances and financial indicators calculation etc. The first set o f upgrade (chart o f accounts, monthly cut off procedures etc) i s expected to be completed by April 30, 2007 and the balance by October 31, 2007. A group o f Trainers who are familiar with the CPMS from well performing SACS will also be developed. ExternalAudit Since the project i s implemented throughoutthe country 42 audit reports were requiredto be submitted by the various states and union territories under NACP I1every year. The audit reports from the SACS under NACP I1were received with some delays and the Bank had to resort to suspension o f disbursement for 5 to 6 SACS inthe years 2001 and 2005. The lessons learnt under NACP I1 are the need to improve the quality o f firms auditing the project, the timeliness o f the audit reports and for NACO to take responsibility for review o f the reports and take appropriate actions to address issues arising from the reports. These are addressedunder NACP I11by: R The process o f selection o f the auditors i s being strengthened with a view to obtain better and timely audit assurance, with the initial shortlist being based on the list of Chartered Accountants empanelled with the C& AG The TOR for audit by C A firms and process o f selection o f auditors has been documented inthe FM Manual and the process o f appointment is also being advanced by six months to addressthe issue o f delay inappointment o f auditors. R NACO will review and provide to the pooling DP's (Bank and DFID) a Consolidated Report on the Audit o f the Project. This report will consolidate the all Project Expenditure incurred by the states. The report will also consolidate the key observations arising from the audit reports o f each state and the actions being taken/ proposed to be taken by NACO to addresses the weaknesses where necessary. The external audit arrangements will be as under: Audit of State AIDS Control Societies: will be done by firms o f private Chartered Accountants as per TOR approved by IDA. Audit of NACO: will be carried out by the C&AG. The audit will be conducted as per the terms of reference agreed by IDA and consented by the C&AG, wherein an opinion 57 on the project financial statements (sources and uses o f funds) will be given by the C&AG. Inaddition, an audit report for special account heldat GO1would also be submittedinthe usual manner. Thus, the following audit reports will be monitored in Audit Reports Compliance System (ARCS): ImplementingAgency Audit Auditors NACO, MOHFW (1 audit Project Audit for Comptroller & Auditor General report) central level activities o f India Consolidated report on audits o f Project Audit for Private Chartered Accountants all state societies (withthe State state level activities reports as attachments)( 1 audit report) D E N G O I Special Account Comptroller & Auditor General o f India InternalAudit Since there are a large number o f peripheral units (blood banks, VCTCs district units, medical colleges etc) to which funds are released by SACS and there is a delay in reporting o f expenditures and settlement o f advances, a system o f internal audit an quarterly basis in 20 large states will be implemented under this project. The audit will include the SACS and a pre-determined sample o f peripheral units very quarter. The terms of reference for internal audit have been reviewed by the Bank have been documented in the FM Manual and the appointment o f the auditors would be would be made by the SACS. A copy o fthe report will be submittedto NACO and shared with the development partnersduringthe supervision missions ManagementAudit A system of management audit is proposed to be instituted by outsourcing to an independent agency. The terms o f reference for the audit have been reviewed by the Bank. This would cover six to seven states a year selected by NACO. The scope of management audit will include the review o f financial management and procurement aspects and operational issues which have a linkage to financial management, review o f adequacy of / adherence to financial and administrative controls, including physical verification o f assets at various peripheral units etc. The findings o f the management audit will enable NACO and SACS to identify internal control weaknesses, process constraints/ bottlenecks and take appropriate remedial action. These reports will be shared with the bankduringthe supervision missions. 58 DisbursementArrangements The Bank and DFID (the pooling partners) will finance a share of the project expenditures incurredby NACO and the SACS, which are not financed by non pooling developmentpartners (GFATM, USAID etc). The pooled funding will be for the period April 1,2007 to March31,2012. The key features of disbursementarrangementsare: The disbursement of pooled financing will be on an annual basis based on the InterimFinancialReports(IFRs) coveringthe previous financial year which will include procurementcontracts under ICB. The programexpendituresreportedin the IFRswill be subjectto confirmation/certificationby the expendituresreported inthe annual auditreportsofthe implementingstates andGOI. The Finance Unit within NACO will provide a consolidated IFR and a consolidated financial statements based on the individual audited financial statements from states and GO1with the audit observations/ disallowances. Any variances between the amount reported in the IFR and the consolidated audited expenditure report will be adjusted (recovered or reimbursed) from the next disbursementto the GO1as perthe schedulebelow. While linking disbursement to audit reports would obviate the need for reconciliations of expenditures as per IFRs with those as per the audit report, experience with Centrally Sponsored Projects (where the funds are providedby the GOI, but implementationremains largely with the states) has indicated that linking disbursementsto receipt of financial reports will act as a strongincentive both at the state level (to send such reports) and at the GO1level (to pursue and follow up such reports). This would also enable receipt of financial information for project monitoring on a timely basis, which could get delayed in cased disbursementsare linkedto the auditreports. DisbursementSchedule * The IFRfor the periodending September eachyear will be submittedbyNovember30 eachyear but this will notbe usedfor disbursement. l3Any recovery arising out of the audit report would have to be physically refunded by the GO1as there would be no future disbursementagainst which it could be adjusted. 59 Other DisbursementFeatures II Disbursementwouldbesubjecttoreceiptofthe ConsolidatedReportofAuditsdue by September each year. Ifthis ConsolidatedReport is not receivedby January of the following year, no further disbursement would be made until the report is received. The GO1would however still be requiredto submit the IFRs on the due dates i.e., May andNovemberof each year. I( Ifthe audit reportsindicatehigher levelsof eligible expenditureas comparedto the IFRs for the same period, the excess will be added to the next report based disbursement; and when the audit report indicates lower levels of eligible expenditure against the relevant IFRs, an adjustment will be made to the next disbursementby way of a reduction. 8 Any default/delay by a state inreportinginannual expenditureintime for the May IFRswill result inunder reportingof project expenditure and such expenditurecan be included in the Consolidated Report on Audits and claimed in the next due disbursement. R In case o f late submission o f an audit report by a state, GO1would not hold back submissionof the ConsolidatedReport on Audits to the Pooling Partners. Ifsuch state audit reports are submitted to the GO1 at a later date, the same would be factoredinthe next disbursement (inJune) provideda revisedConsolidatedReport on Audit i s submittedto the Associationby May. FinancialReportingand Monitoring NACOwill obtainfinancial reportsfrom the states on a quarterly basisto beginwith and gradually move to a monthly basis during project implementation. Based on the individualstate reportsNACOwill prepareandsubmit consolidatedfinancial reportson a six monthly basis to the pooling DP's. The FM report will include a comparison of budgeted and actual expenditures and analysis of major variances. These financial reports will also form the basis/ format of the annual financial statement to be prepared by the SACS. The Financial reporting will be done on a semi annual basis by way of InterimFinancialReports ( IFR) (for the periodended September andMarchevery year) andwill be submittedby May 31andNovember30 of eachyear to the poolingDP's. The IFR's will include state wise and activity wise expenditure for the previous half year, year to date and cumulative to date. The important change is that the reporting to the pooling partners is being aligned with the internal reporting for the project. This will make it useful and relevant for decisionmakingandmonitoring.Under the NACP I1the FMRs were submitted to the Bank, with delays and it was not used for any internal review. 60 PublicDisclosure An annual report will be prepared for the program which will include program and financial information and will be available in the public domain. In addition, the SACS will also be required to prepare an annual report on program performance which will include the audited financial statements and will be posted on the NACO/ SACS websites.This is likely to be implementedina phased manner. Advancefor GO1 An advance of US$35.00 million will be provided to the project which represents approximately 15 % of the Bank's contribution to the pooled financing. Retroactive Financing: The Bank will finance a share o f the eligible expenditures not exceeding US$10 million incurred from April 1, 2007 to the date o f credit signing. The eligibility o f the expendituresto be financed by the World Bank would be determinedby two criteria: i)the expenditures must be in line with the objectives of the project (NACP 111), and ii)the expenditures must have been made using procurement procedures acceptable to the World Bank Le., the procedures agreed upon between the Government o f India and the World Bank for the Project. ProjectCovenants Apart from the covenants regarding audit and submission o f IFRs the following covenants will be included inthe financing agreement. R NACO will maintain throughout project implementationa finance unit headed by a Director (Finance) supported by qualified finance consultants. R Management audit as per terms o f reference satisfactory to the association will be appointed within 3 months o f effectiveness o f the project. R NACO will complete the upgrade o f the CPMS by October 31, 2007 and maintain and support the systemduringthe implementation o fthe project. SupervisionPlan The project would require an in-depth supervision in the initial year especially for ensuring successful implementation o f the state level FM and fund flow arrangements and monitor the implementation o f the FM reform plan. Mid term review would be conducted after two and a half years o f the project to comprehensively review the FM performance o fthe project. 61 Annex 8: ProcurementArrangements ThirdNationalHIV/AIDS ControlProject General This project would be implemented by MOHFW, through NACO at the national level, and by SIS at state level and some Municipal AIDS Control Societies (the term SIS has been used hereafter for both these categories). The NACP I11would follow a program approach and there will be a pool o f funds with contributions from IDA, DFID) and the GOI. NACP I11 i s proposed to be implemented in accordance with the "Three Ones" approach and would be carried out through sustained technical and training support to public/private agencies, NGO/CBO, and organizations o f PLHIV. NACO, in consultation with the pooling partners, has prepared a procurement manual called the "NACO Procurement Manual for NACP 111" dated March 8,2007 for guidance to the procuring agencies at all levels under the project. The Manual gives details o f various procurement methods along with steps and thresholds to be followed under each method o fprocurement. These guidelines will be usedbyNACO and SIS for carrying out procurement under the project. Procurement thresholds for goods and works and hiringof consultant services agreed with NACO are mentionedbelow. Goods and works contracts above US$lOO,OOO and consulting services above US$50,000 will follow the World Banks' procurement/consultant guidelinesrespectively. All other methods will follow the procedures as per the N A C O Procurement Manual. (also applicable for non- intellectual services and the services contracted on the basis of performance o f measurable physical outputs) Goods (only Vehicles) I C B >1,000,000 N C B 100,000 to 1,000,000 Shopping (or DGS&D rate upto 100,000 contract) Consultants' Services (except SSSLCSlCQS Upto 50,000 contracts for TI/CST awarded to NGO/CBOs, Mass Media and IEC Services) 62 Consultants' Services (only SSWCQS Upto 150,000 for TI and CST contracts awarded to NGOs/CBOs) Consultants' Services (only SSS/CQS upto 100,000 for Mass Media and IEC Services) Consultants' Services (all QCBS (or QBS,where Bank Beyond above cases not covered above) agrees) thresholds (i)International shortlist (ii)Shortlist may comprise national >500,000 consultants onlv Ur,to 500.000 Consultants' Services As per para 5.2 to 5.4 o fthe World (Individuals) Bank Guidelines Service Delivery Contractors As per para3.21 o fthe World Bank Guidelines 2B: International Comuetitive Bic ing; NCB: National Competitive Bidding; LIB: Limited International Bidding; SSS: Single Source SelectionrQCBS: Quality- and Cost-BasedSelection; QBS: Quality-Based Selection;LCS: Least Cost Selection; CQS: SelectionBasedon Consultants' Qualifications. Invitation for Bids (IFB) for works, goods and equipment for all ICB contracts and advertisement for calling o f Letters o f Expression of Interest (EOI) for short listing of consultants for services costing more than $200,000 equivalent will be published in UNDBanddgMarket. Limited Tendering (viz. NCB without advertisement but inviting bids from limited number o f suppliers), may be used in place o f NCB only in exceptional circumstances withthe prior approval o fthe Bank. AgreedProcurementArrangements Goods & Works:MOHFW has established an Empowered Procurement Wing (EPW) to professionalize the procurement o f health sector goods and services. An internationally selected consultancy firm (Crown Agents) with appropriate technical expertise in pharmaceuticals, biomedical equipment, quality assurance and supply logistics, i s helping EPW in developing its capacity. The procurement activities o f both Health and Family Welfare Departments will be overseen by this wing. Untilsuch time the procurement and supply management capacities o f the EPW, NACO and SIS are developed to the satisfaction o f pooling partners, all ICB/LIB procurement and the N C B contracts estimated to cost more than US$lOO,OOO for goods and works l4 will be carried out by a qualified procurement agent or through a UN agency hired to do so. In this regard, the 14Procurementof pharmaceuticalsand medical supplies shall be taken up only through ICB/LIB untilthe concerns regardingrevised Schedule Mhave beenaddressedinaway that is satisfactoryto the Bank and the recommendationsofthe Detailed ImplementationReview (DIR) ofthe health sector projects are incorporatedinto the GAAP 63 MOHFW i s in advanced stage o f negotiations with UNOPS to act as procurement agent for central health sector projects including NACP 111. The procurement agent (commercial or UN agency acting as procurement agent) will follow the World Bank Guidelines dated May 2004 and other procurement arrangements agreed for the project. For the interim period (till the procurement agent i s appointed and i s operational), EPW