Document of The WorldBank ReportNo:26025-MAU FOROFFICIAL USEONLY PROJECTAPPRAISALDOCUMENT ONA PROPOSEDGRANT INTHEAMOUNTOFUS$21.O MILLION TO THE ISLAMICREPUBLICOF MAURITANIA FORA MULTISECTORHIVlAIDS CONTROLPROJECT June 9,2003 HumanDevelopmentI1 CountryDepartment15 AfricaRegionalOffice IThis 1 official duties. documenthas arestricteddistributionandmaybeusedbyrecipientsonly inthe performanceoftheir ] Its contents maynototherwisebe disclosedwithout World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate EffectiveApril 2003) Currency Unit = Ouguiya (UM) UM1,000 = US$3.57 US$1 = UM.280 FISCALYEAR January - December ABBREVIATIONSAND ACRONYMS AFAPM Administrative, Financial andAccounting Procedures Manual ART Ante-Retroviral Treatment CAS Country AssistanceStrategy CBO Community-based Organization CDD Community-driven Development CDHLCPI Board for the Respect o fHumanRights,the FightAgainst Povertyand Toward Insertion (Commissariat aux Droits de l%lomme, d la Lutte Contre la Pauvretk et d 1'Insertion) CGEM National Confederation o fMauritanian Employers(Conj2dkration Gknkraledes Employeurs Mauritaniensj CNH National Hygiene Center (Centre National d'Hygikne) CNLS National Committee to Fight Against HIVIAIDS (Comitk national de lutte contre le VIHISIDA) CPA Country ProgramAdvisor CRLS RegionalCommittee inthe FightAgainst AlDS (Comiti rkgional de lutte contre le SIDA) CSI cso Civil Society Initiative Civil Society Organization DHS Demographic Health Survey DGI Investment ManagementDirectorate (Direction GknkraledesInvestissements) DOTS DirectlyObservedTreatment Short Course EA EnvironmentalAssessment EDSM Health andDemographic Survey inMauritania (EnquBte~kmographiqueet de Santk en Mauritanie) EMP Environmental ManagementProgram FAPM Financial andAccounting ProceduresManual FAPONG Directorate of the FightAgainst Poverty (Directionde la Lutte Contre la Pauvretk) FAU Financial and Administrative Unit FBO Faith-basedOrganization FGC FemaleGenital Cutting FIS Financial Information System FLM World LutheranFederation (Fkdkration Luthkrienne Mondiale) GF Global Fund GFC FemaleGenital Cutting GMT Grassroots ManagementTraining GRIM Govemment o fthe Islamic Republic o fMauritania (Gouvemementde la Ripublique Islamique de Mauritanie) GOM Generic OperationManual HIVlAIDS HumanImmunodeficiencyVirudAcquired Immunodeficiency Syndrome IECiCCB Information, EducationandC o ~ ~ i c a t i ~ C o m m u n i c a tfor i o nChangeof Behavior LIL LearningandInnovationLoan MACP MultisectoralHIVlAIDS Control Project MAP Multi-Country HIVlAIDS Programfor the Africa Region MCOI Ministry o fCulture andIslamic Orientation {Ministkre de la Cultureet de I'Orientation Islamique) MCRP Ministry of Communication ando fRelations to the Parliament(Ministire de la Communication et des Relations avec le Parlement) MDN MinistryofNationalDefense(Ministkre de la Dkfense Nationale) MDGs Millennium Development Goals MDRE RuralDevelopment and Environment Ministry(Ministkre du Dkveloppement Rural et de l'Environnement) MEN MinistryofNationalEducation(Ministkre deI'Education Nationale) MFPTJS Ministry o f Civil Servants, Labor, Youth and Sports (Ministire de la Fonction Publique, du Travail, de la FOROFFICIAL USEONLY Jeunesseet desSports) M&E Monitoring andEvaluation MOHSA MinistryofHealthandSocial Services (Ministsre de la Santk et desAflaires Sociales) MSAS MinistryofHealthandSocialServices (MinistGrede laSantketdesAsfaires Sociales) MTCT Mother-To-Child-Transmission NAC National AIDS Council NAES National HIVIAIDS Executive Secretariat NGO Nongovernmental organization PASS Health Sector Investment Project (Projet d'Appui au Secteurde la S a d ) PEV ExtendedVaccination Program(ProgrammeElargi de Vaccination) PHRD Policy and Human ResourcesDevelopment Fund PIM Project ImplementationManual PLWHA People LivingwithHIVIAIDS PMTCT Preventionof HIVMother to ChildTransmission P a s National Programto FightAIDS (Programmenational de lutte contre le SIDA) PPF Project Preparation Facility PRSP PovertyReductionStrategyPaper RAC RegionalHIVlAIDS Committee RAES RegionalHIVlAIDS Executive Secretariat RONASIDA Network o fNGOS active inthe fight against HIVlAIDS(Rkseaudes ONGsactives duns le domainedu VIH/SIDA) RSA Regional Sub-Account SAP Sectoral Action Plan SECF State Secretariatfor the PromotionofWomen (Secrktariatd 'Etat2 la ConditionFkminine) SEN National ExecutiveSecretariat(SecrktariatExkcutif National) SENLS National ExecutiveSecretariatfor the FightAgainst HIVISIDA (Scrktariat Exkcu~~Nationalde Lutte Contre le VIH/SIDA) SERLS Regional Executive Secretariats inthe FightAgainst HIVlAIDS (SecrktariatsExkcutgsRkgionaux deLutte Contre le VIHISIDA) SMM National Industrial andMiningSociety (Sociktk Nationale Industrielle etMinisre) STI Sexually Transmitted Infection SWAP Sector-Wide AnnualPlan TB Tuberculosis UNAIDS UnitedNationsAIDS Organization UNFPA UnitedNations FoodProgramAssistance UNGASS UnitedNations GeneralAssembly VCT Voluntary Counseling andTesting WPA Work ProgramAgreement Vice President: Callisto Madavo Country Director: A. DavidCraig Sector Manager: Alexandre Abrantes Task Team Leader: SergeTheunynck This document hasa restricteddistribution andmay beusedbyrecipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization. MAURITANIA MULTISECTORHIV/AIDSCONTROLPROJECT CONTENTS A. ProjectDevelopmentObjective Page 1. Project development objective 2 2. Keyperformance indicators 2 B. Strategic Context 1. Sector-related CountryAssistance Strategy (CAS) goal supportedbythe project 4 2. Main sector issuesandGovernment strategy 5 3. Sector issuesto be addressedby the project and strategic choices 6 C. Project Description Summary 1. Project components 8 2. Keypolicy and institutionalreforms supported bythe project 12 3. Benefits andtarget population 12 4. Institutional and implementationarrangements 13 D.Project Rationale 1. Project alternatives consideredandreasonsfor rejection 19 2. Major relatedprojectsfinanced bythe Bank andlor other development agencies 19 3. Lessons learnedandreflected inthe project design 21 4. Indications o frecipient commitment andownership 22 5. Value added of Bank support inthis project 22 E. Summary ProjectAnalysis 1. Economic 23 2. Financial 23 3. Technical 24 4. Institutional 24 5. Environmental 27 6. Social 29 7. SafeguardPolicies 31 F, Sustainability andRisks 1. Sustainability 32 2. Criticalrisks 32 3. Possible controversial aspects 34 G. MainGrant Conditions 1. Effectiveness Condition 34 2. Other 34 H. Readinessfor Implementation 35 I.CompliancewithBankPolicies 35 Annexes Annex 1: Project Design Summary 36 Annex 2: DetailedProject Description 41 Annex 3: EstimatedProject Costs 67 Annex 4: Cost Benefit Analysis Summary 68 Annex 5: Financial Summary 74 Annex 6: (A) Procurement Arrangements 75 (B)FinancialManagement andDisbursement Arrangements 87 Annex 7: Project Processing Schedule 95 Annex 8: Documents inthe Project File 97 Annex 9: Statement of Loans andCredits 99 Annex 10: Country at a Glance 101 Annex 11:SocialAssessment ofRuralWomen andTraditional HealthPractitioners 103 Annex 12: Assessment ofNGOs 115 Annex 13: Assessmentofthe Line MinistryAction Plan 122 Annex 14: Project ImplementationArrangements 136 Annex 15: CapacityBuildingo f Communities, CBOs andNGOs: The Grassroots 142 Management Training (GMT) Annex 16: Private Sector Initiative 147 Annex 17: Bio-Medical Waste Management Plan 152 Annex 18: Monitoring andEvaluation System 156 Annex 19: Reductiono fFemale GenitalCutting 171 Annex 20: Collaboration with Traditional HealthPractitioners 174 Annex 21: Supply Chain Assessment o fHealthCommodities 176 Annex 22: Forecast ofHealth Supply 184 Annex 23: Supervision Plan 187 MAP(S) TBRD 25935 MAURITANIA MULTISECTORHIVIAIDS CONTROL PROJECT ProjectAppraisalDocument Africa RegionalOffice AFTH2 Date: June 9,2003 Team Leader: SergeTheunynck Sector Manager: Alexandre V. Abrantes Sector(s): Other social services(41%), Health (30%), Country Director: A. DavidCraig Centralgovernmentadministration (29%) Project ID: PO78368 Theme@): Fightingcommunicablediseases(P), Civic LendingInstrument: Specific Investment Loan (SIL) engagement, Participation andC O ~ ~ driveni n ~ development(S), Gender (S), Rural services and infrastructure(S) ProjectFinancing Data -c [ ] Loan [ ]Credit [XI Grant [ ] Guarantee [ ]Other: For LoanslCreditslOthers: Amount (US$m): $21.0million Responsible agency: GOVERNMENT NationalHIV1AIDS Committee(NAC) Address: Nouakchott, Islamic Republic of Mauritania ContactPerson: Dr.Abdallah OuldHorma, Director ofthe National HIVIDSExecutive Secretariat(NAES) Tel: (222) 630 32 73 - Fax: (222) 529 1614 Email: abdhorma@yahoo.fr Projectimplementation period: 5 years Expected effectivenessdate: 1010112003 Expected closingdate: 0313112009 C s P y l m R I U v I m A. Project DevelopmentObjective 1. Project development objective: (seeAnnex 1) The development objective o f the Multisector HIVIAIDS Control Project (MACP) i s to maintain the level o f human immunodeficiency virus (HIV) infection that causes the acquired immunodeficiency syndrome (AIDS) belowthe prevalence rate o f 1percent andreduce opportunistic infections. This Project is developedwithinthe context o fthe $1.0billion Multi-Country HIVIAIDSProgramfor the Africa Region(MAP). The 2001UNGASS Declaration and the Millennium Development Goals, and the MAP Project Appraisal Document (Report No. 20727-AFR), provide the objectives and framework for national MAP projects. InMauritania, which is at an early stage o f the epidemic spread, the project will help build the country's capacity to organize a pre-emptive response to the HIVIAIDS epidemic. This will be accomplished through the establishment o f an efficient multisector institutional and operational framework, and a program which will aim at reducing its spread and mitigatingits effects by increasing access to prevention services as well as care, treatment, andmitigationfor those infected andaffectedby HIVIAIDS. The project is premised on the development and expansion o f local responses to the epidemic. It aims at enabling Mauritania to achieve these institutional and operational objectives in the short runand reversingHIVIAIDS prevalence inthe longrun. The project will support the Government to implement and expand response to HIVIAIDS through community-based initiatives and also mainstream HIVIAIDS into the work programs o f all Ministries, Departments andAgencies, and involve the private sector. The support for community-based initiatives would involve HIVIAIDS preventionprograms through, inter alia, peer education, IEC activities, andthe provision o f support for Voluntary Counseling and Testing (VCT) services. The care o f orphans, widows and home-based care for Persons Livingwith HIVIAIDS (PLHAs) are planned to be included among the community-based initiatives. The project will be financed by a Grant, for which Mauritania i s eligible as an IDA-only country andfor the purpose o f supporting a national HIVIAIDS program, which is consistent with the criteria and guidelines for IDA Grants established under IDA 13. Becausethis is the first IDA grant for Mauritania, a full discussiononthe useofIDAgrants inthe country will takeplaceinthe next CASplannedfor FY06. 2. Key performance indicators: (see Annex 1) The list o f indicators was selectedand quantified on a participatory basis. Itwas selectedamong a full set o f indicators which is reflected in Annex 1and Annex 18. The limited list below, selected for overall project monitoring, constitutes the summary indicators for output, outcome, process, and impact of the program. It was confirmed duringnegotiations. A. Impact-outcome Indicators 1. HIVIAIDS prevalence rate among pregnant women age 15 to 19 remains below 1 percent. Baseline data (MOHSA report May 2002): 0.57 percent. Mid-term Review: 0.78 percent. Method to measureindicator: surveys. 2. HIVIAIDS prevalence rate among the uniformedservice recruits (Forces Armkes et de Skcuritd) remains below 1percent. Available data for Army recruits: 0 percent. Baseline data for all uniformed service recruits will be available before March2003. Mid-term Review 0.78 percent. Methodto measure indicator: reviews o fthe pre-recruit examresults. - 2 - 3. W l A I D S prevalence rate among tuberculosis patients remains below a value to be determined on the basis o f the results o f the on-going prevalence survey from which data will be available in December 2003. Mid-term Review indicator to be determined at the same time. Method surveys o f tuberculosis patients. B. OutcomeIndicators 4. Ninety-five percent o f respondents (general adult population) correctly identify two or more ways o f preventing the sexual transmission o f HIV and reject three major misconceptions about HIV transmission or prevention. Baseline data in Demographic and Health Survey (DHS) 2001: women 25 percent, men 51 percent. Mid-term review indicator: women 60 percent; men 85 percent. Method to measureindicator: surveys. 5. Safer sexual practices o f youth (15-19): (a) increased age o f sexual inception: women 0.5 year; and men 1 year; and @) 30 percent reduction o f occurrence o f unprotected sexual intercourse. Baseline data will be supplied by survey to be conducted during preparation with PPF. End-of-project indicator andMid-term Review indicator to be finalized after the results o fthis survey havebeenanalyzed. 6. At least 300 sub-projects have been submitted by NGO-FBOs and at least 80 percent have reached eligible criteria andhave been signed. Baseline data: 0; Mid-term review indicator: at least 100 sub-projects have been submitted by NGO-FBOs and at least 80 have reached eligible criteria and have been signed. Methodto measureindicator: NAES reports. 7. At least 1,500 sub-projects have been submittedby CBOs and at least 80 percent have reached eligible criteria and have been signed. Baseline data 0; Mid-term review indicator: at least 500 sub-projects have been submitted by CBOs andat least 80 percent have reached eligible criteria and have been signed. Methodto measureindicator: NAES reports. C. ProcessIndicators 8, National AIDS Council WAC) with publiclprivate membership i s fully functioning and the annual Action Plan is adopted in a timely manner. Mid-term review indicator: the NAC with publiclprivate membership is fully functioning and has approved in a timely manner the annual Action Plan submitted to it for the current year. Methodto measureindicator: NAES reports. 9. Communitylcivil society disbursement reach at least 80 percent o f planned levels. Baseline data 0; Mid-term review: Communitylcivilsociety disbursement reach at least 80 percent o fthe plannedlevel at the Mid-termReview. Methodto measureindicator: financial report o fthe NAES. D.OutputIndicators 10. By the end of the project 100 percent of primarylsecondaryltertiary educational institutions implement HIVIAIDS prevention programs for their students, in accordance with reference modules preparedby the Ministryo f Education (MEN).Baseline data: 0 percent. Mid-term Review: 50 percent o f pri~lsecondaryltertiaryeducational institutions. Method to measure indicator: MEN'Sreports on the progress o fits Action Plan. 11. Bythe end ofthe project, about 2 percent o fthe total number o fpeople ina targeted group inall sectors have been trained as peer educators, and active for at least five days during the previous two months. Baseline data 0 percent. Mid-term Review: 2 percent. Method to measure indicator: Trainers' - 3 - reports on training program o fpeer-educators aggregatedbyNAES, andsurveys. 12. By the end of the project, 1,500,000 participants in LECKCB sessions. Baseline data 0; Mid-term Review: at least 750,000 participants. Method to measure indicator: M&E System andNAES progressreports. 13. Bythe end ofthe project, at least 30 Voluntary Testing andCounselling centers are functioning. Baseline data: 2. Mid-term review: at least 10 "VCTs". Methodto measure indicator: MOHSA progress reports on its Action Plan. 14. By the end o fthe project, the capacity to sell or give away condoms has increased to 1,500,000 condoms per year. Baseline data: 480,000 in2003 (estimated on the basis o f 75 percent o f the condoms provided to the institutions), and Mid-term Review indicator: 980,000 condoms. Method to measure indicator: Report on condom distribution o fthe M&ESystem. 15. Bythe end ofthe project, 60 percent ofpregnant women who test HN-positive are participating in the MTCT program. Baseline data 0 percent. Mid-term Review indicator: 15 percent. Method to measureindicator: MOHSA progress reports on its Action Plan. B. Strategic Context 1.Sector-related Country AssistanceStrategy (CAS) goalsupported bythe project: (see Annex 1) Document number:24122 Date of latestCAS discussion:June 18,2002 Mauritania was one of the first countries to finalize its PRSP (February 6,2001) with poverty reduction at the center o f the economic development strategy o f the Government, based on four main themes: (i) accelerating private sector-led growth; (ii) anchoring growth in the economic environment o f the poor; (iii)developing human resources and ensuring universal access to basic infrastructure and services; and (iv) institutional development andgovernance. The main objective of the 2003-05 CAS is to support the Government implementation of the PRSP with emphasis on capacity-building. The preparation inFY03 o f a Multisector HrV/AIDS Control Project (MACP) to maintain or reduce the HrVlAIDS prevalence at the current low level, is part ofthe base case scenario o fthe 2002-05 CAS (para 70). Regarding the above-mentioned four themes supported by the CAS, the MACP will play the following roles: Accelerating private sector growth. While the CAS mentions the leadership o f the mining and fisheries sectors inthe industrial economy, accounting for almost 100 percent of the country's export earnings, both sectors are hit hard by the HIVlAIDS epidemic, The CAS also mentions the sub-leading role o f the construction andpublic-works sectors inthe current economic growth, which are also amongst the more vulnerable to the HIV/AIDS threat. HIV/AIDS can quickly reverse gains inthese sectors.Theproject will support privatesectorresponsesto HIVIAIDS. Anchoring growth in the economic environment of the poor. While the poverty ratio declined between 1990 and 2000, from 57 percent to 46 percent, this is not uniform and the situation has deteriorated in Nouakchott and the southern part o f Mauritania where HN/AIDS rates are higher than average. Inurban areas where the overall poverty situation improved, inequalities nevertheless increased (Gini rate worsened from 34 percent to 39 percent between 1996 and 2000). Poverty i s a major factor in increasing people's vulnerability to HIVIAIDS risk. The project will emphasize financial support to demand-driven HN/AIDS responses designed and implemented by poor communities. Developing human resources and universal access to basic i n ~ a s t ~ c t u rand services. e - 4 - Mauritania's capacity to provide basic services increased significantly during the past 10 years (primary school enrolment increased from 45 percent to 78 percent and access to primary health services from 30 percent to 70 percent). However, HIV/AIDS is threatening these achievements, becausethe epidemic affects these sectors' staff. Instit~tionaldevelopment and governance. The CAS mentions weak administration as the binding constraint on Mauritania's ability to absorb assistance. The proposed project will address this issue by supporting the creation of a "small" unit, namely the National HIV/AIDS Executive Secretariat (NAES) which would guide programs and facilitate implementation through contracting out services such as financial management, procurement, andmonitoringand evaluation. 2. Main sector issues and Government strategy: HIV/AIDS has only recently been recognized as a major potential threat to Mauritania's future. While knownprevalence rates are low (average 0.57 percent) these are clearly on the rise with prevalence levels upto 1percent inareas such as the northerntown ofNouadhibou, which is the maineconomic center in the country with large fishingandminingindustries, and southern border towns inthe agricultural areao f the Senegal River. Simulations based on a reliable model (Robalino 2002) show that, without any intervention, the prevalence rate may increase to over 5 percent by 2009 and reach 15 percent in 2015 (see Annex 4). The potential impact o f such evolution may be considerable in terms o f human lives, health costs, productivity, social costs, education, and the need for social services, According to the National HIV/AIDS Strategic Framework (August 2002), the higher at-risk groups include: (i) migrant populations, including truck-drivers, seasonal rural workers, and traders, (ii)youth, (iii)women, particularly the young andpregnant, (iv) uniformed persons, (v) sex-workers, and(vi) fishing andmining workers. In Africa, there i s a strong gender inequality v i s - h i s HIVlAIDS (58 percent o f HW-infected Africans are female). Although data are not yet available to confirmthis tendency inMauritania, several social characteristics suggest that women are more at-risk than men; early first marriage o f girls (median age 17 years), frequent divorce and subsequent mamages (39 percent o f women in Nouakchott), combinedwith poverty (46 percent o fthe sedentarypopulation and61 percent o frural people live below the poverty threshold) and low education level o f women (only 28 percent o f women are literate, comparedwith 49 percent o fmen); andthe general practice o fFemale Genital Cutting(FGC) (71percent o fMauritanian females inEDSM2001). NationalInitial Responseto HIV/MDS The Programme national de lutte contre le SIDA (PNLS) was established in 1989, soon after the first Mauritanian AIDS case was identified. A UN Theme Group on AIDS was formed under the chairmanship o f WHO, and a UN technical committee was created to address specific aspects o f a national strategy, usingthe UNGASS as a framework. The national programhadlittle initial support. The Government's response to the unfolding HIV/AIDS situation has been to focus primarily on its medical and health-related aspectsunder the leadership o f the MOHSA through PNLS. More broadly, HIVIAIDS drew limitedattentionfrom the national leadership becauseit was a taboo subject; there were virtually no visible signs that HIVIAIDS existed; and there was a widely held notion that the national culture and behavior shielded the country from the epidemics inother Afiican countries. Under the leadership o f the PNLS, with WHO support and encouragement, an advocacy effort was launched to sensitize opinion makers. It culminated, in 2001, in an AIDS discussion inthe Senate carried live over national radio. O f major importance, after careful study and deliberation, religious leaders began to reach out to their constituents with a message o f tolerance for those infected, and a recognition o f the need to educate the populationonthe risks, andmeans to avoid its transmission (the Mauritanian NGO "Stop-SIDA", one o f the most active in the sector, was formed by an Imam). Community involvement in HIV/AIDS started only recently. International NGOs built partnerships with National NGOs, a sub-group o f which i s - 5 - organizedina network dedicated to HIV/AIDS (RONASIDA) withinwhich the NGO "Stop-SIDA" plays a major role. Recent developments relatedto HIV/AIDS A NationalHIVIAIDS Strategic Framework was discussed during a national seminar inAugust 2002. It recommended the creation o f multisectoral NationalHIV/AIDS Committee (NAC) which was created by the Ministers Council in October 2002 under the chairmanship o f the Prime Minister, comprising high-level representatives o f the public and private sectors, the civil society, and FBOs: Ministers and State Secretaries, the Commissioner for Human Rights, representatives o f local government, Civil Society Organizations (CSO) and NGOs, private sector, and People living with HIV/AIDS (PLWHA). The NAC's mandate is to adopt HIV/AIDS strategies and policies, ensure advocacy and mobilize resources, ensure a multisectoralresponse, donor coordination, andmonitoring andevaluation o f sectoral HIV/AIDS action plans. The HIVIAIDS Strategic Framework provides clear objectives and strategies andconstitutes anappropriate framework for the MACP. The Government and the NAC took rapid actions to speed up the preparation o f the MACP: (i) the Director o f the NAES was appointed by the N A C inNovember 2002. The NAC agreed that the NAES would be staffed with the key following professional experts, selected through competition from the private sector: (i) Deputy-DirectorlCoordinatoro f the Civil Society Initiatives (CSI), (ii) Coordinator o f line ministry action plans, (iii) a specialist in capacity buildingand training, (iv) an IEClBCC specialist, (v) an M&Especialist, (vi)a procurement specialist, (vii) a financial andaccounting specialist, and (viii) a private sector specialist. The selection process has started and will be completedbefore effectiveness. The legal framework for MACP implementation was established by the Government inMarch2003: (i) a Prime Minister Decree (No 027-2003 dated March 24, 2003) created the NAC, the Regional HIV/AIDS Committees (RACs) with a composition mirroring the NAC and a Special Tender Board competent for all HW/AIDS-related procurement; (ii) a Prime MinisterArr& (No 631dated April 1,2003) created the NAES andthe Regional HIV/AIDS Executive Secretaries (RAES). The Biomedical Waste Management Planwas adopted by the Government anddisclosed in-country andinthe Bank's InfoShop inApril 2003. Duringthe MACPpreparation, eight Ministriesprepared their Sectoral HIV/AIDS Action Plans through national and regional workshops. These Action Plans were reviewed by the Bank and approved by the NACbeforeproject negotiations. 3. Sector issuesto be addressedbythe project and strategic choices: The basic issue for the MACP i s to address the spread o f HIVlAIDS in a multisectoral manner. The Multi-Country HIV/AIDS Program for the Africa Region (MAP),approved by the board o f Directors o f the WorldBank Group inJanuary 2002, provides the framework to do so. Mauritania is eligible for MAP fundinginthat ithas satisfied the four basic MAP eligibility criteria, namely: (a) Satisfactoty evidence of a strategic approach to HIV/AIDS. Mauritania has a National Strategic Framework discussedat a national workshop inAugust 2002. (b) A high-level HIV/AIDS coordinating body. The Government created, in October 2002, a high-level, multisectoral, National AIDS Committee WAC) with representation from the public and non-public sectors. The legal status o f the NAC is provided by the Prime Minister Decree No. 027-2003. (c) Government5 agreement to use appropriate implementation arrangements. Government has agreed to accelerate project implementation by contracting services for financial and procurement management, monitoring andevaluation, and for capacity-building. (d) Government`s agreement to use and fund multiple implementation agencies. Government has agreed to progressively expand HIV/AIDS activities to cover a broad range o f Ministries, starting with eight o f them. Most importantly, a large portion of the funding will finance activities undertaken by - 6 - NGOs and CBOs, andthe private sector. HIV/AIDS is a complex, multifaceted, development problem requiring long-term, sustained and broad-based responses, including a range o f activities involving virtually all levels and sectors o f government and society. Rapid spread o f the HIV/AIDS epidemic would have damaging consequences for sectors such as education, agriculture, fisheries, and the mining sector, which are key for the future development o f Mauritania. At the same time, each o f these sectors could, in turn, make significant contributions to the overall fight against HIVIAIDS. The project will begin with core activities that are ready for implementation. Support to capacity-building and policy development will help galvanize the fight against HIV/AIDS, as well as organize preventionand care activities insectors andcommunities not yet engaged. Activities within the various sectors will be geared toward reachingthe personnel and staff involvedinthese sectors and using them as agents in the fight against the HIV/AIDS epidemic. First, uniformed persons, and other civil servants will be trained inHIV/AIDS as well as how to organize prevention and care activities. Second, these staff will be prevention agents for the people with whom they interact. Such sector staff will refer their constituencies to services that will be provided by the health sector. Third, these civil servants, in their capacity as community members, will advocate, contribute to, and participate in community, civil society, and private sector initiatives. Taking an example from a key sector such as education, this approach works in the following manner: First, teachers will be targeted for IEC and BCC programs. Teachers will be enrolled as key agentsand role models inthe fight against HIVIADS. Second, students, when properly informed and educated about the dangers, will themselves become competent communicators o f HIV-related prevention messages to their age group peers, friends, parents, and the society at large. Teachers will also promote behavioral change messages through their interactions with the Parents-Teachers Associations (PTA) and other in-school and out-of-school groups, constituencies, and organizations. Orphans and vulnerable children from HIV/AIDS infectedlaffected families will be possible beneficiaries o f civil society initiatives, e.g. school fees paid from MACP grants. Similarly, the Ministryof Rural Development, as well as the Secrgtariat d'Etat Ci la Condition Fgminine (SECF) and the Ministry o f Labor, Youth and Sports, have important roles to play in the concerted effort to inform andmotivate farmers andpeasants, cattle farmers, m a l women, and youth to prevent the spread o f the virus. Their staff will cooperate inthis effort; extension agents, who are oftenmore mobile than inother sectors --andtherefore more at-risk-, would be trained to communicate with the rural communities about HIV/AIDS.The Ministryo f Culture and Islamic Orientation(MCOI) will also play a crucial andspecific role inthe national fight against HIV/AIDS because it overseesthe activities o f all Imams inthe country andhas decidedto facilitate andorganize their full involvement inthe war against this disease. At MACP appraisal, eight ministries had thoroughly prepared Sectoral Action Plans (see Annex 13) which are ready for implementation. The transport sector is crucial for the future development o f Mauritania. Transport workers, whether truckers, bus drivers, taxi drivers, or those involved in providing services to them (garages, mechanics, road repair and construction crews, food vendors, rest stops) have both the mobility and the income to make them natural vectors for HIV/STI transmission. Improved rural road networks are likely to attract not only settlements, trading facilities, and truckers, but also potential vectors for the spread o f the infection such as commercial sex workers. The miningsector has boththe wherewithal, outside contacts, and working environment which are essential elements for potential acceleration o f the infectionrates. With many permanent and semi-permanent workers, numerous suppliers, visitors from outside and opportunities to go abroad, conditions are ripe for HIV expansion in this sector, unless measures are taken. The fishery sector i s another key productive element inthe economy which represents a possible major conduit o f HIV virus expansion. With incomes above the national average, mobility, contacts with - 7 - highrisk groups inharbors, andtaking into account onboard ship lifestyles and culture, this is a sector which requires special attention. The MACPhas earmarked for the private sector about 10percent o f the resources gearedto support the Civil Society Responses, andthe NAC has agreedto staff the NAES with a specific agent to coordinate the support to the private sector (see Annex 16). The health sector inMauritania has unique responsibilities and expertise. First, this sector i s responsible for specific aspects such as epidemiological oversight, preparation and supervision o f treatment, protocols, testing, management o f the blood supply system, quality assurance and provision o f drugs for HIV/AIDS, STIs, T3, and other opportunistic infections. It i s the supplier o f such services, products, or both, assuring their availability, quality, and affordability. Healthpersonnel (nurses, midwives, doctors, laboratory technicians, pharmacists) need to be proficient in how to provide such services, and counseling related to these services, products, or both. They should also support other sectors to offer simple medical care, amongst others, for PLWHAs and assure that national standards are followed. Second, inMauritania health facilities serve as referral units for other sectors, NGOs, the private sector, and communities. Third, health personnel must become key allies in the fight against HIV/AIDS, in its prevention, treatment, andcare dimensions. Health services will not only have to performtheir customary service supply functions, but also welcome and help patients referred by others. Currently the World Bank-financed Health sector project - PASS - provides resources for the health sector to fulfill some o f these functions; however, available resources will be inadequate to take on the intense level o f activities required. The MACPdevotes a specific component to the Health Sector responseto HIVIAIDS. Community involvement i s fundamental for an effective HIVIAIDS containment campaign. Community, civil society, and private sector activities are needed to support prevention as well as care o f those infected and affected. Such efforts empower communities to heightenthe awarenesslevel o f their risk o f AIDS, fight discrimination against individuals infected andlor affected by the HIV virus, and can be an incentive for individuals to seek preventionandcare services when needed. Despite its recent emergence and weak capacity, the NGO sector has been involved early in the fight against HIV/AIDS, often anticipating activjties which are planned to be scaled-up by the MACP (see Annex 12). International NGOs are already active inproviding HIVIAIDS counselling to high-riskgroups such as sex workers, while national NGOs are active in providing support prevention and care to PLWHAs. International NGOs have nurtured local NGOs specialized in HIV/AIDS peer counselling which already trained several hundred o f peer counsellors amongst uniformed persons and the private sector (SNIM). Some local NGOs such as STOP-SIDA constituted appropriate means for an active involvement o f Islamic leaders in the day-today battle against HIV/AIDS Imams -- as --developing, for instance, a training manual for well as a forum to facilitate discussions andthinkingregardingthe relations betweenIslamic Laws and the status o f HIVIAIDS-infected persons and the fight o f the Islamic community against the HIV/AIDS threat. Mauritanian grassroots-level communities have long standing solid rural and urban community-based organizations spread all over the country, such as Women Cooperatives or Parents Associations. However, these organizations lack formal management capacity and have not yet been involved inthe fight against HIV/AIDS. The MACP will focus on capacity-building o fthe NGOs, FBOs, and CBOs, and will allocate the larger share o f the finds to their community-driven responses to HIVIAIDS. Strong emphasis will be placed on home-based care and counseling o f both patients and families. C. Project DescriptionSummary 1. Projectcomponents(see h e x2for adetailed descriptionandh e x3 for adetailedcost breakdown): The proposed project will have four components: (1) strengthen the capacity o fgovernment agencies and - 8 - civil society, and project administration; (2) expand multisector public (non-health) responses for prevention and care o fHIVIAIDS; (3) expand health sector responses for prevention, treatment, and care of HWIAIDS; and (4) develop and expand civil society organizations and private sector initiatives for HIVIAIDS. Component 1.Strengthen Capacity of Government Agencies and Civil Society, and Project Administration The main objective o f this component is to put the national HIVIAIDS apparatus in place. This component would aim at strengthening Mauritanian capacity to cope with the spread o f HIVIAIDS through the following six sub-components: (i) Capacity Buildingfor National Strategies, Policy and the Program sub-component will support the N A C to ensure that it has the full capacity to perform its responsibility to develop HIVIAIDS-related policies, oversee the national HIVIAIDS program, review its performances and approve work programs and budgets; (ii)the Capacity Building for Project Administration sub-component will support the installation andthe operation o f the National HIVIAIDS Executive Secretariat and the Regional HIVIAIDS Executive Secretariats to ensure they have the capacity to perform their mandates to provide secretariat services to the N A C and the RACs and be responsible for the overall Program administration, coordination, and facilitation; (iii) the Institutional Capacity Building of Line Minis~iesfor HIVAIDS Responses sub-component will help building and maintaining capacity of all participating Ministries to prepare, implement, monitor, and evaluate HIVIAIDS sectoral action plans; (iv) the Insti~utionalCapacity Building of Communities, CBOs and NGOsfor HIVAIDS Responses sub-component will improve the capacity o f CBOs andNGOslFBOs to identify, prepare, and implement sub-projects, mainly through the implementation o f a Grass-roots Management Training (GMT) program; (v) the Advocacy, Training, and Technical Support Activities sub-component will broaden the types of groups engaged inthe fight against epidemic, create networks, ensure that the programwill reach the less visible high-riskpeople, stimulate community-based responses to include socially delicate HIVIAIDS-related issues (such as FGC), and developlimplement a culturally acceptable social marketing approach for condoms; and (vi) the Assessment, Monitoring and Evaluation sub-component will support the installation andoperation of an operational M&E system on the basis of which balanced management and strategic decisions can be made by the NAC and all partners about priorities, contents, andapproachesof the HIVIAIDSprogram, actionplans, andsub-projects. Component 2. Expand Multi-public sector (non-health) Responses for Prevention and Care of HIVIAIDS This component will improve the capacity o f non-health sector line Ministries and associated "projects" to respond to HIVIAIDS, emphasizing prevention and care. The component will have two sub-components: (i)Support to Ministries' Action Plans for HIVAIDS Control; and (ii) Promo~e/EnhanceHIV/AIDS Agenda in Existing "Projects". The objective of the first sub-component will be achieved through development of sectoral policies, coupled with a two-prong action approach, namely: (i) the provision to the line ministries staff and their dependents o f HIVIAIDS and STI education, training, condoms, and other support, to encourage HIVIAIDS and STI avoidance behavior; and (ii) the enhancement o fthe capacity o f these staffto provide their partners andaudiences (e.g. PTAs, mine worker associations, fishing community associations, women's cooperatives and groups) with the means to provide effective HIVIAIDS and STI prevention, ways to access health care facilities, treatment, and care. Line Ministries either have or will appoint HIV/AIDS management committees to carry out policies and action plans for HIVIAIDS and other opportunistic disease control, with support from the Project interms o ffacilities, equipment, andincrementaloperatingcosts. They will integrate the HIVIAIDS sector responseinto their ongoing operations. The objective of the second sub-component is: (i)bringtheHIVIAIDSinformationto"project" implementationagencies,throughmechanismssimilar to - 9 - to the one mentioned above for line ministries, and (ii) use the operational mechanisms currently to implemented by these "projects" to reach out their clients and help them in identifying and submitting sub-projects to the NAESIRAES for subsequent implementationo f these sub-projects with the "project" assistance. In this context, an Urban Development Project Action Plan, for instance, will help Municipalities to prepare and implement HIVIAIDS municipal responses, as decentralization takes on momentum. Seven sectors -education, rural development and environment, culture and Islamic orientation, women affairs, civil service, youth and sports, communication and relations with Parliament, and uniformed services (army, police, national guard)- have prepared Sectoral Action Plans, with UNAIDS and IDA support, which were reviewed during the project appraisal mission and were approved by the NAC before project negotiations. Other Ministries that will demonstrate interest in the course o f the project will be added on an annual basis. Line Ministries have the responsibility to decide how to achieve the two goals o f (i) information andbehavior change o f Ministerial staff as regard HIVIAIDS,and (ii) their staffs reaching their constituencies on issues related to HIVIAIDS. These plans will be implemented in phases and be coordinated by an HIVIAIDS Coordinator through a ministerial HIVIAIDS management committee, They will provide resources for: information, assessments, policy formulation, monitoring and evaluation, training, technical advisory services, HIVIAIDS and IECICCB materials, VCT, condom distribution costs, and support for facilities and equipment, including incremental operating costs to effectively carry out this effort. Component 3. Expand Health Sector Responsesfor Prevention, Treatment, and Care of HIV/AIDS/STIs/TB The Ministry o f Health and Social Affairs (MOHSA), and more broadly the health community, have special responsibilities for HIVIAIDS prevention and management. The basic features differentiating the health sector from other sectors are related to its medical functions such as diagnosis and treatment o f opportunistic infections, care at health posts, health centers and hospitals, and laboratory analysis. This sector therefore warrants a separate component, making provisions for prevention, treatment, and care from a health sector perspective, whether public or private. The health sector response i s composed o f six main sub-components: (i) Surveillance and Epidemiological Research sub-component will provide the information about the evolution o f the epidemic, using biological and behavioral surveillance and additional research among the general population and more particularly vulnerable groups, and may include upgrading o f some existing laboratories within their existing compounds; (ii) the Prevention and Voluntary Testing and Counselling (VCT) sub-component will have the following seven primary objectives: increase the number o f quality VCT to cover all major population concentration sites; promote behavioral changes for safe sex practices through Communication for Change o f Behavior (CCB) strategies; promote condoms; provide quality STI prevention and treatment; prevent Mother-to-Child-Transmission (MTCT); prevent nosocomial infections; and ensure that safe and appropriate blood transfusions are available whenever necessary at the regional level; (iii) the Care and Treatment of People Living With HIV/AIDS ( P L M ) subcomponent will support the provision o f free quality treatment and psycho-social support to PLWHAs in order to reduce transmission, disability among workers and, generally improving peoples' lives; (iv) the Training of Traditional Health Practitioners, Birth Attendants and Community Health Workers sub-component will help the MOHSA reach the population through culturally acceptable channels by involving traditional health practitioners, birth attendants, and community health workers in the prevention, treatment, and counselling o f HIV/AIDS;(v) the MOHSA Personnel sub-component has the objective to create a consciousnessamong the health staff conceming the risks o f sexual transmission o f HIV and adopting safe sexual practices; (vi) the Manage~entof Bio-Medical Waste sub-component will address the current shortcomings inthe matter. - 10- Component 4. Develop and Expand Civil Society Organizations and Private Sector Initiatives for HIVlAIDS Civil society, and private sector initiatives are the backbone o fthe Project. This component's objective i s to provide the resources for a broad spectrum o fpreventive and care activities that reach beneficiaries to the widest extent possible. The largest part o f total project funding will be allocated to these activities, earmarked for nongovernmental, community-based, and private sector initiatives, the latter receiving about 10 percent of this component's resources. Given the differences between partners regarding their visions, roles, and organizations, this component is organized in two sub-components: (i) the first sub-component aims to Expand Civil Society Organization Initiatives to HIV/AIDS, i.e., grassroots communities, CBOs and NGOs, as well as Associations and Local Governments, by building "AIDS competent communities" for prevention, care, and social support; (ii) second sub-component aims to the Develop and Expand Private Sector Enterprise Initiatives for HIV/AID& its objective i s to build awareness and capacity within the private sector -Le. small, medium and large scale enterprises--, and have this sector actively participating to the national AIDS agendaby implementing prevention, care and support strategies for their employees andtheir families. Prevention activities conducted by NGOs and CBOs, as well as the private sector, will be designed to reduce high-riskbehavior andexposure to risk, reduce the vulnerability o fthose who are unaware o ftheir risk or cannot protect themselves, and to "de-stigmatize" the disease so as to increase access to prevention andcare. For families affectedby HIVIAIDS, the objective would be to reduce the impact o f their plight by financing services to provide care for PLWHAs, but especially for HnrlAIDS symptomatic persons and their dependents, for orphans, and for income-generating activities. The management o f this component will be governed by a specific section of the Project Implementation Manual (PIIM). Civil Society Organizations and Private Sector Enterprises and Organizations will identify, prepare, submit and, if eligible, implement sub-projects. Sub-projects o f national or multi-regional scope, or o f large financial amounts, will be evaluated, approved, and financed at the national level by the NACNAES, while sub-projects o f a local scope andlor small financial amount will be evaluated, approved, and financed at the regional level by the RACIRAES. The activities to be financed would be as broad and flexible as possible. The PIM provides a strict negative list, and an "illustrative" positive list which i s not intendedto limit the scope o f activities that may become eligible for funding under this component. Preparation and implementation o f sub-projects will be facilitated by simple forms provided by the PIM andsimplifiedprocurement and financial procedures also provided by the PIM. InMauritania, NGO and CBO capacity has not been sufficiently recognized or tapped, andthis Component will reach out to tap this resource by supporting these groups to strengthen their capacity through a learning-by-doing process (which will be complemented by the capacity-building support implemented under component 1). The operation procedures will be based on a contractual process by which sub-projects' performance will be measured by "results" rather than documentation on input expenditures. Activities would inter alia address the following areas: (i) information education and communicationlbehavioral change communications (IECICCB campaigns); (ii) support to high-risk groups and vulnerable groups subject to sexual abuse; (iii) youth-related activities; and (iv) condom supplyanddissemination. - 11 - 1. Strengthencapacity ofgovernment agenciesandcivil 6.60 28.2 21.9 society, andproject management 2. Expandmulti-public sector (nonhealth) responsesfor 3.90 16.7 3.80 18.1 prevention andcare o fHIV/AIDS/STIs 3. Expandhealthsector responsesfor prevention, 4.70 20.1 4.40 21.o treatment, andcare o fHIV/AIDS/STIs/TB 4. Develop and expand civil society organizations and 7.60 32.5 7.60 36.2 private sector initiatives to HIV/AIDS 5. Project Prenaration Facilitv 0.60 2.6 0.60 2.9 Total Project Costs I 23-41) I 100.0 I 21.00 I 100,o Total Financing Required I 23.40 1 100.0 I 21.00 I 100.0 2. Key policy and institutionalreforms supported by the project: The Project is a multisector and multi-partner operation that has required an important institutional reform to be set up. The key institutional innovations introduced are the following: (i) the establishment o f a multisector/multi-partner National HIV/AIDS Committee (NAC) which brings together key stakeholders from the public sector, the private sector, and the civil society, includingFBOs and ONGs; and Regional W / A I D S Committees (RACs); (ii) establishment of a Secretariat for the NAC, the the National HIV/AIDS Executive Secretariat (NAES) and Secretariats for the RACs, the Regional HIV/AIDS Executive Secretariats (RAES), staffed by high-level professionals; (iii) adoption o f an the HIV/AIDS National Strategic Framework; (iv) the establishment o f an innovative financial mechanism for channelling resources to sectors, the private sector, the NGOs and to the community level; (v) the establishment o f a Special Tender Board for HIVIAIDS-related procurement; and (vi) the establishment of a sound monitoring andevaluationmechanism. Other key policy andinstitutional refonns supported bythe project are: 0 Rights o fpeople livingwith H.IV/AIDS( P L W A ) or people affectedby HIV/AIDS; 0 National HIVlAIDS communicationpolicy; 0 National workplace policy; 0 National policy onVoluntary Counselling and Testing (VCT) for HIV/AIDS; 0 Mauritanian adherence to the "ACCESS" initiative; 0 National policy onthe Preventiono fMother-To-Child Transmission (PMTCT); 0 Legal framework for condompromotion; 0 National policy onpublic sanitation; 0 Cost coverageofcondoms, HIVtesting, andantiretroviral treatment; 0 National planonmedical waste management. 