The World Bank National AIDS Control Support Project (P130299) REPORT NO.: RES36157 RESTRUCTURING PAPER ON A PROPOSED PROJECT RESTRUCTURING OF NATIONAL AIDS CONTROL SUPPORT PROJECT APPROVED ON MAY 1, 2013 TO DEPARTMENT OF ECONOMIC AFFAIRS HEALTH, NUTRITION & POPULATION SOUTH ASIA Regional Vice President: Hartwig Schafer Country Director: Junaid Kamal Ahmad Senior Global Practice Director: Timothy Grant Evans Practice Manager/Manager: Rekha Menon Task Team Leader: Ronald Upenyu Mutasa, Suresh Kunhi Mohammed The World Bank National AIDS Control Support Project (P130299) ABBREVIATIONS AND ACRONYMS ART Anti-retroviral therapy ARV Anti-retroviral CMSS Central Medical Services Society DEA Department of Economic Affairs FSW Female Sex Worker HIV Human Immuno-deficiency Virus IDU Injecting Drug User IO Intermediate Outcome MOHFW Ministry of Health and Family Welfare MSM Men-who-have-Sex with Men NACO National AIDS Control Organization NACSP National AIDS Control Support Project PDO Project Development Objective TI Targeted Intervention The World Bank National AIDS Control Support Project (P130299) BASIC DATA Product Information Project ID Financing Instrument P130299 Investment Project Financing Original EA Category Current EA Category Partial Assessment (B) Partial Assessment (B) Approval Date Current Closing Date 01-May-2013 31-Dec-2019 Organizations Borrower Responsible Agency National AIDS Control Organisation, Department of AIDS Department of Economic Affairs Control,Central Medical Services Society Project Development Objective (PDO) Original PDO The Project Development Objective (PDO) is to increase safe behaviors among high risk groups in order to contribute to the nationalgoal of reversal of the HIV epidemic by 2017. Current PDO The Project Development Objective (PDO) is to increase safe behaviors among high risk groups in order to contribute to the national goal of reversal of the HIV epidemic OPS_TABLE_PDO_CURRENTPDO Summary Status of Financing Net Ln/Cr/Tf Approval Signing Effectiveness Closing Commitment Disbursed Undisbursed IDA-52360 01-May-2013 18-Jun-2013 22-Jul-2013 31-Dec-2019 255.00 147.34 90.13 Policy Waiver(s) Does this restructuring trigger the need for any policy waiver(s)? No The World Bank National AIDS Control Support Project (P130299) I. PROJECT STATUS AND RATIONALE FOR RESTRUCTURING 1. The Project Development Objective (PDO) remains Satisfactory and is on track to be achieved. Based on 2016 data reported by the National AIDS Control Organization (NACO), all three PDO indicators have surpassed the targets for fiscal year (FY) 2017-2018. Updated data will be available in December 2019 from Behavior Surveillance Survey- Lite (BSS-Lite) that will be based on a sample of 14 states (out of a total of 29 states and 7 union territories) in India. 2. NACO has made progress in implementation of project activities in the past 12 months (as documented during the Joint Implementation Review mission held in January 2019). There has been substantial progress in the procurement of drugs, consultancies, and other priority services, which had earlier experienced delays. As such, the rating for implementation progress was upgraded to Moderately Satisfactory in February 2019. Notable project implementation milestones include: a. Revamping the targeted interventions (TI) program by increasing coverage to previously unreached populations through smarter outreach strategies, including combining peer educator outreach and virtual platforms. This is a best practice example of improving the coverage and quality of an intervention in a constrained funding context; b. Substantial progress in the procurement of antiretroviral (ARV) drugs in the amount of US$54 million. The contract has been signed and the first shipment is expected to arrive early June 2019. c. Strengthened institutional capacity of the NACO’s TI Division, with recruitment of specialist consultants, contracting of ten technical support units (TSUs), eight of which were previously financed by USAID, and procurement of agency for hiring of experts of the National Technical Support Unit completed; d. Significant improvement in NACSP financial management and internal control processes; and