will be allowed to handle the urgent procurement under an oversight arrangement satisfactory to the Bank. The remaining procurement of goods and works, if any, under the thresholds for procurement agent shall be handled by EPW on behalf o f NACO, while SIS would initially undertake the procurement up to US$50,000 threshold only. For procurement o f goods and works, NACO will take care o f functions like periodically updating the procurement plan, developmento f specifications, monitoring o f the procurement done by EPW/Procurement Agent and SIS, and supply chain management etc. NACO/SIS may also procure pharmaceuticals and medical supplies directly from UN agencies acting as supplierswith the prior approval ofthe Bank. Services: Until such time the procurement and supply management capacities o f the EPW, NACO and SIS are developed to the satisfaction o f pooling partners, Consultancy services contracts for firms estimated to cost more than US$150,000, and individual consultants costing more than US$50,000 will be carried out by a qualified procurement agent or through a UN agency hiredto do so. However pendingthe outcome o f DIR and other reviews, NACO i s permitted to handle the procurement o f services on its own without involving either EPW or the procurement agent SIS would initially undertake the service procurement up to US$50,000 threshold only except for TI and CST contracts issued to NGO/CBO where the threshold will be US$75,000. The duration o f TI and CST contracts issuedto NGO/CBO contract will initially be one year only and based on the reviews of the contracting arrangements by Bank, SIS andNACO; result o f DIR and other reviews and the performance o f NGO/CBO during the first year o f contract, contracting arrangements for further years will be decided. NACO has proposed to restructure the current procurement organization and under the proposed NACO organogram, ajoint secretary level official shall be the overall incharge o f procurement assisted by the Director Administration and Procurement. The day to day operations would be looked after by the Deputy Director Procurement and six other dedicated procurement staff. Bill & Melinda Gates Foundation has extended a grant of US$1.5 millionto NACO to strengthenthe procurement capacity. Financial assistanceto this endis also provided for inGFATMsupport to NACO. NACO will ensure that allthe key procurement related posts as identifiedinproposed organograms for NACO are filled up by October 31, 2007 (including a dedicated procurement staff/consultant for handling the service contracts to be inplace by March 31,2007). SIS will also be required to fill upthe keyprocurement related posts by October 31,2007. 64 Details for Procurement of Civil Works Most o f the civil works involved would be small works viz. minor modifications/ alterations/renovatiodupgrading o f offices/stores/laboratories and establishing or extending infrastructure for blood safety at the state and municipal levels. These would be procured under shopping or direct contracting. There are no civil works expected to fall inthe category o f NCB/ICB. Wherever it i s unavoidable, works less than US$lO,OOO may also be undertaken by state public works departments using their own resources (Force Account). Total estimated value o f civil works is not expected to exceed US$81 million. Details for Procurement of Goods Apart from the procurement o f pharmaceuticals and medical supplies described in the following paragraph, the project would broadly include procurement of: (i) equipmentfor modernization o f Blood Banks; (ii) Elisa Reader, Shredder for hospital waste, Plasma Fraction units, Blood Separation units and consumables for equipment; (iii) vehicles for AIDS societies, mobile blood banks and refrigerated vans; and (iv) computers, furniture and other office equipment. Total value o f goods excluding pharmaceuticals to be procured i s estimated to be US$85 million approximately. Goods/equipment under the project will be procured following ICB, NCB, LIB, Shopping, and Direct Contracting (DC). Rate contracts o f the Directorate General o f Supplies and Disposals shall also be an appropriate method of procurement under Shopping only. For N C B for works/goods/equipment/pharmaceuticals, NACO will adopt GOI's Task Force bidding documents as modified from time to time. These documents have been approved by the Bank and have been used for several years for all Bank financed procurement. Details for Procurement of Pharmaceuticals and Medical Supplies HIV test kits like Elisa test kits, Hepatitis test kits and VDRL test kits and Blood collection bags shall be supported by the pooled funding with estimated procurement o f US$103 million. For procurement under this category, the standard bidding documents for health sector goods shall be used. Condoms for NACP I11 will continue to be procured by MOHFW under existing arrangements and will be financed by the government outside the pool. However, NACO will set up an arrangement satisfactory to the pooling partners regarding timely delivery and quality assurance (viz. pre shipment and post-shipmenuon-site inspections by accredited labs, adherence o f agreed quality standarddcertification and documentatiodperiodic reporting to the pooling partners) o f the condoms supplied. Expenditures on condoms would be eligible for financing by the Association, as and when arrangements and procedures satisfactory to the Association are being used. The entire procurement for Care, Support and Treatment i s likely to be funded by GFATM. In the unlikelyevent that pooled funding is to be used for ART procurement, acquisition of 65 such medicines will be guided by a WHO list o f approved manufacturers. Furthermore, because o f limited number o f suppliers and high unit prices, the procurement o f ART may require the use o f less competitive procurement methods such as LIB. MOHFW i s in process o f appointing a qualified consultant to be selected internationally through QCBS procedures, satisfactory to the Bank, to conduct a review o f the quality and quantity of pharmaceuticals and medical goods suppliedunder Bank financed health sector projects. The findings of this review will be used to improve quality o f pharmaceuticals and medical goods to be procured by MOHFW under Bank supported projects, including NACP 111. Drugs Controller General (India) (DCGI) is entrusted with issuing Certificate o f Pharmaceutical Products (COPP) Le., Good Manufacturing Practices (GMP) as per WHO certification scheme for ICB contracts. The GMP certificate as per WHO certification scheme (TRS 863) will be issued by a team of three experts, one each from the central government, the state and an independentexpert. Pending new certification procedures, it will be ensured that 100% post certification is done for all successful bidders recommended for award o f the contract on the basis o f existing WHO GMP certificates. Post certification shall include site inspection o f the winning bidder and regular pre and post shipment inspections of the goods/medicines. In case of NCB, shopping and direct contracting, Indian GMP (revised Schedule M), which has been made mandatory for all Indian Pharmaceutical manufacturers, will be applicable. The pooling partners will support procurement of pharmaceuticals and medical supplies through N C B, shopping and direct contracting only after concerns regarding revised Schedule M have been addressed in a way that i s satisfactory to the Bank andthe recommendations ofthe detailed implementationreview (DIR) o fthe health sector projects are incorporated in to the GAAP. Until this i s resolved, the pooling partners will only finance procurement o f pharmaceuticals and medical supplies following ICB (or LIB procedure, if applicable depending upon the market situation o f the item and its value). MOHFW has prepared technical notes to strengthen the Indian GMP and shared the same with the Bank. The workshops to train the state drug inspectors inusingthese technical notes are plannedshortly. Details of Procurement of Services Services to be procured include hiring o f agencies as procurement agent, inspection agent, institutional strengthening, training and preparation o f training guidelines and modules, workshops for inter-sectoral linkages and collaboration, IEC, advocacy, contractual services to private parties and NGOs/CBOs (including TI contracts), maintenance contracts and contractual staff. Total estimated cost o f consultancy services i s US$372 million approximately. For hiring o f consultant services, the method o f selection would be QCBS, QBS, SSS, LCS,CQS,hiringo f service delivery contractors and hiring o f individuals. All consultant services contracts below US$50,000 equivalent shall be made per procedures prescribed 66 inthe NACO Procurement Manual. Above this threshold, consultants would be procured as per the World Bank's "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" dated May 2004 and World Bank's standard request for proposals (RFP)". Due to their reach and economy, state owned agencies like Doordarshan (state television channel), All India Radio (state radio channel), DAVP, DFP, Song & Drama Division etc. are plannedto be contracted on single source basis for IEC campaigns. Based on the justifications provided, IDA has no objection for contracting these dependent agencies on sole source basis as per the details indicated inthe procurement plan. SIS would use the NGO/CBO Guidelines prepared by NACO for conducting the due diligence process to identify the NGO/CBO to be contracted through SSS (alternatively CQS may be used for engaging NGO/CBO) for TI and CST contracts. These service contracts would typically have a maximum value o f USD 75,000 per year, subject to an aggregate o f USD 150,000. NGO/CBO under the service contracts issued by SIS would be permitted to procure pharmaceuticals and medical supplies manufactured by WHO GMP certified manufacturers (as per the list available on MOHFW website) up to 5% o f value of the contract or USD 3500 per annum, which ever i s higher. However this arrangement will be reviewed once the results o f DIR are available. The agreements to be issued to NGO/CBO for TI and CST contracts would include the provisions like the Bank's right to audit, Bank's remedies in case o f fraud and corruption and the agreed arrangements for procurement o fpharmaceuticalsandmedical suppliesby NGO/CBO. In case o f any conflicting provisions between the NGO/CBO guidelines and the agreed procurement arrangements, the provisions contained inagreed procurement arrangements would prevail. Detailsof OperatingExpenditure: The expenditure on routine operation and maintenance o f buildings, equipment, furniture and vehicles; office rentaldutilities bills, salaries to project staff, general office expenses, travel allowances for project staff, expenses for participation o f project staff in training, expenses for hiring o f vehicles etc. shall be governed by the rules and regulations o f the NACO/SIS. Assessment of the Agency's Capacityto ImplementProcurement The Constitution of India (Seventh Schedule) lists specific subjects in which the union government or the state government alone can make laws and concurrent subjects in which both the union and state government can make laws. Procurement falls in the concurrent list. 15Incasethe service providers are engaged for non-intellectual types o fservices andthe services contracted on the basis o f performance o f measurable physical outputs, these will be procured in accordance with the World Bank's Guidelines: Procurementunder IBRDLoans and IDA Credits dated May 2004 andthe thresholds/procurement methods as indicated for goods shall be applicable insuch cases. 67 Procurement of goods/works and services by MOHFW andthe state governments (except for Tamil Nadu and Karnataka, who have passed their own procurement legislations) i s regulated mainly by the General Financial Rules o f the Government (GFR), 2005; Indian Contract Act 1872 as amended to date, Sales o f Goods Act and, in special cases, by the Essential Commodities Act. A Country Procurement Assessment Report (CPAR) was prepared in 2001, which provides an understanding of National Procurement System. A State Procurement Assessment Report (SPAR) was also prepared for the states of Karnataka, Tamil Nadu, Maharashtra and Uttar Pradesh in 2002 and 2003. Based on these assessments, the existing basic framework of rules and procedures in India requires open tenders; open to all qualified firms without discrimination, use o f non-discriminatory tender documents, public bid opening and selection of the most advantageous contractor/supplier. However, the various assessments (CPAWSPAR) revealed significant weaknesses and lack of compliance with the basic framework o f rules and procedures, as follows; absence o f a dedicated policy making department, absence of a legal framework, absence o f credible complaint/challenge/grievance procedures, absence o f standard bidding documents, preferential treatment in procurement, delay in tender processing and award decisions, adoption of two envelope system and negotiations. The issues listed above are generic issues at the country level and are being discussed as part o f the country dialogue with the government. Revised General Financial Rules (GFR) were already issued in 2005 albeit with some shortcomings. This dialogue is continuing with the government to improve the procurement regime in India. However, specific issues for the project are intendedto be addressed through the Governance and Accountability Action Plan (GAAP) and NACO procurement manual. All states and union territories will be participating in the NACP I11project. A review (funded by DFID) o f existing procurement policies and procedures was carried out through a consulting firm in respect o f NACO and a sample o f SIS, local units, and independent support units, to identify areas o f weaknesses and suggestions for strengthening o f the government procurement systems, to allow their use for procurement under the program. The study pointed out various weaknesses in areas such as weak procurement organization (both at NACO and SIS), selection o f PSAs, delays in finalization o f annual procurement plans and poor quality o f procurement plans, ambiguous and incomplete specifications for equipment and pharmaceuticals, procurement procedure followed by NACO, delays in procurement decisions including delay in technical evaluation, piece meal procurement by SIS, absence o f SBD for procurement on rate contract basis, absence o f procurement manual, quality assurance and inspection of goods, supply chain management, logistics and cold storage facilities, capacity o f procurement personnel, post-award reviews, complaint handling mechanism inclusive of independent appeals procedure etc. The areas for strengthening have been identified in the report, and will be addressed through the NACO and the states' own Procurement Reform Programs. The Central GAAP (and State GAAPs, if any) shall be further strengthened, based on the risks identified and the recommendations of the DIR, the procurement review by international consultants supporting the EPW, and the report 68 on the assessment o f quality and quantity o f pharmaceuticals and medical goods/supplies under the Bank supported projects. NACO has beentraditionally procuring the services without involving the PSAs and has developed some in-house capacity for handling specialized service procurement. These services include IEC, specialized studies and training activities, operational and epidemiological research and other services. Based on these factors, NACO will be permitted to handle the procurement o f services on its own and without involving either EPW or the procurement agent. A major parto fthe project will be implementedthroughNGO/CBO, who will be issueda