3. Benefits andtarget population: The Mauritanian population at large will benefit directly from avoidance o f HIV infection, AIDS and other opportunistic infections, and from better access to treatment, care, support, and mitigationactivities supported bythe project. The following beneficiary groups will be particularly targeted 0 Women and youth will benefit from targeted interventions to improve their awareness o f the - 12- diseases, andempower them to protect themselves. Defense and other uniformed persons (police, customs, prison warders), miners, fishersheamen, transport workers, construction builders, which are the more at-risk groups, will have considerable attention and will benefit from specific interventions to empower them to protect themselves, their families, andtheir clients, All ministry staff, their families and the people with whom they work, will have better access to information, counselling, VCT, treatment, care, and support. Communities will be better able to plan and manage their own response to the epidemic o f HIVI'AIDS,tuberculosis, includingsupport to health-related orphans and vulnerable children. Training o f religious leaders and Imamswill be expanded to better help the national community to understand and respond to the HIV threat, and provide community assistance to infectedlaffected peoplelfamilies. PLWHAs will benefit from the reduced stigma and improvement o f human rights, from improved care at home and in their communities, in health facilities, and therefore, from prolonged and healthierlives. Health workers will be better protected against the risk o f being infected during their work, and the population at large will be better protected against risks generated by bio-medical waste including HIV-infectedwaste. Sex workers will also be able to protect themselvesandbenefit from improvedhumanrights. The project will avoid more than 6,500 death andreduce new infections by more than 45,000, especially among young people; therefore having an impact on reducing future suffering and premature death. The prevention o f the epidemic at its early stage, will prevent the human resources destruction that would result from non- or insufficient action at this stage, andwill free budgetaryresources which would have been absorbed by a later response to the epidemic. Both increased financial resources and the healthier labor force made possible by the prevention o f AIDS-related illnesses (and death) will substantially increasethe total economic benefit to all Mauritanians. 4. Institutionalandimplementationarrangements: Mauritania adopted in August 2002 its National Strategic Framework to fight HIV/AIDS d e f ~ n gthe main institutional arrangements. The proposed Project would be implemented over a five-year period within this framework. The rolelfunctions of the various partners in the Project are briefly described below andpresentedinmore detail inAnnex 14. The National HIV/AIDS CommitteemAC (Comitb National de luge contre le MHSIDA -CNLS) oversees the National HIV/AIDS/STI Strategy and Plan o f Action, supervises the national program responding to the HIV/AIDS epidemic -including the proposed MACP- and monitors its performance. The N A C is responsible for the preparation, and implementationo fthe proposed Project andmonitoring its performance. The N A C i s a very high-level, multisectoral and multi-partner committee chaired by the Prime Minister, and includes the following representatives o f both public and non-public sectors: line Ministers and State Secretaries, the Commissioner for Human Rights, Fight against Poverty and Integration, representatives o f Local Govemments, FBOs, NGOs and other SCOs, PLWHA association, the private sector, and development partners. The N A C i s assisted by the NAES. To facilitate its day-to-day work, the N A C has created a Sub-committee (Comitk Restreint) o f eight members reflecting the broad composition o f the NAC. Regional HIV/AIDS Committees (RACs) will be set-up with a composition similar to the NAC, to coordinate the sectoral Action Plans at the regional level and promote, facilitate, and approve sub-projects o f the CSOs at their local level. The N A C creation was decided by the Minister Council dated October 2, 2002. The NAC, its Sub-committee, and the RACs have been establishedunder the Prime Minister Decree N o 027-2003, dated March 24,2003. -13- The National IfIV/AIDS Executive Secretariat (NAES) i s the administrative, coordinating, fiduciary, and monitoringmechanism for the NAC, It will report to the NAC and :(i) serve as NAC secretariat; (ii) coordinate, monitor, and review activities in Mauritania related to HIVIAIDS including: assisting inthe preparation and review o f line ministry annual plans, coordinating HIVIAIDS training and IECICCB, overseeing operational research and studies; monitoring and evaluation o f all HIVIAIDS-related activities; (iii)managing MACP resources with two Special Accounts: one for the Line Ministries' Action Plan(except Health) andthe NACNAES activities, one for the CSI; and a Government's Project Account. The NAES would not be an implementing agency. It will have a small core professional staff comprised o f a Director, Deputy DirectorlCoordinator for the CSI; Coordinator for the line ministry's Action Plans, Capacity Buildingand Training specialist, IECICCB specialist, M&E specialist, Private Sector Specialist, a Procurement specialist and Financial management and Accounting specialists. The NAES Director was nominatedinNovember 2002. The selection o fthe remainingstaff is on-going andi s expected to be completed before negotiations. Regional HIVlAIDSExecutive Secretariat (RAES) will be gradually set up to both serve as RAC secretariats, and be responsible for (i) promoting and coordinating HIVIAIDS actions at the regional level, (ii) managing resources to finance the responses of the local Civil Society, and (iii) providingsupport to local CSOs. The NAES creation was decided bythe Minister Council dated October 2, 2002. The NAES and RAES have been established by the Prime Minister's Arrttd No. 631, dated April 1,2003. Line Ministries. The implementationo f each Sectoral Action Plan(SAP) will be the responsibility o fthe concerned line ministries. Eachministry has appointeda full-time coordinator andhas created a sectoral committee responsible for the preparation and implementation o f the Sectoral Action Plans. They will receive budget allocations through contractual annual Work Plan Agreements (WPA) based on their approved Sectoral Action Plans, to carry out sector HIV/AIDS-related activities. The ministries which have demonstrated a positive experience of managing IDA funds (such as MOHSA, MEN, MDR, and SECF) will manage the resources, allocated to them under the WPA, bythe same project implementation unit which currently manages other IDA funds, including all related procurement activities, Other ministries, which have not demonstrated this capacity, will be assistedby the NAES which will carry out procurement o flarge contracts for them. Ministry of Health and Social Affairs (MOHSA). The Health Sector HIVIAIDS Action Plan will be carried out by the MOHSA, using and building on existing institutional, administrative, and logistical capacity developed under the IDA-financed Health Projects. Given its solid experience inmanagingIDA funds, andits specific role inthe program, the MOHSA will managea specific (third)Special Account to finance its Action Plan. Civil Society Organizations (CSOs). Implementation of sub-projects will be the responsibility o f the promoters: Communities, CBOs, NGOIFBOs, Local Govemments andprivate enterprises participating in the program. Funds for CSOs will be channelled through a demand-driven approach based on contracted sub-projects conceived, submitted, and implemented by CSOs. The project will provide them direct financing inthe form o f grants. For sub-projects o f regional or local scopeandlimited financial amounts, review and approval o f these sub-projects will be managed at the regional level by RACiRAES. Small grassroots communities and CBOs may receive support from NGOs. Procedures describing the sub-project cycle have been developed on a participatory basis with the NGO networks and are incorporatedto the PIM. Implementation arrangements A Project ImplementationManual (PIM), containing all project procedures, includingprocedures for - 14- community-based, and NGO-based procedures has been developed through a participatory process involving all key actors and civil society. It defines institutional and implementation arrangements, the respective responsibilities and mandates o f each participating entity and the fimctional relationship between actors. It i s composed o f four volumes: (i)the first volume describes the institutional arrangement and project management arrangements; (ii) the second volume describes procedures for the implementation o f the capacity-building component (Component 1); (iii) the third volume describes the procedures for the implementation o f the Sectoral Action Pans, including the procedures o f the SAP cycle: preparation, submission, technical review, approval, contracting, and execution o f a Sectoral Action Plan (Components 2 and 3). Itwill include a sample o f standardAction PlanAgreement; (iv) the fourth volume describes the procedures for the implementation o f the Civil Society component (Component 4), including the Sub-project cycle: information, participatory needs analysis, submission, technical review and approval o f sub-project proposals, contracting and execution o f approved sub-project including community-based financial and procurement procedures. The draft PIM was developed and discussed by all stakeholders during the project preparation through an iterative process includingnational workshops duringthe appraisal mission andbefore project negotiations. However, this PIMwill remain a livingdocument that will be fine-tuned accordingto the experience o f managersand implernenters, acquired duringimplementation. At the end o f the first full year o f implementation, it will be reviewedandrevisedwith a view to improvingefficiency inlighto f lessonslearned. The project will be implemented in an incremental manner starting with those Line Ministries, public agencies, decentralized levels o f government, NGOs, CBOs and private enterprises which already have Action Plans or Sub-projects. Coverage will be extended to other sectors and organizations o f civil society as implementationcapacity i s strengthened and Action Plans or Sub-projects prepared. Monitoringandevaluation The project will be a "learning by doing" process; therefore a solid M&Esystem will be a key feature o f the project design. An overall project M&Esystem will be established containing: (i) activity monitoring andevaluation, (ii) monitoring o f the epidemic and its impact, (iii)financial monitoring o f the fmanced action plans and sub-projects. Ownership o f the system, felt by all stakeholders, i s vital and all levels, including the communities will be involved in the development o f the procedures, culminating in a manual o f M&E procedures. Structured feed-back and regular contact by supervisory visits will be a main feature o f the M&E system. The M&E system will establish databases on past activities experiences andresults (both national andintemational), as well as for epidemiological data, that should be readily accessibleat different levels, so that people will be able to learnfrom others' experiences. Experience has taught that program activities have not been sufficiently followed in the past. Inthe Mauritania HIVlAIDS project this will now get ample attention. Activities at every level will be monitored following a relatively simple format, so that even the most peripheral levels are able to keep records o f activities; therefore the collection and reporting procedures must be as simple as possible. It should contain a standardized core: if each implementing partner uses different systems or tools, it will be impossible to analyze or summarize the data. However, this does not preclude partners from collecting additional, situation-specific data. The collected data should be used for improving the execution o f the activities. To achieve this objective, the project will develop the Community's capacity incollecting and analyzing data, necessitating adequate community training andappropriate tools such as self-assessment and auto-evaluation, so that communities will be able to estimate the effectiveness o f the ongoing activities. There will be, training and capacity-building for higher echelons, wherever activities are executed. External supervision will confirm or adapt the findings o f the executing agencies or communities to improve the quality o f the activities and services offered. At higher levels (regional and national), analyses will be more comprehensive andwill enable the verification o f the completeness and - 15- accuracy o f collected data. The system shouldbe able to indicate, on a short-term basis, what activities seems to be effective, inorder to adapt strategies. As there willbe a large volume o f data to be collected, a specialized entity will be contracted to collect and organize (andpossibly pre-analyze) the data before presenting it to the NAES. The data on activities will be linked to the contracts with the executing organizations, inorder to follow-up on the balance between disbursement andactivities executed, The second aspect o f the M&E system i s the monitoring o f the epidemic; this will be done through a national biological and behavioral surveillance o f STIfHIVlAIDSITB, to be translated insexual behavior rates and trends. To this end, the MAP will support Mauritania in implementing, every 2-3 years, a survey o f "a second smart generation" recently developedby WHO and W A D S , combining biomedical and behavioral surveillance, targeting vulnerable groups. Every five years a larger nation-wide survey will be executed with financial and technical assistancefrom other donors. The social impact evaluation will bepart andparcelo fthe monitoring o fthe epidemic, done byintermittent surveys. Finally, financial management monitoring o f NAC, the public sector and civil society utilization o f resources and funds will be done to establish the relationship between disbursement and activities. Combining financial and program monitoring provides a basis to cross-check financial and activity data and to ensure sound finance program data cross-verification. It must be realized that this does not encompassaudit procedures. (A detailed overview i s presented inAnnex 12). Financialmanagementanddisbursementprocedures Details on the project financial arrangements are provided inAnnex 6B. The NAES will have the overall responsibility for project financial management and disbursement. NAES will establish a central Financial and Administrative Unit (FAU) andregional financial units inthe RAES staffed with qualified personnel, The central FAU staff will be provided by a reputable firm. The regional staff will be gradually recruitedby the NAES on a competitive basis, along with the gradual installationo f the RAES. Therecruitmentof the centralFAUstaff will be completed before project Effectiveness. The objective is a smooth, reliable, efficient andwell-controlled flow o ffunds from the NAES directly to the implementing entities, The NAES will managetwo Special Accounts A and B and Project Account 1 to accommodate project counterpart funding. Special account A will be dedicated to payments for the Capacity-building component (Component 1) andto the Line Ministriesexcept MOHSA (Component 2). Special Account B will used by the NAES for payments o f grants to finance sub-projects o f the Civil Society Component (Component 4). Transfers o f funds will be based on contractual arrangements betweenthe NAES andthe implementing agencies, for the execution o f agreed Sectoral Action Plans and Sub-projects. This will facilitate immediate disbursement o f funds to the implementation entities. The MOHSA will manage Special Account C which will be dedicated to payments for the HIVIAIDS Action Plan o f the MOHSA (Component 3) and Project Account 2 to accommodate related counterpart funding. The Regional RAES will manage Sub-accounts financed from Special Account B. The Government has opened the two Project Accounts and confirmed that the funds to be deposited inthe said accounts are available andready to be transferred. An assessment o f the financial managementcapacity o fthe various implementing entities to manage the funds transferred, including the 8 Ministries having prepared a Sectoral Action Plan, was conducted by the Bank during project appraisal (document in the Project File, see Annex 8). Eight to fourteen Ministries may be involved in Component 2 with Action Plans estimated between US$310,000 and US$l,OOO,OOO over five years. MinistryAction Plans will be financed by NAES to each ministry out o f Special Account A. Given the interwoven nature o f financial and procurement management, it was -16- agreed that, for all Ministries including MOHSA, the same unit should have both financial and procurement responsibility for activities related to the ministry's smart W / A I D S Action Plan. On this basis, Ministries were classifiedinto the following two categories: Category 1:Ministries which have an existingprocurement an~~nancialmanagement capacity and Category 2: Ministries which do not have adequate~nanc~aZmanagement capacity. These arrangementsare detailed inAnnex 6 (B). Fundswill be transferred by NAES to each line ministry on the basis of a signed "Sectoral Action Plan Agreement" (Convention)with a first deposit estimated to cover four months o f eligible expenditures and subsequent replenishments on the basis of the provision by the line ministry o f evidence o f actual expenditures. The reporting format will include, notably: (i) a cash-flow statement'position reconciled with the bank monthly statement; (ii)summary o f funds used for defined categories o f expenditures; a (iii)bankstatement;(iv)areconciliationstatement;(v)areportonoutputwithrelatedindicators. a Civil society initiatives will be the core o f the project accordingto the volume o f resources disbursed to them. Financingprocedures would be basedon the Community-drivendevelopment(CDD) approach and financed through a smart grant mechanism incorporatedinto a Sub-project Contract, paidby tranches on the basis of "results" evidenced bythe CSOs through quarterly reports. Models o f "Sub-project Contract'' are incorporated into the PIM. The flow o f funds will be two-folds: (i) Sub-projects o f national or multi-regional scope or o f large financial amount (over US$30,000) will be paid directly byNAES out o f Special Account B; (ii) Sub-projects o f sub-regional and local scope ando f small financial amount (same threshold as above), will be paid to CSOs by the RAES out o f a Regional Sub-account (RSA). To this end, the NAES will transfer resources from Special Account B to the RSAs managed by the MES, corresponding to 4-5 montho f estimated expenditures. Apart from a few internationalNGOs which have a strong financial capacity, the local NGOs' andCBOs' smart financial management capacity is generally weak (see Annex 12). Sub-project promoters (CBOs andNGOs) will be rangedby categories according to their financial capacity as follows: (i) CategoryA: international NGOs and national NGOs with a solid institutional set-up and a good, long-term track record: sub-project amount up to US$30,000; (ii)Category B: nationaylocal NGOs with a good institutional set-up and limited sub-project experience: sub-project amount up to US$lO,OOO; (iii) Category C: emerging NGOs with little or no previous experience: sub-project amount up to US$5,000; (iv) Category D: local grassroots CBOs such as Parents Associations, Women's Cooperatives: sub-project amount up to US$l,OOO, These thresholds may be subject to revisions during MACP annual reviews onthe basis of experience. The PIM will describe the flow o f funds, and provide templates for the different types o f contractual arrangements. A sound financial management system will be put in place in the NAES and the RAES, and the implementing agencies. As a condition of Eflectiveness, a financial management system incorporating all the required features and implementation arrangements cited above, will be established and a Financial and Accounting Procedures Manual, satisfactory to IDA, will be adopted by the Government. Because o f the above-mentioned innovative approaches, special attention will be devoted to financial supervision, inparticular with regard to the financial management capacity o f the line Ministries under Category 2. NAES staff in charge o f fiduciary compliance o f the use o f funds will provide continuous support to the implementing entities and supervision o f the activities carried out by them. The project will be subject to standard audit requirements. As a condition of Effectiveness, an external auditor will be recruitedon the basis o f a competitive selection, withterms o freference satisfactory to IDA. - 17- Procurement Procurement arrangements o f the MACP are based on principles established for MAP operations. They were refmed during appraisal along with the Procurement Capacity Management Assessment carried out by the Bank. Annex 6A provides details o f these procurement arrangements which are firmly grounded inthe procurement capacity assessments o fthe various executing agencies involved inthe project. As such, the procurement functions o f the M A P program will be implemented by three main groups: (a) NAES; (b) Line Ministries and other public sector agencies; and (c) NGOs, CBOs, and private sector organizations. According to this classification, the following procurement arrangements are envisaged The NAES will establish a FAUand Regional Procurement Unitsstaffedwith qualified personnel, which will carry out the procurement functions for: (i) activities to be directly carried out bythe NAES, i.e., all Component 1; (ii)those executing agencies that have little or no experience with IDA-financed procurement and for large ticket items that are at NCB threshold and above for goods, works, and consultingservices. The central FAUstaff will beprovidedby a reputable firm. The RAES will establish, byEffectiveness, aprocurement capacity provided by aprocurement specialist to assist communities and local NGOs in their responsibility to carry out community-based or NGO-based procurement activities included in their sub-projects. The RAES will be supported by the FAU. The recruitment o f the central FAUstaffwill be completedbeforeproject Effectiveness. Line Ministries can be classified into two categories based on their respective level o f procurement experience: (a) Category I: Ministries with experience and capacity with IDA-financed procurement, such as the Ministries o f Education, RuralDevelopment, Women andHealth, will have responsibility for carrying out their own procurement activities related to their agreed Action Plans through Project Implementation Units (PIUs) already established to manage other extemally-financed projects in the sectors. This approach will facilitate the integration o f the HTvlAIDS actions into the Sector-wide Annual Plan (SWAP) o f these Ministries when a SWAP exists (e.g., MEN, MOHSA), and therefore, improve the coordination o f these activities with other activities planned in the ministries' SWAPS; (b) Category 2: Ministries and public sector agencies lacking experience and capacity to carry out IDA-financed procurement will be assisted by the FAU o f the NAES which will carry out, on their behalf, the required procurement for goods and services as indicated in their annual action plan. All contracts which are under tender board thresholds will be carry out by these Ministries. Included inthis category are: the MFPTJS, MCOI, MCRP, andthe Ministryo fNationalDefense (h4DN).Shouldthe PIU o f a ministrypertaining to the first group disappear with the closing o f the project which supports it, the ministry will automatically fall into the second group. For the health ministry, the executing agency is Direction de la Gestiondes Investissements(DGI) which is within its administration. For community, CBO, NGO, and other CSO sub-projects, the sub-project promoters, through their representative committees and recruited intermediaries (NGOslAssociations), would be responsible for the procurement process using simplified procurement procedures as described in the PIM. These procurement arrangementsconform with paragraph 3.15 on Community Participation in Procurement o f the Guidelines anduse the Bank's Guidelinesfor Simpl~edProcurement and Disbursement Procedures for Community-based Investment (February 1998) and the National HIAIDS Programs Generic Procurement ~anagementManual for Community-based Organizations and Local NGOs (March 4, 2003). - 18- D. ProjectRationale 1. Project alternatives consideredand reasonsfor rejection: Initially, it was proposed that the MOHSA manage the multisectoral MAP program. This option was justified because o f MOHSA's previous commitment to HIVIAIDS was unique in Mauritania, and that the PNJ3 hadalready begunsectoral activities (Education, Defense, Police, andNGOs) duringthe years 2000-02. Based on lessons learned from other MAPS(see section D.3. below) and from past experience with the MOHSA showing limited actions in other sectors (see section D.3 below) the case was persuasive for not pursuingthis option. At a National Seminar inAugust 2002, representatives from all stakeholders were invitedto discuss the National Strategic Framework andthe institutional arrangements for the multisectoral strategy implementation; they then rejected the MOHSA approach. Rather, this seminar proposed the creation o f a multisectoral National Committee chaired by the Prime Minister to define HIVIAIDS policy and oversee its implementation, and which would be assisted by an Executive Secretariat for coordination and administration. The Government adopted this approach during the Ministers' Council o f October 2,2002. Initial consideration o f malaria, tuberculosis, and schistosomiasis in the Project was abandoned for several reasons among which: these diseases are currently handled by the MOHSA through its current Healthproject financedby IDA; the Global Fund to Fight AIDS, Tuberculosis,and Malaria acceptedthe Mauritanian's proposals for tuberculosis and malaria financial support; and the management o f these diseases within the framework of a MAP was considered adding too high a level o f management complexity. A 4-year project was initially considered with an estimated IDA support o f US315 million. Taking into account various external andinternal considerations, the Government and IDA agreed to a 5-year project and an IDA support of US$21 million. This time frame is adequate for setting up and testing the innovations introduced by the project, i.e., the NAC, the NAES, the regional RAC and RAES, the new flow-of-funds channel to the implementing entities, the Operation Manuals, and the M&E system. At the end of the project, the lessons learned from all tested innovations will be incorporated into a follow-up effort. 2. Major related projects financed by the Bank andlor other development agencies(completed, ongoing and planned). (a) the foundation for a sustainable development o f irrigated agriculture. Components are: (i)is The Integrated Development Project for Irrigated Agriculture (PDIAM) objectivecreate lay to the policy, legal, and institutional frameworks for irrigated agriculture development; (ii) develop basic infrastructures; (iii)improve management skills o f fanners; (iv) strengthen the traditional irrigated agriculture sub-sector; (v) develop agricultural diversification; (vi) implement mitigation measures to adverse environmental impacts; and (vii) provide M&Efor project relatedissues. (b) The Rainfed Natural Resource Management Project (PGRNP) i s complementary to the PDIAM. Its objective i s to improve basic ecological functions through resource management. Components are: (i) financing investments in250 villages inthe country's rainfedarea; (ii) strengthening government services to support community organizations, and improve the legal framework for local empowerment; and (iii) enhancing skills, and developingand disseminating technologies, reduce child malnutrition inMauritania through: (i)Mobilization social mobilization, andrural radio; (c) The Nutrition, Food Security, and Socialcooperative and Project (Nutricom) objective is to (ii)nutrition counseling and intervention; (iii)micro-projects; (iv) mobilizationand urban integration for nutrition. The project i s implementedthrough selectedNGOs. (d) The Health Sector Investment Project (PASS) objective i s to improve the health status o f the - 19- population through the provision o f more accessible and affordable quality health services. It has four components: (i) expanding health service coverage, performance, utilizationrates, and quality assurance measures; (ii) strengthening planning, management, and administrative performance o fthe MOHSA; (iii) mitigating the effects o f infant and child mortality, maternal mortality, young child malnutrition, and infectious diseases; and(iv) promoting social action. (e) The Education Sector Development Program Project (PNDSE) objective i s to implement bilingual education at primary, and secondary education, while improving their access, equity, and efficiency, and at the same time improvingvocational, technical, and higher education. Components are: (i) improving quality o f teaching-learning processes, contents and outputs in primary education; (ii) increasing universal access to primary and secondary education; (iii) improving the efficiency o f the education system; and (iv) enhancing pedagogic management capacity. Under this project, the MENhas delegated the construction o f 2,700 classrooms to the communities (Associations des parents d'dldves --APES),following the successfulprocedure implementedsince 1999through the two previous education projects. (0 The Urban DevelopmentProgram Project (PDU) objective i s to support Mauritania's central and local govenunents to improve living conditions, and promote employment opportunities in main towns, with special focus on slums. Project components include: (i)provision of basic urban infrastructure inmaintowns; (ii) construction andenterprise development supported byNGOs; and home (iii)capacity-building for the development o furbancommunities andmicro-enterprises. (g) The Mining Sector Capacity Building Project will strengthen the Government's capacity to facilitate and regulate mining activities, and increase private investment in the sector. The main components provide for: (i) capacity building in the Ministry o f Mines and Industry; (ii) geologic infrastructure; and (iii) Environmentalmanagement system. LatestSupervision Sector Issue Project (PSRl Ratings (Bank-fknck projectsonly) Implementation Development Bank-financed Progress(IP) Objective(DO) Rural Development RainfedNatural Resource S S Management Project (PGRNP) 1998-20-- IntegratedDevelopmentProjecl S S for IrrigatedAgriculture (PDIAIM) 1999-2004 Heatlh HealthSector Investment S S Project (PASS) 1998-2003 Education Education Sector Development S S ProgramProject (PNDSE) 2001-06 Social development andnutrition Nutrition, FoodSecurity, and S S Social Mobilization Project (NUTRICOM) 1999-2003 Miningandother extractive industries SecondMiningand Hydrocarbons Sector Capacity BuildingProject 2003-08 UrbanDevelopment UrbanDevelopment Program S S Project PDU) 2001-06 Xher development agencies - 2 0 - Health(UNICEF) Mother's HealthProject Health(FNUAP) National Program for Reproductive Health (with a module Let's Speakabout AIDS) Health(OMS) Project for the FightAgainst Malaria Health(OMS) Project onBlood Safety HIviAIDs Health(OMS) Programfor the FightAgainst Tuberculosis Highly Unsatisfz Learning from other MAPS.Lessons learned from on-going MAP projects in other African countries and summarized in Guidelines and Lessons Learned in Preparing and I~plementingMAP Country Programsfor HIV/MDS in AfLica, preparedbyUNAIDS andthe Bankin2002-03, have been sharedwith the Mauritanian Government and stakeholders. The MAP practitioner learning process was reinforced by active participation o f a 10-personMauritanian team at the regional MAP workshop held inSenegal in January 2003. The Mauritanian team included religious leaders, NGOs, a representative of persons living with HIViAIDS, the private sector, as well as the public sector. This exposure to other MAP practitioners andlessons learned were discussed andincorporatedinthe proposedproject design. Among the key lessonsleamedandincorporated into the project design, are: 0 that the HIViAlDS effort must be multisectoral and with a development focus, and that the leadership shouldreflect this focus ; 0 the need for a mutisectoral oversight body (the National HIVlAIDS Committee -NAC) at the highest level o f Government with participation from sector ministries, civil society groups, the private sector, andPLWHAs (The N A C i s under the Prime Minister); 0 outsourcing key management functions of the NAES will improve procurement, efficiency, timeliness o fthe transfer o f funds, and other fiduciary tasks. Learning from MOHSA's past experience with the multisectoral approach The MOHSA has been interested ina multisectoral approach since 1994: some multisectoral actions in 2002103 were limited in scope and continuity. The limitations o f a multisectoral approach being implemented by one sector was clear. There was a need to transfer overall responsibility to a multisectoral committee chaired by someone with cross-sectoral responsibility (inthe case o f Mauritania, the Prime Minister), while placing responsibility for the design and implementation o f the individual sectoral action plans to the sectors themselves. Lessonslearned from the Education Sector. Since 1990 this sector has successfully transferred to local communities (Parents Associations) the responsibility o f carrying out school construction. Communities are responsible for procurement o f civil works, goods, and services for the construction through simplified community-based contracting procedures, as well as the management of the funds to do so. This mechanism embodied into contractual arrangements betweenthe MENand CBOs, described in an Operation Manual defining simple and transparent rules, and clearly delineating the respective responsibilities o f the partners. This mechanism has successfully operated for 12 years and shows that: (i) communities have substantial under-utilized capacity that can be tapped if (ii) transparent, simple procedures can work and can be the basis of buildingtrust betweenpartners. -21 - Lessons learned across projects. One lesson learned across IDA-financed projects in Mauritania (reflected inthe CAS) i s that weak administrationis the bindingconstraint on the Mauritanian ability to absorb assistance (see para. B.1.5 above). The outsourcing of management functions in the NAES addresses this issue, 4. Indicationsof recipientcommitmentandownership Mauritania has recently strongly increased its commitment to rapid implementation o f HIV/AIDS prevention, care, and treatment. Compared with the slow pace in the past, the speed with which this project has been prepared i s impressive. Since the first letter sent to the Bank to request its support in June 2002, decisions taken by the Mauritanian Government show its high commitment and ownership: August 2002: National Seminar recommending a sound HIVlAIDS Strategic Framework and adequate institutional arrangements; September 2002: submission o f a request to the Global Fundfor financing of HIV/AIDS, malaria and tuberculosis; October 2002: creation o f the multisectoral National Committee chaired by the Prime Minister; submission of a PHRD Grant Request to finance the preparation o f the MAP; November 2002: nomination o f the Director o f the NAES; December 2002 launching o f eight Sectoral Action Plans; February 2003, completion o f the Biomedical Waste Management Plan; March 2003: completiono f 8 Sectoral Action Plans; issuanceo fthe Decree creatingthe N A C andthe RACs and establishing a Special Tender Board for HIV/AJDS-related procurement; April 2003: issuance o f an Arret& creating the NAES and the RAES and beginning o f the selection o f the NAES core team; finalization of the Project Implementation Manual; May 2003: NAC meeting to adopt the HIV/AIDS Strategic Framework, the eight Sectoral Action Plans andthe PIM. 5. Value addedof Banksupportinthisproject: Mauritania's government alone will not be able to prevent the spread o f HIVIAIDS. Efforts are required bothinMauritaniabymany participants, and inother countries. At the national level, it is recognized that the threat o f HIV/AIDS i s not only a health issue, but a development issue engaging vimally all sectors and elements o f society. This i s reflected in the role played by UNAIDS as multisectoral coordinator, cosponsored by the Bank together with other UNagencies. UNICEF, WHO, andUNFPA inMauritania supported a large number o f initiatives during the last two years, and they continue to implement programs within their respective mandates andcompetences.IDA has unique features which complement the work o f these agencies and which are critical to the success o f an effective HIVlAIDS campaign. First,no other external actor operates across the Mauritanian government's development agenda. This is essential inhelping the country elevate HIVlAIDS beyond the health sector, incorporate it into all sector development agendas, and link it to the poverty-reduction strategy. Second, IDA is directly involved in interventions in key sectors in Mauritania including Health, Education, Women Development, Mining, Urbanand Rural Development. IDA canhelp these sectors integrate HIV/AIDSresponsesintheir plans. Third, IDA has extensive experience in Mauritania with project implementation, which will be instrumental inexecuting a project that complements others, and builds on existing capacities developed through other projects. Fourth, IDA'Scommitment to HIVlAIDS over an extended period o f time (12-15 years) i s essential to providing confidence that resources will be available to support and sustain a substantial campaign against HIVI'AIDS. Duringproject preparation the Bank developed an intense partnership with the HIV/AIDS UN Theme Group, including the UNAIDS Country Adviser, WHO, UNICEF, UNFPA, UNDP and other multilateral and bilateral partners such as the EU, France and the United States. The Bank shared with them, and discussed, all information on the MACP preparation, and the UN Theme Group shared with the Bank information on actual and planned activities. There is strong support among all these partners to the institutional arrangementspromotedbythe MACP (the NACmAES andthe RACIRAES), its content and -22- the procedures (particularly the regional management o f funds and the focus on the civil society). The complementarity o f the MACP with these partners' activities is clear and appreciated. It is understood that MACP supervision will involve interested agencies on the basis o ftheir comparative advantage, such as, for instance: WHO for the Health Sector Response, UNFPA for condom distribution and FGC, and UNICEFfor MTCT. E. Summary ProjectAnalysis(Detailed assessmentsare inthe projectfile, see Annex 8) 0Costbenefit 1. Economic (see Annex 4): NPV=US$ million; ERR= % (see Annex 4) 0Cost effectiveness Other (specify) A detailed economic analysis on HIViAIDS required for the present project was carried out for the first phase o f the Multi-country HIVIAIDS Program for the Africa Region--MAP (see Annex 5 o f the PAD, Report N o 20727-AFR). The study covered eight African countries that were eligible for MAP 1. It analyzed the impact o f this scourge on economic development and lookedat the cost-benefit analysis o f anti-HIVfAIDS projects. The main conclusions o f the study were that HIViAIDS: (i) has a negative impact on the economy because it erodesproductivity, national savings, and growth; (ii) increasespublic healthexpenditure andcould reduce the resourcesallocated for other diseasesor to other sectors; (iii) has a negative impact onhouseholds when a family member begins to suffer from HIV-related illness. The MAP for Mauritania has numerous economic benefits. It will lead to: (i)significant reduction in a new infections, especially among the young; (ii)longer andmore productive life for those infectedby a HIV having hadaccess to ARV therapy; (iii)reduction inthe resourcesearmarked for the treatment of a opportunistic diseases such as TB; (iv) brighter economic prospects for families and AIDS orphans. In addition, acting early with the implementation of the M A P in Mauritania will help to avoid incurring much higher costs later and could prevent HIViATDS infections from becoming a full-fledged epidemic at which point it would have spread throughout the population, making its control much more difficult. Other benefits o f MAP, but which are difficult to quantify, are (i) the reduction in suffering and pain, which are important welfare gains and (ii) the reduction of the number o f premature deaths and the number o fchildren dropping out o f school inorder to take care o frelativeswho are afflicted. The cost-benefit analysis shows that the implementation o f the MAP in Mauritania will help to avert at least 46,838 cases o f new infections. Inmonetary terms, this meansthat the direct benefits o f the project will be about US$55,45 1,2 13. The overall net present value (NPV) will amount to US$22,193,2 10 at the end o f the project. The NPV will continue to rise well after the completion o f the project. The analysis also proves that the project can slow down the spread o f the epidemic. However, the point at which the epidemic is likely to slow down will depend on the effectiveness o f the prevention program. On the basis o f the above-mentioned scenarios, it is clear that the project's impact-though less significant during the first sevenyears-will increaseconsiderably after the seventh year. 2. Financial(see Annex 4 and Annex 5): NPV=US$ million; FRR= % (see Annex 4) Not applicable Fiscal Impact: The fiscal impact o f the project is likely to be small. With the large amount o f resources directed at communities and civil society interventions, reliance on NGOs and CBOs and the private sector, the -23- permanent recurrent costs o f the program should be manageable. Works consisting o f rehabilitation and expansion o f existing facilities will not generate significant operating and maintenance costs. However, there will be additional operating expensesfor the NAES operations andthose o f the line ministries. 