e. Procurement, financial management, social and environmental safeguards, and counterpart funding of the project continue to be rated moderately satisfactory. II. DESCRIPTION OF PROPOSED CHANGES 3. This restructuring is being processed based on the request submitted by the Department of Economic Affairs (DEA) of the Ministry of Finance, Government of India, on March 11, 2019. DEA’s letter includes a request to extend the project Closing Date to June 30, 2020. This restructuring does not include the proposed project extension and the DEA request will be reassessed at a later time when there is more significant progress in project disbursements. 4. The changes proposed under this restructuring are: a. Change in institutional arrangement to add the Central Medical Services Society (CMSS) as an implementing agency. CMSS is the central procurement agency of the Ministry of Health and Family Welfare that undertakes procurement and distribution of medicines for various health programs of the Ministry of Health and Family Welfare (MOHFW). A significant proportion of procurement of ARV drugs financed through NACO’s domestic budgetary resources is undertaken by CMSS. For NACSP, CMSS will be procuring and distributing ARV drugs and test kits that are planned under the ‘test and treat’ program. Under NACSP, the approved procurement agent is RITES and its contract is expiring in October 2019. A further extension of the RITES’s contract is not possible as the original contract has been extended by The World Bank National AIDS Control Support Project (P130299) two years already (from October 2017 to October 2019). A brief assessment carried out by the Bank concluded that CMSS has the required capacity and experience to undertake procurement under NACSP. b. Revision of the Results Framework to change the end-of-project target for seven intermediate outcome (IO) level indicators and drop one IO indicator. The NACSP original indicators and targets were set in 2012-13; while four new indicators were added in 2017, to accommodate the "Test and Treat" policy requirements. The targets set for seven IO indicators are not in sync with the changing HIV/AIDS dynamics in the country. Some of the critical behavior aspects like the delinquent health seeking behavior of some high-risk population groups, high mobility and rapidly changing sexual networks and platforms were not considered when these targets were set. The revised targets are based on a careful analysis of the trends over the past five years. A summary of the proposed changes and justification for it are provided in the table below. Sl. IO indicator Baseline Current Actuals Proposed Justification target change 1. Female sex 80% 90% 85% Reduce The denominator was estimated in 2009. At that time, most sexual workers (FSWs) target to networks were concentrated either in hot spots or the streets and who have been 85% the outreach model was based on physical outreach by peer reached by TI in educators. At present, sexual networks are getting concentrated the last year on virtual and mobile platforms. The ten-year-old size estimation is thus outdated and out of sync with epidemic transmission dynamics and scale. The target is being revised to reflect different outreach models as well as different coverage realities. 2. Men who have 67% 80% 73% Reduce As above, the denominator was estimated in 2009. At that time, sex with men target to most of sexual networks were concentrated either in hot spots or (MSM) who 72% the streets and the model was based on physical outreach by peer have been educators. At present, sexual networks are concentrated on virtual reached by TI in and mobile platforms. The ten-year-old size estimation is thus the last year outdated and out of sync with epidemic transmission dynamics and scale. The target is being revised to align it with the technical and implementation context. . 3. TI that report 10% 2% 6.2% Reduce The end targets are being updated to reflect the best available condom stock- target to evidence on trends in condom stock out and the reality that while out in the last 7% High Risk Groups primarily access condoms from NACO outlets, quarter they are also utilizing alternative channels to access condoms. 