large number o f contracts (about 4000 in number). Monitoring such large number of contracts poses additional risk as SIS are not well equippedto do so. Based on the findings o f the CPAR, SPARS, the findings o f the above-mentioned study and the irregularities observed inRCH-I, the procurement risk is considered to be high. Keepingin view the experience gained and lessons learned in the RCH Iproject, issues relating to improving GMP certification process, increasing competition and mitigating collusion, strengthening procurement implementation including supply chain management and contract monitoring, handling procurement complaints, and disclosing information have beendiscussedwithNACO and MOHFW at a senior level, which along with the agreements reached onproposed actions, are described inthe attached GAAP. ProcurementPlan The total value o f the procurement from the pooled finding i s about US$640 million over the five year project period. In the event that further scaling up of the program or inclusion o f new categories under the pool financing is decided at mid-termreview stage, the procurement plan will change accordingly. Duringthe first 18 months, the value of the procurement is likely to be about US$179million. The SIS will handle the procurement o f goods, works and services up to a threshold of US$50,000 in the beginning except for NGO/CBO contracts where the initial threshold will be US$ 75,000. Periodic assessment o f the SIS capacity will be carried out by NACO. On the basis o f the results o f these assessments and also other reviews conducted by the Bank and NACO reflecting the SIS capacity to undertake procurement consistent with the GAAP principles, additional responsibilities for procurement may be transferred to the SIS. Procurement plans have been preparedby NACO for the fillproject period for contracts for goods and works to be awarded under NCB/ICB/LIB and for consultancy contracts aggregated under different activities. NACO has also indicated aggregate values under shopping/DC/Force Account under different categories o f items, which have been reflected in the procurement planwith a note that these shall be procured by the SIS and value of each contract will be below the threshold for shopping/direct contracting/force account. Keeping inview the fast changing scenario inHIV/AIDS sector and also due to 69 new donors coming up for funding the sector, the procurementplanmay require frequent changes. The summary of the procurement plan (including both pooled and non-pool funding) is givenbelow: A Medical Supplies 1 TEST KIT ELISA 2075 ICB NACO 2 HEPITITIS-C ELISA 1689 ICB NACO I 3 I HEPITITIS-CRAPID I 8208 I ICB I NACO , I 4 HEPITITIS-B KIT ELISA 2456 ICB NACO 5 HEPITITIS-B KIT RAPID 5219 ICB NACO 6 VDRLKIT 1535 ICB NACO of Mobile Blood Banks, ICTC & ART Centers ForceAccount 2 Creation of 10Centers of Excellence 200 DClShoppingI SACS Force Account Total for Works 36500 G Services 1 IEC Services from DD/AIR/DAVP/SDD/DFP 13383 CQSISSSIQBS NACO 2 IEC Material Development 500 CQS/QCBS/QBS NACO 70 Prior Review The method o f procurement as well as thresholds for procurement review will be based on the total value o f the bid, rather than the value o f each individual contract/schedule/ lothlice. Thresholds for prior review by the Bank are: Works/Goods : All contracts morethanUS$l.O millionequivalent Services: All contracts more thanUS$l.O million equivalent (other than consultancy) Consultancy Services: >US$200,000 equivalent for firms; and >US$50,000 equivalent for individuals In addition, all contracts to be issued on single-source basis to firms (including NGO/CBO) exceeding US$ 75,000 invalue and to individuals exceeding US$ 50,000 in value shall be subject to prior review. Incase o f single source contract to individuals, the qualifications, experience, terms o f reference and terms o f employment shall be subject to prior review. These thresholds shall also be indicated in the procurement plan. The procurement plan will be updated annually in agreement with the project team or as required to reflect the actual project implementationneeds and institutional capacity. Post Award Review 71 All contracts below the prior review threshold procured will be subject to periodic post review (in accordance with Paragraph 5 o f Appendix 1 to the Bank's Procurement Guidelines) on a sample basis. This includes those contracts handled by the procurement agent (or the UN agency acting as procurement agent), NACO, EPW, SIS as well as NGO/CBO. These reviews are meant to ensure that the agreed procurement procedures are being followed. A multi-stage stratified random samplingi s proposed for the periodic post reviews. For states, this sampling takes into consideration the potential risk as well as volume o f procurement. In the first stage the states are stratified in to three groups: large states, north eastern states and other small states and union territories. Inthe second stage the large states are further sub-classified based on Transparency International's corruption ranking o f Indian states 2005. The third stage o f sampling involves selection o f the district from the sampled state. The sample size in each state will be adjusted according to the risk. Accordingly, there will be higher samples in states carrying out large procurement with very high risk (20%) and high risk (15%), lesser samples in moderate risk (10%) and low risk (5%) states. The procurement directly handled by EPW, NACO and NGO/CBO will use a sample size o f 10% and those by the procurement agent will be 5%. All the percentage shall be decided on the basis o f the number of contracts and the sample shall be representative viz. various procurement methods and sizes o f the contracts shall be proportionally included in the sample to the extent possible. The sample size may be increased or decreased based on the findings of the post reviews. The ex-post review by the Bank will be conducted either by Bank staff or by independent f i r m s hired by the Bank. NACO will implement a document management and record- keeping system to ensure that the data and documentation pertaining to all the contracts are kept systematically by the implementing agencies and are provided to pooling partners in a timely manner. The online database for contracts being developed for RCH I1and TB I1will also be used for NACP I11for the purpose o f post-award review as well as for data miningfor the purpose o f runningthe anti-fraud and corruption software to be developed as part o f GAAP. Another option i s to use the data collected by CPMS. NACO will also hire an independent agency for undertaking yearly post review o f the contracts awarded by the program implementing agencies at all levels (Procurement Agent, NACO, EPW, SIS and also NGO/CBO) to cover a minimum o f 10% of the contracts issued during the year. The TOR for this agency shall be shared with the Bank for no objection. The report submitted by the consultant would be part o f the consolidated audit reports to be submittedto the Bank. Inaddition to the above reviews,the C&AG/State Audit Departments, statutory auditors, management auditors and internal auditors for the SIS (all referred inAnnex-7) may also cover review of procurement process as part o f the financial audit. The agreed procurement arrangement for pharmaceuticals/medical supplies under NGO/CBO contracts would additionally be monitored through a review arrangement satisfactory to the Bank. 72 Misprocurement In case goods, works and services have not been procured in accordance with the prescribed procedures outlined in: (i)the Bank's Procurement Guidelines for ICB/LIB/NCB contracts for goods and works contracts above US$100,000; (ii)the Bank's Consultancy Guidelines for above US$50,000; and (iii) NACO's Procurement Guidelinesfor other methodso f procurement, IDA will declare misprocurement and will cancel its portion o f the credit allocated to the goods and works that have been misprocured. ProcurementSupervision Monitoring the implementation o f the GAAP would be an integral part o f the project review and supervision plan. The supervision of the GAAP has been agreed during the negotiations between the GOI, and the development partners including the Bank, and constitutes one o f the legal covenants for the project. In addition to regular monitoring and prior reviews, the designated procurement specialist will be participating in the review missions on bi-annual basis. Further, the periodic ex-post reviews, the ongoing procurement review by the international consultant supporting EPW, report o f ongoing DIR and the report of the inspection agency reviewing the quality and quantity o f pharmaceuticals and medical goods will provide updates on implementation of agreed procurement processes. 73 Annex 9: GovernanceandAccountabilityAction Plan(GAAP) Third NationalHIV/AIDS ControlProject Introduction NACO, Ministry of Health and Family Welfare (MOHFW), GO1 i s fully committed to improve governance and accountability by ensuring efficient program management, sound financial management, and better competition and transparency in procurement and supply o f health sector goods and services required for delivery o f quality services in all its programs. Various mechanisms such as the N A C B (for overseeing the program management), NACO Finance Unit (for financial management), NACO Procurement Unit (for procurement of services, monitoring of procurement by SIS and supply chain management) and EPW (for procurement o f pharmaceuticals and medical supplies and other goods) are established for this purpose. Scope and Purpose NACO, MOHFW has developed this Governance and Accountability Action Plan (GAAP), in consultation with the Pooling Partners (the Bank and DFID), to summarize critical operational concerns relating to program management, financial management and procurement in NACP 111. The key issues and actions to address these concerns are includedinthe matrix below. The GAAP applies to NACP Phase I11supported by the Bank and other PoolingPartners, articulating the specific roles and responsibilities o f different stakeholders (public, private and civil society institutions). The GAAP will be strengthened, as necessary, based on risks identified and the recommendations o f the R C H Iinvestigations, the DIR, the procurement review by the EPW consultant, and the report on the quality and quantity o f pharmaceuticals and medical goods. The Bank financed "Food and Drugs Capacity Building project (Credit No. 37770)" would also support some o f the broader issues related to strengthening o f regulatory institutions especially effective implementation o f GMP in the pharmaceutical sector as envisaged under the GAAP. 74 0b b b 0 0 0 0 -4g -4g -4 N 0 N 0N 0 N 3 3 3 3 4E .I .I e .I .I Lt Lt Lt E e c F .I c 3 t? .I .I .I 3 P P P P c1 0 Y 0 Y 0 Y 0 $ 2 e, E W f 20 8 -0 B C & 0 6 0 0 N 0 N 3 4g 4 3 .- 3 3 .3 Q .-G2 Q 0 .3 M P B 0 Y 0 c) & %* d d 8l a BB 0 b F F b b F 0 0 0 0 0 0 -4 -4E N 0 N 0 N 0N 0N 0 N 3 i 3 i 3 5 .C 1 .C .C & E 0 0 3 3 3 .C .C .C s D s c0 e 0 0 c0 0 c, Y Y 2& 4 Annex 10: Economicand FinancialAnalysis Third National HIV/AIDS Control Project EconomicAnalysis HIV/AIDS cases have been detected in every state o f India. Although NACP I1 has helpedto reduce the rate o f increase o f HIV infection inHRG, HIV prevalence is 8.44 % for CSWs, 8.74% for MSMs and 10.16% for IDUs. Sentinel surveillance data from Mumbai indicates an infection rate o f 44% in CSWs and nearly 10% in MSM, while the North eastern state o f Manipur has detected 22% infection among IDUs in 2004.16 The cause o f transmission i s overwhelmingly through sexual contact, spreading from HRGto the general populationthrough mobile populationsuch as truckers and migrant w~rkers.'~ The total number o f HIV-positive adult individuals in India was estimated to be 5.2 million in2005, while the estimated number o f infected individuals inHRGi s around 0.5 million. The data therefore points to significant externalities in the transmission o f the epidemic, affecting people who do not engage inhigh-riskbehavior or are not part o f the bridge population. Mapping o f high-prevalence districts show similar levels of prevalence across state borders, for example, between Maharashtra and Karnataka. This indicates the need for a national-level response in dealing with the crisis, since HIV/AIDSalso generates geographical externalities. Recent research has shown significant loss o f income o f PLHIV households across occupational categories, both inurban and rural areas. The most severe implication i s for those households where the primary earning member i s incapacitated due to HIV/AIDS." The absence o f a social safety net implies that most o fthe HIV/AIDSrelated expenditure i s out-of-pocket. This leads households resorting to borrowing, dis-saving and selling assets to pay for increased healthcare costs. Data on income distribution of HIV-positive households i s not yet available in India. However, it i s quite conceivable that, just as for many other health problems, poor households will sink deeper into poverty, which might have inter-generational impact. The growing body o f evidence, therefore, points to strong economic justification for NACP I11 in terms o f both market failure and impact on poverty. Market Failure: Theoretically, a system based completely on market mechanisms will fail to ensure socially optimal provision if there are substantial externalities, either positive or negative. Taking specifically the case o f HIV/AIDS prevention in India, substantial negative externalities exist due to the transmissibility o f the infection from HRGto the general population. The spread o f HIV/AIDS can be restrictedby changes in sexual and high-risk behavior through targeted interventions, information campaigns, and providing integrated support services. Relying only on the market will lead to an undersupply o f these services and a higher cost of access to prevention and treatment for HIV/AIDS.NACP I11also addressesthe need for better institutional capacity as well as a 16 Sentinel SurveillanceData, 2004. Source:NACO Over 85 percentof cumulative AIDS cases untilJuly, 2005. Source: NACO. l8 Socio-economicImpactof HIV/AIDS inIndia.NACO-NCAER-UNDPStudy, 2006 80 revampedsurveillance and monitoring system, which untilnow are perceivedto be weak links in program implementation. These fall in the category o f public goods, and therefore need to be funded by the government. The rationale for public intervention, therefore, i s in part due to the inability o f the market to allocate resources in a cost- effective and efficient manner.Moreover, states acting on the basis o f information within their jurisdiction would fail to account for the spillover effects across sub-national borders. This justifies a national strategic policy framework and its monitoring that takes into account the spillover o f the epidemic across sub-national jurisdictions. Substantial economies o f scale are possible with a publicly funded unified policy, surveillance and monitoring framework, as envisagedinthe PIP. Impact on poverty would provide a strong argument for public intervention, Public expenditure on mitigating the costs of care and treatment i s justified especially for disadvantaged or discriminated-against high-risk groups, and given the unusually large burden that HIV/AIDS poses on households. NACP I11 therefore incorporates both externality and equity considerations in the design o f the program, in line with the recommendations o f the World Bank OED Report on improving the effectiveness of HIV/AIDS assistance.l 9 Cost Effectiveness: Targeted interventions aimed at preventing the spread of the epidemic are justified in terms of their cost-effectiveness and efficiency. Significant advances were made during the NACP I1 period in understanding the nature o f the propagation o f the epidemic in India. Behavioral surveys and geographical mapping provide strong evidence that interventions focusing on HRGwill be better able to disrupt the routes of transmission of HIV/AIDS, and consequently its progression from a concentrated to a generalized epidemic. Since nearly 90 percent o f HIV/AIDS infections inIndia are either through sexual contact (FSW and MSM) or through intravenous drug use, it i s possible to prevent substantial number o f possible future infections if resources are utilized and targeted efficiently. Three possible program designs have been evaluated in the simulation model for the NACP 111. The business-as-usual case o f the NACP I1level o f interventions would lead to a marginal reduction in the number o f people living with HIV in 2011. The second option i s to scale up ART maintaining the same level o f targeted interventions currently being undertaken. The mathematical model predicts that this would in fact lead to more thanamillionmore individuals livingwith HIV by 2011,since there is a highprobability that high-risk behavior may increase with the perceived physiological well-being due to ART. The third alternative is to strategically scale-up prevention activities for HRG, aiming at a coverage o f 80 percent through targeted interventions. This would lead to a reduction in the number o f HIV-positive persons by 2011 by nearly one million. Treatment, care and support would also have intensive counseling built into the program to negate the chances of ART patients resuming high-risk behavior. The combined impact o f these interventions would facilitate the objective o f stabilizing and reversing the epidemic, inline withthe MDGs. 19Committingto Results:Improvingthe Effectivenessof HIV/AIDS Assistance. OperationsEvaluation Department, World Bank, 2005. 