3. Technical: The project design incorporates the best internationally accepted practices for HIV/AIDS responses as definedby MAP experience andby UNAIDS partners, and which are reflected inthe Generic Operations Manual. To improve knowledge and ownership o f these lessons, an important Mauritanian delegation, includingthe NAES director, high-level civil servants o f the MOHSA and representatives o f the NGOs, FBOs andprivate sector, participated in the regional MAP workshop o f January 2003 inDakar. These international practices are tailored to the Mauritanian context. The intention i s to continuously monitor andrefmethe lessonslearnedfrom other MAPSandapply themto the Mauritanian situation. This willbe true with regard to civil society interventions, line ministry practices, health sector standards, protocols, and interventions. Regular contact with the N A C and NAES will provide opportunities for such exchanges, while annual reviews will allow for assessment o f technical performance o f the project, and incorporation o f any changesneeded. Eight line ministry Action Plans were developed duringproject preparationand assessedby the Bank as part o fthe project appraisal mission. The details o fthis assessment are provided inAnnex 13. To assess the quality o f these Plans, a methodology was developed by the preparation team regarding the training process to bringthe required information and knowledge to the various audiences (internal and external clients). This methodology includes the list, content and objectives o f the various training modules; the list and profile o f the various types o f trainers; and the trainerdtrainees ratio by type o f trainer. The details o f this methodology are in the first section o f Annex 13. Duringproject appraisal, the national teams reviewed their Sector Action Plans inlighto fthis methodology and finalized quality Sector Action Plans which are ready for implementation. The Civil Society Initiative sub-program is basedon knowledge accumulated through Community-driven Development (CDD) projects in Mauritania and in other countries, mainly social-fund type projects. Community-based and NGO-based procurement will be based on the recent Generic Procurement Management Manual for Community Based Organizations and Local NGOs developed by AIDS Campaign Team Africa (ActAfi-ica) in March 2003. This assessment of the NGOlCBO capacity (see Annex 12) is the basis o fthe selection o f a range of three different financial ceilings for the amounts o f the NGO sub-projects, andfor the ceiling for the CBO sub-projects. Giventhe new features o fthe project (creation o fthe multisectoral N A C with no previous experience for such type o f program management), the general weakness o f the CSO organizations, the focus o f the project has largely been put on capacity-building activities. To build N A C and RACs capacity, the project will largely use the opportunity provided by the recent creation in Nouakchott o f a Distance Learning Center, and will provide an appropriate level o f resources for the use o f this tool with a view toward developing MauritanianN A C andRAC capacity through regional and international networkingo f decisionmakers involvedinHIV/AIDS fights (Ministers, Congressmen, Religious leaders, Mayors, etc.). 4. Institutional: The new institutional framework adopted by Mauritania--with a National HnillAIDS Committee WAC) chaired by the Prime Minister and comprised o f representatives o f the public andprivate sectors and the civil society including CBOs, NGOs and PLWHA- is appropriate to oversee a multisectoral and multipartner HIV/AIDS program, however, this is a large body which cannot easily meet together between its regular biannual sessions. The creation o f a sub-committee of eight members reflecting the -24- multisector/multipartners composition o f the NAC will improve its capacity to carry out day-today activities. The composition o f the NAES to support the N A C and facilitate the Sectoral Action Plans as well as the private sector's and the community-based responses, i s appropriate. The inclusion o f a private sector specialist inthe NAES team to coordinate the private sector's responsewill ensure an appropriate focus on this group o f stakeholders. The decision taken during pre-appraisal to create Regional I-IIVI'AIDS Committees (RACs) reflecting, at the regional level the N A C composition andmandate, and Regional HIV/AIDS Executive Secretariats (RAES) i s appropriate to manage local civil society responses on a more timely and efficient manner than a central management could. All external partners recognize andsupport the multisectoral approach andthe proposed structure (NAC andNAES) including their regional extensions, which was presentedto them through UNcoordination meetings duringproject preparation. During project preparation one issue was the acceptance by the MOHSA staff o f the transfer o f the overall responsibility o f the HIVIAIDS fight to the NAC. The attitude shift will be fully achieved with the waiving o f the Plan national de lutte contre le SIDA by the MOHSA andits replacement by a Health Sector I-IIV/AIDS ResponseCoordination. 4.1 Executing agencies: Based on the generic MAP design, the Mauritanian MACP will be implemented by a wide range o f executing agencies encompassing public sector ministries, private sector enterprises, and civil society organizations. An institutional assessment was carried out during project preparation by an international consultant financed under PI-IRD. The assessment i s filed in the Documents in Project File (see Annex 8). The assessment concludes that: (i) the selection o f the Coordinator in each Ministry, and the composition o f the preparation teamwas appropriate despite alarge diversity ofcomposition due to the absence o finitial guidelines; (ii) the full time assignment o f the Coordinators--which i s agreed to by all Ministers--is implemented in almost all Ministries and appropriate; (iii) the Terms o f Reference o f the Coordinators need to be clarified regarding hisher relations vis-&vis the Directors o f hisher Ministry; (iv) the relations between each Coordinator and the NAES should not follow the hierarchical flow, but rather follow a network pattern. This should be achieved through initial training sessions to be carried out before or at project start. The civil society response will be implemented by a large number o f local and international NGOs and community-based organizations. An assessment o f the NGO sector was conducted during pre-appraisal, the findings o f which are in Annex 12. The main finding i s related to a general management capacity weakness which i s addressed by the project through its capacity-building component. The capacity o f CBOs to implement a sub-project is generally strong in Mauritania, as evidenced by the 12-year successful delegation bythe Ministryo f Education o f school construction to communities, andthe strong cooperative sector handled by community-based female groups. However, grassroots CBOs generally lack organizational, fiduciary, and reporting capacities. This gap is adequately addressed by the Grassroots Management Training (GMT) program which will be implemented by the NAES under the capacity-building component. The GMT program is developed and assisted by the World Bank through the World Bank Institute (WBI). This GMT program, detailed in Annex 15 i s also appropriate to build capacity o fthe NGOsto provide services to CBOs. 4.2 Project management: The fast-track nature o f MACP andits support o fa multiplicity o f sectoral responses, poses an immediate management capacity challenge. The NAES will continuously support building capacity in the participatingagenciesduringproject implementation. To be able to performthis mandate, the capacity o f - 25 - the NAES, including staffing, equipment, and offices, will be set up before project implementation. Lessons learned from other MAP projects and incorporated in Preparing and ~mplementingMAP Country Programsfor HIV/AIDS in Africa: The Guidelines and LessonsLearned, also knownas Generic Operation Manual (GOM) co-produced by UNAIDS and the Bank, show that an effective way to set-up an efficient NAES i s to outsource, to the m a x i " extent possible, management functions such as: financial management, procurement, private sector response coordination, and civil society response coordination. Monitoring and Evaluation, IECICCB, should be outsourced to professional institutions from the private sector, universities, or the civil society. An agreement for the above-mentioned outsourcing was reached at project identification. The selection process has started, all specialists are expected to be in place by project effectiveness. In the meantime, to manage the PPF, NAES has requested support from the financial and procurement specialists o f the MOHSA who have agreed to provide it. 4.3 Procurement issues: Procurement capacity inBank-financed projects inMauritania is generally low. The creation o f a Special Tender Board--STB (Decree 027-2003 dated March 24,2003)-is appropiate to speedup procurement o f works, goods, and services related to the fight against HIVIAIDS. All responsibilities currently undertaken by the national and ministerial tender boards are delegated to this STB for all procurement carried out under the MACP. The project will provide specific training to the STB members. The NAES will handle a large part o f the procurement, including procurement related to the action plans o f sectorslministries which do not have adequate procurement capacity. The NAES presently has no procurement capacity. The Government agreed to outsource the management o f procurement activities handled by the NAES, and the on-going process for the selection o f the NAES principal procurement specialist is expectedto be completed byproject Effectiveness. A large number o f interested ministries have already built solid capacity for project execution through previous or parallel donor-financed projects including IDA projects. This i s the case o f ministries in charge o f health, education, rural development, and women's development. The procurement capacity assessment o f the interested line ministries was conducted by a Bank procurement team, whose findings are in Annex 6A. The assessment finds that it is appropriate to allow the Ministries--which have demonstrated they have adequate procurement capacity (because they satisfactorily carry out procurement for other IDA-financed projects)-- to carry out 100 percent o f the procurement related to their HIVIAIDSAction Plan. This arrangement : (i) brings fiduciary management closer to the teams in charge to implement the action plans; (ii)builds on what already exists; (iii) consistent with the is objective for sustainedcapacity over time; and (iv) allows tailoring capacity-building to the needso feach specific agency, from training to technical assistance. The NAES procurement specialist will assist the procurement team o f the line ministries as necessary, andtheir procurement activities will be facilitated by the use of the STB. The assessment also found it appropriate to keep the procurement related to Action Plans o f sectors that do not have adequate procurement capacity in the NAES. The concerned Ministries have agreedon such arrangements. Community-based sub-projects to be carried out bylocal NGOsandCBOs will include procurement with community participation. Community/CBOlNGO procurement capacity gaps are adequately addressed through a two-fold approach: (i) the Grassroots Management Training will provide specific training on community-based procurement procedures with special training methods tailored for adults with low levels o f education, using illustrated guides in local languages; and (ii) the RAES will be staffed with procurement specialists whose main role will be to assist communities, CBOs and local NGOs to adequately performthe procurement activities relatedto their sub-projects. These regional specialists will be outsourced within the same contract as the above-mentioned principalprocurement specialist. - 26 - Procurement of drugs, reagents, condoms and medical materials. In the past, condoms were largely procuredthough UNFPA, and other goods by WHO and UNICEF, A DrugProcurement Center (Centrale d%lchat des Mkdicaments-CAMEC) has recently been established. However, this center is not yet fulfilling its mandate through acceptable procedures. The Government has agreed to improve CAh4EC's management and procedures to an acceptable level, through the Healthproject. However, inthe interim, drugs, reagents, condoms and medical materials for the MACP will continue to be procuredthrough UN Agencies. An assessment of the MOHSA's capacity to procure drugs, reagents, condoms and other medical equipment, and the supply chain, conducted during project preparation by an international specialist under PHRDfinancing foundthis arrangement appropriate (see Annex 21). 4.4 Financialmanagementissues: As withprocurement, financial managementcapacity inMauritania is also generally low. The NAESwill manage IDA resources and is expected to manage other donors' funds as well. The financial capacity o f the NAES will be fully built prior to project implementation. To this end, the Government has agreedto outsource NAES financial management and the selection i s expected to be completed by project Effectiveness. A financial capacity assessment o f the MACP executing agencies was conducted during appraisal by an international specialist with PHRD funds and reviewed by the Bank, the findings are in Annex 6B.This assessment finds it appropriate: (i) allowthe Ministrieswhich have demonstratedthey to have adequate financial capacity (because they satisfactorily managed funds of other IDA-financed projects), to carry out 100percent o f the financial management related to their HIVIAIDS Action Plan, for the same reasons as those mentioned above for procurement; (ii) keep in the NAES the to management of funds related to Action Plans o f sectors that do not have adequate financial capacity, for payments above an appropriate threshold and leave this responsibility to the Ministries for payments below this threshold; and (iii)to ensure that in each Ministry, the procurement and financial responsibilities are carried out bythe same unit. For the CSI component, funds will be made available at the regional level, and managed by the RAES which will be equipped with a qualified accountant outsourced within the same contract as the NAES financial specialist. Financial management capacity gaps o f local communitieslCBOsiNGOs will be addressed through a two-fold approach similar to that o f procurement: (i) the Grassroots Management Training will provide specific training on community-based financing and accounting procedures with special training methods tailored for adults with low levels o f education, using illustrated guides inlocal languages; and (ii) the accountant of the RAES will also provide assistance to communities, CBOs, and local NGOs to adequately perform the accounting and financial reporting activities related to their sub-projects. It is worth noting that Mauritania is currently developinglimplementing several initiatives of community-based approaches such as: the ongoing community-based nutrition program implementedby the Secrktariat d'Etat Ci Ea condition fkminine (SECF); the 12-year-old community-based school construction program o f the MEN(with community-based procurement o f works); and the secondphase ofthe Natural ResourcesManagement Project (PGRNP) bythe MinistryofRuralDevelopment. Given the large number o f implementing entities, the financial supervision will have an exceptional dimension and the financial specialists o f the NAESiRAES will have to actively participate in supervision missions. 5. Environmental: Environmental Category: B (Partial Assessment) 5.1 Summarizethe stepsundertaken for environmental assessment and EMPpreparation(including consultation and disclosure) andthe significant issuesand their treatment emerging from this analysis. A Medical Waste Management Plan (the plan) was prepared to complement the efforts o f the proposed - 2 7 - project to containthe spreadofHIVIAIDSinMauritania. The plan noted that environmental and social impacts due to ineffective medical waste management affect mostly healthcare personnel and hospital staff responsible for medical waste management, scavengers, and waste disposal site personnel. These groups face (i) accidental injuries and infections from contact with sharp objects such as glass pieces and syringes; (ii) exposure to the HIV/AIDS, Hepatitis A and 3 virus, to microbes and bacteria leading to tuberculosis, streptococcus, and typhoid fever, and to parasitic illnesses such as dysentery andintestinal worms. Scavengersmay lose incomes as the volume o f medical and other waste reduces due to improved management. Environmental impacts (air, soil, water pollution) relate to (i)buryingmedical waste directly inthe ground within the hospital site; (ii) cancer-producing gas emissions resulting from burning medical waste in the open air; (iii) the disposal o f medical waste along with household waste on public waste disposal sites, thereby expanding the possibilities for infections, injuries, soil and water pollution; (iv) the burning o f medical waste in incinerators that are not used according to technical specifications, thereby causing hmes and related healthimpacts; and (v) liquidwaste disposal without chemicaltreatment. The plan assessed the current effectiveness o f medical waste management in the relevant public and private institutions as well as the country's policies, laws, and regulations pertaining to medical waste management. Overall, it was found that medical waste management is not considered a priority in hospitals, legislation and regulations do not specifically address medical waste management requirements, contracts o f private service providers do not include medical waste management, and responsible ministries such as the MOHSA do not have the necessary financial and material resources to deal effectively with medical waste. Mitigation measureshave been proposed. Inpreparing the plan, the consultant took into account ongoingwork by the UrbanDevelopment Program(UDP) to develop a Solid Waste Management Strategy for Nouakchott which includes a medical waste management component. The HIVIAIDS project will coordinate closely with UDPto avoidduplication. Inpreparingthe plan, the consultant met with representatives responsible for medicalwaste management in the following institutions: technical services at the national and local level, NGOs, private sector associations, development agencies, and hospitals at the central, regional, and local levels. The final plan hasbeen receivedand was disclosed inMauritania and at the Bank's Infoshop prior to appraisal. 5.2 What are the mainfeatures o fthe EMPand are they adequate? The EMP outlines clear institutional responsibilities, time schedules, and cost estimates for the implementation of the proposed mitigation measures. The main features o f the EMP include the following activities: (i) improvement o f the legal framework pertaining to medical waste management; (ii)improvement o fmedical waste managementinhospitals; (iii) o fhospital personnel andthose training responsible for handling medical waste; (iv) raising the public's awareness concerning the dangers o f medical waste; (v) encouragement o f private sector participation in medical waste management; and (vi) support for the implementationo fthe plan. The main features o fthe EMP are adequate. 5.3 For Category A and Bprojects, timeline and status o fEA: Date ofreceipt o f final draft: March 21,2003 5.4 Howhave stakeholdersbeen consulted at the stageo f (a) environmental screening and (b) draft EA report onthe environmental impacts and proposed environment managementplan? Describe mechanisms o f consultation that were used and which groups were consulted? Preparation o f the plan included (a) site visits to: (i) public and private health care facilities (principal hospital of the country, military hospital, an important regional hospital, a private clinic, SNIM's polyclinic in Nouadhibou, two health centers, and a health post); (ii) public and uncontrolled waste -28- disposal sites; and (iii) central urban solidwaste disposal site inNouakchott; and(b) discussions with the representatives responsible for waste management at various institutions such as technical services o f the state; technical services o f local groups; NGOs, private associations, agencies, and development agencies. InMarch2003, a national workshop was conducted inNouakchott to discuss the proposed plan with the relevantstakeholders.The planwas acceptedat this workshop. 5.5 What mechanisms have been established to monitor and evaluate the impact o fthe project on the environment? D o the indicators reflect the objectives and results o fthe EMP? It is proposed that a committee or unitbe established which would include representatives o f the NAC, services o f MOHSA and MDN, hospitals, communities, and NGOs active in the areas o f health and environment. N A C would be responsible for the coordination o f the monitoring activities required under the plan, and would centralize the monitoring information in a database and an information system for medical waste management which could be managed at the level o f the Planning Directorate o f the Ministryo fHealthandSocial Affairs. 6. Social: 6.1 Summarize key social issuesrelevantto the project objectives, andspecify the project's social development outcomes. Issues mentioned in paragraph 87 o f the Multi-Country HIVIAIDS Program for Africa Region (Report No 20727 AFR) are relevant. The project i s expected to have a major effect in addressing the lack o f awareness o f HIVIAIDS among youth, women and men, and vulnerable groups, in giving access to condoms, testing and treatment o f HIVIAIDS, and finally in de-stigmatizing people infected or affected byHIVIAIDS. InMauritania, sex-related issues are difficult to discuss openly. The positive, courageous andpragmatic attitude o fthe religious authorities andtheir constituencies (the Imams) has triggered the beginning o f an attitude shift towards openness and visibility o f other opinion leaders concerning HIVIAIDS. The N A C has provided a sizeable representation (3 seats) o f the Faith-Based Organizations. The Mauritanian religious Islamic organizations have already organized a regional workshop (October 2002) gathering similar organizations from nine neighboring countries to discuss HIVIAIDS issues and solutions. The MACPwill built onthis asset and support continuing work o fthe religious leaders andImams. Some risky behavior is socially and traditionally rooted: limited discussion o f safe-sex practices with youth and between spouses, age-mixing in marriages with older men marryingyoung girls, social shared breast feeding o f children by female clan members, to cite examples. A social assessment o f a range o f potential beneficiaries such as girls and women inrural andurban settings, migrating men, sex workers, and traditional health practitioners was conducted during project preparation with a Danish Trust Fund anda Japanese PHRD Grant. Its findings are inAnnex 11,andthey have been addressedinthe project, either in the advocacy sub-component o f the capacity-building component, or in the civil society initiatives component. The proper implementation o f these recommendations i s expected to result inthe followingproject social development outcomes: (i) HIVIAIDS will take a place in the public discourse through specific communication strategies including the use o fruralradio stations, mobilehealthkiosks inmarket places and bus stations; (ii) information on non-sexual modes o f transmission and the human rights o f both infected and affected people will be a part o f the advocacy against stigmatizationanddiscriminationo fHIVIAIDS victims; (iii) girls' informalsocialgroupswillbereachedbytheprojectsothatunmarriedgirlswillget young access to informationonthe prevention o fHIVIAIDS, gender roles, and other health concerns; (iv) access to prevention, testing, counseling, and treatment services and training for sex workers will relieve some o fthe problems this marginalizedgroup i s facing; (v) the introduction o fpeer education programs for migrating men(e.g., water carters) will achieve a dual -29- positive impact infostering dissemination o f information inurbanand rural areas andfurthermore reduce their ownrisk ofHIV infectionandthe transmission o fthe virus to their families; (vi) breakingdowntraditional healthpractitioners' marginalizationtowards pro-active collaborationwith the modem health sector will support the population in prevention, counseling, and treatment o f HIVIAIDS; (vii) reduction o f female genital cutting (FGC) is expected to result from community-wide decisions for collective abandoning o f FGC, promotedthrough training programs based on participatory village-based choices; and (viii) empowerment strategies enabling women's cooperatives--which count 12,500 cooperatives--will give them access to increased opportunities and economic autonomy in addition to information on HIV/AIDS,FGC, andother healthrisks. 6.2 Participatory Approach: How are key stakeholdersparticipating inthe project? All key stakeholders: (i) already participatedinthe national workshop which proposedthe National have HIV/AIDS Strategic Framework, (ii) adequately represented in the National HIVIAIDS Committee are WAC), and (iii) have prepared eight Sectoral Action Plans through national and regional workshops. Project preparation included (i)participation o f a large Mauritanian delegation including key stakeholders from the PLWHA association, FBO, NGO, private sector, and ministries; (ii) collaborative consultancies (this i s designed inthe TORS);(iii) a national workshop held inMarch 2003 to discuss and adopt the Biomedical Waste Management Plan; (iv) a national workshop on monitoring and evaluation and starting up a multisectoral group of M&E specialists; and (v) national and sub-national workshops to discuss all studies, as well as all elements o f the program, including several iterative workshops to discuss the Project Implementation Manual culminating in a national workshop held before project negotiations. 6.3 How does the project involveconsultations or collaboration with NGOsor other civil society organizations? Duringproject preparation, NGOs, CBOs, and groups not yet formally organized, have been informed, consulted, and invited to participate in the project. During the social assessment, more than 30 focus groups have been carried out in several villages inthe southern Regions o f Trarza, Brakna, Gorgol, and in the cities of Nouadhibou and Nouakchott, with the population of various ethnic groups including Maures, Wolof, Puular, and Soninke. Visits and working meetings were heldwith informal social groups such as sex workers and water carters in the capital and inNouadhibou. Traditional health practitioners have been contacted andthe f r s t working meetings have beenheld. The preparationo f the PIM included direct consultations with about 30 NGOs, and indirect consultation with others through their NGO networks. Several NGOs and CBOs are directly involved in the preparation o f Sectoral Action Plans conducted by eight line Ministries. The Presidents o f the network o f national NGOs, and o f the PLWHA participated inall discussions o fthe WB preparationmissions. All NGOs and community representatives working on issues pertaining to nutrition and FGC, for instance, will be reached through existing networks. NGOs'participation inthe program is beingtested with PPF funds with the objective to test the present version o f the PIMand to update it as needed before project Effectiveness, on the basis o f ajoint evaluation o f the test performance. During project implementation, local communities will be able to express their needs through communitydriven HIV/AIDS activities and to participate as partners (see Component 4). The PIM will be regularly updated during project annual reviews, on the basis o f the experience ofNGOs and CBOs. 6.4 What institutional arrangementshave beenprovided to ensure the project achieves its social development outcomes? This concern is at the heart o f the project. The National HIV/AlDS Committeehas abroadrepresentation o f Ministries, NGOs, religious leaders, and the private entrepreneurial sector which increases the ownership and sustainability o f the project, The main role o f the NAC is to monitor and evaluate the national program and project outcomes, which are mainly social outcomes. Project monitoring and performance indicators include indicators on social development outcomes. The NAES will have the responsibility and the effective capacity o f providing the information on the progress o f each implementing entity and o f the project as a whole, as well as project outcomes, including social development outcomes. 6.5 Howwill the project monitor performance interms of social development outcomes? The first component o f the project includes a specific sub-component to develop the M&E system, with adequate resources to finance assessments, and monitoring and evaluation activities, including social development outcomes. The NAES will include a high level M&E specialist who will ensure that all monitoringmechanisms will be inplace, operating, and the results used. As part o fthe M&Ecomponent, project performance in terms o f social development outcomes will be collected by periodic surveys. Due to the delicacy o fthe matter, these surveys will be executed ina participative manner. Indicators o f social develooment outcomes will cover: the discrimination andstigmatizationo fpeople infected or affectedby HIVfAIDS; the attitude toward women who decide not to breast-feed when HIV positive; that illiterate people also have access to HIVIAIDS-related information; that the poorpeople will have the meansto protect themselves against HIV infection; that youngpeoplewillhave access to reproductivehealthservices; that commercial sex workers have easy access to health services; that MACP fundingis distributedto rural areas, to people without schooling, andto poor people; and that MACP fundingwill not pullout NGOresources from others areas such as childhealth andmalaria, 7. Safeguard Policies: Safety of Darns(OP 4.37, BP4.37) tYesWNo ProjectsinInternationalWaters (OP 7.50, BP7.50, GP 7.50) 'LYes 0 NO ProjectsinDisputedAreas (OP 7.60, BP 7.60, GP 7.60)* '2Yes NO 7.2 Describe provisions madeby the project to ensure compliance with applicable safeguardpolicies. The Medical Waste Management Planprepared for the proposed project complies with the requirements o f OP 4.01 EnvironmentalAssessment (see Annex 17o f the PAD) -31 - F. Sustainabilityand Risks 1. Sustainability: The sustainability o f the program will largely depend on the degree to which: (a) the present high-level commitment to fight the disease i s maintained over time, at least at the same level, (b) the coordinated multisector and multi-stakeholders participatory approach is fully owned and appreciated by all stakeholders; (c) nationalHIVIAIDS programmechanisms are performingtheir functions effectively; (d) key sectors take ownership and actively engage inthe fight against HIVIAIDS; and (e) efforts to reach all Mauritanians with HIV and opportunistic infection-related information, education, and communication messages are successfid, attitudes are changed as well as behavioral practices, and these changes are maintained over the long run. To achieve the above, the design o f the Project i s anchored in: (i) capacity-building, (ii)demand-driven processes, (iii)ownership and responsibility o f individual responses, and (iv) linkages between M&E, including community-based monitoring and sound communication strategies. Both individually and together, these design elements will improve prospects for a lasting impact. These efforts will contribute to better outcomes o f sub-projects and sectoral action plans, andtherefore the sustainabilityo f the overall program. Withrespect to financial sustainability, realistically the Mauritanianfight against HIVIAIDSwill require external financial support for an extended period. The cost o f HIV/AIDS i s an unanticipated external shock added to the many other heavy burdens communities must shoulder, and particularly highly vulnerable communities. At the community level therefore, the fight against HIVIAIDS will require financial assistance for a much longer period than the current project life. This is recognized in the Project design which assists Mauritania inputtinginplace a durable "system" and key mechanisms that will beusedinthe fight against HIVIAIDS for the foreseeablefuture. 2. Critical Risks (reflecting the failure o fcritical assumptions found inthe fourth columno fAnnex 1): Risk Risk Rating I Risk Mitigation Measure -FromNAESmay Outputsto Objective The not remain correctly M -Initially,staffwill be selected on a staffed and fully operational andthe competitivebasis. Eventual staffreplacement decentralization o fthe national shouldfollow the same procedure. HIVIAIDS structures may not be sustained. - Transparency andefficiency ofthe flow S -M&Esystemwill be put inplace at the start o ffunds from NAESto public, o fthe project to follow progress with a large para-statal and private sector, to civil place given to disseminationo f information, society and communities may not be including the flow o f funds. Implementationo f sustained. the conclusion o faudits reports will be carefully monitored - Line ministries maynot staff the M -Prime Minister (NAC's President) to help HIVIAIDS Coordinator andGroup with maintain Minister's commitments. highquality personnelwithadequate Communication system to broadly disseminate levelo fresponsibility, andall sectors information about the progress o fthe maynot have submitted their sector plan Ministries' Action Plan, includingthrough mass andlor may not be willingto implement, media system. monitor, andadapt them. - Support o fthe Govemment including S -Institutional capacity-building i s providedto line ministries to work inpartnership line Ministriesunder sub-component 1.3. - 32 - with NGOs, FBOs, CBOs andthe private Resourcesallocatedto NGOslCBOs. sector may not be continuous. Sub-projects will be carefully monitoredto ensurethey receive their plannedshare. - MOHSA may not have adequately M -Nominationo fthe Coordinator o f the staffed its HIVIAIDSISTI coordinationto MOHSA to be made inconsultationwith implement the Health Sectoral Action NAC's streamlined committee andNAES. Planina timely manner. .Coordinationwith other donors, S -The MOHSAwill include MACP's and other including WHO, UNICEF, UNFPA may donor's support to HIVIAIDS into its not be functioning. consolidated Annual action plans. UNTheme Group members will participate inproject supervision accordingto their comparative advantages. - Choice o fproject activities anddesign S -The M&Esystem (already developed) will flexibility allow fine-tuning andlor provide relevant andtimely information to reallocation o fproject resources as decisionmakers. The communicationsystem requiredmay not be carefully done. shouldhelp decisionmakers to take appropriate andtimely decisions. - Proceduresmaynot be simple enough S - Sub-component 1.4 providesfor NGO to be understood andusedby capacity building, particularly the Grassroots Communities andNGOs. Management Training (GMT) program geared to illiterate groups. Specific sections o fthe PIMwill be inlocallanguages. The PIMwill be revisedas neededduringannual reviews to better adapt it to NGOslCBOs' capacity. The M&E will have indicatorsfor capacity building for NGOs andCBOs. - NGOs maybe reluctant to go to rural S - Process to submit, appraise, approve, and areas andmay capture too large a part o f finance small sub-projects will be decentralized the resources intendedto flow to CBOs to the extent possible. The NAES will monitor andcommunities. Communities may the adequate flow o ffunds to rural areas. The remainreluctant to participate becauseo f GMTprogram will focus onrural areas. The the stigma attached to HIVIAIDS, and M&Esystemwill track the distribution of communities inremote areas will not be resourcesaccordingto urbdrural location o f reachedbecauseo fremoteness. activities. From Componentsto Outputs I - World Bank implementationsupport M - Supervision planwill be carefully developed maybe not intensiveenough, as well as and appropriately funded. Technical and regular monitoring and supervision financial audits will be carefully carried out activities carried out bythe WorldBank andthe implementationo ftheir conclusions Nouakchott Office and the Headquarters monitored. Project supervision will be shared staff. with all donors, particularly UNAgencies according to their comparative advantage. - Line Ministries may not meet to M - Meetingswill take place on a regular basis developpolicies andadopt strategies according to: (i) sub-component 1.1, (ii) basedonmutual agreementwithNAES. Sectoral Action Plans-component 2.1, and (iii) the Project ImplementationManual. - Management o f drugs and commodities M -Improvemento fthe supply o fdrugs and - 33 - supplymaynot be improved. commodities will bejointly monitoredbythe Health Project andthe MAP. Overall Risk Rating S I Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligib1e or Low Risk) I I I 3. PossibleControversialAspects: None. G. Main Grant Conditions 1. EffectivenessCondition Deposit o f25 million UMinProjectAccount 1(managedbythe NAES), and 6.2 millionUMin Project Account 2 (managedbythe DGL'MOHSA), covering the approximate amount o fcounterpart obligations, exclusive o ftaxes, for the first six months o fthe project. Establishacomputerized financial managementsystemintheNAES andthe DGWMOHSA, satisfactory to IDA. Adopt a Financial andAccounting Procedures Manual, satisfactory to IDA. 0 Recruit anExternal auditor, satisfactory to IDA. 2. Other [classify according to covenant types usedinthe LegalAgreements.] IndividualCovenants: The Recipient shall carry out: 0 at the latest by March 1, 2004, an assessment o f HNfAIDS prevalence among recruits o f the armed and security forces, as referred to in Part D 1. (b) o f the Project Development Grant Agreement (DGA); 0 carrying out, at the latest by December 31, 2003, an assessment o f sero-prevalence among TB patients as referredto inPart C.2.(a) (ii)fthe DGA; o 8 carry out, at the latest by December 31,2003, an assessment o f sexual practices among youth (15 to 19years) as referredto inPart D 1. (b) o fthe DGA; 8 carry out ina timely manneran assessment among the populationo ftheir opinionconcerningthe Programso it is available for the MidtermReview. Three months prior to the Completion Date another such assessment will be carried out, as referredto inParts A 1.