4. Injecting drug 28% 80% 68% Reduce Behavior change among IDU is more challenging to address. This users (IDUs) target to was not considered when the target was set. Despite concerted have been 70% efforts to reach out to and motivate IDUs, the IBBS 2015 indicates counseled, and health seeking behavior among IDUs remain low. Proposed change HIV tested in in end targets took recent trends of utilization of HIV counseling the last 12 and testing services by IDU. months 5. High-risk group 0 90% 65% Reduce This indicator was included in 2017, along with the Government’s (core) living target to announcement of ‘Test and Treat policy’. Reaching to 90% of the with HIV who 68% hidden population and undertaking voluntary HIV testing is are diagnosed challenging; the level of effort required was underestimated when target was set. 6. High-risk group 0 90% 89% Reduce This indicator was included in 2017, along with the Government’s (core) currently target to announcement of ‘Test and Treat policy’. The reported data is The World Bank National AIDS Control Support Project (P130299) Sl. IO indicator Baseline Current Actuals Proposed Justification target change receiving 89% based on a small cohort. However, at the end of the project antiretroviral calculations will be based on a larger cohort and the outcome will therapy (ART) likely be lower basing on the global evidence. 7. High-risk group 0 90% 72% Reduce This indicator was included in 2017, along with the Government’s (core) with target to announcement of ‘Test and Treat policy’. Behavior change to known HIV 80% sustain daily intake of medicine throughout the year is challenging. status on ART Treatment adherence at a very high level for long duration is for 12 months difficult to attain and more so in HRGs. The retrospective after initiating calculation for a similar indicator for the general population ART estimated by UNAIDS is nearly 65%. Considering this, the target is being revised to a more realistic level. 8. High-risk group 0 90% NA Delete this NACO started scaling up viral load services in 2017. The system is (core) on ART indicator not ready to systematically track this indicator that was introduced who are who during the 2017 project restructuring. The effort to roll out a are virologically robust monitoring system for viral load monitoring is in place; suppressed however, this takes time to be fully rolled out, and provide credible information to track the indicator. Further, no estimations of this indicator is available for general population in the country. 5. The disbursement estimates are being revised to take into account the implementation progress of NACSP and the planned activities relating to ARV drug procurement by CMSS, field-level activities for the expanded “test and treat” policy of the government, and continuing TI program. By the current Closing Cate of December 31, 2019, additional US$85.5 million is expected to be spent by NACO, which would mean total disbursement of US$217 million approximately (i.e. 93% of the total credit of US$232.9 million). I. SUMMARY OF CHANGES Changed Not Changed Implementing Agency ✔ Results Framework ✔ Disbursement Estimates ✔ Institutional Arrangements ✔ Procurement ✔ DDO Status ✔ Project's Development Objectives ✔ Components and Cost ✔ Loan Closing Date(s) ✔ Cancellations Proposed ✔ The World Bank National AIDS Control Support Project (P130299) Reallocation between Disbursement Categories ✔ Disbursements Arrangements ✔ Overall Risk Rating ✔ Safeguard Policies Triggered ✔ EA category ✔ Legal Covenants ✔ Financial Management ✔ APA Reliance ✔ Implementation Schedule ✔ Other Change(s) ✔ Economic and Financial Analysis ✔ Technical Analysis ✔ Social Analysis ✔ Environmental Analysis ✔ IV. DETAILED CHANGE(S) OPS_DETAILEDCHANGES_IA_TABLE IMPLEMENTING AGENCY Implementing Agency Name Type Action National AIDS Control Organisation, Implementing No Change Department of AIDS Control Agency Central Medical Services Society Implementing New Agency OPS_DETAILEDCHANGES_DISBURSEMENT_TABLE DISBURSEMENT ESTIMATES Change in Disbursement Estimates Yes Year Current Proposed 2013 16,486,290.33 0.00 2014 23,102,209.20 14,846,461.00 