81 It is clear from the simulation modelthat the third strategy, the one set out inthe PIP, is the most effective one in disrupting the core transmission mechanism of HIV/AIDS in India.Analysis o f data on the size o f the HRG, coverage rates and projected expenditure inNACP I11yields a cost of US$500 per person reduction inthe HIV prevalence inthe terminal year o f the program. In comparison, provision o f ART would entail a cost o f US$lOOO per person covered, and has to be sustained over the foreseeable future mainly through public provision. Scaling up o f targeted interventions i s therefore cost effective compared to treatment, care and support. The substantially share o f expenditure for prevention and public goods such as institutional capacity building, program management, surveillance and monitoring in NACP I11budget reflects the priorities o f effectiveness o f interventions both interms of cost as well as outcome, as outlined inthe OED report. Financial Analysis The financial analysis i s structured around three broad themes: (i) review o f NACP I1 a expenditure and the lessons learned from the experience; (ii) justification for scaling up o f the program and the risks involved in doing so; and (iii) long-run sustainability o f the the programinthe context ofthepolitical andfiscal situation ofthe country. Reviewof NACP 11: DuringNACP 11, a total o f nearly US$400 millionwas spentjointly by the World Bank, other bilateral/multilateral institutions such as DFID,USAID and the UNsystem, and the Government of India. However, the total resources for HIV/AIDSis estimated to be one and a half times that amount (nearly US$600 million) since the resources mobilized through private NGOs such as BMGF, CF and other smaller donors could not be tracked inthe NACP I1budgetframework. Although NACP i s a fully central government funded program, SACS/Municipal AIDS Control Societies (MACS) were established to decentralize the planning and implementation at the sub-national level. However, several states have performed well below par in terms of resource utilization. During NACP 111, further devolution o f implementation i s envisaged, subject to the strengthening o f the institutional, infrastructural and organizational capacities both for the SACS/MACS also the public health system. The significant scaling up o f programs and resources would require a higherlevel of efficiency inthe sub-national implementingagencies. NACP I11incorporates two important lessons learned from NACP 11. First, it advocates a "Three Ones" framework, where all DPs will work under one unified program o f action, coordinating with one implementation agency at the central level and will use one agreed monitoring and evaluation framework. This will ensure transparency in resource mobilization and will eliminate duplication o f effort at the implementation stage. Second, the PIP stresses the importance o f improving program implementation and resource utilization capacity both in NACO and the SACS. Effective monitoring o f program indicators are being finalized as part o f the M&E system, which will help match the inputs to outputs and outcomes. NACP I11intendsto generate and use available data and evidence to inform implementation. 82 Justification for Scaling-Up: The latest population projections indicate that nearly 3.3 million people inIndia will die of HIV/AIDSbetween2006 and 2011,and by 2026, the population will be 16 million less than inthe case without HIV/AIDS, assuming current prevalence levels.20 The primary justification for the increased resources needed for HIV/AIDS is that India needs to intervene decisively to stop the transmission of the epidemic by focusing on HRGthat i s likely to save up to 16 million lives inthe long run. Apart from the number o f lives saved, immediate scaling up o f prevention measures costing US$1.6 billion over five years will reduce the long-run cost o f providing universal access to ART, which will cost US$l000 per person inthe period of NACP I11 itself. Increased expenditure on targeted interventions now will therefore significantly reduce long-run budgetaryexpenditure. There i s however a significant risk interms o f the institutional capacity for absorbing the increase in expenditure at the sub-national level, which has to be effectively monitored. Sustainabilitv o f the Program: During the last two years o f NACP 11, there was a significant increase indomestic expenditure by the GOI, averaging nearly US$55 million between2004-05 and 2005-06. Government spending on HIV/AIDS was 32 percent of total public health expenditure, and 4.75 percent o f the total GO1expenditure on healthin 2005-06. However, HIV/AIDS spending was 76 percent of expenditure on all central disease control programs put together. A significant scaling-up o f expenditure on HIV/AIDS may affect resources available for diseases such as tuberculosis, malaria, leprosy and other vector-borne diseases. Projections o f health expenditure indicate that while this might indeed be true inthe first two years o f NACP 111, it i s mitigated by two factors. First, there is significant front- loading of NACP I11expenditures in the first half of the program in conjunction with the increase inthe scale o f targeted interventions. Second, there has been an average increase o f 15 percent in the health budget over the last four years, and this trend i s likely to continue in the future. Public health expenditure in the health budget of GO1 (including other disease control programs) has increased by nearly 25 percent annually from 2003- 04 onwards. This implies that in the last year o f NACP 111, the share o f HIV/AIDS expenditure will be around 23 percent of public health, compared to 32 percent inthe last year o f NACP 11. There i s also a convergence plan between NACP and the newly- launched NRHM, which is designed to ensure continuity o f HIV/AIDS interventions in the long term. The political commitment to increase public health expenditure, combined with continuedhigh-level DP support, and a strong institutional set-up for the response, make the scale-up of interventions under NACP I11a realistic. A continued strong focus o f the program on prevention also will help India to deal with its HIV/AIDS epidemic in the long run. 2o Population Projections for India and the States,2001-2026.Office ofthe Registrar General and Census Commissioner, Government o f India. 83 Annex 11: SafeguardPolicyIssues Third NationalHIV/AIDS ControlProject EnvironmentalAssessment Provision of preventative and treatment services under the HIV/AIDS project i s expected to generate infectious bio-medical wastes such as sharps (infected needles and syringes, surgical equipment, IV sets) infected blood, HIV test kits used in VCT centers, blood banks and laboratories and pharmaceutical wastes. These wastes, if not managed and disposed o f properly, can have direct environmental and public health implications. Systematic management o f such clinical waste from source to disposal i s therefore integral to prevention o f infection and control o f the epidemic. As per the World Bank's Safeguard policies, this project i s classified as Category Bygiven that negative impacts can be easily managed. NACO commissioned an Environmental Assessment study, whose main objective was to develop a comprehensive IC-WM Plan, which builds on existing documentation, to ensure the efficient and sustainable management o f potentially harmful waste generated from healthcare facilities which cater to the prevention, care and treatment o f HIV/AIDS. The study employed primary and secondary qualitative and quantitative data that was obtained by review o f existing institutional, legal and administrative framework related to healthcare waste management inthe country, field visits to four selected states and survey o f sample facilities and consultations with stakeholders. The main findings o f the study included that awareness o f regulatory requirements for IC-WM is highbut compliance i s low and generally, greater attention is paid to infection control thanto waste management. Awareness o f recommended practices for IC-WM and availability and use o f personal protective equipment i s comparatively higher in SACS- runfacilities. However monitoring and evaluation of IC-WM practices is inadequate and linkages with related programs such as RCH and RNTCP are weak or non-existent despite the cross-cutting nature o fthis component. The IC-WM Plan includes recommendations pertaining to: (i)the enhancement o f the institutional framework for the implementation, monitoring, review and evaluation o f health care waste management; (ii) capacity building, including induction and refresher training o f all relevant health care workers; (iii) development o f appropriate guidelines and instruction manuals; (iv) provision o f equipment and protective clothing; and (v) increasing public awareness and IEC. The Plan also recommends that an external independentaudit be conducted to ensure that the proposed activities are on track and are effective. The draft IC-WM Plan was discussed with relevant stakeholders at a consultation workshop in Delhi on May 8, 2006. Participants included representatives from SACS, Medical Colleges, Vector-borne disease program, Common Treatment Facilities and NGOs. The key recommendations from the workshop included the following and these were incorporatedinto the draft IC-WM Plan: 84 8 Infection Control is the responsibility o f an IC-WM Task Force, which should operate at state and district levels. 8 Availability and use o f barrier protection and immunization is of prime importance. R There are four key components o f infection control: awareness, immunization, protection gear and management o f PEP R External agencies like the Indira Gandhi National Open University and Toxics Linkshould bemade apartoftheprocess especially for training andmonitoring. R There i s need for standardization and dissemination o f tools and methodologies andpractices for training, monitoring, evaluation andreporting. Inadditionto meetingBank's requirement,the IC-WM Planwill enable the project to be in compliance in accordance with Government of India's BioMedical Rules. Once the systems, as recommended in the Plan, are put in place and efficiently implemented,the potential harmful environmental and environmental health impacts can be controlled. However, successful and sustainable implementation o f the IC-WM Plan requires close ongoing collaboration and consultation between NACO and the MOHFW and their respective state-level agencies. It has to be recognized that sharps and blood safety are not limited only to the HIV/AIDS program but should be followed by all healthcare workers. The NACP I11will support IC-WM activities only within the scope o f its own program, but effective waste management from source to disposal can only be achieved if the existing infrastructure ofthe state healthsystems is also strengthened. NACO plans only minor civil works under NACP 111, such as rehabilitation and remodeling o f existing buildings. The IC-WM Plan includes guidelines and instructions to mitigate adverse environmental impacts from the proposed minor construction activities. The Plan also mentions the steps NACO will need to take if major construction i s planned inthe future. IndigenousPeoples Social Assessment and Consultations. The project i s expected to provide indigenous (tribal) people with benefits within its ambit to expand HIV/AIDS prevention, treatment, care and support to vulnerable rural and tribal areas, and i s not expected to have any negative impacts on them. To develop appropriate program strategies and an implementation planfor tribal areas, a social assessmentwas carried out by the GOI. The assessment included primary and secondary data collection and analysis, a review o f the social dimensions o f other project preparation studies, and primary and secondary consultations with tribal stakeholders and other participating agencies (e.g., the Ministry o f Tribal Affairs, and civil society organizations). Important among tribal stakeholders are people who are infected or affected by HIV/AIDS, and those at risk of infection, especially sex workers, migrant workers (and families) and IDUs.The Northeast region o fthe country, especially the states o f Manipur, Nagaland and Mizoram, has predominantly tribal populations, and high HIV prevalence, 85 fueled significantly by injecting drug use. Tribal areas near cities such as Mumbai, and through which truck routes pass are also highly vulnerable. The social assessment consultants interacted with these groups (and especially with women among them), and with health and non-health organizations working with them, in several states and districts in different parts o f the country. Secondary consultations were held at the national level. In addition, the NACP I11Planning Team and 14 Working Groups who preparedthe project also interacted with tribal (and non-tribal) people across the country. The draft social assessment report and Tribal Action Plan (TAP) were disclosed inMay 2006 on a widely-known and interactive UNAIDSDJACO organized "AIDS Solution Exchange" website. The final social assessment report and TAP take into account the feedback received through this mechanism, as well as through the consultative workshops and formal reviewers. They were made available on the NACO website in November 2006. The SACS and DAPCUs will disseminate summaries in the appropriate local languages withinthe next six months. Key findings of the social assessment include: (i) awareness and knowledge o f low HIV/AIDS and STIs among tribal people, except inthe Northeast; (ii) variation in wide sexual and marital practices which have a bearing on partner infection; (iii) lowvery access to modern health facilities and high use o f traditional healers or unqualified practitioners; (iv) and high vulnerability among youth and those who come into contact with non-tribal populations, including migrants and women who engage in sex work. The TAP aims to address these