(b) andC. 2. (a) (i) o f the DGA. Disbursements under Conventionswith line ministries: the Recipient shall: without limitation upon the provisions o f Section 4.01 o f the DGA and the Recipient's progress reporting obligations set forth inparagraph 1o f Schedule 4 to the DGA, andthe provisions set forth in Schedules 1 and 5 to the DGA, for the purposes of disbursement of funds from the Special Account A, under Category (6) o f the table set forth under paragraph 1of Schedule 1to the DGA, cause Line Ministries to fumish quarterly reports, in form and substance satisfactory to the Association, to the =S, for the purpose o f continued financing for carrying out the Action Plans under Conventions. - 34 - H. Readinessfor Implementation c] 1.a) The engineeringdesigndocumentsfor the first year's activities arecomplete andreadyfor the start of project implementation. 1.b) Not applicable. 2. The procurementdocumentsfor the first year's activities are complete andready for the start of project implementation. 3. The Project Implementation Planhasbeenappraisedand found to be realistic and of satisfactory quality. c] 4. The followingitems arelackingandare discussedunderloanconditions (Section G): I. Compliancewith BankPolicies 1.This project complies with all applich,,,: Bank policies. 2. The following exceptionsto Bank policies arerecommendedfor approval. The project complies with all other applicable Bank policies. p" SerLe'Theun ynck Alexandre V. Abrantes Team Leader Sector Manager - 35 - Annex 1: Project DesignSummary MAURITANIA MULTISECTORHlVlAlDSCONTROL PROJECT Data Collection Strategy Critical Assumptions Sector Indicators: iectorlcountryreports: (fromGoal to Bank Mission) To mitigate the negative 1. The economic growthrate impact o fthe HIVlAIDS (projection 6% growthper Government to-maintain epidemic on: (i)economic annum)willnotbe affectedby leadership inthe fight against growth, (ii)economic the AIDS epidemic. HIVlAIDS (sustained environment o fthe poor, (iii) adherence to the 4 MA humanresources development criteria). anduniversal accessto basic infrastructure. I 2. Incidence o fpoverty 'RSP monitoring report and SustainedGovernment decreases according to PRSP loverty studies. commitment to support PRSP objectives. and implementation o f social sector programs. 3. HumanDevelopment JNDP HumanDevelopment indicators and access to basic LeportsandProgress Annual infrastructures are achieved eports onEducationand according to objectives. Iealthprograms. IProjectDevelopment Outcomei Impact 'roject reports: (fromObjectiveto Goal) Objective: Indicators: To maintain the prevalence o f 1.The percentage o f JAC/NAES reports. 1. Multisectoral activities, humanimmunodeficiency HIVlAIDSprevalenceamong specifically BCC, will leadto virus (HIV)inthe general pregnant women age 15-19 sustained change o fbehavior populationbelow 1%. remains below 1%. regardingpreventiono fHIV. 2. The percentage o f jurvey MDN. 2. IntensifiedHIVlAIDS HIVlAIDSprevalence among program for preventionwill be the uniformed services recruits socially andculturally remains below 1%. acceptable. 3.95% o frespondents 3eneficiary assessment. 3. Community involvement (general adult population) will leadto abetter correctlyidentify 2 or more understandingo fmechanisms ways o fpreventing sexual o fhealth and improves care transmission o fHIV, and for people affected by AIDS reject 3 major misconception and 01. about HIV transmission or prevention. 4. The percentage o f In-going survey and Annual 4. The importance o fyouth HIVlAIDSprevalence among eports from TB program. oriented HIVlAIDSprograms tuberculosis patients remains is acknowledged and actively below a value to be supportedby society. determined basedonthe results o fthe on-going survey. Data to be available in December 2003. 5. Safer sexual practices: 3eneficiary assessment. -36- youth (15-19): (a) increased Sexual behavior survey age o fsexual inceptionand (b) reducedoccurrence o f unprotected sexualintercourse (number o fcasual partners diminishedby 20%). 6. At least 1500 sub-projects Monitoring andEvaluation have been submitted by CBOs reports o fCBOs and civil. andat least 80%havereached society initiatives. zligible criteria and have been signed. Outputfrom each Output Indicators: Project reports: FromOutputsto Objective) Component: 1. To develop institutional 1.1, The NAC is well AnnualAction Plans are (a). The NAES remains capacity for planning, delivery functioning. timely reviewed and approved. orrectly staffed and hlly and monitoring of HIVIAIDS iperational. multi-sectoral program, and 1.2. The NAES is hlly staffed Annual Reports onthe capacity o fline ministries, andfunctioning. Program are timely and (b). Sustained private sector and civil society correctly submitted to NAC. lecentralization o fthe national (CBOs, NGOs and iIVIAIDS structures on communities) have similarly 1.3. At least 300 sub-projects Monitoring andEvaluation egional and Moughataa level been developed. have been submitted by reports o fCommunity-based NGOIFBOs, o fwhich at least andCivil Society initiatives. SO% have reached eligible criteria and are signed. 1.4. Advocacy issues such as BeneficiaryAssessment (c). Sustained transparency female genital cutting, surveys. ndefficiency o fthe flow of violence against women, imds from NAES to public, :ollaboration withtraditional iara-statal andprivate sector, health practitioners are o civil society and addressedin 10 sub-projects. :ommunities. 1.5. The M&ESystemis in NAES annualM&Ereport. place and functioning, producingadequate information to decision makers. 1.6.All line ministries have NAES annual reports. (d). Relevant public sector ieveloped and implemented ninistries arelremain willing agreed Sector Action Plans. o adopt, implement, monitor i dadapt HIVlAlDS Action 'lam 2. Mechanisms andprocesses 2.1 At the end o fthe project NAES annual IEClCCB !(a). The line ministries have ofmulti-sector responses o f 1,500,000 participants have report. taffed the HIVIAIDS the line ministries are 3een reached byECKCB zoordinator and Group with developed, expanded and ictivities iighqualitypersonnelwith operational, including .dequatelevel o f promotion ofHIVIAIDS in esponsibility. existing "project" activities 2.2. Bythe end o fthe project, MDNsector report !(b). Ministries have adequate - 37 - at least 90% o funiformed nplementation capacity to services have beenreachedby xecute plans. HIVIAIDSISTIprevention programs. 2.3. At least 2% o ftargeted Line Ministries' reporting and (c). Ministries have adequate groups or 100 staffineach YAES consolidation o fthese inancial managementcapacity sector have beentrained as reports. Jdisburse and adequately peer educator, andwere active :port to the NAES for 5 days duringlast month. MENsectorreports, NAES eplenishment. mnualreport. 2.4. 100% o fall educational institutions (primary1 secondawhertiary) have a HIVIAIDSprogram for their students. .Provisionofthe Health 3.1. Twenty Sentinel Surveillance data byM&E. ,ectorResponsethrough surveillance sites established xpansion o f services for : bythe endo fthe project. i)surveillanceofthe 3.2. ThirtyVCT centers have Year report NAES based on pidemic; been established and are RAES data. ii)preventionandvoluntary functional. ounselling and testing, icluding: communication for 3.3. At the end o fthe project, Year report RAES Survey. hange o fbehavior, condom 1,500,000 condoms are lrovision, treatment and soldlgiven free per year. 'reventiono f STIs and other lpportunistic infections, 3.4. At the endo fthe project Surveillance data combined dTCT prevention, prevention 60% of women tested withHealthfacility survey. I fnosocomial infections, and HIV-positive are participating afe blood transhsion; inthe MTCT program. Two iii)Careandtreatmentof pilot programs functionalby leople livingwith HIVIAIDS; midterm review. iv) Training o ftraditional .ealthpractitioners and birth 3.5. At the end o fthe project, NAESannual report, ttendants; 8 centers give comprehensive v) Management o f medicalandpsycho-social lio-medical waste. care to PLWAs, MTR: 3. 3.6. At the end o fthe project, HMISISNIS data Reports on 15,000 men and women, Le. drug stocks out. Survey for about 60% of STIpatients, are public, civil andprivate sector receiving care according to byMOHSA (IP6 and 7). national standards. 3.7. 100%o fall blood CNTS data. transfusionstested on HIV. 3.8. 80% o fall medical Health Facility Survey services have implemented a plano faction for prevention - 38 - National Strategic Planfor CCB; Yearly action planfor communication. .Communities, Civil Society HMIS-FIS data consolidated 4(a). NGOs are able to shift hganizations andprivate annualreports. fiomtheir former role of ector are successfully executing agenciesto new role mplementing initiativesfor o fcommunity support. IIVlAIDS, TB prevention and HMIS TB program. are through sub-projects, 4(b). NGOs will not stay in leveloped andimplemented urbanareas and will operate in lythem, withassistanceo fthe rural areas. iealthsector. Monitoring reports ofNAES on Civil-Society sub-contracts. 4(c). NGOs will not capture funds intendedto CBOs. 4.4. At least 2,000 sub-projects Vlonitoring NAES annual d), NGOswillnot capture have beenimplementedby %porton Civil-Society ds intendedto CBOs. CBOs to cope with HIVfAIDS sub-contracts. impact. Communities will not be tant to participatebecause 4.5. At least 50 private companies have launched YAES annual report, HIVlAIDS programs for their Survey o fprivate sector employers andtheir families. 4.6. 80% ofgeneralpopulation Beneficiary survey (DHS). 0.Communitiesinremote canmentionthe locationo fan willbereached bythe (accessible) VCT center where te of condoms canbepurchased ccessibility JrojectComponentsI Inputs: (budgetfor each Projectreports: (fromComponentsto Sub-components: component) Outputs) Project supervision and IntensiveWorld Bank 2overnmentAgencies and activity reports. implementation support, as 3vil Society, and Project well as regular monitoring and idministration supervision activities carried ~ out bythe World Bank National Strategy and Action Nouakchott Office andthe 'lans. Headquartersstaff. Coordination and Idministration ofthe 'rogram. Advocacy, Training and rechnical Support. Assessment, Monitoring and - 39 - Evaluation. JS$3.90 million. teports to NAES, ,ine Ministries will meet to :onsolidated byNAES for the evelop policies and adopt JAC andthe Bank. trategies basedonmutual greement withNAES. TS$4.70 million. IealthManagement mprovement inmanagement nformationSystem. fdrugsandcommodities SNIS report; UPPlY. 'rogram reports. gloves, testing kits and laboratory equipment etc. - research. N.DevelopandExpand JS$7.60 million. W S reports to NAES, Community, CivilSociety :onsolidated byNAES for the Organizations, and Private \IAC andthe Bank. Sector Initiatives to HIVlAIDS Private sector-based sub-projects for prevention and care o fHIVIAIDS. Community-based sub-projects for prevention and care o fHIVIAIDS. V. Project Preparation JSS0.60 million Facility -40- Annex 2: Detailed Project Description MAURITANIA MULTISECTORHIV/AIDSCONTROL PROJECT Withinthe Mauritania's National Strategic Frameworkto fight HTVIAIDS, the project will support the start-up andlor the expansion ofHIVi'AIDS-related activities carriedout by a wide range o fpublic sector agencies, private andnongovernmental organizations, andby community-based organizations. Itwill be carried out over a five-year period extendingfrom 2003 to 2008 andwill be complementary to other donor activities, as well as IDA-financed projects inthe same sectors. The project will also build additional capacity o fpublic andprivate entities to cany out the project activities. Itwill be implemented through the following four components: (1) strengthen capacity o f government agencies andcivil society, andproject administration; (2) expand multi-public sector responsesfor preventionand care o f HIVIAIDS; (3) expandhealthsector responsesfor prevention, treatment, andcare ofW f A I D S ; and(4) develop andexpand civil society organizations andprivate sector initiatives to H N / A I D S . ByComponent: Project Component 1 US$6.60million - Strengthen Capacity of Government Agencies and CivilSociety, and Project Administration The main objective o f this component i s to put the national HIV/AIDS apparatus in place. This component would aim at strengtheningthe Mauritaniancapacity to cope with the spread o fHIV/AIDS by supporting six sub-components: (i)Capacity-Building for National Strategy, Policies and Program Oversight, (ii) Capacity-Building for Project Administration; (iii) Institutional Capacity-Building o f Line Ministries for HIV/AIDS responses, (iv) Institutional Capacity Buildingo f Civil Society for HIV/AIDS Responses, (v) Advocacy Training, and Technical Support Activities, and (vi) Assessment, Monitoring and Evaluation (Le., including behavioral surveillance and mapping, operational research and pilot testing, and other monitoring and evaluationactivities). Sub-component 1.1. Capacity Buildingfor NationalStrategy, Policies andProgram Oversight Diagnosis. The NAC i s responsible for: (a) guiding the development and approval o f the national AIDS strategy and action plan, (b) reviewing and approving annual work programs and global budgets, (c) reviewing progress in the implementation o f the program, and (d) serving as the lead advocate for attentionto the HIV/AIDS program. The N A C faces several challenges: (i) its work i s made difficult by its size: about 30 members; (ii) N A C has no experience in approving annual work programs or the oversight o fproject mobilization; and (iii) it hasno experience inmonitoringandreviewingthe program. This will requireconsiderable capacity-building andtraining. Objective. The objective o f this sub-component i s to have: (i) fully functional NAC, (ii) a regular revisions o f the AIDS strategy and action plan, (iii) close N A C oversight o f the Project by reviewing annual work programs and their performance, (iv) decisions taken by the N A C on HTV/AIDS-related policies (see Section C2 o f the PAD); and (iv) decisions taken by the N A C for program guidance and orientationbasedonmonitoring and evaluationdata. Strategy. To improve its operational capacity, the NACwill: (i) with the NAES andother partners, liaise through a LimitedNAC or "Comitd national restraint'' (LNAC) o f eight members acting on its behalf between its regular meetings, and (ii) oversee and review the regional HW/AIDS programs through Regional HIViAIDS Committees (RAC). The skills, knowledge, and decision-making capacity o f N A C -41 - and RACs members will be enhancedthrough regional andinternationalnetworking o fpeer stakeholders (Ministers, Congressmen, Mayors, Religious Leaders, NGO leaders) in other countries also fighting against HIVlAIDS, mainly through extensive use o f the Distance Learning Center (DLC) as a tool for sharing internationalknowledge and goodpractices. Activities. Activities financed under this subcomponent include: (i) technical assistance to the N A C to review and update the National Strategic Framework, and prepare background papers for policy decisions, (ii) training o fthe NAC and RAC members to improve their skills, particularly but not only in program monitoring and evaluation, and (iii) national and regional workshops to: discuss policy issues, review the progress o f the regional and national HJYlAIDS yearly programs and action plans and adopt subsequent ones, and ensurenational mobilization. Implementation Arrangements. The NAC is responsible for implementing this sub-component. The LNAC will be responsible for the regular oversight o f activities inliaison with the RACs. The NAES and the RAES will be responsible for day-to-day program operations. An Agreement will be signed between the NAES and the DLC for the use o f its facilities for distance learning on the basis o f predetermined unit-costs for networkconnection. CostandFinancing.The IDAGrantwill finance the inputsrequiredfor performingthe activities. Sub-component 1.2. CapacityBuildingfor ProjectAdministration Diagnosis.The NationalHIVlAIDS Executive Secretariat (NAES) is providing secretariat services to the N A C and i s responsible for the overall Program administration, coordination, and facilitation. It will assumethe responsibility for the facilitation o fthe MAP. The Regional HIVlAIDS Executive Secretariats (RAES) will provide secretariat services for the RACs and are responsible for facilitating the coordination o f the line ministryaction plansat the regional level, andthe facilitation o f initiatives o fthe regional Civil Society Organizations. As with the N A C and the RAC, the NAES and the RAES are totally new institutions into which capacity has to be entirely established. Objective. The objective of the sub-component is to put inplace the NAES andthe RAES and support their coordinatiodfacilitation mandate. Strategy. The NAES and the RAES will be and must remain relatively small units to coordinate and facilitate implementation. The strategy is to install a full NAESlRAES capacity before project implementation so as to ensure that NAESlRAES will perform, throughout the project, their mandate to empower implementing agencies in ministries, civil society, and communities, rather than buildingtheir own capacity. To this end, the mainNAES and RAES specialists will be contracted out from the private sector and civil society. The NAES team will comprise: (i) Deputy DirectorlCoordinator for the Civil Society Initiatives, (ii) Coordinator for the Public Sector Action Plans, (iii) Coordinator o f Private Sector Initiatives, (iv) Capacity-Building andTraining Specialist, (v) IEClBCC Specialist, (vi) M&E specialist, (vii) Procurement specialist, (viii) financial and accounting management specialist, and (ix) Social Marketing specialist. RAES will be composed o f a Regional Executive Secretary, a regional accountant and a regional procurement specialist to assist the communities and local NGOs inproperly performing their obligations, inparticular infinancial andprocurement matters. Activities. The activities o f the NAES include: (i) preparation o f all necessarydocumentation for N A C meetings and implementing NAC decisions, (ii) implementation of the Capacity-Building component, i.e., Component 1, including the coordination of the social marketing program; (iii) coordinationlfacilitation of all other components, Le., Components 2 to 4; (iv) day-to-day MACP -42- coordination and administration, including: financial management, procurement, monitoring and evaluation, organizational training, information management, annual program elaboration, and(v) liaison with other agencies and donors. Activities o f the RAES include: (i) preparation o f all necessary documentation for RAC meetings andimplementation o f RAC's decisions, (ii) day-today administration o f MACP regional sub-programs, including: coordination o f the line ministries' action plans at the regional level, financial management, procurement, monitoring and evaluation o f the regional Civil Society HIVIAIDS response, organizational training, information management, annual regional program elaboration, andliaison with other agencies anddonors at the regional level. Implementation,Onbehalfo f the NAC, the Director o fthe NAES has the responsibility for setting up the full NAESIRAES capacity and for the management o f their activities. The Director will report to the NAC. Each NAES specialist will have the responsibility to coordinate a domain, respectively: (i) Civil Society Initiatives; (ii) Public Sector Action Plans; (iii) Sector Initiatives; (iv) Capacity-Building Private and Training; (v) IECIBCC; (vi) Social Marketing; (vii) M&E; (viii) Procurement; and(ix) Financial and Accounting management. The Regional Executive Director will report to the National one, while the RAES procurement andfinancial specialists will report to the respective NAES specialists. The Director of the NAES was nominated at project identification. The process for the selection o f the remaining NAES andRAES staff has started with the publication o f a Requestfor Expression of Interest, The TOR were approvedbythe Bank, and the recruitmentprocess i s ongoing; offices have beenidentified. Cost and financing. The IDA grant will finance the NAESIRAES staff and equipment with the exception o f the Social Marketing specialist for whom the French Cooperation has expressed interest. Office rent will be financed by the Govemment. Operating costs will be shared between IDA and the Government. The PPF supports the set upo fthe NAES duringproject preparation. Sub-component1.3. InstitutionalCapacityBuildingof LineMinistriesfor HIV/AIDSResponses Diagnosis.With the exception o f the MSAS, none o fthe line Ministries has experience inimplementing a sectoral response to the HIV/ALDS threat. However, seven non-health line ministries have made good progress by establishing a Sectoral Committee for the Fightagainst HIVIAIDS with a Coordinator to lead the preparation o f the Action Plans. Nevertheless, the assessment highlights the need for each line ministry to designate a full-time program officer to coordinate the implementation o f the plans by the responsible directorates and units (national and regional levels), facilitate their access to funds, serve as secretariat to the Committee, liaise with the National Executive Secretariat for the Fight against HIV/AIDS (NAES), and lead the preparation o f the ministry's action plans. Some line ministries have experience and skills to manage external resources and may need limited capacity improvement, while others have none, and need full capacity-building. The MOHSA already has a strong capacity to implement a wide range o f WIAIDS-related activities and has the experience managing the " Programme national de lutte contre le VIH//SIDA"organized along the lines o f traditional "vertical" health projects, An assessment o f the pros and cons o f the "vertical" versus "horizontal" approach was done duringproject pre-appraisal. Objective. The objective o f the sub-component is to build and maintain capacity in all participating ministries to prepare, implement, monitor andevaluate their HIVIAIDS Action Plans through contractual agreements (Conventions) with the NAES. This objective will be measured by the number o f ministries able to provide acceptable annual progress reports and action plans for the subsequent year. Strategy. For Sectoral HIVIAIDS Action Plan implementation, the strategy is to integrate HIVIAIDS-related activities within the ministries' regular plan o f action. This i s in line with the -43- "sectoral" program approach already adopted and implemented by some ministries, such as Education and Health. The coordination o f the sectoral HIVlAIDS response will be the responsibility o f a "Coordinator" reporting directly to hisiher Minister, The MOHSA has decided to adopt this "horizontal" integrated approach and, for HIVfAIDS, depart from their "vertical" approach for other specific diseases. The strategy to enhancethe Coordinators' capacity to act as a catalyst, coordinate, andmonitor the Sector Action Plan is, on one hand, to include himher (and hisher close collaborators) into a regional and internationalnetwork o fpeer Coordinators operating insimilar sectors inother countries (mainly through the channel o f the DLC), and on the other hand, to provide the Coordinator, not only with resources to carry out monitoring duties, but also to finance local operational research. As far as financial and procurement management are concerned, the strategy is to buildon and expand existing capacity where it exists, and to create it where it does not. Line ministries such as MOHSA, MEN, SECF, andMDRhave already set-up financial and procurement capacities through donor-financed projects such as, respectively, the PASS, PNDSE, Nutricom and PGRNPPDIAM. Inthese cases, the Unit incharge o f the procurement and financial management o f the existing project will add HIVlAIDS responsibility. For ministries inwhich such capacity does not exist, the Projectwill help them create the requiredcapacity to carry out specific limited activities o f the Action Plan. Other activities, requiring more capacity, will be carried out by the NAES on behalfo fthe givenministry.An appropriate contract thresholdwill delineate which activities are carriedout bythese ministries or the NAES. Activities. As far as capacity buildingo f line ministries is concerned, activities to be financed by the project include: (i) coordination o f the sectoral response; (ii) collection o f informationon the pandemic withinthe sector andon the type o fprograms which has proven efficient, and for which the sector has a comparative advantage, (iii) monitoring o f progress o f the Sectoral Action Plan; (iv) production and analysis o f information on the sectoral response to HIVlAIDS; (v) monitoring o f the financial resources channeled to the sector to finance its action plan; (vi) monitoring o f the appropriateness and timeliness o f the procurement activities related to the action plan; (vii) evaluation o f the sectoral response, including operational research; (viii) coordination with the NAES and with other sector responses as needed; (ix) submission o f quarterly annual progress reports and annual progress reports for consolidation by the NAES for the annual review meeting with partners and donors; (x) training o f Coordinators mainly through DLC; and (xi) operational research. Implementation. The implementation o fthe line ministrycapacity enhancement sub-component will be the responsibility o f each participating Ministry. The Coordinator will have responsibility for overall preparation andimplementing coordination o fthe Action Plan o fhisher line ministry,including capacity building. Helshe will ensure that the required capacity has been built in the various Directorates as needed. The Coordinator will not substitute for the Directorates or Agencies which have responsibility to implement the activities o f the Sectoral Action Plan, but helshe will ensure timeliness andconsistency of the implementation o f these different activities within the framework o f the agreed action plan. The Coordinator will report directly to the Minister. Cross-sector capacity-building activities such as procurement o f vehicles and computers, organization o f the DLC program for all Coordinators and relatedteams, as well as regional study tours will be coordinated andmanagedbythe NAES. Cost andFinancing.The IDA Grant will finance the following activities: (i) meetings andworkshops to coordinate the sectoral program which will be organized by the Coordinator, (ii) training to enhance skills o f ministry staff to develop and implement a sector HIV/AIDS response, (iii) and technical studies assistancecarried out on request o f the Coordinator to assist incoordinating, monitoring, andevaluating the Sectoral HIVlAIDS action plan, (iv) research to be carried out with regard to the progress of the Action Plan, (v) workshops to share: concerns on specific issues, external knowledge, lessons learned, best practices, results o fresearch, output o fmonitoring and evaluation activities; and (vi) studytours and -4.4- participation inregional or internationalworkshops on HIVIAIDS. Sub-component 1.4. Institutional Capacity Building of Communities, CBOs and NGOs for HIVIAIDS responses Diagnosis. The assessment o fNGOs andCBOs to conduct development programs reveals mixed results: (i) oneside, Mauritaniangrassroots-levelCBOscapacitytoimplementcommunity-basedinitiatives on has a goodtrack record, evidenced by the strong, long-established network o frural women's cooperatives (``coopdrativesfkminines") promoted and assistedby the SECF, or the successful Ministryo f Education delegation o f the school construction to local Parents Associations (APES)carried out since 1999. However, these CBOs have not yet been mobilizedfor HIV/MDS-related activities; they lack knowledge about how to access available funds, and have limited fmancial andprocurement capacity; (ii) national NGOsare young, limitedinnumber, although currently rapidly expanding. The assessment o f a group o f NGOssee (Annex 12) showsthat most are inNouakchott andhave less than five years o f existence, they seriously lack technical, organizational, andmaterial capacities, and they lack entrepreneurial spiritwhile being full o f good intentions. Under a Bank-financed Institutional Development Grant (IDF 27306), 30 local NGOs received, in 2001, some initial limited training on participatory approaches, microfmance, project preparation, financing, monitoring and evaluation. According to some NGOs, there was only limited capacity improvement. Objective. The objective o f this sub-component i s two-fold: (i) improve the capacity o f CBOs to identify, prepare, and implement sub-projects, including community-based management o f funds and procurement in order to become AIDS-competent communities and to buildgrassroots-level capacity to access MAP funds; and (ii) improve the capacity o f local NGOs to identify, prepare, and implement HIV/AIDS sub-projects to support communities in their efforts for HIV/AIDS prevention, care, and mitigation, At the end o f the project, it i s expected that CBOs and NGOs will have acquired sub-project management skills andwill have been able to successfully submit and carry out, respectively, at least 300 and 1,500 HIV/AIDS sub-projects. Strategy. To buildCBO and local NGO capacity, the strategy i s based on the Grassroots Management Training (GMT) methodology developed by the Word Bank Institute (WBI) country partners through several projects inAfrica andIndia, and detailedinAnnex 20. As a training methodology, GMT has been designed for and with CBOs/NGOs and training institutions, to use participatory and gender-aware training materials to strengthen the capacities o f people active in grassroots organizations in order to improve their conditions o f life by better managing their groups, projects, andbusiness in groups or as individuals. GMT will be the most appropriate means to train Mauritanian trainers to strengthen capacities o f communities and local NGOs for their participation in the HIV/AIDS project. Specifically, the GMT program will be geared for general improvement o f managerial and financial capacities and HIVlAIDS prevention, care, and mitigation. More specifically, it will focus on: (i) organizational development: group formation and sensitization, management skills for small organizations, leadership, human resource management, strategic planning, and local governance; (ii) problem-solving skills and feasibility assessment skills; (iii) basic financial and material management: bookkeepingandaccounting, administration, disbursement and procurement at the community level, simple contracting procedures, contract management, and supervision; (iv) project management: participatory project design, project implementation and monitoring; and (v) communication: social communication, traditional systems o f communication, advocacy, adult training, training o f trainers, community radio, gender sensitization. Capacity-building activities will take into account the literacy level o f beneficiary groups andwill tailor all material developed, courses given, and any hands-on experience, to the capabilities o fthe participants. The GMT program will provide training to: (i) CBO members, (ii) trainers, (iii) NGO Ministries and -45- "Project" staff involved in community-based development, and (iv) NAES and RAES staff. To build NGO capacity to manage externally-funded sub-projects, this sub-component will build on and expand the existing Capacity Building Program (Programme de Renforcement des Capacitks-PRC) financed under the IDF Grant 27306, aimed at enhancing NGO professionalism to reach the poor. The MAP will expand on the PRC approaches by completing the unfinished training program, and expand to include smaller NGOs basedoutside o fNouakchott. Activities. Activities carried out under this sub-component include: * for the GMT program: (i) compilation o f an inventory o f the available GMT trainers inMauritania; (ii) ofSeniorGMTexpertstodeliverthetrainingoftrainersworkshops; (iii) selection executiono f a training needs assessment (TNA) inall regions; (iv) development of training materialsbased on the conclusions o f the TNA, including local content and geared to HIVIAIDS issues and solutions; (v) development by the pool o f senior trainers o f a set of trainer's manuals; (vi) training o f Junior trainers, Le., people working at the grassroots level, eventually working for an NGO; (vii) training, follow-up, and monitoring o f community leaders using HIVIAIDS sub-project identification and preparation as a support; (viii) revision o f training materials and translation in local languages, and (ix) specific training o f more vulnerable groups including HIV/AIDS-affected ones to encourage their participation inthe project. * For the NGOcapacity-buildingprogram, the activities will buildon andexpand those started under the IDFGrant, with more focus on: (i) regional NGOs; (ii) participatory identification o ftraining needs; (iii)less theoretical-more practical training methodology (recherche-actionformation); and (iv) enhancingNGOs' capacity to provide services ofHIVIAIDSpeer educators. Implementation Arrangements. The Coordinator o f the Civil Society Initiatives o f the NAES will be responsible for the implementation o f this sub-component. The NAES will recruit a GMT expert who will have the responsibility o f organizing and implementing the GMT program. The implementation o f the NGO capacity-building program may be delegated to a large NGO selected through competition, while the implementationo fthe GMT program will be contracted to localNGOs also contracted through competition. Cost and Financing. The IDA grant will finance the GMT program. For the NGO capacity-building program, the cost will be shared between IDA and several other interested Agencies, including UN agencies. A consolidated financing plan will be developed. Bank non-objection will be requested for its share o fthis plan, Sub-eomponent 1.5. Advocacy Training, andTechnical Support Activities, Diagnosis: Religious leaders, parliamentarians, women's groups, businessmen, youth groups, traditional health practitioners andthe media are generally favorably disposed to actively supporting an enlightened HIVIAIDS approach, and willing to reach out to their respective communities. These are the opinion makers, law makers, decision makers, andaffected populations. InMauritania there has not been a great deal o f experience in carrying out and sustaining HIVIAIDS advocacy programs on a comprehensive basis. HIV/AIDS is an issue that has many developmental, political, and social aspects, therefore requiring multiple voices speaking on it. On the other hand, there i s little to no visibility or support to voiceless highly affected groups such as PLWHAs, and people affected by HIVIAIDS such as AIDS orphans, foster children, caregivers o f those made vulnerable by the disease, or families taking care o f infected family members. Additionally, some high risk groups such as commercial sex workers, caregivers o fPLWHA, abusedwomen or orphans and other vulnerable children have little or no voice in addressing HIVI'AIDS. Therefore, there i s also a need to warrant pro-active considerations to bring -46- HIV/AIDS-related issues such as prostitution, Female Genital Cutting (FGC), violence against women and children, MTCT, and health services provided by traditional health practitioners forward on the agenda. Objective The objectives o f this sub-component are to: (i) significantly broaden the types o f groups engaged in the fight against the epidemic, (ii) create networks which contribute to improvements in policies and programs under the national HIV/AIDS policy and program, (iii) that the program ensure will reach the less visible high-risk people, and (iv) stimulate community-based responses to include socially delicate HIV/AIDS-related issues (such as FGC, Annex 19). At the end of the project it i s expected that at least sevenhighpriority groups havejoined inthe struggle, that at least 10 networks are operational with highparticipationlevels, andthat at least 15 sub-projects addressFGC. Strategy: The strategy is to recognize that the N A C needs to have both effective outreach and inputs coming from a wide spectnun of society (see for example, Annex ZO), if it i s going to be successful in fulfilling its mandate. While regular NAC meetings and those o f the RACs will bringtogether many elements o f Mauritanian society, a much more pro-active approach which galvanizes crucial communities, and keeps them fully engaged, i s also needed. Such groups, once identified will be provided with: (a) advice and assistance in developing an appropriate motivational campaign for their specific interest group; (b) resources to develop ideas and approaches which can be considered by the NAC, for inclusion in the national HIV/AIDS program. For highpriority groups who are not organized as a formal group, an initial mobilization will be carried out, mainly through interested NGOs and working in conjunction with development partners such as UNICEFwith respect to young children and their caregivers, or UNFPA for FGC. These proposed programs would be developed into simple annual plans which would be submitted to the NAES for review, comment, and approval, with coordination responsibility ofthe NAES IEClBCC Specialist. Activities: Activities to be carried out under this sub-component include: (a) an assessment to identify the key priority groups to be drawn more actively into the HIV/AIDS campaign; (b) an assessment o f the readiness (acceptance) o f beneficiaries to address key priority topics which are perceivedas socially and culturally sensitive; (c) consultancies to assist high-priority groups in evaluating their current advocacy programs for HIV/AIDS, how these might be promotedlexpanded, and program preparation; and (d) support for implementing the programs o f these high priority networks in areas such as (i) network coordinator training, (ii) workshops and seminars to bring members together and build consensus, (iii) workshops and seminars to allow for cross-fertilization, (v) exchanges with other similar groups from other countries and attendance at regional HIVlAIDS conferences, and (vi) technical assistance in refiningproposals with respectto the nationalpolicy andstrategy for consideration bytheNAC. Implementation: The IECBCC coordinator in the NAES will have the responsibility o f this sub-component. Implementation o f the Advocacy program for a group will be the responsibility o f that selectedhigh-priority group, overseenby the NAES IEClBCC Specialist, andcarried out inconformance with the MACP Implementation Manual with respect to financial and procurement fiduciary rules. Actions related to children will make use o f the joint World Bank/LJNICEF Operation Guidelinesfor SupportingEarly Child Development (ECD)in ~ultisectoralHIVtAIDSPrograms in Africa. Cost and Financing: The IDA Grant will finance all o f the activities described above, as long as the selected high-priority advocacy group provides substantial in-kind contributions in terms o f active participation o f its membership and leadership. (A work plan would be expected to accompany any submission.) Fundingwill include consultancy services, support for media costs (internet, radio, poster), the cost ofworkshops, seminars, andworking group meetings to prepare concepts, limitedexternal travel -47- to cover the costs o f participation inexchanges with other countries on relevant issues andthe costs o f bothqualitative andquantitative monitoring o f advocacy group efforts. Sub-component 1.6. Assessment, Monitoring and Evaluation (Le. includingbehavioral surveillance andmapping) Diagnosis. Monitoring and Evaluation (M&E) i s well known in Mauritania. The national government, the internationalorganizations, and localNGOsalways monitoredand evaluated their activities. This was usually done byperiodical reporting, more oftenthannot ina descriptive way. Hence, it is difficult to use data as a managementtool, becausequantitative information cannot be easily extracted. Every agent had its own approach, therefore making comparisons andor aggregations difficult. Objective The objective is to have a performing M&Esystem on basis o f which balanced management and strategic decisions can be made about the priorities, the contents, and the approaches o f the AIDS program. The overall project M&E system will contain: (i) activity monitoring and evaluation; (ii) monitoring o f the epidemic and its impact; (iii) financial monitoring o f all the financed action plans and sub-projects, inorder to identify emerging problems inexecution o f activities; and (iv) social monitoring impact, to assess the impact o f the project on the vulnerable groups in society and to identify emerging problems inexecution o f activities; and(iv) social monitoring impact, to assess the impact o f the project on the vulnerable Strategy. The project will be a "learning by doing" process; therefore a reliable M&E system will be a key feature o fthe project design. Activities. To achieve the objectives, the activities will include: (i) advocacy activities to underline the importance andthe cost-efficiency o f a goodM&E system, and to bringtogether the various actors inone single system; (ii) development and procurement of tools, fonns, equipment, etc. necessary to process data; (iii) training o f all levels in collecting, analysis o f data, and self-evaluation; (iv) collecting and analyzing data, and establishing a database containing the descriptions and results o f national and international M&E activities, easily accessible to every user; (v) executing inter alia a beneficiary assessment survey o f the general population three months before the mid-tenn review and project end; and (vi) disseminating data ina useful format to all stakeholders. Detailed activities o f the M&E system are described inAnnex 18. Implementation arrangements. Monitoring and Evaluation in the National HIVIAIDS program o f Mauritania is the ultimate responsibility o f the NAC. The daily managementwill be the responsibility o f the NAES through its M&E specialist. This specialist will coordinate the M&E system, but not execute the activities. Data processing and analysis will be outsourced to a consultant selected on a competitive basis. The GAMET (Global AIDS Monitoring & Evaluation Support Team supported by WB and WAIDS) will provide technical assistancefor the longterm(at least 3 years). Cost and financing. It is generally accepted that 10 percent o f total program costs must be allocated to Monitoring and Evaluation, however, a large part o fthese costs will be financedunder other components, such as: (i) second-generation surveillance o f target groups and sentinel system costs, under the health sector component (subcomponent 3.1); (ii) M&E specialist, under the capacity-building component (sub-component 1.2); and (iii) training ofNGOs, CBOs, andFBOs incollecting data will also be covered under the capacity-building component (sub-component 1.3.) and the civil society component 4. The remainingcosts will be financed under this sub-component: the project will finance the M&Emachinery, Le., equipment to process data, related technical assistance, training and workshops, and operation costs. -48- Itwill also contributeto the DHSwithother interesteddonors. . ProjectComponent2 US$3.90 million - Expand Multi-public sector (non health) Responsesfor Preventionand Care of HIV/AIDS This component is two-fold: (i) support to Ministry's Action Plans to controlHIV/AIDS, and (ii) the the use o f existing "Projects" to support the fight against HIV/AIDS. Sub-component 2.1. Support to Ministries' Action Plans for HIV/AIDS Control Diagnosis: InMauritania, the fight against HIV/AIDS has been essentially managed by the Ministryo f Health and Social Affairs (MOHSA) through its National Program o f Fight against AIDS (Programme national de Iutte contre le VIH/SIDA, PNLS) established in 1987. Despite the creation o f the National HIV/AIDS Committee in 2000, the Government's response to the unfolding HIV/AIDS situation has been limitedto its medical and healthaspects under the MOHSAlPNLS leadership. The adoption in2002 o f the National Strategic Framework to fight HIVIAIDS (NSFA) was a decision to