2015 33,264,653.76 21,478,320.00 The World Bank National AIDS Control Support Project (P130299) 2016 49,146,846.71 32,625,367.00 2017 47,000,000.00 26,861,635.00 2018 49,000,000.00 23,790,667.00 2019 37,000,000.00 23,927,297.00 2020 0.00 85,500,000.00 . The World Bank National AIDS Control Support Project (P130299) . Results framework COUNTRY: India National AIDS Control Support Project Project Development Objectives(s) The Project Development Objective (PDO) is to increase safe behaviors among high risk groups in order to contribute to the national goal of reversal of the HIV epidemic Project Development Objective Indicators by Objectives/ Outcomes RESULT_FRAME_TBL_PDO Indicator Name DLI Baseline Intermediate Targets End Target 1 Increase safe behaviors among high risk groups Female sex workers who report using a condom 80.00 80.00 95.00 with their last client (Percentage) Men who have sex with men who report using a condom during sex with their last male partner 45.00 50.00 90.00 (Percentage) Injecting drug users who do not share injecting equipment during the last injecting act 45.00 50.00 85.00 (Percentage) PDO Table SPACE Intermediate Results Indicators by Components RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Scaling Up Targeted Prevention Interventions and Test as Prevention (TasP) for core group The World Bank National AIDS Control Support Project (P130299) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 FSWs who have been reached by targeted 80.00 80.00 85.00 85.00 85.00 85.00 interventions in the last year, by 2019 (Percentage) Action: This indicator has been Revised High Risk MSM who have been reached by targeted 67.00 70.00 70.00 71.00 71.00 72.00 interventions in the last year, by 2019. (Percentage) Action: This indicator has been Revised IDUs who have been reached by targeted 81.00 81.00 81.00 81.00 83.00 85.00 interventions in the last year, by 2019. (Percentage) TIs that have validated high risk group size data in the 60.00 65.00 65.00 70.00 70.00 75.00 last 12 months. (Percentage) TIs will be graded according to the performance 60.00 65.00 65.00 70.00 70.00 95.00 indicators of SIMS. (Percentage) TIs reporting condom stock out, in the last quarter 10.00 9.00 8.00 7.00 7.00 7.00 (Percentage) The World Bank National AIDS Control Support Project (P130299) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 Action: This indicator has been Revised Planned prevention interventions for migrants 70.00 75.00 80.00 85.00 85.00 90.00 implemented as per plan (Percentage) Planned prevention interventions for truckers 70.00 75.00 80.00 85.00 85.00 90.00 implemented as per plan (Percentage) Behavior Change Communications NGO contracted as per SACS annual plan 60.00 70.00 70.00 80.00 80.00 90.00 (Percentage) States updating, reporting and responding to 75.00 75.00 75.00 80.00 85.00 95.00 dashboard indicators (Percentage) FSW who have been counseled and HIV tested in 35.00 35.00 40.00 45.00 45.00 80.00 the last 12 months (Percentage) High risk MSMs who have been counseled and HIV 35.00 35.00 40.00 45.00 45.00 80.00 tested in the last 12 months (Percentage) The World Bank National AIDS Control Support Project (P130299) RESULT_FRAME_TBL_IO Indicator Name DLI Baseline Intermediate Targets End Target 1 2 3 4 5 IDUs have been counseled and HIV tested in the last 12 28.00 35.00 40.00 45.00 45.00 70.00 months (Percentage) Action: This indicator has been Revised High risk group (core) living with HIV who are 0.00 30.00 40.00 50.00 60.00 65.00 diagnosed. (Percentage) Action: This indicator has been Revised High risk group (core) currently receiving ART. 0.00 50.00 60.00 70.00 75.00 80.00 82.00 (Percentage) Action: This indicator has been Revised High risk group (core) with known HIV status on ART 0.00 4.00 50.00 65.00 70.00 75.00 80.00 for 12 months after initiating ART. (Percentage) Action: This indicator has been Revised High risk group (core) on ART who are virologically 0.00 50.00 60.00 70.00 80.00 90.00 90.00 suppressed. (Percentage) Action: This indicator has been Marked for Deletion IO Table SPACE The World Bank National AIDS Control Support Project (P130299) The World Bank National AIDS Control Support Project (P130299)