issues, involving and benefitingtribal communities, as an integral part o f the NACP 111. Tribal Action Plan. The implementation plan (see matrix below) is designed to improve the access of tribal people to information, prevention and comprehensive care and support under NACP 111, and i s tailored to three types o f tribal situations. First, in the predominantly tribal northeastern region, AIDS prevention and treatment services will be strengthenedand scaled up state-wide through NGOs and CBOs and government health facilities, under plans prepared and monitored by the SACS and DAPCUs. Second, in states with designated tribal sub-plan areas which have concentrated tribal populations (Le., about 195 sub-district areas), the SACS and DAPCUs will map the vulnerable tribal groups and collaborate with officials o f the Integrated Tribal Development Authorities (ITDAs) to improve prevention and treatment services. Inboth these sets o f states, IEC materials will be translated (with the help o f the local Tribal Research Institutes), and local communication channels would be used to promote safe behavior, increase access to condoms, and provide referrals to ICTC and ART services. NACO and the SACS will cooperate with the Health departments o f all states to strengthen ICTC and ART services. These services will be provided free o f charge to poor tribal people. Patients and attendants who travel to health centers for diagnostic or treatment services will be compensated for travel and related expenses. Districts have been categorized according to HIV prevalence and different packages of services (requiring difference resource allocations) will be made available for each category. Third, tribal people who are dispersed among non-tribal populations will be reached through mainstreaming efforts, particularly IEC, interventions for migrant workers, and other local initiatives. In all three situations, NGOs/CBOs (especially but not only those involved in tribal 86 development activities, such as residential schools and producer cooperatives) will collaborate in prevention and referral activities, and those with hospitals and mobile dispensaries will also support treatment and care. Within all three situations, districts in the highandmoderate prevalence categories will be givenpriority attention. The TAP includes activities to: (a) systematize information about HIV/AIDS in tribal areas/populations; (b) increase the access o f tribal people to the range o f services provided under NACP (including by improving cultural appropriateness); and (c) integrate HIV/AIDS prevention efforts in the work o f other relevant government departments, local development agencies (NGOdCBOs), and public and private health providers to expand reach to tribal people. The activities include: mapping o f risk and vulnerability to HIV among tribal people; increasing awareness campaigns and condom distribution intribal areas, with communication intribal languages; increasing referrals o f tribal people to ICTCs, STI/OI clinics, ART and other healthprograms; increasing ICTCs and other ART facilities in tribal areas; and traininghemitizing personnel of other departments so that they can promote HIV/AIDS prevention and care. The TAP will be translated inlocal languages within six months after effectiveness. Implementation Capacity. As the NACP I11is expected to expand significantly in rural and tribal areas to scale-up HIV/AIDS prevention, treatment, and care and support activities, increasing implementation capacity i s a central feature. The TAP includes: establishment o f a Tribal Technical Resource Group at the national level, and a regional office o f NACO inthe Northeast; contracting o f NGOs and CBOs that are familiar with tribal culture and development work to implement action plans inthe districts as well as to carry out broader activities such as training at district and state levels; and increasing the capacities ofother government agencies-from state-level tribal councils to field staff - to implement and monitor HIV/AIDS activities for tribal people. Inall states the SACS will ensure that tribal people receive due attention and benefits from the program as well as other marginalized groups. The TAP also aims to sensitize health staff to cultural differences and train them to reach out and provide services to tribal people, and to involve traditional health practitioners inthe program. As the social assessment found that there are few NGOs in tribal areas, the program will build on other existing initiatives for social mobilization and community involvement, notably those o f the Health and Tribal Affairs departments, particularly the ITDAs. The ITDAs have Tribal Facilitators who carry out IEC activities. The NACP will collaborate with these departments as well as with private health service providers and institutions, and civil society organizations engaged intribal development programs. 8 Monitoring and Evaluation: Implementation of the TAP will be monitored at least annually at the district, state and national levels on the basis of reports filed by the implementingagencies. These reports will be made available to the Bank and other Development Partners during annual review missions. Budget. The Northeast Region will get 10 percent o f the total budget for program implementation, which i s "earmarked" and "non lapseable". This would cover all six 87 prevention components, treatment, care and support. Costing has been done with the special characteristics of the Northeast in mind. Inother tribal areas, the ITDAs (which are "single-window" authorities inwhich all departmentsreport to a Project Officer) have a health budget for primary health care, mobile units, referrals to city hospitals, etc. The NACP I11will make an additional grant of a minimum of Rs. five lakhs to each ITDA through the SACS to raise awareness and mainstream HIV into all programs being implemented by the ITDAs. Further funds will be provided through the micro-plans preparedby the SACS and DAPCUs, andhencecannot be computed at this time. 88 Tribal Action Plan Activities Responsibility Implementation Schedule (see Note1) Mechanism Year Year I I Year I Year Year I I I1 I11 IV v 1Q142 3 For EntireProgram Set up Tribal NACO (with X Technical Resource MOTA) Group (TRG) at NACO Hold quarterly NACO X X X meetingsof TRGs x x Prepareguidelines NACO (with X for mapping ofrisk MOTA) and vulnerability amongtribal groups Translation of NACO through Tribal Research X X X Training tools, MOTA Institutes (TRI) x x protocols, IEC/BCC and advocacy materials Monitoring of tribal NACO Consultants X X X X X interventions x x Preparationof DAPCUs, x x X X X X quarterly reports on SACS and x x activities for tribal NACO people Evaluation of tribal NACO Consultants X X X X interventions X Scaling up of SACS and Contractswith interventions among DAPCUs NGOs and CBOs HRGs (see note 2) a. Map hotspots and vulnerable groups I b. Select NGOs and CBOs for TIS c. Continue support x x to on-going projects x x Advocate, facilitate, RACUand Coordinate with x x coordinate and SACS state Tribal x x support mainstream Departments, capacity building Councils, etc. Dromxmsfor IEC 89 Activities Responsibility Implementation chedu !(seeote 1)- Mechanism Year Year Year Year Year I I1 I11 I V V Q1 2 3 4 andbehavior change, Contract with and training o f NGOs or others to departmental officers conduct training. to mainstream HIV intheir work - Increase numbers o f NACO and State Health x x X X X X ICTC and ART SACS departments x x facilities at government health centers Monitoring of NACO Consultants X X X X X activities x x Evaluation NACO Consultants X X X X X ForTribal Sub-Plan I other tates Maphotspots and SACS and TRIs and X vulnerable groups DAPCUs Consultants X Maphealthcare SACS and TRIs and X facilities and DAPCUs Consultants X providers Prepare specific SACS DAPCUs (with X X X X X tribal action plans help as needed) within district AIDS T*is control plans Increase access to DAPCUs prevention and treatment services a. Sensitizekrain x x X X X X ITDA staff and DAPCUs (with x x partner NGOs/CBOs b. Include x x X X X X HIV/AIDS DAPCUs (with x x prevention, care, ITDAs) support and treatment activities inthe health activities o f ITDA projects 90 Activities Responsibility Implementation chedi !(seeote 1) Mechanism Year Year Year Year Year I I1 I11 IV V Q1 2 3 4 c. Implement SACS and Links with other x x X X X HIVIAIDS DAPCUs (with agencies and x x awareness ITDAs) contracts with campaigns NGOs d. Expand SACS and Contracts with x x X X X prevention, DAPCUs NGOs and CBOs; x x treatment, and care links with ITDAs services through and related state hospitals, girls' departments complexes and residential schools in tribal areas e. Buildcapacities SACS and Contracts with x x X X X X o f health care DAPCUs NGOs and CBOs x x providers including traditional healers f. Support mobile SACS and Contracts with x x X X X X dispensaries DAPCUs NGOs x x g. Healthcheck-ups SACS and Contracts with x x X X X X and condom DAPCUs NGOs x x promotion at weekly markets h.Establishreferral SACS and Contracts with x x X X X X services for STI and DAPCUs local x x 0 1treatment and hospitals/NGOs ART i.Ensurecoverageof SACS DAPCUs to x x X X X contiguous tribal coordinate with x x areas each other Increase ICTC and NACO and State Health x x ART facilities at SACS departments x x government health centers inthese areas Reimbursecost of DAPCUs and State Health x x travel and expenses SAC departments x x to ICTC facility for patient and attendant and waive CD4 and ART costs for tribal people 91 Activities Responsibility Implementation Schedu :(see ote 1) Mechanism Year Year Year I11 IV V Translate IEC/BCC SACS (with TRIs and contracts X X X materials into local State Tribal withNGOs y+ x x dialects; make them Departments) culture sensitive Conduct training SACS and TRIs and contracts x x X X X programs on HIV DAPCUs withNGOs x x prevention(using trained trainers) Monitoring o f SACS Consultants X X activities Evaluation SACS Consultants X X 'onulations Promotion o f SACS and Contracts with HIV/AIDs DAPCUs NGOs awareness and condom use Increase referrals to SACS and Contracts with x x ICTCs, and STI/OI DAPCUs NGOs treatment and ART for tribal migrant workers, slum dwellers, etc. Baseline valuesand numerical targetsfor the above activities will befinalized along with thosefor theprogram at large by the end of thefirst quarter ofproject implementation (expectedJune 2007) and included in the overall M&E Planfor NACP II. Notes: (1) In Years I1to V, activities will be carried out continuously and reported and monitored every quarter. (2) Interventions to: (a) increase access to (i) (ii) BCC condom promotion services, (iii)STI services (iv) referrals to ICTCs, (v) referrals to care, support and treatment facilities, (vi) mobile dispensaries and (vii) health check-ups and condom promotion through weekly markets; and (b) build the capacities o f private practitioners (including traditional healers) in tribal areas to manage STIs, OIs, condom promotion, and referrals to ICTCs. The number and quality of these interventions would be reported and monitored separately. 92 Annex 12: ProjectPreparationand Supervision Third NationalHIV/AIDS ControlProject Planned Actual Project ConceptNote review 06/28/2005 06/16/2005 InitialPID to PIC 07/15/2005 06/29/2005 Initial ISDS to PIC 07/15/2005 06/29/2005 Appraisal 08/30/2006 07/2812006 Negotiations 02/26/2007 02/26/2007 BoardIRVP approval 04/26/2007 04/26/2007 Planneddate of effectiveness 08/15/2007 Planneddate of mid-termreview 10/15/2009 Plannedclosing date 09/30/2012 Key institutions responsible for preparationofthe project: NACO Bank staff and consultants who worked on the project include: Name Title Unit Kees Kostermans LeadPublic Health Specialist/Task Team Leader SASHD Suneeta Singh Senior Public Health Specialist/Task Team Leader SASHD Mariam Claeson Program Coordinator (HIV/AIDS) SASHD Michele Gragnolati Senior Economist SASHD SnehashishRai Chowdhury Operations Officer SASHD Aakanksha Pande Junior ProfessionalAssociate SASHD Julie-Anne Graitge ProgramAssistant SASHD Roselind Hari Team Assistant SASHD ShivendraKumar Consultant (Procurement) SASHD Shanker La1 Procurement Specialist SAWS MamChand Senior Procurement Specialist SARPS Om Prakash Consultant (Procurement) SARPS Meera Chatterjee Senior Social Development Specialist SASES Ruma Tavorath Environmental Specialist SASES MohanGopalakrishnan Senior Financial Management Specialist SARFM Thao L e Nguyen Senior Finance Officer LOAG2 Shellka Arora LegalAssociate SARIM Syed A b e d Lead Counsel, Operations LEGMS Mario Bravo Senior Communications Officer EXTCD DavidWilson Senior Monitoring & Evaluation Specialist HDNGA 93 Bankfunds expendedto date onproject preparation: 1. Bankresources: $564,393.89 2. Trust funds: $ 10,490.70 3. Total: $574,884.59 Estimated Approval and Supervision costs: 1. Remaining costs to approval: $ 35,000 2. Estimated annual supervision cost: $250,000 94 Annex 13: Classification of States and Districts Third NationalHIV/AIDS Control Project The Classification of States States have been classified for attention and service delivery packages based upon an understanding o f several evidence points: states with HIV prevalence o f more than one per cent HIV among antenatal mothers presenting to general clinics (as a proxy for HIV prevalence among the general population) have been classified as having "high prevalence"; states with more than five per cent HIV positive among high risk communities as having "moderate prevalence"; and the remainder as having "low prevalence". However, on the basis o f vulnerability factors such as migration, size o fthe population, and status o f health infrastructure, "low prevalence" states/UTs are further classified as "highly vulnerable" and "vulnerable" states/UTs. High Prevalence Tamil Nadu Gujarat Assam Arunachal Pradesh Andhra Pradesh Goa Bihar Haryana Maharashtra Pondicherry Delhi J & K Karnataka Himachal Pradesh Meghalaya Nagaland Kerala Mizoram Manipur Madhya Pradesh Sikkim Punjab Tripura Rajasthan A & NIslands Uttar Pradesh Chandigarh West Bengal D&NHaveli Chhattisgarh Daman & Diu Jharkhand Lakshadweep Orissa Uttaranchal District as the Unit of Service Delivery In NACP I11 the basic unit o f implementation is district. The following criteria have been used for categorizing districts: time inany ofthe sites inthe last 3 years 2 Less than 1%ANC/PPTCT prevalence inall the sites B 59 duringlast three years Associated with More than 5% prevalence inany HRGgroup (STD/CSW/MSM/IDU) 95 3 Less than 1%inANC prevalence inall sites during the last C 278 three years with less than 5% inall STD clinic attendees or any HRG WITH KNOWNHOT SPOTS (migrants, truckers, large aggregationof factory workers, tourists, etc.) 4 Less than 1%inANC prevalenceinall sites during the last D 111 three years with less than 5% inall STD clinic attendees or any HRG OR No or Poor HIV Data With No KnownHot SpotsLJnknown Total Districts 611 It is postulatedthat demands for HIV-relatedservices are likely to be more inthe "Category A" district as against Category ByC or D.It is also reasonableto assume a graded demandfrom A to Dtypes. 