shift towards an effective broader-base multisectoral approach to the fight against HIV/AIDS. At this stage, there i s a total lack o f basic quantitative andqualitative data on the ministries personnel with regard to HIV/AIDS (civil servantsbeingafflicted by the virus and on the level o f knowledge these employees have on at-risk behaviors), and no ministry has yet to embark on organized actions gearedto its personnel, their families, and their "clients." However, the Ministry o f National Defense is taking care o f its HIVIAIDS-affected personnel, andother ministries, such as the State Secretariat for Women's Affairs (Secrktarzat d'Etat de la condition fdminine, SECIF) the Rural Development and Environment Ministry (MinistGre du dkveloppement rural et de l'e~vironnement,MLIRE) and the Ministry o f National Education (Minist&-e de I'dducation nationale, MEN with large numbers o f staff located in remote areas (teachers, rural development agents, etc.) are particularly concernedabout the threat o f HIV/AIDS. Objectives: The objective o f this sub-component i s to initiate, facilitate, and support the mainstreaming of HIVlAIDS activities into public line ministries with a view to bringingabout desired changes inboth institutional and individual behavior. The objectives o f each individual line ministry are to: (a) focus primarilyon preventive interventionsand psycho-social counseling activities with the objective to reach all staff and their families; (b) train staff to provide a similar range o f services to their clients according to their comparative advantage; and (c) build the ministry's capacity to plan, develop policies, and implement its HIV/AIDS action plans. Seven non-health ministries have completed the preparation o f their action plan(MEN,MDRE, SECF, MDN,MCOI, MFPTJS, andMCRP). The project will start with these. However, other ministries that may demonstrate interest during the course o f the project could be addedgradually on an annual basis. Strategy: The strategy i s to ensure full responsibility o f each individual Ministryfor the identification, preparation, implementation, and monitoring o f its own action plan, which will be financed by the project. These action plans and budgets will cover the central, regional, and sub-regional levels. The ministries' action plans, including sectoral objectives with performance indicators, list o f activities, planning, and estimated cost will be "contractualized" between each ministry andthe NAC, through the NAES, which will monitor their progress. N o t w i t h s ~ d i n gthe fact that each directorate andfor unit is responsible and accountable for carrying out the respective activities o f the ministry's agreed plan, outsourcing o f some o f these activities for which CSOs andfor the private sector have proven comparative advantage, can be envisaged. An assessment o f the draft five-year action plans o f the seven non-health ministries, was carried out during appraisal. Annex 13 presents in box format the key elements and particularities o f each o f the seven sector action plans. The detailed five-year plans have been submitted to the NAC and approved. A PPF has been granted to allow, among other things, for the -49- testing o f one action plan (MCOI) to learn from experience and adjust the approach and the PIM, if warranted, prior to project start-up. Activities: Plannedactivities can include: Capaci~-Building,Planning & Policy. This includes inter alia: . Conducting sector HIVIAIDS impact assessments focusing on target groups, and establishing qualitative andquantitative database on staff; Establishinga simple M&E systemanddeveloping capacities to analyze the data for actions; * Strengthening policy formulation with regardto HIVIAIDS with a focus on: (i) benefit packages for staff and dependents with respect to long-term care; (ii) ensuring protection o f humanrights policies for P L W A and minimizing discrimination in the workplace; and (iii) gender-specific policies and programs affecting bothministry staff andpopulations served; * Fostering collaboration and coherence o f actions between Public Sector Organizations, where appropriate, to maximize impact (e.g., SECF, MFPTJS, andMOHSA); * Training key staff inpreparation, execution, andmonitoringo f action plans; and providing a limited number o f well-selected study tours for committee members to learn from experiences from other MAPSinthe Region. Standard Training on HIV/AIDS to be implemented in all ministries. This includes inter alia: * Implementinga program o f IECICCB for PSOsstaff (internal clients) andtheir constituencies (external clients), comprising: (i) identification and training o fEducators, (ii) advancedHIVIAIDS training for all staffby Educators, (iii) identification andtraining o f Resource Persons, Peer-Educators andCounselors; (iv) training o f outreach workers as trainers on HIVIAIDS;and(v) basic trainingon HIVIAIDS for the ministry'sexternal clients (see details inAnnex 13). * Promotiono f condoms at national and regional levels; * Distributionto all staffof information regardingavailable health andsocialbenefits to HIV sero-positive individuals; distribution o f information regarding available health and social services, includinglocation o fVCT sites; andsupport to the mainstreaming o fgender issuesrelatedto . HIVIAIDS; and Utilization o f available sector infrastructures to reach personnel and its clients to convey messages; Ministry`s Specific Activities, Each ministry, depending on its sector and its clientele, may propose specific activities. For example, the MENwill include HIVIAIDS inthe educational curricula, the MDN will address system weaknesses within its own health care structures. The MCOI has developed a specific program regarding Islamic Laws and HIVIAIDS; the MCRP has developed a program for preparingand disseminating messagethrough mass media. Implementation:Ministries' action plan proposals will be submitted to the NAES for approval by the National Committee for the Fight Against HIVIAIDS (Comit4 national de lutte contre le VIH/SIDA, CNLS) and subsequent funding. A formal, five-year Action Plan Agreement (Convention), including action plan and budget with agreed input and output indicators, will define the respective roles and responsibilities o f the contract signatories and frame the relationship between the various executing agencies and the NAES and M S . Action Plan Agreements will be conceived around a performance-based management approach, whose primaryfocus i s around accountability for results. The first disbursement will be made upon signature o f the Action Plan Agreement, with subsequent quarterly payments to be made on the basis o f satisfactory quarterly reports providing evidence of: (a) performancelresults in light o f indicators specified in the work program agreement; (b) documentation evidencing expenditures incurred during the previous quarter; and (c) planbudget for the subsequent quarter that would be consistent with the lessons learned from previous experience. Random technical -50- and financial audits will validate such reporting. A sample for Convention is included in the Project ImplementationManualto be adopted by Board Approval. Cost and Financing: The estimated cost o f the five-year action plans are ranging between $310,000 (e.g., MCOI) and $1,000,000 (MEN). The project will finance training, workshops, study tours, technical advisory services, HIVlAIDSlSTI and IEC materials, voluntary counseling andtesting (VCT), condoms and their distribution, support for facilities (small rehabilitation), equipment, and incremental operating costs. Sub-component 2.2. PromotelEnhance HIV/AIDSAgenda inExisting"Projects" Diagnosis: Several ministries and other Mauritanian institutions are implementing "projects" which finance specific activities not fully integrated into, andinterrelated with, the ministry's regular activities. This i s the case, for instance, for some IDA-financed projects such as the Urban Development Project (UDP) or the Nutricom project in the SECF. As a result o f this disconnection, these projects and their personnel are not included into Sectoral Action Plans prepared by ministries in the context o f the above-mentioned sub-component 2.1. On the other hand, most o f these projects have resources for HrV/AIDS activities which have been found to be difficult to identify andimplement and would benefit to be coordinated with the MACP strategy. Objective. The objective o f this sub-component is to bringthe HrV/AIDS information, and particularly the information about the opportunities to fight HIV/AIDS provided by the MACP, to "projects" and organizations which are the "clients" o f specific projects. For instance, using one o f the same examples as above, to reachlocalgovernments which are the clients o f the UDP. Strategy. The strategy is to provide the opportunity for "projects" to submit and implement an Action Plan, through similar mechanisms as those which are set up for the line ministries under sub-component 2.1, and, throughthese Action Plans, to (a) focus primarilyon preventive interventionsandpsycho-social counseling activities with the objective to reach "Project" staff; (b) use the operational mechanisms currently implemented by these "projects" to reach out to their clients andinform them about HIVfAIDS and the opportunities offered to them by the MACP to prepare HIV/AIDS sub-projects which can be financedunder component 4; and (c) help these clients to identify, prepare, submit, and implement their sub-projects. Activities. Eligible activities are similar to those o f Sectoral Action Plans. However, the main focus o f this sub-component i s to facilitate the incorporation o f the HIVIAIDS dimension into the agenda o f the "projects" so that they will help their clients inidentifying and submitting sub-projects to be financed by component 4. The main output o f the "project" activities carried out under sub-component 2.2 will be the number of HIV/AIDS sub-projects that the client o f these "projects" will submit to the NAES and implement with the funds o f component 4. To keep the same UDP example again, the main result o f the UDP Action Plan would be the number o f Communes which have submitted a quality Municipal HIVi'AIDS sub-project for Component 4 financing. Implementation. "Project" Action Plan proposals will be submitted to the NAES. A formal, multi-year contract (Convention), including action plan and budget with agreed input and output indicators, will define the respective roles and responsibilities o f the contract signatories and frame the relationship between the "project" and the NAES and RAES. A sample performance-based contract will be included inthe ProjectImplementationManualto be adoptedby Effectiveness. -51 - Cost and financing. Most interested "projects" already have resources for HIVIAIDS activities. The Project Action Plan will clearly define the complementarity between the "project's" own resources and the MACP resources which may eventually be needed to fully support the "Project" Action Plans. Activities to be financed include: training, workshops, technical advice, VCT, condoms, andincremental operating costs, The financial impact o f this sub-component i s expected to be financed under component 4, because the main output of this sub-component i s the number o f sub-projects implemented by the clients ofthe "projects." ProjectComponent3 US$4.70 million - ExpandHealth Sector Responsesfor Prevention, Treatment and Care of HIVAIDS In Mauritania, the fight against HIVIAIDS has been the responsibility of the Ministry of Health and Social Affairs (MOHSA) through its National program o f fight against AIDS (ProgrammeNational de Iutte contre le VlH/SlDA) established in 1987. The Ministry has developed considerable competence in the fight against HIVIAIDS, however very much limited to a medical paradigm. The adoption o f the National Strategic Framework HIVIAIDS (NFSA) in 2002 was a crucial shift towards a multisectoral approach. The MOHSA now has to make a strategic and conceptual change andhas to reflect on how to effectively fulfill its responsibility inthis new environment. The Health staff has to become accustomed to its new role; a reorientationfrom being the leader inthe fight against AIDS, toward a role inwhich the emphasis i s more on advising, establishing norms for services, and provision o f medical and epidemiological information to other players inthe field. It should, however, not be forgotten that the provision o f quality medical services remains the cornerstone o f the fight against AIDS andthe MOHSA now can concentrate on improvingthese services. The mainareas that needto be strengthenedinclude: (i) assuranceo f quality services, (ii) protocols for medicalprocedures and treatment, (iii) and commodity procurement, (iv) drugs management health information system and M&E o f medical services, (v) qualitative and fundamental research, (vi) interpersonal communication and counseling skills, (vii) safe blood transfusions, (viii) training and re-training health staff inthe aforementioned areas, and(ix) bio-medical waste management. The overall objective o f this subcomponent is to: (a) provide other players inthe field with medical and epidemiological information; (b) enable the general population to protect themselvesbythe promotiono f safe sexual practices and the provision o f information andskills; (c) offer quality medical andpreventive services covering HIVIAIDSISTIITBIOI, and(d); prevent the non-sexual transmission o f HIV. It will be implemented through the following six sub-components: (i) surveillance and epidemiological research, both biological and behavioral; (ii) prevention and voluntary testing and counseling; (iii) andcare treatment of people living with HIVIAIDS, (iv) training o f traditional health practitioners, traditional birth attendants, and community health workers; (v) MOHSA personnel; and (vi) management o f bio-medical waste. Sub-component 3.1. Surveillance andEpidemiologicalResearch, both Biological and Behavioral Diagnosis. Available data are fragmented and lack reliability. Regular sentinel surveillance has been done only for the blood donor group (since 1992). Apart from this, the only information is given by a HIV sero-prevalence survey conducted by MOHSA in 2001 among pregnant women in all regional capitals that gave an overall rate o f 0.57 percent. The last EDSDHS (2000) gave some insight into practices and knowledge with regard to HIV/AIDS in the general population, but this information is rather general. Objective. The objective is to have detailed information about the evolution o f the epidemic, using - 52 - surveillance and additional research among the general population and more particularly vulnerable groups. Strategy, As the spread o f the epidemic has only just begun, prevention will be the mainfocus o f the MOHSA's response, targeting primarily at-risk and vulnerable groups: sex workers, STI patients, women, youth aged 15-20. PHC clinics and OPD inhospitals will be reorganized so that: (i) these groups be given convenient, friendly, and easy access to health services, (ii) treament o f STIs, VCT and prophylaxis and treatment o f opportunistic infections be provided as part o f an integrated package o f services offered to everyone including to PLWHA, so they can live better, longer, and protect their partners and children. Activities. Surveillance o fHIVprevalence will be undertaken yearly in 10 sites amongpregnant women attending antenatal care, along with surveillance o f syphilis in 10 sites among key vulnerable groups: STI patients (2 sites), military (1 sites), sex workers (3 sites), miners (2 sites) and fishermen. For the vulnerable groups this will be combined with sexual behavioralresearch, but at a lesser frequency (once every 2-3 years). A larger national surveillance will be done every five years, also combined with sexual behavioral research usingthe DHS format. The surveillance sites for the vulnerable groups will be used to promote safe sexual behavioral andoffer treatment o f STIs. Detailed activities include: (i) monitoring o f the target groups over time to detect evolutions in behavior and tailor prevention interventions and messages; (ii) mapping, and wherever possible, combined withprevalence and behavioral mapping; risk (iii)qualitative and quantitative research to answer to unresolved questions, or to improve services, and (iv) creation andoperation o fan ethical researchcommittee to protect the rights o fthe people. The National Hygiene Center-CNH will be strengthened in its institutional capacity to be able to efficientlyexecute and analyze the surveillance activities. It will be equipped with additional biomedical equipment in order to function as the reference HIV/AIDS/STI laboratory. Existing laboratories o f the MOHSA and the MDNwill be upgraded and staff will be trained. Technical assistance will be made available through USAID, collaborating with the staff o f the CNH in order to transfer capacity in research and surveillance. As necessary, some existing laboratories may be rehabilitated or expanded within their current compounds to better support the objectives o f the proposed project. Because these facilities are currently in active use, there will be no need for land acquisition. This has been confirmed bythe MOHSA. Implementation.The CNH will be overall coordinator o fthe surveillance andresearch; outsourcingthe execution o f the activities to other agencies (NGOs, other departments within the MOHSA or other ministries). Cost andFinancing.The IDAgrant will provide funds for laboratoryequipment, small rehabilitationfor a documentation and information center, as well as the operational costs o f surveillance and research. The technical assistance is expected to be financed by USAID. The execution o f the DHS is usually sharedwith other donors, like N A P or USAID. Sub-component 3.2. PreventionandVoluntary CounsellingandTesting The MOHSA objective for prevention covers seven areas: (i) Voluntary Counseling and Testing (VCT); (ii)Communicationfor Change of Behavior (CCB); (iii)Condom provision; (iv) Treatment and Prevention of Sexually Transmitted Infections; (v) Prevention o f Mother-To-Child-Transmission (MTCT); (vi) Preventiono fnosocomialinfection, including (vii)transmission bybloodtransfusion. - 53 - Diagnosis. VCT. High-quality counseling and testing is offered intwo facilities, one inNouakchott and one in Kiffa. Some private practitioners and NGOs do offer VCT, but the quality i s not always assured. Testing i s not done ina systematic way, andi s subject to whatever tests are available. There are not many professionally trained counselors available and, moreover, there are neither national standards nor training modules for counseling. CCB. The MOHSA has made extensive efforts to inform the population about HIV/AIDS, with reasonable success (DHS 2001). However, no inroads are made into "Change o f Behavior," which needs a more intensive approach. A clear strategy has not been defined, which causes a jumble o f approaches and messages; it i s also clear that the MOHSA cannot do the job alone and all other - sectorswill have to contribute Condomprovision.Untilnow condoms havebeendistributedfree through health serviceswith little or no involvement o f the private sector and NGOs; there i s little knowledge o f their actual use. Although condom use is promoted, very few facilities actually explain how to correctly use the condom. Evenwithin the MOHSA there is resistance to condom promotion. Additionally, there i s no effective strategy for condom promotion. The capacity o f the public health sector to make condoms . available at the community level is low. Female condoms are currently not available inthe country. Treatment and prevention of STIs. Treatment o f sexually transmitted infections (STI) is considered one o f the most effective ways to prevent the transmission o f HIV in Africa. The Syndromic approach has been solidly introduced in Mauritania. Currently the management o f STIs encounters four main obstacles: low use o f formal services (high use o f informal providers and self-medication); use o f an incomplete developed syndromic approach; a drug supply that is not 100 percent reliable; andhigh-cost becauseit is not subsidized * MTCT. The prevention o f HIV transmission from Mother-to-Child by a short regimen of anti-retrovirals and adequate infant feeding has been shown to be highly cost-effective in high prevalence countries (>5 percent), but has a low priority in Mauritania given the epidemiological data. There i s no experience whatsoever concerning prevention o f vertical transmission in Mauritania. ' Prevention of nosocomial infection. In Mauritania this danger is hardly recognized, yet it goes beyond HIV infection: some other potentially lethal viruses can be transmitted by sharps' injuries (injections, surgery, etc.). Equipment for safe disposal is generally lacking, and potentially dangerous procedures are not standardized, which can easily leadto accidents. * Safe blood. Provision o f safe blood for transfusion is well under way, but coverage is incomplete. There have been some efforts to create a group o f voluntary donors, but little emphasis has been placed on the need to rationalize the prescription o f transfusions or to address anemia in the most frequently transfused groups like pregnant women and under-five children. Procurement o f commodities necessaryfor bloodtransfusionis not reliable. Objectives, * VCT. Increasethe number o fVCT centers byensuring availability o fquality VCT inall regions and major population concentration sites, run both by the public and private sectors, as well as NGOs. Indicator 1: at the end o f Project year 1, at least every region has a VCT center and at least 20 VCT centers at the end o f the project. Indicator 2: 20 percent increase inthe number o f volunteers tested peryear. CCB. Maintaining awareness o f HIV/AIDS risks and protection measures; promoting behavioral changes for safe-sex practices; and advocating with respect to human rights. Main targets include: adolescents, women, youth, commercial sex workers, patients inOPD consulting for STI, and health workers, At the end o fthe project: 95 percent ofrespondents (general adult population) who can both correctly identify ways o f preventing the sexual transmission o f HIV and reject major - 54 - misconceptions about HIV transmission or prevention ; increase o f 20 percent o f youth under 20 reporting having used condoms during their last sexual encounter or used other safe practices; 25% o f percent o f males and 10%o f females adult reporting usingcondoms with irregular partners during last 12 months. 50 percent o f commercial sex workers reporting consistent use o f condoms (survey or general surveillance system). Condom promotion. To have condoms widely available at affordable costs including female condoms. Indicator: Inevery Wilaya, number o f condoms given or sold at affordable cost. STI preventionand treatment. The objective is to have quality STI treatment widely available. At the end o f the project, 15.000 men and women per year corresponding to about 60 percent o f STI patients are receiving STI care according to guidelines, from facilities with trained staff and uninterrupted supply o f drugs. Prevalence o f self-reported STI among sex workers duringinterviews is 20 percent; 80 percent o fhealthworkers trained insyndromic approach treatment o f STI. MTCT. To buildup experience inthe prevention o fMTCT. By the end o f Project year 1, two pilot programs o fMTCT are functional. Prevention of nosocomial infection,To have a safe working environment inmedical facilities. By the end o f project year 1, every medical service has a plan o f action for prevention o f nosocomial infections. Quality assurance teams have been established inall regional andnational hospitals. Safe blood. To have safe and appropriate blood transfusions available, whenever necessary, at the regional level. At the end o f the project 100 percent o f all blood transfusions are tested for HIV and five additional facilities are equipped withbloodbanks. Strategy. - VCT. Voluntary Counseling and Testing for HIV has been shown to trigger behavior change, even when the result o f the test is negative. The project aims at rapidly scaling up VCT for HIV both inside public health services as well as in private and civil sector health services. Both negative as well as positive testedpersons shouldbe organized in self-help groups. VCT promotes awareness and empathy to PLWHA among health and other counseling staff, which is an additional vital advantage. Regarding facilities, the strategy is to upgrade existing ones, including one ineach regional hospital, three in Nouakchott, two SNIM health centers in Nouadhibou and Zouerate, and the Ministry o f . Defense's hospital CCB. The strategy is basedon the use o fmass media, bothpublic and private as well as traditional channels, and the promotion o f social marketing, Strategic coordination o f IEClCCB messages and content i s key for the success o f behavioral change. The IEClCCB unit in the NAES will stimulate involvement o f agencies and ministries (including MCRP) and coordinate HIVIAIDS communications programs. The input o f the MOHSA is crucial because it has considerable experience inIEC- a preamble for CCB- but also becauseitmustassure that the correct messages are communicated. Finally, once the demand for services i s created, health services must be able to respond adequately. A special effort will be made to promote responsible sexual behavior for the health staff, to provide them with proper information about sexual transmission, andto improve their skills to avoid sexual transmission. * STI. The syndromic approach will be pursued, with further development. Healthstaff working with STIpatients will be trained ininterpersonal communication skills. Attention will be paid to take care o f partners o f STI patients. Drug availability and drug resistance patterns will be monitored at the facility level. Their cost will be subsidized. Special attention will be given for the offer of Reproductive Health Services to young people with their participation. To make the services more accessible for adolescents, opening times have to be adapted; staff will be trained in the specific demands and approaches; and discussions will also be engaged with the parents to address their . apprehensions. This intervention i s covered inthe WorldBank-financed HealthProject. Condoms.A two-pronged approach will be pursued (i) condomdistribution whenever condoms free - 55 - are promoted, and (ii) additional supply by social marketing mechanisms. Special attention will be paidto instructionsabout obtaining andusingcondoms. MTCT. Prevention of MTCT will be tested through two pilot programs in (risk) areas to gain experience inthis matter, andwill be scaled up later, when appropriate. The project will prepare this intervention by providing support to networks o f women affected by HTV as a way to minimize the stigma and discrimination toward women livingwith HIV as part o f the civil society response sector. Nosocomial infections and safe blood. For their prevention, the health sector will ensure a safe blood supply and universal precautions against nosocomial infections at all levels through health staff awareness training on the existing dangers, and provision o f skills and tools to prevent nosocomial infections. Regional hospitals, and selected private facilities, will be able to test blood for HIV and syphilis, as well as Hepatitis B and C. A special effort will be made to mobilize voluntary blood donation. Inaddition, there will be efforts to diminish unnecessary transfusions as well as prevention o f anemia inthose groups (women and children) most frequently transfused. Activities. VCT. Activities to develop VCT include: (i) a national VCT strategy for Mauritania; (ii) defining preparing modules for training, (modules from neighboring countries can be adapted to the local context); (iii)proposingprotocols for testing, usingrapidtests for quick results inthe periphery; (iv) training o f 10 trainerslsupervisors, training o f 100 counselors, followed-up with intensive on-site supportive supervision to counselors in place; (v) scaling-up VCT per region choosing the most appropriate vehicles: NGOs, private or public health facilities; (v) developing counseling, including definition o f different types o f counseling services to be offered, differentiation o f counselor profiles, and training curriculum adaptation; (vi) policy formulation to define the testing protocols; and (vii) rapid on-the-spot HN tests at the decentralized level with tests initially procured through the UN system and when possible through the CAMEC with a minimummargin corresponding to stock and distribution costs. . CCB activities include: (i) contribution to the development o f a national Communication strategy in coordination with the MCRP and all important actors. The MOHSA will ensure that correct messages are communicated; (ii) training o f staff in interpersonal communication skills, training a wide range o fpeer-educators/-counselors; (iii) technical support to the production o f communication support materiel (radio and television broadcasts, printed material, writing theatre plays andpoems, etc.); and(iv) improvedcommunication skills inall contact with the public. * STIs prevention activities include: (i) improvement o f MOHSA's capacity to market a quality standard approach to STI treatment in both the public and the private sector; (ii) revision and expansion o f modules o f treatment; (iii) provision o f treatments as kits containing the necessary drugs in proper quantity and instructions at a subsidized price (social marketing) for each given syndrome; and (iv) once the syndromes modules have been adapted and completed, retraining o f health staffinthe use o fthe syndromic approach andthe prescription o f the treatment kits, as well as distributedfor free duringpromotion activities. * Condom provision activities include: preparation and implementation o f a middle-term (3-5 years) procurement plan supported by MOHSA through UN Agencies and, when possible, through CAMEC, together with major donors (for 2004, UNFPA has indicated its commitment to provide suMicient condoms). During the preparation phase a consultant will be assisting the MOHSA in setting up a procurement strategy. Condoms will be made available inall public health facilities for the use o fhealthpersonnel andpatients. -56- MTCT activities include: (i)execution o f an action research in two pilot districts where seroprevalence o fpregnant women is about or above 1percent; (ii) training o f staff in: interpersonal communication, managing tests and interpretation, counseling o f seropositive and negative mothers, informing mothers about the range o f possibilities when identified seropositive, providing ARV to mother and child, counseling mothers on breastfeeding and its alternatives, supplying milk supplements when abstaining from breastfeeding, sensitizing the population about ANC use, initiating actions against discrimination o f seropositive and non-breastfeeding mothers; and (iii) procurement o f test kits, artificial milk supplements, ARV (Nevirapine will be available for free, as soon as a proposalfor a solid programhas been approved). * NosocomialInfectionsprevention activities include training of health staff in: (i) establishment o f quality assurance teams in regional and national health facilities; (ii) universal precautions for the prevention o f nosocomial infections, following strict protocols when working with potentially dangerous fluid and materials; and (iii) proper treatment and disposal o f HIV/AIDS waste (see Component 3.5). * Safe blood supply activities include: (i) completion, as needed, o f the coverage currently supported by the World Bank-financed Health program and other donors, (ii)capacity-building through training; and (iii)procurement o ftest kits and laboratory reagents. Implementation. * VCT. The UDAGwill coordinate training; it will identify and organize the partners to complete the coverage. The DGIwill be responsible for the rehabilitation ofexisting facilities. . CCC. The NAES will be responsible for general coordination. The MSAS willbe responsible for the proper content o f the messages and assuring that uniform message are used. The coordination mechanisms will be incorporated in a letter o f understanding between the major actors in communication: MOHSA, MCRP, EPI, UNFPA, UNICEF, Worldvision, etc. STIs. The Reproductive Health (RH) program, which has introduced the syndromic approach in Mauritania, will be responsible for: (i) o f the treatment modules, their adaptation and the revision follow-up; and (ii) newly introduced syndromes. The CNH will execute research about resistance patterns o f STI and biological identification o f the syndromes. Treatment kits will be obtained through the UN system and, as soon as possible, through the CAMEC with a minimum margin correspondingto stock anddistribution costs. . Condoms. Althoughmanyactors will play a role inthe distribution and promotion o f condoms, it is ultimately the responsibility o f the MOHSA. UN Agencies will continue to support the MOHSA because the CAMEC will be able to assume the responsibility to ensure the availability o f good quality condoms in sufficient quantity. The middle term (3-5 year) plan for procurement o f condoms will be developed by MOHSA incollaboration with major donors. Instructions about obtaining and usingcondoms mustbe developedinthe CCB component. . MTCT. The program will be implemented under the responsibility o f the Reproductive Health Program in the MOHSA. UNICEF will give technical assistance and will be able to assist in the analysis o f the results. Nevirapine will be donated for free by Boehringer Ingelheim. The CAMEC willplayitsrole inthe provision o fdrugs, as soonas its strengthening is completed. -57- Prevention of Nosocomial Infection. The responsibility for this action will reside under the DPS ( Direction de la protection sanitaire). The development o f protocols for the potentially dangerous medical procedures mayuse the JHPIEGO educational materiel. Safe blood. The implementationo f the assuranceo f a safe blood supply will be the responsibility o f CNTS (Centre national de transfusion sanguine) in collaboration with the DGI, where some rehabilitationwill be done. Cost and Financing. The IDAgrantwill finance: (a) training o fmedical and other staff in: (i) prevention of nosocomialinfection, (ii) interpersonal communicationlcounseling, (iii) handling and interpretation o f HIV testing, (iv) use of sophisticated bio-medical equipment inlaboratories, (v) diagnosis andtreatment of TB, STIs, HTVlAIDS and Opportunistic Infections, (vi) Reproductive Health care for young people, (vii) safe blood transfusion in all its aspects, (viii) instructions for the use of condoms, and (ix) preventiono fMTCT and accompanying activities; (b) drugs andprophylaxis for care o fPLWHA and for treatment of 01s and STIs, HIV (rapid) tests, (c) operational costs for the surveillance studies; (d) strengthening o f laboratory facilities o f CNH; (e) costs for the MTCT pilot studies; (f) elaboration o f strategy papersandprotocols, and (g) contribution to the scaling-up o fVCT services. Sub-component 33. Care and Treatment of People Livingwith HIVIAIDS. Diagnosis. Given the low prevalence o f HIV in Mauritania, it is-fmancially and organizationally-feasible to treat HIV-positive persons when indicated. Treatments and prophylaxis o f opportunistic infections for PLWHA are cost-effective, and can prevent life-threatening infections for PLWHA. However, Mauritania has no capacity to provide treatment services to PLWHAs. More than 60 infectedpeoplepreviously went to Senegal for biological follow-up and for ARV. Objective. To provide free, quality treatment and psycho-social support to PLWHAs inorder to reduce transmission, to reduce disability among workers, and generally improve people's lives. Given the low prevalence rate, it i s estimated that 100percent o fthe patients can be treated. Indicator: 8 referral facility providingdiagnosis, care, andtreatment to PLWHA inan integrated manner; 80 percent o fpatients using ARV regimeninyear 1and 200 at the end o f the project; 50 percent of PLWHAreceivingpsychological support. For HIV/AIDS prevalence rate among tuberculosis patients, the targeted rate remains a value to be determined on the basis o f the results o f the on-going prevalence survey from which data will be available inDecember 2003. Strategy. The two sub-components 3.2. and3.3. will be implementedinan integrated manner. Treatment o f STIs, VCT, and prophylaxis and treatment o f opportunistic infections will be part o f an integrated package o f services offered to everyone includingto PLWHA. The strategy will include: (i) improve the general condition o f PLWHA, prophylaxis for 01, proper nutrition, healthy life style and provide psycho-social and economic support; (ii)develop ARV policy, make ARV available, and create necessary conditions for their effective use; (iii) decentralize Directly Observed Treatment Strategy (DOTS) at the lowest level possible o f the health system; and(iv) ensure proper diagnosis and treatment for 01. The project will ensure availability o f the necessary drugs, test and laboratory facilities, strengthen drug management, and patients' management at facility levels. The Government will take all measures to procure ARV drugs via ACCESS at low prices. The ARV treatment will be available in CHN and intwo other referral centers (Kiffa andNouadhibouhospitals). Activities. Planned activities include: (i) defining treatment and diagnostic protocols; (ii) provision o f - 58 - equipment for diagnosis and biological follow up; (iii) provision o f drugs for 01; (iv) basic laboratory services for diagnose o f TB put in place; (v) support to free DOTS implementation with extensive supervision and monitoring and decentralized as much as possible; (vi) prophylaxis o f PCP (Pneumocystis Carinii) and other infections by Cotrimoxazole will be made available to all PLWHA at a standardized minimizedprice, amounting to about USSlO per person per year; (vii) basic treatment for fungal infections (Fluconazol) and drugs against diarrhea and dehydration (ORS, Ringer solution, Metronidazole) will also be part o f the standard package; (viii) provision o f ARV to PLWHA; (ix) capacity-building to diagnose andtreat TB at the healthdistrict level, includingtraining o fHealth staff in diagnosing 01and providing the appropriate treatment. Specific training will be offered to some key staff; and (x) support activities will include clear definition o f the package and o f treatment indications and standards, training and supervision, and development o f a standardized pricing scheme for all the treatments. Implementation. The responsibility for the execution o f the TB aspect resides under the TB program. The treatment o f HIV with ARV will initially start in the CNH and will be extended to two regional hospitals before the end o f the project. The CNH director, incollaboration with the DMHandDPS, will be responsible for the design and definition of the conditions for ARV treatment. The CNH has the responsibility for the biological follow up o f the PLWHA. The DPS will be responsible for the training modules concerning the diagnosis andtreatment o f 01. Cost and Financing. The IDA grant will finance studies, laboratory equipment, training, and drugs including ARV and reagents. Subxomponent 3.4. Training of Traditional Health Practitioners, Traditional Birth Attendants and Community Health Workers Diagnosis.Large numbers o fMauritanianpatients consult (andhave full confidence in) traditional health practitioners, traditional birth attendants (the "matrons") and community health workers (the Unitds sanituires de base-USB- are responsible at the village level for maternal and child health-related activities). The MOHSA recognizes the potential for working closely with traditional health practitioners in the fight against HIV/AIDS, especially with regard to prevention, and possibly the treatment of opportunistic infections (thishas yet to be established), andsocio-psychological care for PLWHA, There is currently no formalized dialogue, but efforts to establish a working relationship have been started. Objective. To reach the population through culturally acceptable channels by involvingtraditional health practitioners, birth attendants, and community health workers in the prevention, treatment, and counseling o f HIVIAIDS. At the end o f the Project year 2, it i s expected that 500 traditional health practitioners are trained. Strategy. The traditional sector will be considered as an important force, which can be an important factor in the fight against AIDS. The approach will be careful and participatory. To ensure that educational materials are appropriate, they will be developed inparticipation with the traditional health practitioners. The methodologies used during the training will take into account that many traditional healthpractitioners andbirthattendants are illiterate. - 59 - Activities. Training activities for traditional health practitioners and birth attendants include: (i) basic principles o f HIV/AIDS and its transmission; (ii) diagnosis o f opportunistic infections; (iii) simple treatment for 01; (iv) identification o f traditional medicines for 01; (v) basics o f nutrition; (vi) maternal andchildhealth; and(vii)personalhygiene; andsanitation. Implementation. The Progam for Reproductive Health has started discussions with the traditional health practitioners and should pursue this carefidly towards an active involvement inthe fight against HIV/AIDS. To improve collaboration with the MOHSA, the traditional sector will be assisted in organizing itself in associations (see sub-component 1.5). Use will be made o f reputed leaders in the traditional sector, who can act as peer-educators. Sub-component 3.5. Trainingof MOHSA Personal on HIVIAIDS (internal clientele) Diagnosis. Arguments used for other sectors to indicate that staff i s at risk for HIV infection, also apply to health staff (isolated working conditions, separated from family and relatives, regular income in an environment where poverty i s rife, etc.) Health personnel are as much at risk as others in similar positions like uniformed persons, truck drivers, fishermen, etc. One advantage i s that they have knowledge, but knowledge does not necessarily promote healthy behavior. The position o f the health staffis particular, becausethey are role models inthe communities andare expected to promote a healthy life-style. In addition, many o f the staff in the MOHSA are not medical personnel (administrators, drivers, cleaners) and do not dispose o f information about HIV. Objective. To create a consciousness among the health staff concerning the risks o f sexual transmission o f H I V and make them adopt safe sexual practices. Indicator : 60 percent o f the MOHSA staff applied safe sexual practice(s) intheir last casual contact. Strategy. The approach has to be diversified for non-medical and for medically trained staff, but the strategies are overall the same: information and regular updating; consciousness training applying life-skill training techniques; reinforcement o f this training by improving inter-personnel and negotiating skills; insertion o f ethical aspects o f their work; and illustrationo f the effects o f their behavior on the community. Activities include the following: (i) o f level o f knowledge and attitudes; (ii) o f sexual survey survey behavior; (iii)developing appropriate training materials for different levels; (iv) training in different stages, starting with non-medical personnel (the training can be combined with the inter-personnel communicationskills training); (v) follow-up by supervision; and (vi) repeat surveys. Implementation arrangements. The department o f Human Resources will be responsible for the coordination and implementation. Due to the delicacy, this activity will be outsourced, with solid guarantees for protection o fprivacy. Cost and financing. The IDA Grant will finance: training, technical advisory services, andstudy tours. Sub-component 3.6. Management of Bio-Medical Waste Diagnosis. Medicalwaste consists of: (i) liquidwaste such as blood, chemical fluids, post-surgery fluids, radiology fluids, waste water; and (ii) waste such as anatomic waste, sharps, dressings, syringes, solid and pharmaceutical products. The medical waste management plan estimated that Mauritania's health facilities generate about 3,300 kglday o f solid waste, o f which 21 percent (678 kglday) consists o f -60- medicalwaste; 16.5 percent (534 kglday) consists o f infectious waste; andabout 4.5 percent (144kglday) i s made up o f sharps. The environmental and social impacts resulting from ineffective medical waste management and the proposed mitigation measures are outlined in the environmental section o f this PAD. Itwas further established that current policies, laws, andinstitutional arrangementsinMauritania as well as the absence o f the necessary decrees o f application, do not allow for effective medical waste management, For example, medical waste management is not included as a priority inthe Plan directeur de la santk et des aflaires sociales (1998-2002); it i s covered only in general terms under the Code de I'hygikne (1984) which does not include a decree o f application; and the preliminary report on sanitary conditions in hospitals, issued by the CNH, highlights that hospital waste management and hospital hygiene are among the major problems. The Environment Code (2000) makes a very broad reference to medical waste management and stipulates that all activities likely to have negative environmental impacts-which include medical waste-be subject to an environmental assessment; however, the absence o f a decree o f application makes it difficult to enforce this requirement. The MSAS does not have the necessaryresourcesto effectively managemedicalwaste. Objective. The objective o f this sub-component is to address the current shortcomings through: (i) improving in the legal and institutional framework; (ii) improving the medical waste management in health facilities; (iii)training; (iv) public awareness raising; (v) private sector participation; and (vi) support for the implementationo fthe proposedmedicalwaste managementplan. Strategy. The strategy for improved medical waste management in Mauritania focuses on capacity-building and training to meet the above objectives. Standard health infrastructure plans and a standard list o f equipment for various health facilities will be updated taking into account the need for good waste management, It takes into account preparationby the UrbanDevelopment Programo f a Solid Waste Management Strategy for Nouakchott which includes a medicalwaste management component Activities. To implement the above strategy, the following activities will be supported (i) establishment of a national committee responsible for coordination and monitoring; (ii)preparation o f a national hygiene policy which focuses on hospital hygiene and medical waste management; (iii) preparation o f legislation that addresses issues related to pre-collection, collection, transport, disposal, treatment, and elimination o f medical waste; (iv) preparation o f technical directives regarding, for example, safe medical waste management, hospital hygiene, safety o f sanitation professionals; (v) institutional responsibilities for medical waste management; (vi) provisiono f equipment for medical waste collection at hospitals; (vii) development o f a system for triage and treatment at hospitals; (viii) promotion o f recycling; (ix) public information campaigns; (x) training for various groups exposed to medical waste; (xi) partnership arrangements between the public sector, private operators, and civil society; (xii) strengthening the private sector's capacity to manage medical waste; (xiii) establishment o f an organizational structure for coordination and monitoringpurposes; (xiv) regional workshops to discuss the plan; (xv) assessment o f medical waste and inventory o f available equipment in hospitals; and (xvi) monitoring at the regional level. ImplementationArrangements. . The plan will be implemented under the supervision o f the ConseiI national de la Iutte contre le SIDA (CNL,S) and in close coordination with the Urban Development Program and MOHSA. Cost and financing. The planproposes financing the following activities: (i) improving the institutional andlegal framework; (ii) (iii) awareness campaigns; and (iv) support for implementation training; public -61 - o f the plan. It i s anticipated that the cost o f the improvement o f medical waste management at hospitals would be borne by the relevant institutions; for instance, the cost o f the Solid Waste Management Strategy for Nouakchott is includedinthe existing UrbanDevelopment Project. ProjectComponent4 US$7.60 million - Develop and ExpandCivilSociety Organizations and Private Sector Initiatives to HIV/AIDS This component is two-fold: (a) Develop and Expand Private Sector Initiatives to HIVIAIDS, and (b) ExpandCivil Society Organizations Initiatives to HIV/ADS. Sub-component 4.1. Developing and Expanding Private Sector Enterprise Initiatives regarding HIV/AIDS Diagnosis. The private sector in Mauritania i s relatively small and scattered throughout the counq. The principle industries are Mining, Fishing, Agriculture, Transport, and Construction. There are very few large companies inthe country, includingthe SNIM. The majority o f industryandenterprise has less than 50 employees, and a considerable amount o f private sector activity can be categorized as informal, such as markets, boutiques, andindependent businessesandtrade. Despite recognition that HIVlAIDS i s a critical issue for businesses inMauritania, there has been very limited attention paid to addressing the issue through the private sector. There is no national workplace policy, and none o f the Employers' Federation organizations have started any programs to provide information to their constituencies, provide condom distribution, discuss risks associatedwith behavior, or consider the option o f a sectoral or national workplace policy on the issue. However, the largest employer in Mauritania, SNIM, has launched an extensive program for their employees-with their own financial resources and limited external technical assistance-including awareness campaigns, youth programs, expert seminars and speeches, training o f 300 staff as peer-educators by implementing prevention care and support strategies for their employees and families and counseling (in partnership with NGOs such as SOS and FLM), VCT, and treatment. There i s no data available on the impact o f HIV/ADS on the productivity and profitability o f businesses in Mauritania; however, it can be assumed that the rate o f infection in companies i s approximately that o f the general population (0.56 percent-1 .O percent); therefore companies have not felt a need to address the issue. But, there i s a growing understanding that the key players in the private sector in Mauritania are high-riskcategories-fishing, transport, agriculture-and need to catch the diseasebefore it becomes an epidemic. The leadership o f the Employers' Federations is preparedto provide assistanceto the organizations to sensitize andengage their large memberships Objective. The objective of this sub-component is: (i) buildawareness and capacity withinthe private to sector: (ii) to have the private sector actively participating in the National AIDS Agenda. Highpriority will be given to developing communications and awareness campaigns, condom distribution, peer education, forums to discuss risks, and data collection on prevalence rates. This objective will be measuredby the Confederation, a number o f Federations, and different sectors able to provide evidence, through annual reports and longer-term action plans, that their membership and employees have participated inawarenessprograms andare developing and usingtools for education andprevention. Strategy. The most efficient vehicle to reach the private sector i s through the sectoral Federations. Efforts will be made to assist the leadership o f the private sector, through the Confederation, the Federations, and influential industries in preparing, implementing, monitoring, and evaluating action plans for their membership. A strategic planwill be developed andresources will be allocated to support their collective and individual initiatives. Special focus and technical assistance will be given to encourage the active participation o fthe informal sector andthe micro andsmall enterprises that make up the majority o fthe private sector inMauritania. - 62 - Activities. First activities will be informative meetings under the leadership o fthe Confederationo f the national Employers' Federations and SNIM; and the execution o f a prevalence survey in large industries or Federations. Following this, a short-term action plan will be developed on a participatory basis to: (i) define the full range o f constituencies included in the private sector-large companies, SMEs, micro-enterprises, non-formal sector including: commercial sex workers, independent truckers, shop keepers, open markets; (ii) create a framework for private sector involvement by developing eligibility criteria and application forms for access to financial resources to support private sector-lead HIV/AIDS programs, including counterpart funding requirements; (iii)plan for disseminating research findings, information, andother resourcesavailable for the private sector; (iv) discuss options andissue workplace guidelines for Federation members; (vi) conduct an initial workshop for the private sector to propose HIV/AIDS sub-projects; (vii) implement a limited number o f sub-projects in key areas in order to pilot the approach and process o f working with the private sector; and (viii) review and evaluate the pilot program. On the basis o f lessons learned, the private sector sub-program will be scaled-up. The project will provide technical assistance (TA) to the private sector to identify, develop, and submit sub-projects to the National HIVISIDA Executive Secretariat (Secritariat exicuty national de lutte contre le VIH/SIDA-SENLS) for review and approval, as well as for developing tools for outreach and monitoringandevaluation. Implementation Arrangements. The SENLS will be responsible for implementing and managing a fi-amework for private sector access to the new grant facility being designed to support their participation inthe NationalAIDS agenda. Keyorganizations will identifya focalpoint for HIV/AIDS, inparticular: the Confederation, and Federation members. Sub-project implementationwill be the responsibility o f the proposing organization. Eligibility criteria for the sub-projects, as well as the Sub-project cycle will be identical to these o f sub-component 4.2. Technical assistance may be provided-on a competitive basis bynational and internationalNGOsthat are currently working inpartnership with several high-risk parts o f the private sector-to develop sub-projects, so preventing overlap between sectors and leveraging experience, and to assist in sub-project implementation. To facilitate the implementation o f this sub-component, the NAES will recruit a specialist experienced with managing private sector activities and will coordinate this process on behalf o f the NAES, for buildinga coalition among the Federations andcoordinate withother keygroups, donors, and stakeholders. Costs andFinancing: The CNLS will allocate approximately 10percent o ftotal IDAfunds for the civil society initiatives to the private sector. The IDA Grant will also finance SENLS staff through sub-component 1.2. The PPF will fmance the capacity assessments consultancy, initial meetings, and workshops. The PPF will also finance at least two selected pilot projects. Cost sharingarrangementswill be pursued with interested agencies, including USAIDfor the initialprevalence study. Sub-component 4.2. ExpandCivil SocietyOrganizationInitiativesregardingHIV/AIDS. Diagnosis. There is consensus that the factors that determine H N transmission are largely outside the influence o f governments. This is also recognized in Mauritania where a group o f local NGOs interestedspecialized inHIVIAIDS created a dedicated network (Ronasima). The role o fNGOsi s crucial where cultural values and community noms can only partly be addressed by the public sector. This is particularly true in Mauritania where Islam plays a fundamental role in the population's beliefs and behavior. The early involvement o f the NGO "Stop-Sida" chaired by a top religious leader, and the participation o f Imams and Ulemas Associations in project preparation, are visible examples o f the commitment o f FBOs in the HIVIAIDS war. Because o f the intimate, personal, and sensitive nature of HIVIAIDS, the Government recognizes that prevention, support, and care responses are best addressed -63- through local, community initiatives. Both Government and NGOs recognize that promotionand scaling- up o f community involvement is the only way to reach all individuals, particularly in this large desert country. Despite their small number, recent existence, and capacity weaknesses, the strong involvement of national NGOs inthe HIV/AIDS battle i s a considerable asset on which the project will build(under the present sub-component) and at the same time will provide capacity-building (through sub-component 1.4). International NGOs are playing a double role: on the one hand, they conduct their own programs which often include HIVIAIDS-related activities, onthe other hand, they facilitate partnerships with local NGOs-including Ronasima network) which help the latter in conducting projects while receiving technical support andcapacity-building from the former. It is recognized that CSO responsesrepresent an economical and effective way o f reaching and serving large numbers o f beneficiaries and leads to increased community ownership, leadership, andmanagementofW / A I D Sresponses. Objective. The overall objective is to build "AIDS-competent communities." The achievement o f this objective will be measured through the number o f HIV/AIDS-related services offered by communities (CBOs) and by NGOs to communities. At the end o f the project, it i s expected that at least 300 sub-projects will have been submitted byNGOlFBOs and 1,500by CBOs. Strategy. The strategy is based on a demand-driven approach by which grassroots communities, local NGOs, or international NGOs will identify, develop, submit, implement, and monitor sub-projects for HIV/AIDS prevention, support, and care o f individuals or groups. An indicative positive list o f eligible activities anda strict negative list are included inthe Project ImplementationManual. Activities. The indicative positive list o feligible activities financed under this sub-component includes: . Sensitization and advocacy activities, including parenting programs and other forms of non-formal education to inform community members not only about the risk o f HIVIAIDS, but care-giving and support practices for people both infected and affected by HIVIAIDS, including women and vulnerable children. Prevention activities to reduce new HIV infections, including inter alia: (i) non-formal and community-based IEC to individuals and groups, on preventing W / A I D S and sexually transmitted infections, on the risks carried by traditional practices such as female genital cutting, and beast feeding by HIV-positive mothers; (ii) similar activities for at-risk groups such as vulnerable children; (iii)production o f education materials inlocal languages; (iv) training o f community-based trainers, local communicators; and/or peer and parents educators, (v) development o f locally suitable participatory methods for CCB; (vi) information and education on the prevention o f W / A I D S and STIs andMTCT, (vi) provision o f condoms; and (vii) provision of educational materials and bicycles . to traditional practitioners to improve their capacity to contribute to the HIVI'AIDS fight. Home-based care activities (HBC) including inter alia: (i) voluntary counseling and testing; (ii) provision o f psychosocial support; (iii) food supplements; (iv) clinical management o f STIs targeted and opportunistic infections, including provision o f home-based kits; (v) training and support to caregivers andcommunity counselors; and (vi) improvemento f local drugsupply. * Support to P L M including inter alia: (i) psychosocial support to families, (ii) economic support such as capacity-building andor financial support for income-generating activities; (iii) support to orphans and other vulnerable children including their caregivers, and AIDS-stricken, impoverished households. * Program participation support activities including inter alia: (i)information dissemination; (ii) participatory community needs evaluation and community planning; (iii)community-based managementtraining; and(iv) community-based monitoring andevaluation, includingthe monitoring o fvulnerable children. -64- Implementation Arrangements. The NAES will be responsible for the overall management o f the sub-component. The Deputy Director of the NAES will have the responsibility to coordinate the sub-component. Communities andlor NGOs will be responsible for the identification, preparation, submission, contracting, implementation and monitoring o f their own sub-projects, including the managemento f the funds delegatedto thembythe project to execute the activities o f the sub-project, and the management o f the procurement o f works, goods, and services related to the sub-project activities. The Sub-project cycle includes: (i) information mechanisms; (ii) participatory evaluation o f community needs; (iii) sub-project identification, preparation, and submission; (iv) sub-project evaluation by a technical evaluation committee on the basis o f predetermined criteria; (v) sub-project approval by the competent committee; (vi) execution by a community or NGO o f the approved sub-project; including financial management o f resources and related procurement; (vii) internal monitoring of, and reporting on, the sub-project by the executing agency (NGO or community); and (viii) external monitoring and evaluation by the NAESIRAES. Dependingon the scope o fthe proposed sub-projects, the administration o f some segmentso fthe sub-project cycle will be managed at the national or regional level, as follows: (a) Sub-projects o f local scope (within a region) ando f a small amount (under the threshold of $30,000) will be regionally managed by the RAES as follows: (i) local communitiesiNGOs will submit their sub-project to the RAES; (ii) RAES will establish the regional technical evaluation the committee to evaluate the eligibility o f the proposed sub-projects; (iii) the RAES will approve eligible sub-projects; (iv) approved sub-projects will be subject o f a Sub-project Agreement between the RAES and the concerned communityBG0; (v) the RAES will be responsible for financing the contracted sub-project intranches, on the basis o fpredetermined progress benchmarks; (vi)CommunitiesiNGOs will execute the sub-project, including community- or NGO-based procurement according to agreed simplifiedprocedures, and report to the RAES about the progress o f the sub-project in order to receive subsequent payments; (vii) the RAES will provide technical support to communitiesiNGOs as needed, andmonitor the progress ofthe sub-project implementationbythem; and (viii) the RAES will report ina timely manner to the NAES about the progress ofthe regional program while the NAESwill monitor it. (b) Sub-projects o f supra-regional scope (two regions or more) andlor large amount (above the above-mentioned threshold), will be managed by the NAES as follows: (i) NGOs will submit their sub-project to the NAES; (ii) the NAES will organize the technical evaluation committee to evaluate the eligibility o f the proposed sub-project; (iii) NAES will approve eligible sub-projects; (iv) approved the sub-projects will be subject o f a Sub-project Agreement between the NAES and the concerned NGO; (v) the NAES will be responsible for financing the contracted sub-project in tranches, on the basis of predetermined progress benchmarks; (vi) NGOs will execute their sub-project, including NGO-based procurement accordingto agreed simplifiedprocedures, and report to the NAES about the progress o fthe sub-project in order to receive subsequent payments; and (vii) the NAES will monitor the sub-project progress. Monitoringand Evaluation Arrangements.Routine supervision and technical support o f the regional programs will be provided by regional RAES through outsourced NGOs and regional teams o f line ministries including Health District teams. Sub-projects will include performance indicators pertaining to the project list o f indicators. The RAES will monitor the indicators o f all sub-projects and report in a timely manner to the NAES, which will consolidate them at the national level. Cost andfinancing. Sub-project promoters (CBOs andNGOs) will be rangedby categories according to their financial capacity as follows: (i) CategoryA: International NGOs and national NGOs with a solid institutional set-up and a good, long-term track record sub-project amount up to US$30,000; (ii) Category B: nationalllocal NGOs with a good institutional set-up and limited sub-project experience: sub-project amount up to US$lO,OOO; (iii)Category C: emerging NGOs with little or no previous experience: sub-project amount up to US$5,000; (iv) CategoryI>: local grassroots CBOs such as Parents -65- Associations or Women's Cooperatives: sub-project amount up to US$l,OOO. These thresholds may be subject to revisions duringMACP annual reviews on the basis o f experience. The disbursement profile o f the funds for this sub-component is the following: at the end of years 1, 2, 3,4, and 5, respectively, 10 percent, 25 percent, 50percent, 80 percent, and 100percent o fthe funds are expected to be disbursed. - 66 - Annex 3: EstimatedProjectCosts MAURITANIA MULTISECTORHIWAIDSCONTROLPROJECT Local Project Cost By Component US $million 1.Strengthen capacity ofgovernment agenciesandcivil 5.50 0.60 6.10 society, andproject management 2. Expandmulti-public sector (non health) responsesfor 3.40 0.10 3.50 prevention andcare ofHrV/AIDS/STIs 3. Expandhealth sectorresponsesfor prevention, treatment and 1.80 2.30 4.10 care ofIV/AIDS/STIs/TB 4. Develop andexpand civil society organizations andprivate 7.60 0.00 7.60 sector initiatives to HIV/AIDS 5. Project Preparation Facility 0.60 0.00 0.60 Total BaselineCost 18.90 3.00 21.90 Physical Contingencies 0.20 0.10 0.30 PriceContingencies 1.oo 0.20 1.20 Total Project Costs1 20.10 3.30 23.40 Total FinancingRequired 20.10 3.30 23.40 Works 0.05 0.05 0.10 Goods: vehicles (Iequipment 0.10 1.oo 1.10 Drugsand tests 0.00 2.20 2.20 ConsultantServices 4.05 0.05 4.10 Training 5.10 0.00 5.10 Grantfor Community Sub-projects 7.60 0.00 7.60 OperatingCosts 2.60 0.00 2.60 PPF Refinancing 0.60 0.00 0.60 Total ProjectCostsI 20.10 3.30 23.40 Total FinancingRequired 20.10 3.30 23.40 1Identifiable taxesandduties are 0.96 (US%m)and the total project cost, net oftaxes, is 22.44 (US$m). Therefore, the project cost sharing ratio is 0% oftotal projectcost net of taxes. - 67 - Annex 4: Cost BenefitAnalysis Summary MAURITANIA MULTISECTORHIVlAlDSCONTROL PROJECT SummaryofBenefits andCosts: HIVIAIDS is likelyto have serious economic consequencesinmostAfricancountries. Itis different from other diseasesinthat it affects people during their most productive years and is fatal inalmost all cases. The consequences vary from country to country depending on the seriousness o f the epidemic (rate o f prevalence) and the structure o f the economy. Poverty, inequalities (income, gender, etc.), STDs, migration andconflicts are factors that contribute to the rapid spread o f HIV/AIDS. But, it i s the impact that HIVIAIDS has on some o f the factors o f economic growth, such as national savings, social and human capital that undermines economic and social growth. As it prevents a large proportion o f the population from participating ineconomic growth, HIVIAIDS increases poverty. This results ina vicious circle: HIV reduces economic growth and increases poverty, which in turn speeds up the spread o f the epidemic. Externalresourcesneedto be mobilized inorder to reduce the number o fnew infections and to launch care and treatment programs for people living with HIV (PLWA). The aim o f this annex i s to analyze the costs andeconomic benefits o f such an investment. The estimated direct cost o fthe MAP i s US$20 million over a periodo f 7 years (2003-2009). Giventhat this amount will be disbursed over the entire project period, its net present value (NPV) is US$ 15,139,792. Inorder to arrive at an estimate for the number o f HIV cases averted, projections had to be made for the rate o f prevalence, incidence and number o f AIDS related deaths for the project period taking into account two scenarios, that is (i) 1without the MAP intervention and (ii) 2 with its case case intervention. The projections were made on the basis of information on HIVIAIDS prevalence, AIDS deaths obtained from the epidemiological fact sheet on HIV/AIDS and STDs o f UNAIDS. The data on populationwas drawn from the mainfindings o fRGPH2000. The data on economic indicators was taken from the Website o f the World Bank, (WBI, 2002). The model for the spreado fHIVfAIDS developed by Robalino et al, 2002 was used for the forecast. Economic analysis Benefits US$55,451,213 costs US$20 000 000 Cost benefit ratio 2.77: 1 Net benefit (WV) 22,193,2 10 Direct benefits of theproject:one o fthe main direct benefits o f the project is to bringdown the number o f new infections. Without the implementation o f the MAP, the HIVIAIDS epidemic will continue its alanning spread. In recent years, the HIV-prevalence rate has grown, increasing from 0.03 percent in 1992 to 0.52 percent in 1999 and to 1 percent in 2001. If current trends prevail, the projected HIV-prevalence rate will grow from 1.92 percent in2003 for the populationaged 15-49 to 5.44 percent in 2009, andwill continue to rise thereafter. With the implementationo fthe project, the prevalence rate will drop significantly. It i s thus expected to be 1.23 percent in2009. This downward trend will continuewith the rate falling to 0.66 percent in 2015. The most important outcome is that there will be 46,838 fewer cases o f new infections among those aged 15-45 by 2009. Inmonetary terms, the benefits o f the project (loss o fproductivity prevented and treatment costs averted) will amount roughly to US$55,45 1,213. The net presentvalue isprojected to be US$22,193,210. - 68 - Indirect benejits oftheproject :One important indirect benefit o f the MACP is that it will help set up a monitoringand evaluation system, which would address some o fthe knowledge gaps that exist as well as providing an evaluation system which would help better designs any follow-up to the current MAP. Another indirect benefit, but one that is difficult to quantify, i s that it will help to reduce the number of premature deaths and the number o f children dropping out o f schools to take care o f relatives who are afflicted. To complete this analysis, a series of economic analyses could be carried out during the project, all the more so that additional information will be available once the surveys among a certain number o f target groups are completed. Some o f the potential topics for analysis could be (i) the cost-effectiveness o f ARV therapy, (ii) fiscal impact o finterventions; etc. the -69- Population (without HIVIAIDS-related deaths) Adult HIVprevalence Year Total populationAdults aged 15 Incidence on Number of Prevalence Number of to 49 adults HIV/AIDS Rate YO adult deaths cases Source:- HIV-prevalence rate and HIVIAIDS-related deaths obtained from the epidemiological fact sheet o f UNAIDS, 2000 (0.3 percent in 1992,0.52 percent in 1999and 1percent in2001) - ---- Data on populationdrawn from the results o fRGPH 2000 o f ONSM Population growth rate estimatedby ONS to be 2.4 percent, AIDS-related deaths at time (t-1) subtracted from the population o ftime t Projectionmethodfor the spread o fHIV is that developedbyRobalino (2002) Max. prevalence rate estimatedto be 30 percent in 2030 -70- Table 2: Mauritania MAP Evolution inthe prevalence of HIVIAIDS - (Scenario 2: WithMAP implementation) Ideaths) Population (Without HIVIAIDS-related Adult HIV Prevalence Total Adultsaged Incidence on Number of Prevalence Number of 'gg population 15to 49 adults HIVIAIDS rate% adults who cases have died 2,350,363 1,129,254 1,26( 6,300 0.52 610 2.408.159 1.157.023 1.661 8,343 0.72 808 2,465,147 1,184,4031 2,361 11,844 1.oo 1,147 2,523,164 1,2 12,278 3,362 2,582,092 1,240,59 1 4,775 2004 2,631,424 1,264,293 3,161 2,682,800 1,288,97? 3,222 24.255 1.88 1.213 2,735,243 1,3 14,174 3,281 ~ 2007 2.788.835 1.339.923 3.35( 20.4231 1.52 1 1.0211 2,843,591 I 1,366,234 3,41( 18.746 1.37 I 9371 2,899,524 1,393,105 3,48: 17,199 I.23 860 2,956,656) 1,420,554 3,55: 15,784 1.11 789 3,015,0001 . . 1.448.586 3.62 1 14.486 724 _ _ I 1.oo 3,074,576) 1,477,204 3,69: 13,295 0.90 665 ~ 2013 3.135.4021 1.506.434 3.76t 12,202 0.81 610 11,200 0.73 560 10,280 0.66 514 6,698 0.39 335 ~ 4,365 0.23 218 2030 2.845 0.14 142 Source: HIV-prevalence rate and HIV/AIDS-related deaths obtained from the epidemiological fact sheet o f UNAIDS, 2000 (0.3 percent in 1992,0.52 percent in 1999 and 1percent in2001) Data onpopulationtaken from the results o fRGPH2000 o fONS Populationgrowth rate estimatedto be 2 percent since 2004 AIDS-related deaths at time (t-1) is subtracted fromthe population o ftime t - 71- Table 3: Mauritania M A P Project Benefits - of infection l i e years Productivity Cost of care ($) Benefit ($1 Year averted 1 saved 1 ~~ 2003 1 Number of cases Number of I I I I I I I 2004 3,609 3,609 1,987,316 285,i 14 2,272,430 2005 6,379 9,988 5,646,125 789,071 6,435,197 2006 7.041 13.4201 7.787.790 1.060.2 15 8,848.005 Source: Author's calculations Assumptions: Number o f cases o f infection averted is the difference between the incidence o f table 1 and the incidence o ftable 2 - Number o f life years saved is the sum o fthe number o f cases o f infections averted for time t-1 and the number o fcases o finfections averted for time t GDP per capita is U S $ 509 for 2001 with an average growth rate estimatedto be 2.66 percent by Year - Average cost o fintervention without ARVs estimated to be US$79 perperson andper year - 72 - Table 4: Mauritania MAP -Net Benefits of the Project in NPV Year I Project Cost I Project INetProject Discount Rate 1 1 Net Projected1 NPV($) 1 i?]Refer to annex 5 o fthe PAD for the MAP ,report 20727 AFR iz1Roabalino, Jenkinsand ElMaroufi. 2002.Risks and macroeconomicimpactso fHIVIAIDSinthe MENA Why waiting to intervenecanbe costly, World BankPolicyResearchworking paper2874 [?INational Statistical Ofice Summary of Benefits and Costs: Main Assumptions: Sensitivity analysisI Switching values of critical items: - 73 - Annex 5: FinancialSummary MAURITANIA: MULTISECTORHIVIAIDSCONTROL PROJECT Years Ending 2008 I Year1 I Year2 I Year3 I Year4 IYear5 1Year6 IYear7 Total FinancingRequired ProjectCosts InvestmentCosts 1.o 4.8 4.7 3.4 3.4 3.3 0.2 RecurrentCosts 0.1 0.4 0.5 0.5 0.5 0.5 0.1 Total ProjectCosts 1.1 5.2 5.2 3.9 3.9 3.8 0.3 Total Financing 1.1 5.2 5.2 3.9 3.9 3.8 0.3 Financing IBRDllDA 1.o 4.6 4.8 3.5 3.5 3.4 0.2 Govemment 0.1 0.6 0.4 0.4 0.4 0.4 0.1 CentraI 0.0 0.0 0.0 0.0 ' 0.0 0.0 0.0 Provincial 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Co-financiers 0.0 0.0 0.0 0.0 0.0 0.0 0.0 User FeeslBeneficiaries 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Other 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total Project Financing 1.1 5.2 5.2 3.9 3.9 3.8 0.3 Mainassumptions: Five-year project implementationperiodwith effectiveness: October 1,2003; completion date: September30,2008; andclosing date: March 31,2009. - 74 - Annex 6(A): Procurement Arrangements MAURlTANIA MULTISECTORHIV/AIDS CONTROL PROJECT Procurement General 1. A Country Procurement Assessment Review (CPAR) for Mauritania was carried out inFebruary 1999 andupdated in2002, which found that ingeneral nationalprocedures for the procurement o fworks, goods andservices are acceptableto IDA subject to a few amendments. So far the findings o f the CPAR remain valid. A new procurement code has recently been adopted inFebruary 2002 on the basis o f the recommendations o f the CPAR with the assistance o f the Bank (IDF Grant) and will be substantially revised after a transition period o f about one year in order to improve transparency, efficiency and good balance between public and private sector according to Bank's suggestion o f October 2002 under procurement reform follow-up o f Mauritania. N o special exceptions, permits, or licenses need to be specified in the Grant documents for Intemational Competitive Bidding (ICB), since Mauritania's procurement regulation allow IDA procedures to take precedence over any contrary provisions in local regulations. National Competitive Bidding(NCB), advertised locally, would be carriedout inaccordance with Mauritania's procurement laws and regulations acceptable to IDA, provided that they assure economy, efficiency, transparency, andbroadconsistency withkey objectives o fthe BankGuidelines. Guidelines 2. All civil works and goods financed by IDA shall be procured in accordance with Bank's Guidelines: Procurement under I3RD Loans and IDA Credits, January 1995 and revised inJanuary and August 1996, September 1997 and January 1999. The Bank Standard BiddingDocuments (SBD) for goods and Standard EvaluationReport will be usedfor ICB. National Competitive Bidding(NCB) would be carried out in accordance with Mauritania's procurement laws and regulation, acceptable to IDA, provided that: (i) are advertised in national newspapers with a wide circulation; (ii) bid bids the document clearly explains the bid evaluation, award criteria and bidder qualification; (iii) are bidders given adequate response time to prepare and submit bids (minimum four weeks); (iv) technical and financial bids are publicly and simultaneously opened; (v) bids are awarded to the lowest evaluated bidder; (vi) no eligible bidder is precludedfrom participation, regardless o f nationality; (vii) no domestic preference margins are applicable to domestic manufacturers or suppliers; (viii) prior to issuing the first call for bids, a draft standardbiddingdocument would be submitted to and found acceptable byIDA. 3. Consultant services contracts financed by IDA grant will be procured in accordance with Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers, January 1997 and revised in September 1997, January 1999 and May 2002. The Bank's Standard Request for Proposals dated July 1997, and revised April 1998 and July 1999 and forms o f contracts (lump-sum, time based, andor simplifiedcontracts for short-term assignments and individualconsultants) as well as the Sample Form o f Evaluation Report for Selection o f Consultants would be used for appointment o f Consultants. Simplified contracts will be used for short-term assignments simple mission o f standard nature (i.e., - those not exceeding six months) - carriedout by individualconsultants or firms. 4. Small works, goods and services for community sub-projects shall be governed in accordance with paragraph 3.15 o f the Guidelines (Community Participation in Procurement) and with the Bank's Guidelines: SimFli~edProcurement and Disbursement for Communi~-3asedInvestments (February 1998) and the ~ationalHI/AIDS Programs Generic Procurement Management Manual for Community - 75 - Based Organizations and Local NGOs (March 4, 2003). These procedures would be described in a Project Implementation Manual (PIM) adopted by Government before presentation o f Board package to the RVPfor signature. 5. During negotiations, the Government will give assurance that it will: (i) the Project use ImplementationManual; (ii) use the Banks Standard BiddingDocuments for ICB, the Standard Request for Proposals for the selection o f consultants, and the Standard Bid Evaluation Reports; (iii) apply the procurement procedures andarrangements outlined below; (iv) update the procurement planon a regular basis during annual reviews with IDA and other donors, to compare target times and actual completion, and transmit it to IDA, during implementation, with all procurement-related documents; and (v) cany out, duringquarterly andor annual reviews, an assessment o fthe effectiveness o fbiddingprocedures and performance, as they relate to the project's procurement experience, and propose for IDA and other donors' consideration any modification to the current procedures to the extent that it would accelerate procurement, while still maintaining compliance with the Bank's Procurement Guidelines and adequate control over contract awards and payments. Standard bidding documents to be used under NCB procedures for goods will be included in the Administrative, Financial and Accounting Manual to be adoptedby effectiveness. Advertising 6. Given the urgency o f the project, a General Procurement Notice (GPN) for the first year o f operations will be prepared before board presentation and will subsequently be published in the hard copy edition of United Nations Development Business and, in a national newspaper to advertise for International Competitive Bidding (ICB) and major consulting assignments to obtain expression o f interest, Publicationof a GPN inthe national pressi s also requiredfor NCB. The GPNwould be updated on a yearly basis and would shown all outstanding procurement. Specific Procurement Notices (SPN) and Requests For Expressions of Interest (RFEOI) for large contracts for consultants services (above US$lOO,OOO equivalent for goods; and, for consultants US$200,000 equivalent) will also be advertised in UNDB and sufficient time will be allowed for responses to such specific notices before preparing the short-list. The f r s t SPN andRFEOIwill be publishedaccordingly to the provisions set up by paragraph 2.7 o fthe guidelines and the date o fpublication is that o fthe hardcopy ofUNDBto start counting. ProcurementImplementationArrangements 7. The procurement implementation arrangementsare firmly grounded inthe procurement capacity assessment o f the various executing agencies involved in the project. The procurement functions o f M A P program will be implementedby four maingroups: (a) National HIV/AIDS Executive Secretariat (NAES); (b) Regional HIVlAIDS Executive Secretariats (RAES); (c) line Ministries and other public sector agencies; and (d) NGOs, CBOs and private sector organizations. All public entities (NAES, RAES, and line ministries) will work through the Special Tender Board (STB) which i s responsible for the procurement process for contracts exceeding UM 2 million for goods and consultant services (US$7,000 equivalent) and 3 million for works (US$10,700 equivalent). According to this classification, the followingprocurement arrangementsare envisaged: (a) NAES will establish a Financial andAdministrative Unit (FAU) staffed with qualified personnel provided by a reputable firm including a procurement specialist, The FAU will carry out the procurement functions for: (i) all activities to be directly carried out by the NAES i.e. Component 1; (ii) executingagenciesthathavelittleornoexperiencewithIDA-financedprocurementandfor those large ticket items that are at NCB threshold and above for goods andall consulting services. - 76 - (b) RAES will establish by effectiveness a procurement capacity provided by a procurement specialist to assist communities and localNGOs intheir responsibility to carry out community-based or NGO-basedprocurement activities included intheir sub-projects. The RAES will be supported by the FAU. (c) Line ministries can be classified into two groups based on their respective level o f procurement experience: (i) Firstmoup: ministries with experience andcapacity with IDA-financed procurement, such as the Ministries o fEducation, Rural Development, Women andHealth, will have responsibility for carrying out their own procurement activities relatedto their agreedAction Plans through Project Implementation Units(PTus) already established to manage other extemally-financed projects inthe sectors. This approach will facilitate the integration o f the HIVIALDS actions into the Sector-Wide Annual Plan(SWP) o f these Ministries when a SWP exist (such Education, Health), and therefore, improve on the coordination o f these activities with other activities planned inthe ministries' SWPs; (ii) group:ministriesandpublicsectoragencieslackingexperienceandcapacitytocarryout Second IDA-financed procurement will be assistedby the FAU o f the NAES which will carry out, on their behalf, the required procurement for goods and services as indicated intheir annual action plan. All contracts which are under tender boards thresholds will be carry out by these Ministries. Should the PIU o f a ministry pertaining to the first group disappear with the closing o f the project which supports it, the ministry will automatically fall into the second group. For the health ministry, the executing agency i s Direction de la Gestion des Investissements (DGq which i s within its administration. (d) Procurement for works, goods and services financed by the program through sub-projects arrangements for the CSOs and the private sector will be carried out by these entities, according to paragraph 3.15 on Community Participation in Procurement of the Guidelines and using the Bank's Guidelines for S i m ~ l ~ eProcurement and Disbursement Procedures for Community-Based d Investment (February 1998) and the National HI/AIDS Programs Generic Procurement Management Manual for Community Based Organizations and Local NGOs (March 4, 2003). For community sub-projects, the communities, through their representative committees and recruited intermediaries (NGOslAssociations), would be responsible for the procurement process using simplified procurement procedures as described inthe ProjectImplementation Manual. 8. Inthe Mauritanian procurement system, each executing agency inthe ministries should award contracts through the Departmental Tender Board (DTB) o f the ministry or the National Tender Board (NTB) depending on the contract amount. The MACP will be coordinated by the NAES which is attached to the National HIVIAIDS Committee chaired by the Prime Minister. There is no DTB within the prime minister office. The NTB has a good procurement capacity but given its workload with all the country large contracts, its response time may not be adequate to HIVIAIDS-related contracts which cannot suffer any delay. Inview to speed up the implementation o f this MAP and based on the above mentioned, the Government issued a decree creating a Special Tender Board(STB) by derogating to the Procurement Code on all prerogatives o f the DTB andNTB (decree 027-2003 dated March 24, 2003). This STB will be competent for all MACP-related procurementTby delegation o f all responsibilities currently undertaken by the DTBs and NTB (all contracts up to UM 2 million for goods or consultant services andup to UM3 million for works). This adhoc tender board will be incharge o f opening o f the bids, analyzing and awarding of all MACP-related contracts. It will be composed o f five members. The secretariat o f this commission shall be under the responsibilities o f the procurement specialist at the FAUof NAES. The Special Tender Board will receive specific training related to the procurement of HIVIALDS-related goods and services, to build a specialized capacity for this type o f procurement. - 77 - However, the special tender board will seek assistance from a specialist with relevant technical skills in the subject under review, when necessary. 