96 Statewise Distributionof Districtsby Category I 20 I MadhyaPradesh 11 1Total 141 I 46 I 309 I 114 1 610 97 Annex 14: Documentsinthe ProjectFile ThirdNationalHIV/AIDSControlProject Project BackgroundDocuments R World Bank, 2006, AIDS in South Asia, Understanding and Responding to a Heterogeneous Epidemic, World Bank, Washington DC RR World Bank, 2004, Country Strategy for India, World Bank, Washington DC World Bank, 2004, Attaining the MillenniumDevelopment Goals in India: How likely and what will it take?, World Bank, Washington DC 8 World Bank, 2001, Raising the Sights: Better Health Systems for India's Poor, World Bank, WashingtonDC Government Documents R NACO, 2005, National AIDS Control Program Phase 111, 2006-2011, Strategic Framework, National AIDS Control Organization, Ministryof Health and Family Welfare, India R NACO, 2006, National AIDS Control Program Phase 111, 2006-2011, Strategy and Implementation Plan, National AIDS Control Organization, Ministry of Health and Family Welfare, India 8 Ministry of Health and Family Welfare, National Program Implementation Plan for the Reproductive and Child healthProject 11, Ministry of Health and Family Welfare, India Pro-iect PreparationDocuments NACO, Revised Strategic Framework NACP Phase 111, October 14,2005 NACO, Reportsof Fourteen Working Groups for Design ofNACP Phase 111, October 14,2005 DraftNote for Monitoring andEvaluation Arrangements for NACP Phase 111, October 14,2005 SocialAssessment of HIV/AIDSAmong Tribal People inIndia, July 2006 Draft Institutional Arrangements for Implementingthe NACP Phase 111, October 14,2005 Draft Financial Management for NACP Phase 111, October 14,2005 NACP I11Programme Implementation Plan, A Draft Note on Human Resource Requirements(A Tentative Estimate), October 14,2005 Enhancing the Role of Civil Society in the NACP Phase 111, National Consultation by Civil Society held inDelhi 14-15 October, 2005 Report from The National Consultation the "Three Ones in India" (presentation) by NACO and UNAIDS, October 10and 11,2005 Report on Stakeholder's Consultation on Environmental Assessment (Infection Control and Waste ManagementPlan) for NACP Phase 111, May 8,2006 by PRIA Report on Procurement Capacity Assessment of NACO & Other Implementing Agencies under NACP Phase I11-Volume I& I1Executive Summarywith recommendations, May 7,2006 98 Annex 15: Statementof Loansand Credits Third NationalHIV/AIDSControlProject Differencebetween expected and actual OriginalAmount in US$ Millions disbursements Project FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd ID PO73651 2005 Disease Surveillance 0.00 68.00 0.00 0.00 0.00 65.67 -1.28 0.00 PO73370 2005 MadhyaPradeshWater Sector 394.02 0.00 0.00 0.00 0.00 371.82 -10.53 0.00 Restructuring PO75058 2005 TN HealthSystems 0.00 110.83 0.00 0.00 20.06 81.99 -7.50 0.00 PO77856 2005 Lucknow-MuzaffarpurNational Highway 620.00 0.00 0.00 0.00 0.00 620.00 0.00 0.00 PO77977 2005 RuralRoads 99.50 300.00 0.00 0.00 0.00 376.96 7.84 0.00 PO94513 2005 IndiaTsunami ERC 0.00 465.00 0.00 0.00 0.00 452.69 0.00 0.00 PO86518 2005 MSMEFinancing&Development 120.00 0.00 0.00 0.00 0.00 79.40 -7.27 0.00 PO84792 2005 Assam Agric Competitiveness 0.00 154.00 0.00 0.00 0.00 148.98 -10.50 0.00 PO84790 2005 W A RWSIP 325.00 0.00 0.00 0.00 0.00 325.00 0.00 0.00 PO84632 2005 Hydrology I1 104.98 0.00 0.00 0.00 0.00 104.98 4.23 0.00 PO78550 2004 Uttar Watershed 0.00 69.62 0.00 0.00 0.00 66.54 -3.35 0.00 PO82510 2004 KarnatakaUWS Improvement 39.50 0.00 0.00 0.00 0.00 39.50 14.70 0.00 PO50655 2004 RajasthanHealthSystems Development 0.00 89.00 0.00 0.00 0.00 87.59 17.00 0.00 PO79865 2004 GEF Biosafety 0.00 0.00 0.00 1.00 0.00 0.90 0.12 0.00 PO55459 2004 ElementaryEducation(SSA) 0.00 500.00 0.00 0.00 0.00 372.73 14.04 0.00 PO73776 2004 Allahabad Bypass 240.00 0.00 0.00 0.00 0.00 199.68 46.08 0.00 PO73369 2004 MaharRWSS 0.00 181.00 0.00 0.00 0.00 186.25 9.51 0.00 PO73094 2003 AP Comm ForestMgmt 0.00 108.00 0.00 0.00 0.00 78.76 -5.87 0.00 PO72123 2003 TechnicianEngineeringQuality 0.00 250.00 0.00 0.00 40.11 225.98 57.96 0.00 Improvement PO71272 2003 AF' RuralPoverty Reduction 0.00 150.03 0.00 0.00 0.00 87.37 74.46 0.00 PO67606 2003 UP Roads 488.00 0.00 0.00 0.00 0.00 409.29 109.50 0.00 PO76467 2003 Chatt DRPP 0.00 112.56 0.00 0.00 20.06 94.46 6.38 0.00 PO75056 2003 Food & Drugs Capacity Building 0.00 54.03 0.00 0.00 0.00 55.10 18.49 0.00 PO50649 2003 TN Roads 348.00 0.00 0.00 0.00 0.00 308.71 34.47 0.00 PO50647 2002 UP WSRP 0.00 149.20 0.00 0.00 0.00 149.05 111.71 0.00 PO72539 2002 KeralaState Transport 255.00 0.00 0.00 0.00 0.00 176.21 12.55 0.00 PO74018 2002 Gujarat EmergencyEarthquake 0.00 442.80 0.00 0.00 80.23 200.80 315.28 -21.93 Reconstruct PO50668 2002 Mumbai Urban Transport 463.00 79.00 0.00 0.00 0.00 451.68 119.93 0.00 PO71033 2002 KarnatakaTank Mgmt 0.00 98.90 0.00 0.00 0.00 98.56 31.79 0.00 PO69889 2002 Mizoram Roads 0.00 60.00 0.00 0.00 0.00 44.74 5.63 0.00 PO40610 2002 RajasthanWSRP 0.00 140.00 0.00 0.00 15.04 111.15 70.00 0.00 PO50653 2002 KarnatakaRWSS I1 0.00 151.60 0.00 0.00 15.04 130.08 56.30 0.00 PO71244 2001 GrandTrunk RoadImprovementProject 589.00 0.00 0.00 0.00 0.00 329.42 251.09 0.00 PO70421 2001 KarnatakaHighways 360.00 0.00 0.00 0.00 0.00 190.85 86.85 0.00 PO67216 2001 KarnatakaWatershedManagement 0.00 100.40 0.00 0.00 20.06 74.34 74.16 0.00 PO35173 2001 Power Grid I1 450.00 0.00 0.00 0.00 0.00 122.61 93.61 18.63 PO10566 2001 Gujarat Highways 381.00 0.00 0.00 0.00 31.00 167.71 167.38 108.02 PO50658 2001 Technician EducationI1 0.00 64.90 0.00 0.00 0.00 25.30 10.33 -6.26 PO55454 2001 KeralaRWSS 0.00 65.50 0.00 0.00 10.00 34.33 19.44 0.85 Differencebetween expected and actual OriginalAmount in US$ Millions disbursements Project FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm.Rev'd ID PO55455 2001 Rajasthan DPEPI1 0.00 74.40 0.00 0.00 0.00 41.54 13.19 0.00 PO59242 2001 MP DPIP 0.00 110.10 0.00 0.00 20.06 50.42 38.23 12.51 PO38334 2001 RajasthanPowerI 180.00 0.00 0.00 0.00 2.02 63.30 64.99 -2.72 PO55456 2000 TelecommunicationsSector ReformTA 62.00 0.00 0.00 0.00 20.00 11.47 31.47 5.02 PO59501 2000 TA for EconReform 0.00 45.00 0.00 0.00 12.03 22.95 4.38 10.20 PO10505 2000 RajasthanDPIP 0.00 100.48 0.00 0.00 0.00 53.17 41.55 16.26 PO50667 2000 UP DPEPI11 0.00 182.40 0.00 0.00 0.00 32.89 32.43 21.88 PO50657 2000 UPHealth Systems Development 0.00 110.00 0.00 0.00 30.09 50.79 57.64 0.00 PO09972 2000 National Highways Ill 516.00 0.00 0.00 0.00 0.00 224.20 215.69 -25.80 PO67330 2000 Immunization Strengthening 0.00 142.60 0.00 0.00 0.00 1.29 -87.22 0.00 PO49770 2000 RenewalEnergyI1 80.00 50.00 0.00 0.00 18.00 60.47 60.79 39.11 PO45049 2000 AP DPIP 0.00 111.00 0.00 0.00 0.00 31.76 7.90 0.00 PO45050 1999 RajasthanDPEP 0.00 85.70 0.00 0.00 0.00 20.64 17.83 17.83 PO41264 1999 WatershedMgmt Hills I1 85.00 50.00 0.00 0.00 0.00 4.12 6.65 0.00 PO50651 1999 Maharashtra HEALTH SYS 0.00 134.00 0.00 0.00 35.01 17.50 47.3 1 8.56 PO50646 1999 UP Sodic Lands I1 0.00 194.10 0.00 0.00 0.00 47.85 39.91 0.14 PO45051 1999 2"* NationalHIV/AIDS Control 0.00 191.00 0.00 0.00 0.00 27.77 24.78 -5.36 PO35827 1998 Women andChild Development 0.00 300.00 0.00 0.00 25.07 64.98 78.43 23.88 PO49385 1998 AP EconomicRestructuring 301.30 241.90 0.00 0.00 0.00 76.08 72.63 38.27 PO10561 1998 NationalAgriculture Technology 96.80 100.00 0.00 0.00 18.00 4.78 27.80 -10.28 PO38021 1998 DPEPIll(Bihar and Jharkhand) 0.00 152.00 0.00 0.00 30.09 22.84 43.49 21.85 PO10496 1998 OrissaHealth Systems 0.00 76.40 0.00 0.00 0.00 20.71 14.95 9.94 PO44449 1997 Rural Women's Development 0.00 19.50 0.00 0.00 6.72 3.59 11.07 3.71 PO10511 1997 MalariaControl 0.00 164.80 0.00 0.00 46.50 25.94 71.82 25.43 PO10473 1997 Tuberculosis Control 0.00 142.40 0.00 0.00 13.04 35.90 53.02 39.63 Total: 6,598.10 6,742.15 0.00 1.oo 528.23 8,164.13 2,785.26 349.37 INDIA STATEMENT OF IFC's Heldand DisbursedPortfolio InMillions ofUSDollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 2005 ADPCL 42.08 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2005 AP Paper Mills 35.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2005 APIDC Biotech 0.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 2002/03 ATL 1.33 0.00 0.00 0.00 1.oo 0.00 0.00 0.00 2003 BHF 10.98 0.00 10.98 0.00 10.98 0.00 10.98 0.00 2001/04 BILT 0.00 0.00 15.00 0.00 0.00 0.00 15.00 0.00 2001 BTVL 48.03 5.00 0.00 0.00 44.60 5.00 0.00 0.00 100 ~ ~~~~ Committed Disbursed IFC IFC FYApproval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 2003 Balrampur 16.01 0.00 0.00 0.00 16.01 0.00 0.00 0.00 2001 BasixLtd. 0.00 0.98 0.00 0.00 0.00 0.98 0.00 0.00 1984 Bihar Sponge 7.26 0.00 0.00 0.00 7.26 0.00 0.00 0.00 2001103 CCIL 1.55 0.00 0.00 0.00 0.64 0.00 0.00 0.00 1990192 CESC 13.09 0.00 0.00 29.18 13.09 0.00 0.00 29.18 2004 CGL 15.00 0.00 0.00 0.00 8.00 0.00 0.00 0.00 2004 CMScornputers 10.00 10.00 2.50 0.00 10.00 0.00 0.00 0.00 2002/05 COSMO 0.00 4.20 0.00 0.00 0.00 4.20 0.00 0.00 2004 CairnEnergy 40.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1995105 Centurion Bank 0.00 0.07 0.00 0.00 0.00 0.07 0.00 0.00 2005 DCM Shriram 30.00 0.00 0.00 0.00 15.00 0.00 0.00 0.00 2003 DQEL 0.00 1.50 1.50 0.00 0.00 1.50 1.50 0.00 2003 Dewan 12.95 0.00 0.00 0.00 12.95 0.00 0.00 0.00 EXB-STG 0.31 0.00 0.00 0.00 0.31 0.00 0.00 0.00 2001 GTF Fact 0.00 1.20 0.00 0.00 0.00 1.20 0.00 0.00 1994 GVK 0.00 7.45 0.00 0.00 0.00 7.45 0.00 0.00 1998 GlobalTrust 0.00 0.00 3.00 0.00 0.00 0.00 3.00 0.00 1994 Gujarat Ambuja 0.00 0.61 0.00 0.00 0.00 0.61 0.00 0.00 2003 HDFC 100.00 0.00 0.00 100.00 100.00 0.00 0.00 100.00 1998 IAAF 0.00 1.13 0.00 0.00 0.00 0.96 0.00 0.00 1995/00 ICICI-SPIC Fine 0.00 2.23 0.00 0.00 0.00 2.23 0.00 0.00 1998 IDFC 0.00 15.46 0.00 0.00 0.00 15.46 0.00 0.00 2001 IIEL 0.00 3.20 0.00 0.00 0.00 2.06 0.00 0.00 1990193198 IL& FS 0.00 0.84 0.00 0.00 0.00 0.84 0.00 0.00 1992195 IL&FS VC 0.00 0.18 0.00 0.00 0.00 0.18 0.00 0.00 1996 IndiaDirect Fnd 0.00 1.10 0.00 0.00 0.00 0.63 0.00 0.00 2001 Indian Seamless 6.00 0.00 0.00 0.00 6.00 0.00 0.00 0.00 1993 Indo Rama 5.24 0.00 0.00 0.00 5.24 0.00 0.00 0.00 1996 Indus I1 0.00 0.86 0.00 0.00 0.00 0.86 0.00 0.00 1992 Indus VC Mgt Co 0.00 0.01 0.00 0.00 0.00 0.01 0.00 0.00 1992 Info Tech Fund 0.00 0.39 0.00 0.00 0.00 0.39 0.00 0.00 2005 K MahindraINDIA 22.00 0.00 0.00 0.00 22.00 0.00 0.00 0.00 2003 L&T 50.00 0.00 0.00 0.00 50.00 0.00 0.00 0.00 1990193 M&M 0.00 0.01 0.00 0.00 0.00 0.01 0.00 0.00 2002 MMFSL 10.09 0.00 8.01 0.00 10.09 0.00 8.01 0.00 2003 MSSL 0.00 2.29 0.00 0.00 0.00 2.20 0.00 0.00 2001 MahInfra 0.00 10.00 0.00 0.00 0.00 0.70 0.00 0.00 1996199100 Moser Baer 19.38 9.68 0.00 0.00 19.38 9.68 0.00 0.00 1997 NICCO-UCO 1.88 0.00 0.00 0.00 1.88 0.00 0.00 0.00 2001 NIIT-SLP 8.69 0.00 0.00 0.00 0.05 0.00 0.00 0.00 2003/04 NewPath 0.00 3.00 0.00 0.00 0.00 2.33 0.00 0.00 2003 Niko Resources 37.78 0.00 0.00 0.00 37.78 0.00 0.00 0.00 2001 Orchid 0.00 3.03 0.00 0.00 0.00 3.03 0.00 0.00 1997 Owens Coming 8.59 0.00 0.00 0.00 8.59 0.00 0.00 0.00 2004 Powerlinks 77.76 0.00 0.00 0.00 32.14 0.00 0.00 0.00 Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1995 Prism Cement 10.90 1.96 0.00 5.45 10.90 1.96 0.00 5.45 2004 RAK India 20.00 0.00 0.00 0.00 15.00 0.00 0.00 0.00 1995/04 RainCalcining 10.00 0.00 0.00 0.00 10.00 0.00 0.00 0.00 2001 SBI 50.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1997/00 SREI 8.00 0.00 0.00 0.00 8.00 0.00 0.00 0.00 1995 Sara Fund 0.00 4.16 0.00 0.00 0.00 4.16 0.00 0.00 2004 SeaLion 5.15 0.00 0.00 0.00 5.15 0.00 0.00 0.00 2001/03 Spryance 0.00 1.oo 0.00 0.00 0.00 1.oo 0.00 0.00 2004 SundaramFinance 45.74 0.00 0.00 0.00 45.74 0.00 0.00 0.00 2000/02 SundaramHome 9.53 0.00 0.00 0.00 9.53 0.00 0.00 0.00 1998 TCW/ICICI 0.00 1.12 0.00 0.00 0.00 1.12 0.00 0.00 2002 TML 50.00 0.00 0.00 0.00 50.00 0.00 0.00 0.00 2004 UPL 17.50 0.00 0.00 0.00 17.50 0.00 0.00 0.00 1996 UnitedRiceland 7.50 0.00 0.00 0.00 7.50 0.00 0.00 0.00 2002 UshaMartin 21.00 3.34 0.00 0.00 21.00 3.34 0.00 0.00 2001/05 Vysya Bank 0.00 3.51 0.00 0.00 0.00 3.51 0.00 0.00 1997 WIV 0.00 0.57 0.00 0.00 0.00 0.57 0.00 0.00 1997 Walden-Mgt India 0.00 0.01 0.00 0.00 0.00 0.01 0.00 0.00 Total portfolio: 886.32 104.09 40.99 134.63 633.31 78.25 38.49 134.63 Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic. 2005 AP Paper Mills 0.00 0.01 0.00 0.00 2000 APCL 0.01 0.00 0.00 0.00 2005 Allain Duhangan 0.00 0.01 0.00 0.00 2005 BharatBiotech 0.00 0.00 0.00 0.00 2004 CGL 0.01 0.00 0.00 0.00 2004 CIFCO 0.00 0.00 0.02 0.00 2001 GI Wind Farms 0.01 0.00 0.00 0.00 2004 OceanSparkle 0.00 0.00 0.00 0.00 2005 SRF Ltd. 0.02 0.00 0.00 0.00 2005 URLExpansion 0.01 0.00 0.00 0.00 2001 Vysya Bank 0.00 0.00 0.00 0.00 Total pendingcommitment: 0.06 0.02 0.02 0.00 102 Annex 16: Summary of ResearchStudies for NACPI11 Third NationalHIV/AIDS ControlProject HIV/AIDS and MenWho Have Sex with MenInIndia:A DeskReview Description: This report presents a desk review of Men who have sex with Men (MSM) literature and interventions from India to provide recommendations for NACP I11 planning process. The objectives o f the study are to familiarize policymakers and program implementers with issues related to MSMbehaviors and persons; review reports and recommendations of the working groups set up by NACP 111, particularly those on targetedinterventions, communication and advocacy, greater involvement ofpeople living with HIV/AIDS, humanrights, andlegal and ethical issues; review literature/reports on the recent developments, initiatives, and interventions related to MSM; examine the social and sexual profiles o f men who engage in same-sex activities, and the nature o f their sexual behaviors and sexual networks. Groups at Risk: Men who have sex with men include groups identified as kothis, hijras, panthis/girias/parikhs, and masseuses. Other groups that occasionally engage in MSM behavior include truckers (2 to 40 per cent), street children, and prison populations. The size o f the MSM population for the whole country i s estimated to be 2,352,133 and M S M sex workers are estimated to be 235,213. The size o f high risk MSM populations (those with 5 or more than 5 partners) i s two times bigger than the size o f the female sex worker population. Community- based studies show that men who have sex with men are more likely to have different partners and are likely to have more female partners than heterosexual men. Key Results: The main results from this desk review are that (i)the extent o f MSM behavior appears to vary widely by region, although accurate prevalence estimates are not available; (ii) sexual networking and behaviors o f MSMplace them and their partners at highrisk o f HIVETI infection; (iii) condom use and inappropriate use o f lubricants exacerbates HIV/STIrisk due low to perceptions that the infection i s transmitted only through heterosexual intercourse, particularly with sex workers; (iv) poor social acceptance of sexual diversities results in high levels of stigma, discrimination, and violence against MSM; (vi) criminalization o f homosexuality further marginalizes MSM. ProgramRecommendations (i)Increasethenumber oftargeted interventions for themostvisible MSMpopulations such as kothis and hijras as a potential means to reach `invisible' M S M clients and female sex workers. Separate interventions for Hijras should be instituted given their unique identity; (ii)IdentifyandinstituteprogramsforMSMgroupsthatarehiddenandunorganizedsuch as male sex workers, masseurs, and hotel boys; (iii)Address bisexual men in the general population by identifying places or contexts that promote and sustain homosexual activities such as male student hostels, beaches, lodges, prisons and public toilets; 103 (iv) Mainstream M S M intervention programs to reach married men and youth from the general population. Anal sex issues should be an integral component o f sexual health promotion strategies and education materials; (v) Create a network o f NGOs/CBOs working on M S M issues that will ensure the protection o f human rights, reduce stigma and violence, enhance visibility and help buildcommunity organization, provide platforms for organized care and support service delivery, and act as channels for capacity buildingand monitoring o f activities. (vi) Develop innovative BCC programs and specific IEC materials for MSM programs to provide sensitive non-judgmental messages on the risk o f multi-partner sex and the benefits o f reducingthe number o fpartners among MSMs; (vii) Reduce stigma and eliminate violence against MSMs through media sensitization on responsible reporting o f MSM issues, promoting interactions between MSM groups and other community members, organizing public speakers forums for MSMs, and organizing film festivals, exhibitions o f paintings on HIV themes, and recitation o f poems. (viii) Initiate strong advocacy programs for legal reforms on MSMissues. There is an urgent needto undertake legal reforms that repeal Section 377 o fthe IndianPenal Codes which criminalizes M S M sexual activity. PreventionRecommendations (i)Appropriatecondomsforanalsexandsachetsofwater-basedlubricantsshouldbemade widely available at public and private locations by community-based agencies. (ii)Healthcareprovidersshouldbetrainedandsensitizedtodiagnoseandmanageanaland oral STIs. Improving access to STI services for MSM should be an integral part o f this program. (iii)Medicalcurriculuminthecountryshouldbereviewedandupdatedtoincludetraining on diagnosis and treatment o f anal and oral STIs. (iv) VCT services should be made MSM-friendly so that MSMs are encouraged to access these services to learntheir status and access care and treatment services ifneeded. (v) Existing drop-in centers for NGOs can actively provide counseling services for MSMs. Care and SupportRecommendations (vi) Current care and support efforts o f M S M groups, PLHIV networks, and NGOs/CBOs working with M S M population to utilize drop-in centers and forge linkages with mainstream service delivery systems should be carefully monitored. (vii) MSM PLHIV groups should be initiated and efforts should be made to link them with PLHIV networks inthe country. (viii)Current care and support interventions should provide counseling support to MSM PLHIVs to address the stigma faced by them in society. Efforts can be made to involve families o f MSMPLHIVs incare giving ifapproved by the individual. (ix) Health care providers should be sensitized to the needs and rights o f MSM PLHIVs. This is essential to ensure that MSM PLHIVs have access to ARTSand adhere to treatment. 