9. The GoM recently created a central procurement office for all public sector medical needs ( Centrale d'Achat de ~ ~ d i c ~ ~ eCAMEC). The capacity assessment o f this agency shows a lack of n t s , organization which confirms the January 2003 PASS mission's aide-memoire, N CAMEC, formally created a year ago, i s not operational yet )).A recent diagnostic made by AEDES led to the same conclusion. CAMEC which acknowledges these findings, hasbegun work to address the issues.Basedon this assessment CAMEC is not in a position, at least inthe short term, to meet the procurement capacity needs ofthe MACP. Improvement o f CAMEC's capacity i s part o fthe parallelHealthProject agenda. As soon as CAMEC will be able to prove its capacity, the NAES will sign an agreement with this agency to supply health commodities required for the MACP. Meanwhile, procurement of these commodities will be carriedout through UNagencies. ProcurementCapacityAssessment 10. Since the STB and NAESIRAESare recently created andthe fiduciary agency, which will supply the core fiduciary staff o f the NAES, i s not yet selected it is not possible to assess its procurement capacity. The procurement staff o f the NAESIRAES should include senior procurement agent at the central level and regional procurement agents in the regions. These specialists should be familiar with World Bank's procurement procedures as reflected inthe TOR approved by the Bank. The central senior procurement agent will: (i) monitor all procurement activities o fthe Project at all levels, (ii) supervise the regional procurement agents, (iii) build capacities of agencies which have not enough procurement capacities. 11. Inthe lineministries such as Health, Education, Women, Rural Developmentwhichhave already Bank-financed project units (PASS, PNDSE, Nutricom and PGRNP), the procurement capacity assessment o f these units confirmed their capacity to handle procurement and financial activities. So procurement risks are evaluated low for these agencies. For NGOs, CBOs and Private Sector Organizations, there i s no need o f assessing the capacity because the strategy i s based on a demand-driven approach. Civil society organizations will identify, develop, submit, implement and monitor activities through signed conventions. Therefore participating organizations are not yet identified as well as the type o f activity andrelatedprocurement they will propose. 12. Based on the assessment, an action plan has been prepared and agreed upon with the Borrower and focus on: (a) for the NAES: (i) establishing procurement capacity through the recruitment of a procurement specialist to manage procurement activities financed under the Project Preparation Facility (PPF), adequatetraining andguidance from IDA specific to procurement; (ii) office supplies and logistic support for proper filing o f procurement documentation, (iii)procurement planning and contract managementsystem integrated inthe computerized Financial management system; (b) for the RAES, the strengthening measures include: (i) the hiring o f additional project procurement specialists for the regional offices; (ii)training sessions inprocurement, with emphasis on community-based procurement, contract management, and filing system as necessary; (iii)training as trainers for community-based procurement to build their capacity to provide support to communities and local NGOs; (c) a procurement planning and contract management system to be integrated in a computerizedmanagement systemto be installedat the central level(NAES). - 78 - Action Deadline Responsible Recruitment o f procurement specialist to manage Before the recruitment o f NAES procurement activities financed under the Project the FAUstaff Preparation Facility (PPF) for the NAES. Recruitment o f FAU /Beforeeffectiveness NAES Make available for the Special Tender Board(STBIAIDS) Before effectiveness NAES (Commission SpCcialedesMarch& CSMISIDA) a suficie space for meeting, preparation o f bidding documents an conservation of files. Supply necessary equipment for preparation, copying andBefore effectiveness NAES conservation o fprocurement documents to the STBIAIDS. Trainingo f STBIAIDS staff Duringfirst 6 months after NAES effectiveness Hiring o f regional procurement specialists for the regionalDuring first month after NAES offices the establishment o f the regional offices Trainingo fregional procurement specialists o fthe RAES Duringfirst 6 months afterFAU establishment o f the regional offices. Supply necessary equipment for preparation, copying and During first month after NAES conservation o fprocurement documents to the RAES. the establishment o f the regional offices ProcurementMethods Works (US$O.l million, excludingCommunity-BasedSub-Projects) 13. There will not be any major civil works contract under the project. Small refection o f facilities for line ministries estimated at less than US$SO,OOO equivalent, up to an aggregate not to exceed US$O.l million will be procured under lumu-sum. fixed-mice contracts awarded on the basis o f quotations obtained from three qualified domestic contractors invited inwritingto bid. The invitation shall, among other things, include a detaileddescriptiono fthe works, includingbasic specifications, relevant drawings and bill of quantities where applicable, the required completion date and a basic form of agreement acceptable to the Bank. A sufficient bid submission period will be allowed and bids will be opened in public. The award will be made to the lowest evaluated responsive bidder who has appropriate experience and resourcesto successfully complete the contract. Before the first two biddingpackages are solicited, the draft solicitation letters and other relevant documents to be used will be reviewed and cleared by the Bank. Works will be done within the compoundcurrently usedby the facility and will not leadto issue relatedto landacquisition. For those small works that may be included incommunity-based sub-projects, given the sub-projects size, amount and demand-driven nature, these contracts would be governed when applicable by the Guidelines for Simplified Procurement and Disbursement for Communi~-~asedInvestments(February 1998) and the Project Operations Manual. Goods(US$3.3 million) 14. The total cost o f goods including drugs i s estimated at US$3.3 million equivalent for the project, not including contracts for goods under the community sub-projects. The items would include: - 79 - office equipment, furniture and materials, audio-visual and laboratory equipment; vehicles; HIVIAIDS-related health commodities, condoms; IEC materials, and other project related supplies. Procurement o f goods will be bulked where feasible into packages valued at US$lOO,OOO equivalent or more per package and will be procuredthrough ICB. (a) Goods estimated to cost lessthanUS$lOO,OOO per contract, up to an aggregateamount o f US$0.2 million equivalent wouldbe procuredthroughnational competitive bidding(NCB). CO) Goods estimated to cost US$50,000 equivalent or less per contract, and up to an aggregate o f $0.1 million equivalent may be procured through ~ a t i o n a land/or International Shopping procedures. Contract will be awarded on the basis o f written solicitation issued to at least three qualified suppliers, following evaluation o f bids received in writing from such qualified suppliers. The award would be made to the supplier with the lowest price quotation for the required goods, provided ithasthe experience and resourcesto execute the contract successfully. (c) HTVIAIDS-related goods including health commodities may be procured through UNICEF, UNFPA and WHO and equipment may be procured through W S O in accordance with provisions o f paragraph 3.9 o f the Guidelines. In particular, goods such as drugs and reagents and medical supplies, tests kits (elisa, hemoglobin, hepatitis, RTD), blood-takinglgiving sets, milk substitutes, ARV, antiseptics andanti-TB drugs, estimated to cost less than US$500,000 per contract can be procured through the United Nations Agencies, up to an aggregate o f US$2.1 million equivalent, inaccordancewith the above mentionedBank Guidelines. However, procurement o f such goods may be procuredthrough the CAMEC after the completion o f its improvement planprovided that an assessment o f its capacity to perform procurement has been declared satisfactorily by the Bank. (d) Procurement o f medical equipment and supplies, other specialized equipment, and spare parts for WlAIDS, which must be purchased from the original supplier to be compatible with existing equipment, or are o f proprietary nature, may be procured directly from a particular supplier inaccordancewiththe provisionsofpara 3.7. ofthe Guidelines. Grantsfor Community-BasedSub-projects(US$7.6 million) 15. Grants for community-based sub-projects, including civil society. The project will fmance communitykivil society sub-projects related to W / A I D S activities, such as IEC-related activities and materials, minor repairs or works, purchase o f generic drugs, care and support for AIDS patients and orphans, awareness campaigns, income generating activities for persons livingwith HIVIAIDS andtheir dependents. 16. Financing, in the form o f grants, will depend on applications received from communities, CSOs and private organizations against an indicative positive list o f activities and eligibility criteria. It is not possible to determine the exact mix o f goods, small works, and services to be procured under these activities due to their demand-driven nature. Therefore, the types of activities to be financed and their procurement details will depend on the needs identifiedby these groups. Procurement of items for the implementation o f sub-projects would be carried out in accordance with simplified procurement procedures referred to in Section 3.15 o f the Guidelines and in accordance with the PIM. The manual will contain a special chapter describing the procedures and tools (submission form, contracts, etc.) in accordance with those found in the Bank's Guidelines: Simplified Procurement and Disbursement for Community-Based Investments (February 1998) and the National HI/AIDS Programs - Generic - 80 - Procurement Management Manual for Community Based Organizations and Local NGOs (March 4, 2003). The NAES and RAES will be responsible for ensuring compliance with these guidelines. ConsultingServices, Studies,andTraining (US%9.2million) 17. Consultant services, studies and training financed by IDA would be for the following types o f activities: studies and surveys related to the monitoring and evaluation activities, trainers, community development specialists, public relations firms (IECIBCC campaigns), NAES and RAES core stdf, procurement, financial management, financial andtechnical audits, and accounting specialists. (a) Ouality-and-Cost-based Selection: All consulting service contracts for f m s would be awarded through Quality andCost Based Selection (QCBS) method. To ensure that priority is given to the identification o f suitable and qualified national consultants, short-lists for contracts estimated at or less than US$lOO,OOO equivalent may be comprised entirely o f national consultants (in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines), provided that a sufficient number o f qualified individual or firms (at least three) are available. However, if foreign firmshave expressedinterest, they wouldnotbeexcluded fromconsideration. targetedConsultant's for which organizations with specialized expertise, strong capacities to work (b) interventionsOualification Selection may be used for consulting services for research, and with vulnerable groups andproven track records would be recruited. The amount o f the contract is estimated to cost less than US$lOO,OOO. This method may also be used for the selection o f training institutions whentraining cost lessthan US$50,000equivalent per contract (c) Least-Cost Selection would be the most appropriate method to be applied for FinanciallTechnical audits andother services o fa standardnature not exceeding US$50,000. (d) Consultants for services meeting the requirements o f Section V o fthe Consultant Guidelines will be selectedunder the provisions for the Selection o f IndividualConsultants method. Individual Consultants (IC) will be selected through comparison of curriculum vitae against job description requirements o f those expressing interest in the assignment, or those having been identified directly bythe Borrower. Consultants hiredunder the project cannot be civil servants, (e) Single-Source Selection will be used for contracts with the Distance Learning Center (DLC) which is the unique institution in Mauritania able to provide video-conferencing services for intemationally-based training offers. The contract will be limited to the video-conferencing service and will not include the training programs to be procured separately by the NAES. Contract with the DLC will be based on the pre-determined unit cost o f the DLC (per hour). Services for: (i) training; (b) specific tasks; and (c) small assignments, which meet paragraphs 3.8 to 3.11 requirements, may also be selectedthrough the single-source method. 18, Training, Workshops, Study Tours, and Conferences. The total cost o f these activities is estimated at US$5.1 million equivalent for the project. Training, workshops, conference attendance and study tours will be carried out on the basis of approved annual training promams that will identify the general fiamework o f training and similar activities for the year, including the nature o f training, study tours, workshops, the number o fparticipants, andcost estimates. ProcurementPlanning 19. Procurement plans for all procurement to be carried out at the national level for the first year -81 - activities will be finalized before Board approval. The exact mix o f procurement will be determined on an annual basis duringthe annualjoint reviews between the NAC/NAES, line ministries, IDA, and other partners, where a draft procurement plan for the following financial year will be presented and agreed upon. The detailed procurement plans for subsequent years will be developed and submittedto IDA for review and approval. The planwill include relevant information on goods, works andconsulting services under the project as well as the timingo feach milestone inthe procurement process. These planswill be reviewed by IDA supervision missions and by the external technical audits. This being a multisector project, the respective annual plans would also need to be closely coordinated with other operations in the various sectors such as the ongoing Education Sector Project, Health Sector Program, andthe Rural Development Programs. To this end, one o f the key responsibility o f the focal point for the fight against HIVIAIDS named in each of the line ministry will be to ensure that risks of overlapping and uncoordinated efforts are minimized as much as possible by keeping track o f activities fmanced under ongoing IDA operations andor other sources o f financing inthe area o fHlV/AIDS. 20. Modification or waiver o f the scope and conditions o f contracts. Before agreeing to any material extension, or any modification or waiver o fthe conditions o f contracts that would increaseaggregatecost by more than 15 percent o f the original price, the Borrower should specify the reasons thereof and seek IDA's prior non-objectionfor the proposedmodification Project Implementation Manual (PIM) and Administrative, Financial and Accounting Manual(AFAM) of the Project 21. The Project ImplementationManual (PIM) will define andspecify the procedures for the execution o f the Project. It will be composed o f 5 volumes detailing the implementation procedures for: (i) the capacity-building component (Component l), the (iii) lineministryResponsecomponents(Components2 and 3); (iv) the Private Sector Response component (Component 4.1); (v) the Civil Society Response component (Component 4.2); and (v) the monitoring andevaluation system for the Project. Each section will describe the specific procurement arrangementsto be carriedout bythe concernedexecuting agency, andwill contain specific models for "Conventions" with lineMinistries and Sub-project Agreements and, as well as simplified procurement documents for community-based procurement. The draft version was reviewedduringthe appraisal mission and the final version will be adopted bvBoardapproval. 22. The Administrative, Financial andAccounting Manual (AFAM)will describe the internal control o f procurement actions, the technical specifications in each case, as well as reference to the model contracts as per the Bank's SBD and RFP, etc. (submission form, contracts, etc.). It will include: (a) a specific section on procurement detailing (i)procedures for planning, calling for bids, selecting contractors, suppliers andconsultants, (b) a Project Implementation Plan and a Procurement Plan for the first year o f operations. It will describe: (i) the supervision andcontrol procedures, includingoperational guidelines defining the role o f each executing agency and reporting requirements; and (ii) disbursement procedures; and (c) implementation arrangements for procurement by the Special Tender Board created for the MAP. 23. Inaddition, the Government gave assurance that it will take the necessary measures to ensure that procurement phasesdo not exceedthe following target time periods : - 82 - I Procurement Phases MaximumDelaysinWeeks Preparation o f BiddingDocuments 6 (and 3 small contracts) Preparation o f BidsbyBidders 8 (and 4 for NCB ) BidEvaluation 4 (and 2 for small contracts) Signature o f Contracts 2 Payments 3 Prior Review 24. Table B below provides the prior review thresholds based on the findings o f the Capacity Assessment carriedout at appraisal. Post Review 25. Monitoring and evaluation o f procurement performance at all levels (national, regional, and community) would be carried out during IDA supervision missions and through annual ex-post audit and or technical independent audit. All contracts which are not subject to prior review according to Table B, would be subject to post review in accordance with paragraph 4 Appendix Io f the Guidelines. This review would: (a) verify that the procurement and contracting procedures andprocessesfollowed for the projects were in accordance with the IDA Development Grant Agreement (DGA); (b) verify technical compliance, physical completion and price competitiveness o feach contract inthe selected representative sample;(c) review and comment on contract administration and management issues as dealt with by participating agencies; (d) review capacity o f participating agencies inhandling procurement efficiently; and (e) identify improvements in the procurement process in the light o f any identified deficiencies. Finally, at the minimum 1out o f 10contracts managedbythe NAES and 1out o f 3 contracts managedby line ministries for goods, works and services will be subject to post review. 26. The Borrower and IDA will review all thresholds stated in this section on an annual basis. Amendments may be agreedupon based on performance and actual values o f procurement implemented. Amendments to the DGAmay beproposed accordingly. - 8 3 - Procurementmethods (TableA) (0.00) (0.00) (0.10) (0.00) (0.10) 2. Goods 0.80 0.20 2.30 0.00 3.30 (0.80) (0.10) (2.20) (0.00) (3.10) 3. Services 0.00 0.00 3.80 0.30 4.10 (0.00) (0.00) (3.40) (0.00) (3.40) 4. Training 0.00 0.00 5.10 0.00 5.10 (0.00) (0.00) (5.10) (0.00) (5.10) 5. Grantfor Community 0.00 0.00 7.60 0.00 7.60 Sub-projects (0.00) (0.00) (7.60) (0.00) (7.60) 6. OperatingCosts 0.00 0.00 1.80 0.80 2.60 (0.00) (0.00) (1.10) (0.00) (1.10) 7. PPF Refinancing 0.00 0.00 0.60 0.00 0.60 (0.00) (0.00) (0.60) (0.00) (0.60) Total 0.80 0.20 21.30 1.10 23.40 (0.80) (0.10) (20.10) (0.00) (21.00) - 84- Table AI: Consultant Selection Arrangements (optional) (US$ millionequivalent) I\ Including contingencies Note:QCBS = Quality- and Cost-BasedSelection QBS = Quality-based Selection SFB= Selectionunder a Fixed Budget LCS= Least-CostSelection CQ = SelectionBasedon Consultants'Qualifications Other = Selectionof individualconsultants (per SectionV of ConsultantsGuidelines),Commercial Practices,etc. N.B.F. = Not Bank-financed Figures in parenthesesare the amountsto befinanced by the Bank Grant. - 8 5 - Priorreview thresholds(Table6) Table B: Thresholdsfor ProcurementMethodsand Prior Review' Contract Value Threshold Less than USS50,OOO None US$lOO,OOO or more ICB All ($0.8) Less thanUS$lOO,OOO NCB Firstthree contracts ($0.1) US$50,000 or less Shopping None Drugsand Direct Contracting All Pharmaceuticals ($0.1) Less thanUS$500,000 UnitedNations Agencies All ($2.1) (3.Services Firms US$lOO,OOO or more QCBS All ($1.0) Less thanUS$lOO,OOO QCSS; CQ First3 contracts Individuals ($0.3) US$50,000 or more Comparison of 3 CVs All ($2.0) Less than US$50,000 3 cvs None Single Source All ($0.1) 4. Training IAnnual trainingplans, includingfor local and out-of-county training; Workshops, terms o freference; estimatedbudgets; names o f I candidates; content o f courses, periods oftrainingand selection of training institutions ~ 5. Miscellaneous Annual lineministrieswork program; Any amendments to existing contracts raising their values to levels equivalent or above the prior review thresholds Total value of contracts subjectto priorreview: US$6.5 million Overall ProcurementRiskAssessment: Average Frequency of procurement supervision missions proposed: One every 6 months (includes special procurement supervision for post-reviewlaudits) 1\Thresholds generally differ by country andproject. Consult "Assessment ofAgency's Capacity to Implement Procurement" and contact the Regional Procurement Adviser for guidance. - 86 - Annex6(B): FinancialManagementand DisbursementArrangements MAURITANIA MULTISECTORHIV/AIDSCONTROL PROJECT FinancialManaPement 1. Summary of the FinancialManagementAssessment 1. The design o f the financial management system for the Mauritania operation draws heavily on basic principles o f soundfinancial managementunderthe MAP. 2. Organizational arrangements. Ministries and Civil Society Organizations (CSOs) will play a key role in the implementation o f the MACP. The NAES will facilitate this role. The procedures for channeling funds from the NAES to the line ministries under the Multisector Responses to HIVIAIDS (Component 2) and to the Civil Society Organizations are described in the Project Implementation Manual. The procedures intend to be based on a quick andsimple mechanism to channel the funds from the NAESto the implementing agencies, while ensuring a sound financial management. 3. The organizational arrangementsbetween the NAES and the line Ministries will be govemedby a multi-year "Action Plan Agreements" with annual "Work Program Agreements", while the organizational relation between the NAESlRAES and the CSOs will be govemed by "Sub-Project Agreements", The following scheme summarizes the various arrangements: these Agreements will include a clear description o f the obligations o f bothparties, particularly regarding: (i) description o f the objectives and activities, (ii)conditionalities, (iii) evaluation, (iv) approval, (v) financial arrangements, (vi) supervision, and (vii) clausesfor suspensionor termination. 4. Roles andResponsibilities. 0 At the central level, the NAES will have overall responsibility for financial management. The NAES will manage two Special Accounts A and B and a Project Account 1 to accommodate project counterpart funding. Special account A will be for payments o f expenditure related to Component 1 (Strengthen capacity o f government agencies and civil society) and Component 2 (Expandmulti-public sector responses for prevention and care o f HNIAIDS, i.e. payments o f Action PlanAgreementslWork Plan Agreements). Special Account B will be managed by the NAES for expenditure related to Component 4 (Develop and expand civil society organizations and private sector initiatives to HIVIAIDS, i.e. payments o f grants to finance the Sub-Project Agreements). Transfers o f funds will be based on contractual arrangements between the NAES and the implementing agencies, for the execution o f agreedSectoral Action Plansand Sub-Projects. This will facilitate immediatedisbursement o ffunds to the implementationentities. 0 The MOHSA will manage Special Account C which will be for payments for Component 3 (Expand health sector response for prevention, treatment and care o f HIVIAIDS, i.e. the HIVIAIDS Action Plano fthe MOHSA) and a Project Account 2 to accommodate relatedcounterpart funding. 0 The Regional RAES will manage Sub-Accounts financed from Special Account B. The NAES will have the responsibility of the preparation o f consolidated financial statements, contracting audits, standard financial reporting functions, and coordination with other stakeholders on the technical aspects ofthe project. - 87 - RAES Action Plan Sub-Project Sub-project Agreement Agreement ' Ministries ' Nat. NGO 5. Financial management capacity of the NAES. The NAES will include, at a minimum, a financial manager, a procurement specialist and several accounting staff (e.g. chief accountant, a couple o f assistant accountants). At the regional level, the responsibility for financial management aspects will placed inthe RAES which will be staffed with a professional accountant. Inaddition, an internal auditor will berecruitedto ensurethat the internal control procedures are adequately applied. 6. Financial management capacity of the Line Ministries. Within each participating line ministry, it was agreed that: (i) financial management o f the funds delegatedthough the Action Plan the Agreement, should be carried out by the same entity which will manage the procurement activities related to the Action Plan Agreement, and (ii) these activities should be managed by Directorates or Units which have already experience inthe management o f external funds. This approach isjustified by: (i) cost-efficiencytouseexistingcapacitywhenitexists,(ii) lowleveloftheamountsinvolvedby the the the Action Plans (between US$310,000 and US$l,000,000) does notjustify the creation o f new units to manage these funds. On this basis, Ministries were classified in two categories and the following arrangementswere agreedfor each o fthem: e CategolyI:Ministries which have an existingprocurement andfinancial management capacity. The management o f the finds to finance the Action Plan Agreements will be carried out by either: (i) a directorate, or (ii)an existing PIU. Fall into this first category: (i) DGI (Direction Gknkrale des the Investissements) of the Ministryo f Health, (ii)the DPEF (Directiondes Projets Education et Formation) of the Ministry o f Education, and the project NUTRICOM o f the Secrktariat d'Etat ti la Condition Fkminine. These three entities have already experience in IDA-financed project management; they are familiar with Bank's procedures, have qualified, competent andexperienced staff. They already apply the required organizational rules, namely: (i) expenditures are committed through double signature o f the Director and the Coordinator; (ii)financial information are recorded by accountants; and (iii) disbursementsare done under double signature o f the Director andthe accountant. e Category 2: Ministries which do not have adequatefinancial management capacity. For these Ministries, the financial managementwill be two-folds: (i) for expenditures relatedto contracts under the threshold requiring the Special Tender Board (thresholds are set according to the national rules detailed inthe Administrative, Financial andAccounting Manual), the management of procurement and related funds will be carried out, on behalf o f the Ministry, by the NAES; (ii) expenditures below this for threshold, the management o f funds will be carried out by an accountant o f the Ministry, under the authority o f the Secrktaire Gknkral o f the Ministry.These accountants will be responsible to manage the funds delegated to the Ministry under the Action Plan Agreement, with double signature with the -88- Coordinator. The terms o f reference o fthe said accountantswill be included inthe MAFC. Fall into this category are: the MFPJS, the MCOI, the MDN, and the MCRF' and the MDR. The Minisdre du DkveloppementRural et de I~Environnement(MDm)has selectedthe DRFV (Direction de la Recherche, la Formation et la VuZgarisation)to carry out the management o f the funds related to its Action Plan Agreement. This Directoratei s staffed with two accountantswith past experience with externally-funded projects. 7. Expenditures Management e Expenditures related to Component I will be carried out by the NAES, through Special Account A, according to Bank' procurement guidelines. Goods and services purchased by the NAES will be subsequently transferred to the accounts o f the beneficiaries; e Expenditures related to Component2 to finance Action PlanAgreements betweenthe NAES and individual Ministries will be carried out according to the following arrangements: (i)for Ministries o f Category 1, the ministries will carry out 100 percent of the expenditures related to their Action Plan Agreement through a sub-account managed by the Ministries and funded by the NAES from Special Account A; (ii) for Ministries of Category 2, the NAES will carry out, on behalf the Ministries, expenditures related to contracts equal to or above the threshold requiring the Special Tender Board involvement while these Ministries will manage expenditures below this thresholdthrough a sub-account managedbythem andfunded bythe NAES from Special Account A; e Expenditures related to Component 3 will be carried out by the MOHSA through Special Account C; e Expenditures related to Component 4 will be carriedout through Special Account B managed by the NAES and will finance Sub-Project Agreements entered between the private sector andor the Civil Society Organizations andthe NAES for nationallregional large scale sub-projects or the RAES for local andsmall scalesub-projects. 8. Special Accounts, Sub-Accounts and Project Accounts will be opened in commercial banks. For Special Accounts A and B, withdrawal Applications will be submitted by the Direction des Financements o f the Ministzre des Aflaires Economiques et du Dkveloppement, upon request o f the NAES, while for Special Account C, withdrawal applications will be submitted by the DGI of the MOHSA. It was agreed that RAES Sub-Accounts will operate as "comptes en rkgie" and will be replenished on a quarterly basis as follows: e Sub-accounts of Line Ministries. Initial deposit will be made on the basis o f estimated expenditures for 4-5 months o f activities planned in the respective annual Work Program Agreement and upon signature by both parties o f the "Convention". Subsequent payments to a Ministry will be made on the basis o f submission to the NAES o f the following documents, notably: (i) withdrawal request signed by the authorized authority o f the MinistryExecutingagency; (ii) Statement o f Expenditures together withjustificative documentation; (iii) reconciliation statement of the account; (iv) the most recent bank statement reconciled; (v) financial statement at the end o f the 3 month period; (vi) the operation report; and (vii) forecast statement o f expenditures for the subsequent quarter, and the plannedprogramwithitsbudget. a Sub-accounts in M S . Initial deposits will be made on the basis of the estimation of 6 months of planned activities related to sub-projects submitted by CBOslNGOs and private sector, to be approved by the RACs. Payments will be made upon submission o fthe following documentation: (i) statement of progress o f CBOilNGOs sub-project agreements justifying the payment o f subsequent tranches; (ii)requestsfor payment bythe manager of the NGOICBO; (iii) justificative documentation o f expenditures already incurred; and (iv) forecast statement o f expenditures for the subsequent 4-5 months period. -90- 9. Administrative, financial and accounting system. The Financial Administrative Unit of the NAES will be supported inthis tasks by an appropriate administrative, financial and accounting system for the project, including a comprehensive Manual o f Administrative, Financial and Accounting Procedures and an adequate accounting software. The Manual will outline the main activities to be carried out and their timing, to ensure the readiness o f the system. It will include a description o f the internal control and accounting system, management and flow of funds, documentation and reporting requirements, budgetary procedures, and procurement guidelines and procedures to be used by all stakeholders. Key activities to be carried out include: (i) defining the organizational structure for the operation, and the roles andresponsibilities o f all stakeholders; (ii) preparing an accounting manual and designing the accounting system, (iii) defining the main accounting principles to be applied, and the frequency o f the various financial reports, and (iv) elaborating appropriate internal control procedures. The Manual o f Administrative, Financial andAccounting Procedures satisfactory to IDA will be adopted before Grant effectiveness. 10. For the purpose o f monitoring, theBnancia1 statements will include, but not be limited to, the following: (a) Summary Sourcesand Uses of Funds, showing IDA andcounterpart funds separately; (b) Annual WorkPrograms with respect to line Ministries. For subsequent semesters, financial statementsandperformance basedprogress reports; (c) Special account reconciliation along with the bank statements showing deposits and replenishments receivedand payments effected for canying out activities; and (d) Uses of Funds by Grunt Activity, summarizing credit expenditures by line item, consistent with the objectives andactivities supportedunderthis operation. 2. Audit Arrangements 11. Audit. The NAES through its Financial Manager, ,assisted by competent and experienced accountants and administrative support staff, will establish and maintain, to the satisfaction o f IDA and the Government, the accounts andrecords to be usedexclusively for the MACP operation. The accounts will be maintainedinaccordance with sound and internationally accepted accounting principles andthe Government o f Mauritania financial reporting requirements. The financial and accounting staff will produce the annual financial statements to be audited by an independent auditing firm with experience acceptable to IDA. 12, Each line ministrywill submit quarterly financial reports to the NAES. The unitwill consolidate all project financial reports and prepare the project financial statements for auditing purposes. Annual financial audits, to be carried out incompliance with internationally accepted audit standards, will cover Bank requirements for audit of the project accounts and review of internal control systems, when implemented, as well as review o f the SOEs. Audit reports on project financial statementswill include, inaddition to the auditors' short formreportandopinion, separateaudit opinionsonthe Special Accounts and SOE, as well as a Management Letter. Community sub-projects will also be audited on a sample basis. All necessary documentation supporting the MACP-related disbursements and financial transactions will be maintained at the respective level for inspection by IDA supervision missions, Government, and the independent auditors. -91 - 3. DisbursementArrangements 13. The project is expected to be completed over a five-year period accordingto the categories shown inTable C above. Government counterpart funds neededfor eachfiscal year to cover the shareo f recurrent costs not financedbyIDA will be deposited bythe Government ina ProjectAccount managed bythe FinancialandAdministrative Unit(FAU) ona semi-annualbasis. Allocationof grantproceeds(TableC) Table C: Allocation of Grant Proceeds ExpenditureCategory I Amount in US$mitiion I Financing Percentage 1 1.Works I 0.10 1 100%o fforeign expenditures and 85% o flocal exuenditures 2. Goods 0.80 100% o f foreign expenditures and 85% o flocal exuenditures 3. Drugs andTests 2.10 100% 4, Consultants' Services 2.00 100%foreign; 85% local fm;90% local individual 5. Training 1.60 100% 6, Grants for line ministryand "Project" 3.50 100%o famount disbursed ctionPlans 7. Grant for Civil Society Sub-projects 7.00 100% o f amount disbursed 8. Operating Costs 1.30 85% 9. PPF Refinancing 0.60 10.Unallocated 2.00 Total ProjectCostswith Bank Financing 21.00 Total 21.00 14. The project will be disbursed using the Bank's transaction-based disbursement procedures, in accordance with the Bank's Disbursement Handbook, as simplified along the lines o f procedures agreed by the Bank under Fiduciary Managementfor Community-Driven Development Projects. Disbursements for all expenditures will be made against full documentation, except for items o f expenditures for: (a) contracts for consulting f i m s in an amount inferior to $100,000 equivalent, (b) contracts for individual consultants inan amount inferior to $50,000 equivalent, (c) contracts for works inan amount inferior to $50,000; (d) contracts for goods in an amount inferior to $100,000, and (e) community sub-projects, training, and operating costs, which will be claimed on the basis o f Statement o f Expenditures (SOEs). All supporting documentation for SOEs will be retained at a suitable location at the level of the community, line ministry and other public sector agency, NAESRAES,andreadily accessible for review byperiodic IDAsupervision missions andextemal auditors. 15. It is anticipated that payments under sub-projects will be made most often against the modality outlined inpara 42(b) of the Guidelines for Fiduciary Managementfor Community-Dr~venDevelopment Projects through disbursement of lump-sum trenches, based on payment schedules in the sub-project financing agreements, whereby payments fall due when certain sub-project milestones are reached. - 92 - 16. Disbursements under Conventions with line ministries and MSAS: Without limitation upon the provisions o f Section4.01 o f this Agreement and the Recipient's progress reporting obligations set forth inparagraph 1o f Schedule4. to this Agreement, andthe provisions set forthinSchedule 1and 5 to this Agreement, the Recipient shall, for purposes o f disbursement o f funds from the Special Account A, under Category (6) o f the table set forth under paragraph 1o f Schedule 1to this Agreement, cause line ministries to furnish quarterly reports, in form and substance satisfactory to the Association, to CNJS, for the purpose o f continued financing ofthe carrying out Action Plans under Conventions. Special account: 17. To facilitate project implementation and reduce the volume o f withdrawal applications, the NAES will open two Special Accounts ina commercial bank on terms andconditions acceptable to IDA. Special Account A will finance expenditure relatedto Component 1 (Strengthen capacity o f government agencies and civil society) and Component 2 (Expand multi-public sector responses for prevention and care o f HIV/AIDS), while Special Account 3 will fmance Component 4 (Develop and expand civil society organizations and private sector initiatives to HIV/AJDS). The authorized allocation will be US$700,000 for Special Account A and US$700,000 for Special Account B and will cover about six months of expenditures. Upon effectiveness, IDA will deposit the amount o f US$350,000 in Special Account A and US$350,000 in Special Account B representing fifty percent o f the authorized allocations. For the Ministry o f Health and Social Welfare, the DGIwill open a Special Account C ina commercial bank on terms andconditions acceptableto IDAto finance expenditure relatedto component 3 (Expand health sector response for prevention, treatment and care o f HIV/AIDS). The authorized allocation will be US$800,000 and will cover about six months o f expenditures. Upon effectiveness, IDA will deposit the amount o f US$400,000 in Special Account C representing fifty percent o f the authorized allocation. 