104 Assessment of Extent of HIV/AIDS Prevalence Among Central Police Force and Paramilitary Forces Description:The study examines the extent o f HIV/AIDSamongparamilitary forces inIndia. It consists o f a K A P survey and focus group discussions with paramilitary personnel, in depth interviews with medical officers, and case studies with HIV infected patients inthe paramilitary forces. Groups at Risk: Groups at risk include paramilitary forces and their families. This includes members of the Assam Rifles, Border Security Force, Central Industrial Security Force, Central Reserve Police Force, Indo-Tibetan Border Police, and Rashtriya Rifles. Key Results: (i) Estimated crude prevalence rate among the different battalions ranges from 1.35 to 3.57; however, there were several limitations regarding the calculation o f this estimate; (ii) There are no separate STD/HIV/AIDS clinics in any o f the sector/ zonal/base hospitals o f the paramilitary forces, and most hospitals do not have standard test kits or systematic blood testing for HIV; (iii) Behavior patterns and data from focus groups reveals a propensity for risky behavior; (iv) Awareness levels varies with CRP personnel being generally less aware and BSF personnel being generally more aware; (v) Awareness regarding the sexual spread o f the infection i s generally low among all forces as compared to awareness o f spread through infected needles, breastfeeding, blood transfusions; (vi) There i s a lack o f awareness o f condoms as a preventive intervention and it is generally used for family planning purposes. In addition, the strong focus on the `sanctity o f the family' makes it difficult to aggressively market condoms. Condoms are more regularly used for cohabitation with spouses as compared to during extra marital interactions with potentially HRG; (vii) Audio-visual media i s considered a more important source o f information on HIV/AIDS than print media; (viii) Most paramilitary personnel disapprove or discriminate against HIV infected patients. There i s an almost complete isolation o f HIV affected patients and their families; (ix) ART pharmaceuticals are in short supply and there is no reimbursement on drug expenditure. Most patients rely on homeopathic or ayurvedic treatment. Recommendations (i)Assessment of prevalence should be undertaken on a regular basis using NACO approved methodology. Record keepingand reporting should be standardized. (ii)A working group shouldbe set up inMHA to coordinate efforts anddisseminate guidelines on interventions for the paramilitary forces. (iii)Senior staff (especially battalion commanders) should be sensitized to HIV. There should be a focus on safe sex practices including use o f condoms. Existingchannels of communication can be augmented through the dissemination of informational pamphlets. (iv) ARTSshould be available for forces through local SACS. Condoms should be made available at easily accessible places where anonymous transactions are possible (telephone booths, entry o f battalion, toilets). They can also be part o f weekly or monthly rations. VCT facilities should be available at all centre hospitals. 105 (v) Care and treatment o f affected populations should be addressed through tie ups with local NGOs that provide such services, use o f referral hospitals, and transfer to centre/ sector headquarters for appropriate follow up. (vi) Medical officers and paramedical staff should be trained in STI/HIV/AIDS treatment. Barbers should be giventraining insafe practices regardingblades andrazors. Assessment of the Vulnerability of RuralPopulationsto HIV/AIDS Description:This study assesses the vulnerability ofrural populationsto HIV/AIDS. Groups at Risk: According to 2003 estimates, rural India accounted for 59 per cent of HIV infections in India affecting 29.80 lakh people o f which 10.95 lakh were women. Women and youth are especially at risk inrural areas due to a low level o f knowledge about HIVIAIDS. Key Results: (i) Correct and complete knowledge on transmission and prevention i s still low, particularly in Haryana and Eastern U.P. Youth, men and educated people are better informed. Radio and television, posters, banners, skits, and interactions with health personnel are the sources o f knowledge. (ii) behaviors inrural areas are varied and range from pre-marital Sexual to extra-marital, oral to anal to vaginal, homosexual to heterosexual, and consensual to forced sex. Instances o f multiple sexual relations among rural communities are often found which are mostly unprotected encounters since people know each other and have mutual trust. Poor women and girls are highly vulnerable and sexual exploitation by land owners and construction contractors i s rampant; (iii)Since HIV i s often regarded as the `Disease o f others' perception o f risk is low. STI is often seen as a sign o f virility, hence men are reluctant to get treated; (iv) Condoms are primarily used as family planning interventions. However, condom use i s comparatively higher among highrisk populations than the general population. Use o f condoms i s less among the uneducated, poor and MSM groups. Quality, non availability, and rupture of condoms, and religious beliefs are cited as the reasons for not using condoms; (v) AIDS has had a multi-dimensional social, psychological and economic impact o f HIV/AIDS on rural populations. Access to public health services inrural areas i s limited and people depend largely on unqualified doctors and quacks. Recommendations a) A "key influencer" or a person who wields influence on the village community such as a teacher, a panchayat member, or SHG representative should be identified. The training for key influencers may be organized by the district administration in consultation with the District AIDS Officer and would include explaining the benefits of spreading awareness about HIV/AIDS in villages, ways o f communication with people including unmarried adolescents about the modes o f transmission o f HIV/AIDS, ways to avoid myths and misconceptions regarding HIV,associated health problems o f HIV infection, ways to eliminate stigma and discrimination, means to support infected individuals, ways to prevent HIV, and promotion o f abstinence from pre/extra marital sex and safe sex practices. 106 The key influencer should identify and train 4-6 people to form a HIV support group which would spread awareness about modes o f transmission, prevention, and sexual risk (HIV/STI) reductionto the village population. The AIDS control society should plan and conduct a study to understand local sexual networks. These networks should be targeted for AIDS interventions. Messages on HIV designed by the AIDS control society or local level organizations need to be culture-specific and should target a wide range o f the population. Messages should be delivered initially to the women groups or other welfare groups present at the village level followed by other populations. Use o f fear based communication messages such as "AIDS ekjaadeva bimari hai should be shunned to eliminate stigma and discrimination " inrural areas. Use o fstandardized folk mediawould be ideal to give informationon HIV to rural illiterate population. Increasing rates o f trafficking and exploitation o f girls invarious sectors are o f immediate concerns in rural areas. Prevention o f trafficking must be given a priority in HIV prevention programs. There must to be synergy with state and central government run social welfare programs such as poverty alleviation, universal education, and gender equity to protect women against trafficking and exploitation. Increase the training o f local doctors on Reproductive Tract Infection (RTI)/STI. Knowledge o f the doctors on the treatment o f sexually transmitted diseases i s limited. Since, health care providers at the local level are seen as important sources o f information by the residents o f village, in each district efforts should be made to train the private health care providers on syndromic management o f STDs. Adequate and regular supply o f pharmaceuticals for STD treatment should be made available in sub-centers/PHCs/CHCs. If feasible, a mechanism may be developed by district health authority to keep essential pharmaceuticals for STDs with the local private health care providers as i s done incase o ftuberculosis management. Currently available testing centers for STDs and HIV/AIDS are not adequate. The state health departments along with the state AIDS control societies should increase the number of testing centers and VCTs so that people who need services can get easy access. Partner notification and treatment for STDs should be encouraged. Necessary steps may be taken to strengthen couple counseling and testing o f positive clients. Dual protection o f condoms should be advertised. Easy access to quality condoms and instruction for usage and disposal should be made available. Condoms should be promoted through HIV support groups, SHGs, PRIs and other non-conventional access channels. Family members o f the infected individuals and the society at large should be educated about HIV to reduce stigma and discrimination; however, special efforts should be made by the state AIDS cell through the district authority to provide care and support to the infected individuals. Treatment o f OIs, counseling services, and ARTS should be available to all patients. Rapid Survey of Health Workers Awareness and Attitudes to People Seeing HIV/AIDS Testing, Care and Support Description: The study aims to understandthe attitudes of medical and paramedical personnel towards persons seeking HIV/AIDS related services and towards HRG. It consists o f a literature 107 review on available information on this topic, and a survey in six states (1 high prevalence, 2 moderate prevalence, 2 highly vulnerable, 2 vulnerable) and intwo districts with in each state (1 high prevalence, 1 low prevalence). 932 staff members were respondents for this study. Semi structured interviews, key informant interviews, focus group discussions and a survey was administered to subsets o f the respondents. Groups at Risk: Study deals with medical and paramedical personnel who deal with groups determined highrisk according to state specific context. Key Results: (i) Awareness: Awareness with regards to signs and symptoms o f HIV i s inadequate in vulnerable states. There is especially inadequate knowledge on mother to child transmission o f HIV through breast feeding. Health workers are unaware o f the existence o f voluntary counseling and blood testing facilities; (ii) Capability of Health Workers: Grass root health workers usually have only twelve years o f general education or BA level of education which may make them unable to perform complex health functions; (iii) Communication: Mass media i s generally the most important source o f information regarding HIV/AIDS for general population as also the health workers; (iv) Supplies of Materials: Audio-visual materials do not appear to be in adequate supply. Condom supply was generally satisfactory with more availability in high and moderate prevalence states. However there does not appear to be a continuous and uninterrupted availability o f condoms. (v) Institutional and Organisational Systems and Networking: There is no clarity or guidelines interms o f roles and responsibility of different health functionaries whether in urban hospitals, PHCs or sub-centres, in respect of AIDS Control Programme. Communication with the clinical and field staff especially in rural areas i s ad hoc and unstructured and mostly through random personal interactions with the dedicated AIDS Control Programme staff. The institutional arrangements and networking for delivery o f services for the AIDS Control Programme i s yet to be put in place except in high populationcapital cities such as Ahmedabad and Bangalore. Recommendations (i)Role and Responsibility of Health Workers: The role of health workers in rural areas with respect to HIV/AIDS should be formalized and limited to advise persons whom they suspect to be HIV+ to report to the district or the nearest VCTC for counselling; to keep and distribute IEC material in areas having inadequate mass media presence; to send details of such persons periodically to the VCTC so that the referred persons who do not approach the VCTC can be contacted individually and counselled/tested if willing. The role of Medical officers in PHCs/CHCs/Sub Divisional Hospitals/District Hospital could be the same as indicated above i.e. referring and reporting people to the nearest VCTCNCTC havingjurisdiction. (ii)OrientationandTrainingof HealthWorkers:Toenableextensionstafftoperformtheir new role effectively, they should be educated/exposed/trained clinical and physical symptoms o f HIV/AIDS/STI and opportunistic infections. Pamphlet and guidelines on safety precautions including disposal of waste should be circulated and workshops should be held periodically with the aim o f covering all hospital and clinical staff at least once a year. All clinical institutions (PHC etc.) must have such material at their institutions. All institutions in the health department including sub centres should have 108 IEC material inprinted form and where feasible (PHCs etc.) audio visual material at all times. It may be difficult to assess individual needs for so many centres and norms for supply could be fixed for every six months. It has been suggested that an interactive phone service should be made available at each district headquarter so that calls from field health institutions for supply o f IEC material can be provided immediately. (iii)SuppliesandServices-Availabilityof Condoms:Thereisneedtodevelopanewmodel for ensuringeffective availability o f condoms, outside the public domain thoughpublic sector facilities. The basic requirement i s to make condoms easily accessible/available in anonymous surroundings. While it has not been examined in detail, one obvious possibility for urbanareas is to ask all banks to install condom vending machines at the ATMs which are open 24 hours. The Banks could even be asked to install the machines at their cost and subsidise the price inpublic interest as a promotional activity. This will ensure competition andthus quality o f condoms. (iv) Institutional and Organisational Capacity andNetworking: Each district, irrespective of prevalence/vulnerability, should have at least one AIDS Control Centre which can be runas VCTC also. This should be a specific formal/legal entity as is the case at the state level. A VCTC set up within the PHC will not be the appropriate institutional mechanism for providing various services. Each District AIDS Control CentreNCTC should have 5 to 10 paramedical staff under a dedicated AIDS Control Programme Officer who are well trained in AIDS related issues and will be in charge o f the detection/testing/care and support aspects o f the affected persons for the whole district. A fully equippedautonomous team at the district headquarters is likely to be muchmore cost and result effective. The centres should be authorized if necessary to contract out the care and support functions, to carefully screenedNGOs. The district centres should make use of their extensive network of land lines and mobile phones. 24 hours help lines have been installed at the state headquarters and are good for providing information but are not interactive. Each district VCTC/AIDS Control Center could be given a number (as for police control rooms) which in the same all over India and initially it can start operating within defined hours, if not for 24 hours. Finally, the risk groups in any district should be the direct responsibility o f District AIDS Control Centres and the programmes inrespect to these categories can be (as i s being done even at present), implemented by the NGOs. Patch work interventions such as ad hoc distribution o f condoms to petrol stations for distribution to truckers may not be effective. Moving Ahead: Assessment of Current Communication Efforts and Strategies for HIV/AIDS Description: This study reviews available information, education, and communication (IEC) material on HIV/AIDS. The study evaluates the quality and effectiveness o f present IEC/BCC strategies o f NACO, SACS and Partners under NACP 11; the extent to which these strategies and interventions are evidence-based; and the extent to which they are coordinated and comprehensive. Based upon this analysis, it provides recommendations for a comprehensive IEC/BCC strategy and its implementationinNACP 111. 109 Key Results (i) isamismatchbetweenthenationaldrivenBCCframeworkandthecapacityachievable There on the ground i.e. at the Panchayat, community, district and state level; (ii)Long and short term goals o fNACO are not beingwoven into the present BCC strategies. The prevailing belief i s that these goals are too broad and are beyond the scope o f the program; (iii) NACO has formulated a good set o f BCC guidelines in its IEC/BCC framework (2004) which should be operationalized into its communication activities; (iv) There has been a continuing shifting in communication messages at the national level (from an emphasis on condoms, to women, to youth), that makes consistent BCC messagesdifficult to formulate. Recommendations Technical Input: Second generation technical input should shift from essential service delivery to service demand utilization. A strategy should be developed to reduce the impact o f the epidemic in rural areas. As a result, the approach should shift from "hot spots" to sexual networks or clusters. Front-end advocacy should be formulated to create an "empathetic attitude" towards PLHIVs. Stigma should be reduced though greater involvement o f people living with HIV/AIDS and respect for their humanrights. STI/RTI: Misconceptions persist about sexual health among rural women which needs to be addressed. The perception o f the poor quality o f government services also needs to be changed to increase demand. Early identification o f STVRTI through BCC will help with the control of HIV. BCC should be focused on men to increase their perception of risk. Condom Use: BCC activities should be focused to reduce myths and embarrassment about condom use. Service Delivery:Riskperceptionneeds to be increased and community outreach should take place throughHCPs. Communication efforts should target the general population. Mainstreamingadvocacy: Advocacy attempts should dovetail with existing platforms and create new platforms. Religious leaders should be involved in advocacy attempts. Inter-departmental/ ministerial collaboration should take place with technical support from NACO/SACS. Research and Knowledge Management: The evidence based response should be strengthened with increased capacity building for communications research. Also capacity o f communications NGOs should be built. Gender, Youth, Adolescents, Children: A large percentage of youth have misconceptions about HIV. In addition, existing services do not cater to youth. There should be an effort to reach out to youth and mitigate their vulnerabilities. Contraceptives are presently positioned for married couples, but should also be positioned for youth. Care Support and Treatment: Vulnerabilities of PLHIV should be mitigated through advocacy efforts at the state and national level. IEC should be available for ART use, treatment o f OIs, and care and support o fpatients. 110 SocialMarketingPlan for NACP I11 Description: This study outlines a social marketing plan for NACP I11 and asks for a highly analytical leadership role in NACO and the SACS as interpreters o f the environment and designers o f good targeted social marketing programs. A second capacity required by NACO will be as a large-scale contract manager for social marketingimplementationat the state levelor at the level o f highly vulnerable districts. The study aims to provide a brief overview o f social marketing and its application in India, including under the NACP thus far; outline opportunities for increased social marketing investment under NACP 111; and create a plan for actions to be taken to support behavior change through social marketing. Groups at Risk: Priority groups for social marketing are the widely-dispersed, bridge populations who require intensive communication, condom and STINCT service provision on a large scale. Social marketing also i s supportive o f educational interventions among the general population and efforts among core risk populations through the provision and promotion of condoms, service franchises, and VCT. Summary of Plan Preparation: In order to develop such a large-scale social marketing approach, the NACP I11 team will require a preparatory period to put inplace a number o f key elements: Adequate human resources to lead intensive social marketingproject management. Assessment and revision where necessary o f social marketingpolicies which may require adjustment to makepossible adequate support for HIV/AIDS prevention. Funding and contracting mechanisms will need to be secured prior to major programming. Orientation at state level on the capacity and role of social marketing. Condom and other product procurement standards and mechanisms. Segmentation o f districts by prevalence and risk behaviour. Program Design: Project designs will be led by NACO's central team with strong collaboration with the states. Priorities for funding and intensity of social marketing efforts will be allocated by the level of need identified by the district. Four categories o f districts are identified with various inputs and investments suggested: Focus Districts: HighRisk Districts inhighprevalence states Vulnerable Districts: Highrisk behaviour districts inlow prevalence states Diffusion Districts: Low risk behaviour districts with highprevalence nonetheless Low Risk Districts: These districts display neither the prevalence level nor the risk profile to sustain an epidemic. 111 Implementation:Social marketingis anoutsourced activity which will require: A precise tendering, selection and contracting process 0 Persons at the state level to advocate for and support social marketing projects, facilitating necessary approvals, supporting networking and collaboration with other aspectso f the effort. 0 Monitoring to track the reach and effectiveness o f activities Evaluation: This is the final component of the planand is necessary to establish the success of social marketing efforts inbringing about the desired behaviour change. 112 Annex 17: MultiSector Mainstreaming-A StrategicApproach Third NationalHIV/AIDS ControlProject Background Multisector mainstreamingis one ofthe approaches ofthe NACP 1111to scale upthe prevention of HIV infections in HRG and in the general population, and to increase care, support and treatment o f people living with HIV and AIDS. Mainstreaming i s a means to maximize the benefits of a multisector engagement inHIV and AIDS, drawing on the comparative advantages, different reach, and potential synergies between sectors. Accelerating progress and scaling up require that several key sectors make HIV and AIDS an integral part o f their core business. With the current epidemic dynamics (Le., concentrated epidemics among marginalized groups at high risk, vulnerable youth, urban/rural spread with feminization, mobility and migration, selling and buying sex, injecting drug use.. .) clearly the prevention and control o f HIV and AIDS can not be achieved by one sector alone. AIDS i s a health and development problem, several sectors are affected and some o f them have key roles and responsibilities for stopping its spread and mitigating its impacts. The driving forces o f the epidemic have to be tackled from different fronts including tackling the critical societal constraints and implementation obstacles (widespread stigma, discrimination, taboos) and other structural amplifiers (poverty, inequities, migration). Definition of multi sector mainstreaming: Key sectors make HIV and AIDS their core business; incorporate HIV and AIDS as an integral part o f their policies, products and processes; identify their added value, roles and responsibilities; develop plans and allocate budgets to contribute to the development objectives o f the national program; and, coordinate their activities within one common national framework. Rationale Several factors underpin the NACP I11 decision to continue to involve multiple sectors in the fight against AIDS. 1. The inter-dependences o f the many risks and vulnerabilities that influence the epidemic andrequire a multisector response. 2. The possibilities to increase the program coverage o f different segments o f the population, such as, improving knowledge, life skills and changing attitudes among youth before they are exposed to risks; creating a workforce that i s better informed and protected; and, enabling groups at high risk to access prevention, treatment and care without harassment. 3. The mainstreaming helps to institutionalize the response, and to develop shared ownership among key sectors and partners, such as, education, public and private health, labor, tribal development, public and private sector corporations, roads, railroad and transport, justice and legislative bodies, police and prisons, social protection, to name a few key sectors and agencies. 113 SituationAnalyses Under the NACP I1the government established a high level multi sector National Council on AIDS, chaired by the prime minister. Among some of the achievements to date are initiatives taken to improve workplace policies, inform & educate and provide prevention, treatment and care services for employees, by the India Business Trust/CII, Steel Authority o f India, National Highways Authority o f India, Central Board o f Workers Education (MOLE), Ministry o f Defense, Home Affairs, Social Justice and Empowerment. But, many challenges remain: low overall prevalence can lead to complacency and lack o f perceived threat; AIDS i s often viewed as NACO/SACS exclusive agenda and as an add on activity to other organizations' work programs; and, lack o f dedicated staff with technical support have resulted in lack o f follow up action, and the inability to translate policies into action. Most ministries and organization do not have workplace policies, dedicated resources, staff or guidelines and they remain untapped resources to the national effort. The InstitutionalArrangementsandNACO's Role The National Council on AIDS with the membership of 31 Central Ministries, six State Chief Ministers and civil society provides the highest political support, leading the mainstreaming o f HIV into the works of all organs o f government, private sector and civil society. States will establish State Council on AIDS along the same pattern as the National Council on AIDS, to be chaired by the Chief Minister with the Minister o f Health as Vice Chair. N A C O and SACS have an important steering role and functions at national and state levels, respectively. The agreed on national strategic framework forms the basis for the National Council on AIDS, and it i s envisaged that a DP partnership agreement would also support the multi sector mainstreaming. To strengthenNACO's and SACS' steering role, it is proposed that they would have a dedicated senior core staff, with desk and team, serving as focal person for mainstreaming. A multi- stakeholder Technical Advisory group (TAG) o f the National AIDS Council would help to share information and problem solve. NACO/SACS would be responsible for advocacy, capacity development and initial hands on support and facilitation - providing technical support. NACO would take the lead in developing a network o f institutions and experts to draw on for these mainstreaming efforts. Identified key ministries and organizationwill have their own trained and dedicated unitdfocal person and a work plan, including benchmarks and indicators to measure progress. Multi sector collaboration takes different forms, such as convergence of inter dependent programmatic areas or o f programs reaching the same target audience (e.g., TB, HIV/AIDS, Reproductive health), stronger coordination to maximize the benefits, and integration o f HIV/AIDSinto existingprograms and new nationalprograms (e.g., youth, Rural HealthMission, Integrated Tribal Development Authorities) . 114 StrategicObjectivesof Multi Sector Mainstreaming The strategic objectives of the NACP 1111are: key government, non-government, private sector and labor organizations adapt core business to respond to the challenge of HIV and AIDS; internal resources are allocated; and, HIV i s mainstreamed into the 11th five year plano f the GO1 at state and national level. 115 Annex 18: Countryat a Glance ThirdNationalHIV/AIDS ControlProiect SQUtft tor- Wi A*, i- 1.Wd 1.470 2.353 729 e82 580 Lifeexpectancy m.1 1.005 1.364 T i.5 1.7 19 1 1 2.T 23 29 29 29 31 e3 a3 59 6-2 66 $a 47 45 39 Acoess to improwdwater 5 0 ~ ~ 0 a6 82 75 e1 (ID (52 W6 110 1W $20 116 110 212 105 99 1995 P I 4 mu5 3553 w . 7 785.5 2e.5 30.1 3t.O 11.a 10.0 22.1 z.3 28.1 27-3 268 30A 2e.e -111 0.9 -1.4 1 2 0.4 26.1 17.7 27.8 12.1 15.8 ?2,8 2 W 2H5 po0509 a5 9.5 ?.7 7 1 7.0 1.5 -hi& -LO~armcqrWp 3 . 3 19.3 212 1985 1995 2004 2wIs (X olOW) - h o f o p i l a i d w ( t q Agricumre 33.7 282 1Q.B 18.3 = lndusby 26.4 28.1 27.3 27.1 20 Manufaaunng 164 18.1 16.0 15.9 Serwces 398 43.1 53.2 54.e 0 HwsehdrJha1arnsurnp4ioneXp%diRpe 874 836 BO 7 10.6 -10 Generalgovlfinlconuunptw ewndibre 11.4 10.8 11.3 I 2 2 __ Importsofgoodsw d 5wioe5 78 12.2 210 2418 I 19Ei-95 199505 2004 MDS 3.5 2.0 0.7 23 s 6.5 40 e.7 5.7 8.g. 0.0 5.5 8.1 94 30 6.7 8.1 9.9 9.7 IC. ID 5.7 5.3 7.2 4.8 G 42 8.0 9.2 15.6 5.4 8.5 12.8 11.3 9.9 113 41.9 15.0 Note 2M5 data are preliminaryestmaks. 2005representshda Rx;J Y w SWSMI. &G+ run3 from April 1to Much31 'Thedainmdsshowbwkeyindicalmu)bemnlry(inbold)ampaedwithIbincome-gmupawenpe.Ifdadaacemrsrmg,hedrnmdwill be ncompkte 116 117