18. The remaining balance will be made available when the aggregate amount o f withdrawals from the grant account plus the total amount o f all outstanding special commitments entered into by the Association shall be equal or exceedthe equivalent o f SDR 2 million for each o f the Special Accounts A and B, and the equivalent o f SDR 2.2 million for Special Account C. Replenishment applications will be submitted monthly. Further deposits by IDA into the Special Accounts will be made against withdrawal applications supported by appropriate documents. The Special Accounts will be audited annually by external auditors acceptable to IDA. SpecialAccount A Special Account B Approximate number o f SGSAs to be esta- blished (actual number cannot be establi- 8-15 10-13 shed untilimplementationunderway) Advance to cover an average o f 4-5 months estimated expenditures 4-5 months estimatedexpendit. Type o fBank commercial commercial Currency Ouguiya Ouguiya Managedby PIUinline ministries (where financial management is satisfactory; Financial RAES Offices Agent where financial management is not satisfacton;). - 93 - Counterpart Funds 20. Total counterpart funds are estimated at about US$2.4 million equivalent, includingall taxes. As a condition of mnt effectiveness, the Govemment will deposit an initial amount of LJM 25 million in Project Account 1and LJM6.2 million inProject Account 2, each account represents the first six months ofcounterpart expenditures for the Project, excluding taxes. - 94 - Annex 7: Project ProcessingSchedule MAURITANIA MULTISECTORHIVIAIDSCONTROL PROJECT IProject Schedule Planned Actual Timetaken to preparethe project(months) 12 12 FirstBank mission(identification) 0611312002 0611612002 Appraisal missiondeparture 0410512003 0410612003 Negotiations 0511212003 0512I12003 PlannedDateof Effectiveness 1010112003 Prepared by: The project has beenpreparedbya largemultidisciplinaryteam incollaboration withGovernment counterparts anddevelopment partners inMauritania. Preparation assistance: Project preparationgreatly benefitedfrom the support o f a PHRDJapaneseGrant, which financed technical and analytical work. A PPFwas also granted to finance key technical work andthe establishment o fthe NAES prior to project start up. Bank staff who worked on the projed included: Name Speciality Serge Theunynck Task Team Leader (AFTH2) Richard Seifman Act-Afi-ica Advisor (AFRHV) Johanne Angers Operations Officer (AFTH2) andComponent 2 CherifDiallo Senior Program Officer (AFTH2) DavidBlankhart Consultan~onitoringand Evaluation (HDNVP) OusmaneBangoura Sr. Health Spec. TTL HealthProject (AFTH2) ElizabethAshbourne Private Sector Partnership (AFRHV) HawaCisse Wague Economist (AFTP4) SalamataBal Social Development Specialist (AFTES) EdeltrautGilgan-Hunt Environment Specialist (AFTES) Siaka Bakayoko Financial Management Specialist (AFTFM) Hans-Werner Wabnitz Sr. Counsel (LEGAF) Vivian Nwachkwu-Irondi Team Assistant (LEGAF) Sangeeta h j a Sr. HealthSpecialist (HDNHE) Ahmedou OuldHamed Procurement Specialistnocal Development (AFTPC) Guy-Joseph Malembeti Procurement Specialist'Local Development (AFTPC) BrahimOuldAbdelwedoud UrbanDevelopment Specialist (AFTU2) Nicole Hamon Language ProgramAssistant (AFTH2) Mercy Tembon Sr. Education Specialist (AFTH2) Amadou Oumar Ba Agricultural Specialist (AFTR2) Kees Kostermans LeadPublic HealthSpecialist (AFTH2) Fatima Cherif Team Assistant (AFMMR) - 95 - MichelVoyer ConsultantlOperations Manual andSocial Dev. Spec. HelleM.Alvesson ConsultantlAnt~opologist Claude Ghouzi ConsultantlFinancial Management Specialist Antoine Gennaoui ConsultanthstitutionalSpecialist Boubacar Macalou ConsultantlGrassroots Management Training Specialist Alice Morton Consul~tlSociolo~stlAnt~opologist KimBeer ConsultantlHealthCommodities Chair Assesment Specialist & Social MarketingSpecialist BassirouMbengue ConsultantlCOSTAB Specialist Frode Davanger Operations Officer (AFRIN) JonathanBrown Global HIV/AIDS UnitlACTAfiicaPeer Reviewer (AFTOS) DavidWilson Global UnitM&ETeamlPeer Reviewer ( " V P ) Christopher Walker HDNHEPeerReviewer (AFTH1) ElizabethLule HDNHEReer Reviewer (HDNHE) Ross Pfile Editor - 96 - Annex 8: Documentsinthe Project File" MAURITANIA MULTISECTORHlV/NDS CONTROL PROJECT A ProjectImplementationPlan Project ImplementationManual: Projet Multisectoriel de Lutte Contre le VIW.SIDA: Manuel #Execution duProjet: Volume 1: Composante 1: Renforcement des Capacites des Agences Gouvemementales et de la SociCtk Civile et la GestionduProjet Volume 2: Composante 2: RkponsesMulti-Sectorielles (Non-SantB) pour la Preventionet les Soins Lies au SIDA Composante 3: Renforcement de la Rkponse du Secteur de la SantC pour la Prevention et les Soins Lies auV W S I D A Volume 3: Composante4.2: Developpement et Expansiondes Initiatives de la Societe Civile; Volume 4: Composante 4.1: Dtveloppement et Expansiondes Initiatives duSecteur Priv6; Volume 5: Manuel OpCrationnel de Suivi et d'Evaluation, prepared on the basis of the UNALDS Generic Manual. B. Bank StaffAssessments - Social - Assessment o f RuralWomen andTraditional Health Practionners, byMs. Helle Alvesson Social Assessment of Men and Women at Risk in the North (Nouadhibou) and Women at Risk in Nouakchott, byAlice Morton; --NGO Assessment, by Michel Voyer; Evaluation des CapacitCs de Gestion Administrative et Financiere des structures d'execution - Claude -Ghouzi, C2G Conseil, Annex to the Aide-Memoire o fthe Project Appraisal Mission; Mission de Renforcement des Capacitks Institutionnelles du MAP en Mauritanie du 21 au 30 avril 2003, byAntoine Gennaoui, C2G Conseil; - HealthCommodities Sypply Chain Assessment, byKimBeer. C. Other ---CommunicationRelative Cadre StrategiqueNationalde Lutte Contre les I S T N W S I D A2003-2007 (Aoirt 2002) A la Mise en Place du ComitC Natinalde Lutte Contre le SIDA Evaluationdes Capacites des ONGNationales(Commissariat aux Droits de l'Homme, Zi la Lutte -- Islam Contre la Pauvretb et a 1'hsertioniDirection de la Lutte Contre la PauvretC, Mai 2000) &VWSIDA: Guide d'Action Sociale et Educative (MSAS; JHUISFPSiUSAID; STOPSIDA) Manuel de Formationen Communicationpour Leaders Religieux: IslamISTNIHSIDA (ONG STOP -Note SIDA) Technique SLXle Programme de Renforcement des CapacitCsdes ONGNationales2001-2002 CDHLCPI (Commissariat aux Droits de l'Homme, a la Lutte Contre la PauvretCProgramme - Pland'Action de Renforcement des CapacitBsdes ONGnationales) Sectoriel de Lune Contre les I S T N W S I D A chez les Femmes (Secretariat d'Etat a la Condition FemininelComitC Sectoriel de Lutte Contre le SIDA) - Pland'Action Triennal de LutteContre lesISTNWSIDAduDkpartement de laCulture et de - Pland'Action l'orientation Islamique - Plan Sectoriel Triennal de Lutte Contre les I S T N W S I D A du Secteur de 1'Education Sectoriel Triennal de Lutte Contre ISTNWSIDA duMinistere de la Santeet des Affaires Sociales - 97 - -Plan&Action Triennal de Lutte Contre les ISTNWSIDAduSecteurde la Fonction Publique, du -Pland'Action Travail, de la Jeunesse et des Sports Triennal de Lutte Contre les ISTNIWSIDA duSecteurduDCveloppement Ruralet de --Plan 1Bnvironnement Plan&Action Triennal de Lutte Contre les ISTlSIDA duSecteur des Forces h k e s et de SCcuritk Sectoriel duMinistkre de la Santh et des Affaires Sociales de Lutte Contre ISTNIWSIDA -Programme (MSASIComitk Sectoriel SantC, Draft fevrier 2003) T'wizk A Nouakchott, Mauritanie (SKATIRAS Case Study Series - Dossier: Habitat Social -Rksultats SH5,2001) de 1'Enquete sur la Prevalence de 1'Infection V M chez les Femmes Enceintes en Consultation - Strategie Prknatale (MSASProgramme Nationalde LutteContre les MST et SDA, Mai 2002) Nationale de Promotion Feminine 200112005 (Secrktariat d'Etat a la Condition FeminineDirectionde la Cooperation et de la Planificationdes Projets) *Including electronic files - 98 - Annex 9: Statementof Loansand Credits MAURITANIA: MULTISECTORHlVlAlDSCONTROL PROJECT 21-Mav-2003 Differencebetweenexpected and actual OriainalAmount inUS$ Millions disbursements' PrnierlID FV Pumnsn IBRD IDA Cancel, Undisb. Orig FrmReVd PO69095 2002 UrbanDevelopmentPrcgram 0.00 70.00 0.00 74.66 15.94 0.00 PO71308 2002 EDUCATIONSECTOR DEVELOPMENTPROGRAM 0.00 49.20 0.00 48.39 -4.71 0.00 PO71881 2002 MR GlobalDistanw LearningCenter 0.00 3.30 0.00 2.78 1.28 0.00 PO64570 2000 CULTURALHERITAGE 0.00 5.00 0.00 2.82 1.94 0.00 Po44711 2000 MaurANTEGOEV PROGFOR IRRIGATEDAGR 0.00 38.10 0.00 15.93 4.43 0.00 Po86345 2000 MR EGYMIATERISANITATIONSECTOR REFORM 0.00 9.90 0.M) 5.48 8.03 0.00 PO57875 1999 MININGSECTCAPACITY 0.00 15.00 0.00 5.72 4.00 0.00 WE3791 1999 MR -TELECOMB POSTALREFORM 0.00 10.80 0.00 2.68 2.79 0.00 Po55003 1999 NUTRITION(LIL) 0.00 4.90 0.00 2.28 2.11 2.38 PO35689 1998 HE4LTHSECTORINVEST 0.00 24.00 0.00 8.52 6.62 7.84 PO46650 1997 MR REGIONALPOWER 0.00 11.10 0.00 1.30 1.49 4.20 Total: 0.00 241.30 0.00 170.55 45.92 10.00 - 99 - MA" STATEMENTOF IFC's HeldandDisbursedPortfolio J u ~ 30 2002 - InMillionsUSDollars Committed Disbursed IFC IFC FYApproval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1997 BMCI 3.50 0.00 0.00, 0.00 3.50 0.00 0.00 0.00 1996100 GBM 7.00 0.00 0.00 0.00 7.00 0.00 0.00 0.00 1999 PAL-Tiviski 0.50 0.00 0.00 0.00 0.44 0.00 0.00 0.00 1999 SEF Lemhar 0.44 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Total Portfolio: 11.44 0.00 0.00 0.00 10.94 0.00 0.00 0.00 AoorovalsPendingCommitment FYApproval Company Loan Equity Quasi Partic Total PendingCommitment: 0.00 0.00 0.00 0.00 -100- Annex IO: Countryat a Glance MAURITANIA MULTISECTORHlVlAlDS CONTROL PROJECT sub. POVERNandSOCIAL Saharan LOW. Mauritania Africa income Developmentdiamond* 2001 Population, mid-year (millions) 2.8 674 2,511 GNI percapita(At/asmethod, US$) 350 470 430 Lifeexpectancy GNI (Aflas mathod, US$billions) 0.96 317 1,069 - Averageannualgrowth, 199541 Population(%) 3.2 2.5 1.9 Laborforce (%) 3.3 2.6 2.3 GNI - Gross Most recant estimate (latest year available, 1995-01) per primary capita nrollment Poverty(% ofpopulationbelownationalpovertyline) 46 Uhanpopulation(% oftotalpopulation) 59 32 31 Lifeexpectancyat birth (years) 52 47 59 - infantmortality(per 1,000live births) 74 91 76 Childmalnutrition(% ofchi/dmnunder5) 32 Accessto improvedwater source Access to an improvedwater source (?Aofpopulation) 37 55 76 Illiteracy(% ofpopulationage 15+) 59 37 37 - Gross primaryenrollment (% ofschool-agepopulation) 88 7a 96 Mauritania Male 89 85 103 Low-incomegroup Female a2 72 a8 KEYECONOMICRATIOSand LON&-TERMTRENDS 1981 1991 2000 2001 Economicratios' GDP (US$billions) 0.86 1.1 0.98 1.o Gross domestic investmenffGDP 26.5 17.9 30.3 26.7 Exportsof goodsand serviceslGDP 39.3 44.1 40.1 38.2 Trade Grossdomestic savingslGDP 0.5 9.7 18.4 14.0 - Gross nationalsavingslGDP 9.6 9.7 29.8 19.9 Current account balancelGDP -17.1 -8.2 1.1 -5.1 Interest paymentslGDP 2.1 2.2 Totaldebt/GDP 112.7 193.6 189.5 181.9 Totaldebt servicalexports 22.4 17.3 Presentvalue of debffGDP 61.7 60.0 Presentvalue of debffexports 128.4 136.8 Indebtedness 1981-91 1991-01 2000 2001 200145 (average annualgrowth) GDP 0.2 4.3 5.1 4.6 5.8 -Mauritania GDP percapita -2.3 1.3 1.6 1.4 3.1 ~ Low-income arom Exportsof goods and services 0 2 3 1 119 8 0 8 6 STRUCTUREof the ECONOMY I981 I991 2000 2001 (% of GDP) ' Growth of investmentandGDP (%) Agriculture 31,g 28.7 21.3 20.9 75 * 1 Industry 26.2 30.0 29.1 28.6 Manufacturing .. 10.8 8.6 8.0 Services 41.9 41.3 49.6 50.5 Privateconsumption 65.4 72.1 64.7 70.4 Generalgovemmentconsumption 34.2 18.2 17.3 15.6 Importsof goodsandservices 65.3 52.3 52.2 50.7 -GDI -O-GDP I 1981-91 199141 2000 2001 1 (avemga annualgrowth) Growthof exportsand impods (%) I Agriculture 1.4 4.6 2.8 -0.2 Industry 4.7 2.1 6.7 1.4 Manufacturing -1.6 0 . 5 3.3 5.9 Services 1.1 5.6 5.9 8.5 Privateconsumption -0.9 2.2 -16.4 14.6 Generalgovemmentconsumption -3.5 2.5 23.2 -5.6 Gross domestic investment 3.4 10.6 57.5 -5.4 Importsof goods andservices -1.7 2.9 14.8 4.8 Note: 2001 da:a are preliminaryestimates. *The diamonds showfour key indicatorsin the country (in bid) comparedwith itsincome-groupaverage. Ifdata are missing.the diamond will be incomplete, - 101- ~ a u r i t a n ~ a PRICESand GOVERNMENTFINANCE 1981 1991 2000 2001 Domestlc prices ~Inflation(36) I (77 change) ~15- Consumer prices 5.6 3.3 4.7 ImplicitGDPdeflator 7.3 9.8 10.7 5.4 Governmentfinance of GDP, includescumntgrants) Current revenue 22.6 25.8 28.1 Current budgetbalance 1.4 9.0 11.4 Overallsurplusldeficit -5.7 -3.1 2.4i -GDP deflatw ' O ' C P I I TRADE I 1981 1991 2000 2001 (US$mi//ions) Exportand importlevels(US$mill.) Total exports (fob) 434 359 345 Ironore 212 202 188 Fish 222 157 155 Manufactures Total imports (ciff 416 343 357 Food 121 120 113 Fueland energy 39 100 92 Capitalgoods I 78 78 61 Export price index(1995=100) 110 82 87 I 95 98 97 98 99 Ml O1 Import priceindex (1995=100) 108 98 95 Terms of trade (1995=100) 101 83 91 BALANCEof PAYMENTS 1981 I991 2000 2001 (US$ mi//ions) ' Currentaccountbalanceto GDP(X) Exportsof goods andservices 319 498 392 385 1 5 - Importsof goods and services 514 591 493 496 Resourcebalance -196 -93 -101 -111 Net income -51 -61 -20 -58 Netcurrent transfers 99 62 132 117 Current account balance -147 -93 I1 -51 Financingitems (net) 171 121 -35 18 Changes in net reserves -24 -28 24 33 Memo: Reservesincludinggold (US$mi//ions) 166 67 255 286 Conversion rate (DEC, /oca//US$j 48.3 81.9 238.9 255.2 EXTERNALDEBTand RESOURCEFLOWS 1981 1991 2000 2001 (US$mi//ionsj :omposition of 2001debt(US$ mill.) Totaldebt outstandinganddisbursed 967 2,188 1,852 1,836 IBRD 11 43 0 0 IDA 44 224 449 475 G 324 Totaldebt service 77 88 75 IBRD 1 15 2 0 IDA 0 2 7 9 Compositionof net resourceflows Officialgrants c:119 Officialcreditors 145 25 Privatecreditors -15 -2 Foreigndirectinvestment 12 2 42 14 Portfolioequity 0 WorldBank program Commitments 3 0 63 123 L E Bilateral - Disbursements 17 14 57 47 I IDA -- IBRD D Other multilateral - F- Private Principalrepayments 0 12 6 5 :-IMF G Short-ten - Netflows 17 1 51 42 Interestpayments 1 5 3 3 Nettransfers 16 -4 48 38 At II-4 -102- AdditionalAnnex I 1 SocialAssessmentof RuralWomen and Traditional Health Practitioners MAURlTANIA MULTISECTORHlV/AlDS CONTROL PROJECT 1. Objective. The social assessment reviews social and cultural variables that are relevant in reachingand involving local communities inorder to prevent the spread o f HIVIAIDS inMauritania. Views andperspectives on HIVIAIDS have been collected from a range o f potential beneficiaries. A strong emphasis on community empowerment is expected to enhancethe effectiveness of the project, It is clear that women are vulnerable to HIVIAIDS and that a wide gap exists between rural and urbanpopulations with regard to access to information on and support to address health risks. It is therefore criticalto understand gender-based roles andrelationships inthe Mauritanian context. With this premise inmind, the social assessment aims to: Analyze the knowledge and perceptions o f HIVIAIDS, Sexually Transmitted Infections (STIs), and sexual behavior among rurallurbangirls andwomen. Assess the capacity o f Women's Cooperatives to participate inthe project. Assess the capacity o f traditional health practitioners to support communities inpreventing HIVIAIDS. Identifystrategiesto addressthe practiceo fFemale GenitalCutting(FGC), Analyze migratingmen's perceptions andpractices relatingto HIVIAIDS. Identifystrategiesto addressHIVIAIDS inthe maledominated part o fthe private sector. 2. Methodology. The social assessment is based on existing literature and studies, key-informant interviews, directed discussion groups, focus groups, and semi-structured interviews with girls, women, and staffat public and private sector institutions andassociations. This work was conducted at the national, municipal, and community levels. The attitudes and behavior o f both men (in particular migrating men) andfemale sex workers withrespect to HIVIAIDS andsexual activity were explored at the local level in urban and peri-urban areas. These communities o f interest are most densely represented and accessible in such areas, in particular Nouakchott and Nouadhibou. Semi-structured group discussions and directed group discussions were held with 20 female sex-workers4 inNouakchott and 14inNouadhibou. Selection o f the institutions to be visited was made in consultation with other Bank mission team members, key government interlocutors, and NGOs already working in the area o f HIVIAIDS. Key informants were identified in some 20 government agencies, local industries, associations, private sector-based federations, and internationalandnational NGOs andCBOs, The results of the social assessment on girls and women are based on focus group discussions; semi-structured interviews; and consultations with national and international agencies, NGOs and CBOs (such as Women's Cooperatives), Secretariat o f State for Women's Affairs (SECF) in Nouakchott and its regional representatives and education sites for youth. In total, 324 women participated in 30 focus group discussions. In the rural areas, 12 focus group discussions with Women's Cooperatives with women older than 25 and eight focus groups discussions with younger married and unmarriedwomen were carried out, In urbanareas, seven focus groups with young girls and newly married women 14-25 years old were carried out; women with teenage daughters participated in three focus groups. Semi-structured interviews were carried out with traditional healthpractitioners and with FGCpractitioners. - 103- The villages and Women's Cooperatives targeted for study were selected inconsultationwith SECF andUNICEF. Data collection was conducted in the capital, Nouakchott, and in the three southern regions o f Traza, Brakna, and Gorgol (which according to the CAS 2001 have among the highest poverty rates inthe country). The sample population included women fiom all four ethnic groups, i.e., Maures, WoloJ Poulaar and Soninke. The young girls andwomen targeted inNouakchott were selected inconsultationwith directors o f three different "Centre depromotion de conditionfeminine ," which offers short-term training programs for vulnerable girls. The participants were equally represented by ethnic group and included girls both in and out o f school. Some o f the girls are currently enrolled in courses at the centers and some have recently moved to Nouakchott. The primary issue considered in the focus groups were girls' and women's sexual and reproductive health. Specific topics covered included general sources o f information; talking about sex with friends; gender roles; dating; commencement o f sexual activity, abstinence; risk prevention and condoms; knowledge anduse o fhealth services; and female genital cutting. The sample populationi s not representative o f girls and women in urban and rural settings. Instead, the aim o f this research was to reach a heterogeneous grouping o f respondents to gain a perspective about their relation to sexual practices and HIVIAIDS (as well as their involvement in Women's Cooperatives). The premise behindthis method i s to elucidate contrasts inthe data collected so that social processes can potentially be identified. Social stratification in Mauritania i s very complex. Differences in attitudes and practices among ethnic groups, urban and rural dwellers, and members o f different tribes and castes are probably considerable and may be highlynuanced. Duringproject preparation, the social assessment team did not have sufficient time or the ability to determine the nature andextent o f these differences indetail. To mitigate this knowledge gap, future studies are already planned for PPF funding, including a quantitative survey o f female sex workers; a study o f the economic and social impact o f HIVIAIDS on private sector growth and profits; and a pilot project with inter-urban bus drivers. In addition, a review and annotated bibliography on socio-cultural literature should be undertaken to facilitate implementationo fthe MACP. Particular attentionshouldbe paid, inter alia, to gender roles interms o fhow they differ among ethnic groups, classes, andcastes. 3. HIVIAIDS awarenessamongurban and rural women. The Demographic Health Survey (DHS) o f 2000-2001 provides valuable information on knowledge o f and attitudes toward HIVIAIDS. The purpose o f the focus group discussions was to create a context for these data. The DHS revealed that a relatively higher percentage o f women had heard about AIDS in Mauritania (76.3 percent) than in other comparable countries in which AIDS prevalence is under 1 percent. However, the rural-urban gap with regard to information availability was relatively wide: 62.6 percent o f the women in rural areas said they had heard about AIDS, compared with 94.3 percent in Nouakchott. When it comes to knowledge about symptoms o f the disease andhow to recognize a person with AIDS, knowledge is muchmore limited. HIVIAIDS is largely perceived as a disease that comes from neighboring countries, and the general perception i s that only sex workers, foreigners, Mauritanians who have been abroad, and those who don't comply with religious norms are at risk o f infection. Women's estimation o f their own risk i s low, in keeping with patterns in other countries. This finding has, in part, been interpreted as an expression o f risk denial and the general difficulty o f talking about the possibility o f dying from AIDS. The current denial o f the risk that Mauritanians will be infected with HIV, together with the moral judgment implied in statements like "people who comply to the religion are not afraid o f AIDS," indicates a need for advocacy against the stigmatizationo f and discrimination against people who are diagnosed with the disease. There i s also a clear need to disseminate information on -104- non-sexual modes o ftransmission andthe humanrights o fbothinfectedand affectedpeople. 3.1. Perceptions of STIs. The prevention o f STIs is an efficient way to reduce women's vulnerability to HIVIAIDS Studies indicate that improved STI treatment can reduce the incidence o f HIV by 40 percent. According to the 2000-2001 DHS, levels o f STIs inMauritania are estimated to be 3.4 percent for women and0.8 percent for men; only 14percent o f women had heard about STIs other than HIV/AIDS. This result was confirmed in the focus groups conducted during the social assessment, in which very few young girls and women had heard o f STIs. The young girls participating were, however, very interested ingetting information on the symptoms o f STIs. This findingindicated awillingness and concern onthe part ofyounger girls to gainaccess to information on reproductivehealthissues, 3.2. Perceptions on virginity, marriage, and sexual activity from the focus groups. Throughout Mauritania, prevailing social and religious noms generally confer the right to be sexually active through marriage. The preservation o f a girl's virginity untilmarriage i s critical, as evidenced by its mention in focus group interviews as one of the greatest preoccupations o f mothers. Girls are circumcised partly to reduce their level o f sexuality and are brought up with strong guidelines regarding how to behave. Cultural beliefs regarding the ideal age o f first marriage is a matter o f intense debate inMauritania. Results from the 2000-2001 DHS suggest that the median age o f first marriage inMauritania varies primarilydue to years of schoolingandgeographic location. Inrural areas, it is 18.1 years, while in Nouakchott it i s 20.6 years. The trend for the whole country is that girls are getting married at an increasingly older age. At the same time, fewer girls marry very young (Le., at less than 15 years o f age). Among today's 15-19 year olds, 13.4 percent were married at age 15. Early marriages, as well as some o fthe marriages o f older teenagers, are arranged. This fact implies that the age o f the formal sexual debut is, to some extent, decided by the parents o f adolescents. Nationwide differences inage o f f r s t marriage are even larger when seen in the context o f years o f schooling. Among today's 25-29 year olds with no education, the median age o f first marriage is 16.7 years, while women who have completed at least secondary school education are 23.5 years old at first marriage. Unmarried women in their twenties mentioned that young girls who prefer to finish high school or university before getting married face a strong conflict. Participants mentioned early marriage and pregnancy as effectively forcing young women to quit school, but on the other hand also expressedthat it is far more difficult for a woman to finda husband when she i s inher mid-twenties. Marryingat a later age posesa challenge withregardto expectations that girlswill maintaintheir virginity untilmarriage. Ingeneral, menenter their first marriage almost ten years later thanwomen, ie., at a median age of 26.5 years. The differences between geographic location and years o f education are much smaller among men than women (25.4 years for men without any schooling and 27.4 with completion o f at least secondary schooling). Locationdoes not seemto affect the age o f first marriage for men. Focus group findings indicate that there is some acceptance o f men having sexual experiences before marriage. Age-mixing, whereby older men are married to younger women, is considered to be one o f the explanations for young women's higher prevalence o f HIV/AIDSrelative to their male peers in African countries. Focus group interviews revealed that sex before marriage was a phenomenon both known and perceived as a problem. According to their age, the perception o f the focus group participants was different: young women have the impression that a low percentage o f women are not virgins when they marry, while older women have the feeling that this phenomenon may reach much more - 105- significant levels. It is likely that mothers' own fear that their daughters are sexually active is reflected intheir highestimate. Some groups o f women did not agree and said it was very rare for girls not to be virgins at marriage. In several of the focus groups, participants spontaneously suggestedthat bothboys and girls ought to take an HIV-test before they get married. This i s a very interestingandpragmatic measure to recommend, given the social preference for virginity at time o f marriage. Sexual activity before marriage was explained as being caused by a lack o f supervision, insufficient Islamic education, too much social independence, bad influences, and exploitation by men; poverty was also frequently mentionedas a key factor. A highproportiono fMauritanianwomen are divorced(particularly among theMuures);according to the 2000-2001 DHS, 25 percent o f women marry more than once. Divorced women assume responsibility for children, a fact that many o f the interviewees referred to as an economic constraint. Divorced women manage households alone, leading many to become active in women's cooperatives, travel, and engage in trade. Polygamy is practiced among almost 12 percent o f the population. Young girls inurban areas emphasizedthat this was a practice they themselves not could accept; however, they also acknowledged that if the husband wanted a polygamous household the woman would not be able to resist. 3.3. Information on sexual and reproductive health. The right to information on and access to sexual and reproductive health services i s limited to married girls and women. Sex education between mothers and unmarried daughters i s seen as a difficult task. Older women explained that they could not, for example, talk about sexual relations and condoms with their daughters because they were afraid that this would be understood as an encouragement to be sexually active. Young women confirmed that they didnot talk to either o f their parents about their sexual health concerns before they were b e d . A few young girls said that they would have likedto, but were too shy to bringupthe topic and assumedthat their mothers would feel the same way. Participants indicated that the most frequently used channel o f information on sexual and reproductive health for young girls was other people, i.e., friends and siblingswho both have and do not have sexual experience. Close friends were generally seen as the best people o f whom to ask questions. Sex education in Mauritanian schools is primarily limited to information on abstinence and fidelity to one's husband. Some girls who are in high school also mentioned the existence of new information campaigns that included the promotion o f condom use. Most girls were open to the idea o freceiving more sex education inthe school environment. Health Centers were generally not considered to be a source o f information and support for young unmarried women. It was stated very clearly by many participants that unmarriedwomen could not benefit, insome cases, of the rightto receive information or services regarding provision o f condoms or other contraceptives, a factor that discourages health center visits. In addition, the infomution needs o f young people are not properly taken into account by the health care system. The development o f youth-friendly health centers through the World Bank-financed Health Sector Investment Project could be an important area o f intervention. (It should be noted, however, that cultural justifications for limiting information to unmarried people are deeply rooted in the perceptions o f rights and obligations o f the individual, and are therefore probably not subject to quick change.) The response o f young women to questions regarding how they can be reached by the project was that dissemination anddiscussion o f HN/AIDS-related information must occur inan organized way inorder for promoters to be taken seriously. The distributiono fprintedmaterialswas mentionedby - 106- participants as one way o f facilitating this process. In addition to formal channels such as the education system, the traditional type o f women's association "tontine" was seen as a possible venue for distributing information. In the tontine, members contribute a sum o f money weekly, biweekly, or monthly, which i s then pooledanddistributed to all participantson a rotating basis. The number o f participants can vary from 10 to more than 30 girlslwomen. The tontine process can take many different forms; sometimes money is saved for large investments, while on other occasions (especially when younger girls are involved), contributions are spent on clothing and other personal items or on food for social gatherings o f the entire group. In addition to being a way to provide credit, the tontine i s a social group based on trust infinancial matters. The tontine also provides a socially and culturally appropriate situation for discussions on the health o f girls and women, gender roles, andother relevant topics, and is anespecially important influence for young girls. UNFPA is inthe processo fproducingvarious communications tools on adolescent health, including a youth magazine and radio programs. Importantly, young people themselves participate in the production o f such tools. With the help of NGOs and other entities, such items could be distributed and discussed ininformal groups such as the tontine. Inorder to make HIV/AIDS a part o fthe public discourse, the MACP will expand the use o f existing channels o f communications such as ruralradio stations and include new ones, for example mobile preventive kiosks set up at marketplaces andbus stations in the regional capitals and smaller cities. These kiosks would offer a social space where information can be disseminated freely, as addressedinthe SECF action plan (Annex 13). 3.4. Perceptions of condoms. Focus group questions about the knowledge and use of condoms elicited different responses. Some women simply laughed, while others stated that they couldhardly talk about condoms because they were good Muslims. Condoms are apparently largely associated with infidelity and promiscuity, and are thus seen as necessary only for those people with such practices. In fact, women participants spoke the word "condom" reluctantly, referring instead to "protection." Very few o f the married women participants had actually seen a condom. This is consistent with the 2000-2001 DHS, which indicates that only 6.9 percent o f women living inrural areas o f Mauritania mention condoms as a method for the prevention o f HlV/AIDS. Inthe DHS, 29.6 percent o fwomen inNouakchott identifiedcondoms as a preventivemethod. Interviews with women younger than 25, revealed large variations inknowledge about condoms. Not surprisingly, girls with only a few years of education or living in remote villages tended to have limited knowledge on the subject. Girls living in regional capitals (or close to them) and in Nouakchott, and who were still attending school at age 18 talked more easily about condoms and were more likely to have seen one. Some o fthe girls explainedthat it initially was very embarrassing to mention the word "condom," but that their uneasewas alleviated through exposure with friends at school, the pharmacy, or via their brothers. According to focus group participants, condoms are sold at pharmacies and at the market in Nouakchott by the same people who sell medicines, for prices ranging fiom 20 to 100 UM(8-40 US cents) depending on quality. It is, however, considered difficult for a woman to buy condoms since doing so could be interpretedas a sign o f infidelity or promiscuity. Anonymity inaccess to condoms would be essential for increasing the purchase o f condoms. According to an international NGO, a few religious leaders have championed open discussion o f condom use as a means o f protection against the spread o f HIV/AIDS. This i s considered to be an important initial step toward de-stigmatization ofthe use o f condoms. Several o f the younger women considered condoms to be ineffective, saying that they break easily. - 107- Participants gave examples o f couples who had unsuccessfully used condoms as a contraceptive. Others stated that if condoms were effective, then HIVIAIDS would be less prevalent inthe world. Finally, condoms were interpreted as a sign o f distrust. Monogamy i s the cultural belief that was seen as describingthe idealrelationship; a common view was that when you know your husbandyou do not needcondoms. The monogamous narrative on condoms i s paralleled by practices at Health Centers, where only married women are given access to condoms. Married women's access to family planning is restricted by whether or not her husband accepts that she uses birth control. For a Mauritanian woman to receive family planning, her husband must give his consent either in person or through presentation o f his personal identification card. The female condom is not imported andi s not a part o f services provided at the Health Centers. Very few women have even heard o f this contraceptive method, althoughsome sex workers have usedthemthrough a free distributionprogram. 3.5. Gender issues and male migration. A large number o f married couples, particularly in the southern andcentral regions, are separatedfor several months eachyear because o f male migration to Nouakchott, other cities in Mauritania, or neighboring countries, including those with a high HIVIAIDS prevalence. Such temporary relocation offers mena chance to earn income for the family, but is also a challenge in terms of preventing HIVIAIDS. Separation o f husbands and wives increasesthe possibility o f extramarital relations, which can include unsafe sex with sex workers. In addition, separatedcouples are less likely to know about each other's sexual practices. According to the women interviewed, it i s very difficult to ask a migrating husbandif he has had unsafe sex during his travels. Women are reluctant to ask, and husbands may be reluctant to give them an honest answer. Young, newly married women are particularly vulnerable and there i s no rights equality within the couple, to make decisions in reproductive issues. Furthermore, the time when men return to their villages is seen as an opportunity to try and become pregnant, which, in turn, encourages unprotected sex. According to the DHS, the desired number of children among 15-19 year oldwomen i s 5.1. Bringingup the issue of unsafe sex with one's husband and suggesting behavioral changes in the family requires strength and decision-making capability. Empowerment strategies that enable girls and women to develop self-esteem have proven highly effective for HIV prevention and will be addressedby the project (Annex 19).Additionally, under the PPF, the project will provide funds for associations o f male migrant workers-water and waste carters, fishermen, sailors, truckers, and others-to increase awarenesso fHIVIAIDS andto runpeer-basedIECICCB campaigns andtraining. Because male migrant workers are often seen as opinion leaders when they return home, increasing their awareness so that they will modify their behavior, both while away and at home, should help support parallel efforts to empower their wives and other women family members. Fromthe point o fview o f women livinginNouakchott, it i s recognized that many men live andwork inthe capital andonly meet their families livinginruralareas a few times eachyear. This situation often fosters new business opportunities for women, for example through women's cooperatives that set up local restaurants where food i s served, and home delivery food services. Typically, temporary male workers sign up for eating in restaurants on a monthly basis, making the restaurants excellent venues for education activities onthe prevention o fHIVIAIDS. 3.6. Vulnerability among young women. Young girls are, ingeneral, quite vulnerable. They are growing up at a time when Mauritanian society is transforming quickly and the generation gap i s - 108- strong. A number o f very vulnerable groups o f young girls have been identified: teen-age mothers, maids working inprivate households and restaurants, sex workers, girls inprisons, sexually violated girls. Some o f these groups are sexually active are hard to reach, and face higher risks o f being infectedor affectedby HIVIAIDS. Unwantedpregnancy among unmarried young women i s a particular problem, since sexual relations before marriage i s considered to be a great dishonor to one's family. As a result, the majority o f pregnant unmarried girls are forced to leave their parents' home, placing them in an extremely vulnerable situation riddled with stigma and health risks. Pregnant girls are often given shelter by a relative in a different part o f the country, but participants reported that illegal abortions are camed out inorder to avoid such a situation. Female maids working in private households or, for instance, in restaurants often live under very poor conditions, and often have children and a family to support. Focus group participantsmentioned that their relations with male co-workers are often difficult. In addition, girls participating in the focus groups mentioned that the "sugar daddy" phenomenon is increasing. Insome regions, sexual violence against girls and women was mentioned as an increasing problem. Both medical treatment andpsycho-social support for abusedgirls andwomenneedsto be considered. Violence, inparticular sexual violence, is addressedinthe project (Sub-component 1.5 inAnnex 2). 3.7. "People with multiple partners." BothMauritanian andimmigrant women (as well as young male) sex workers are people inneed o f immediate and continuing support. Prostitution i s illegal in Mauritania, A general feeling i s that sex workers are mainly women who have migrated into the country. This social and occupational category is extremely marginalized, as indicated by the fact that no govenunental agency or NGO can agree on what terminology to use when addressing this group. For instance, some NGOs use the term "women in danger," while others suggested "women with multiple partners.'' Young girls in focus groups said "prostitutes," as did men in the private sector. Directed group discussions with 20 women living independently in poor districts (quartiers) in NouakchottandNouadhibouwere structured to elicit information on life and career histones, current marital status, national origin and current nationality, family status, prior work experience, present intentions and aspirations, and anecdotal budget descriptions. Duringthe social assessment, it was not possible to estimate the numbers o f occasional, part-time, and full-time women sex workers in urbansettings or inruralareas. Most women interviewedhadbeen engagedinmany different jobs, includinglocal, cross-border, and even longerdistance trade; hairdressing; tailor and tailor's apprentice; operating restaurants; street food vending; domestic services; and a range o f other legal occupations. However, many o f the sex workers had failed at these endeavors. All o f the women encountered hadbeenmarried at least once. Only one was currently married, although living separatefrom her spouse. These personal histories also spoke of spousal infidelity; lack of family planning; poverty, domestic violence, and exposure to corruption; having dependent children; influence o f relatives and in-laws for whom what they made legitimately was never enough; illness; andbeing forced to drop out o fmore legitimate, remunerative work in order to help sick parents and relatives. Some cited polygamous marriage as particularly troublesome, as well as large family size. The primaryneed expressedbythe members o f this group is for income on which to live day-to-day, to pay for their children's education and, if possible, to send home elsewhere in Mauritania or to - 109- other countries for extended family members. None o f the participants in this group had been in Nouakchott for more than six years; all indicated that they came to the city originally to find paid employment, to trade, or to open small businesses. As a point o f pride, they emphasized that they had all invested their own funds and had savedmoney one way or another before investing in more significant commercial activities. Their enterprises had failed due to either poor management on their part, or through problems relatedto insufficient working capital and lack o f repayment o f credit they extended to retailers, street sellers, or apprentices. Possession o f condoms is seen as the key indicator that a woman is a sex worker. There is a small-scale sensitization program funded by the U.S. Embassywith the objective o fpromotingbehavioralchangestowards sex workers. Some o f the women encountered in both cities were already part o f a pilot program run by an international and a local NGO. Under this program, women are sensitized and trained in issues related to STIs and HIVIAIDS, and then become outreach workers to other women in the neighborhood. This peer-educator approach creates concentric women's groups, the members o f which benefit from awareness building, the possibility o f VCT, and access to free condoms. Ifthey test positive, their medical fees are paid andthey receive a small stipend ifthey agree to give up sex work. Though the total sample i s small, 30 percent o f those tested through the program were seropositive. When asked to propose a range o f activities and support that could mitigate their currently perilous and sometimes illegal situations, all the women informants expressedgreat interest inreceiving management training. Once on their feet and retrained, they would prefer to work as trainers o f others for some time, inorder to achieve some financial stability and be able to leave the quartier. They would, however, be willing to continue to act as peer educators in the quartier, and then serve as role models for others. Furthermore, almost all participants reiterated that while they welcomed skills and management training or retraining and start-up capital, they did not want to participate in micro- or SME credit schemes. The group tends to be risk-averse due to prior experiences with wholesalers, clients, and others who had extended credit or to whom they had extended credit, which were seen as central to their failure as entrepreneurs. Important interventions for this group include immediate and continuing awareness-building, training, VCT, medical attention, and access to anti-retroviral (ARV) andother types o f drugs. They also need management training and capitalization for SME income-generating activities. Special attention should also be given to the needs o f dependents in and outside o f Mauritania, because sex workers support their children and members o ftheir extended families based on what they are able to earn inNouadhibou andNouakchott. 4. Men in the private and para-public sectors. It i s crucial to reach out to male youth and men in the public, para-public, and private sectors in order to integrate the male perspectives on HIVIAIDS inthe project. Intheprivate sector, bothformal andinformalsub-sectors areimportanttargets. Men unwillingly share decisions about sexual activity, family size, and health care, including protection from STIs and HIVIAIDS. They migrate to towns and cities for work or markets, and then return home, sometimes as opinion leaders. Others out-migrate to Europe for the short or long term. Fishermenusingthe Port autonome inNouadhibouinclude crews flown inregularly from Russia and China. There are also many Senegalese and people from countries with which Mauritania has signed fishing agreements. Specific target groups include long-distance drivers; bus and taxi drivers; sailors; fishermen; dock workers; intermediaries and traders at ports; miners; factory workers; barbers; sellers o f traditional medicines; and carters and truckers who deliver water, collect household waste, and deliver fish and other products from port or factory to towns, markets, neighborhoods, and households. The new -110- Ecole nationale de 1'enseignement maritime et de la p&he in Nouadhibou provides an excellent venue for outreach to 12,000 sailors who are trained in groups o f 4,000. The Director o f the establishment is already a strong advocate o f awareness and outreach activities. Inaddition, 18,000 fishermen and five fisherwomenwho usethe Port artisanal. A significant number ofmen's associations exist, includingRotary andLions Clubs, federations, and unions for virtually every formal-sector occupation and some informal ones in which men predominate. Faith-based organizations are perhaps even more significant and include mostly men but also manywomen. Successful efforts undertaken by NGOs (such as SOS, Pair Educateurs and Stop-SIDA) should be replicated and scaled up. Where possible, women's associations should also be included. The various groups o f Ulema should be involved, as they have demonstrated willingness and capacity to deal well with sex- and STI-related issues in many instances. Professional associations that include both men andwomen, such as the Ordre de mbdecins and the Ordre depharmaciens, shouldbe involvedandgivenadditional management and outreach skills. 4.1. Male attitudes toward HIVIAIDSinthe urban north. All those interviewed inNouadhibou were forthcoming about the need to have more awareness-building campaigns along the lines o f those already being done by SNIM. However, whether most o f them understood what the next steps would need to be after awareness buildingis not clear. Some private sector federation heads and industrialists interviewed definitely understood that there was a clinical side to the problem that they would have to address. Most are aware that condoms are a significant part o f the "answer." Attitudes among elites toward sex workers are, at least pro forma, negative. The sex workers are seen as migrants who are mainly in Mauritania in transit toward clandestine immigration into Europe; Nouadhibouis a way-station for them, as it is for many o f the menwho are their clients. The Mauritanian private sector, at least as it exists inNouadhibou, is already highlystructured. Each sub-sector has a union or federation or both. Competing medium-scale private entrepreneurs are unlikely to join federations because they are still too few in number. The established federations, meanwhile, are already divided into sections and sub-sections with elective offices. They are self-sustaining and can deal directly with each other, or could form an HIVJAIDS Working Group that would be loosely structured and nonduplicative. This approach follows the best practice o f keeping structures as close to the beneficiaries as possible. 4.2. Private sector counterpart participation. Almost all private sector federations and entrepreneurs volunteered their willingness and capacity to make some up-fi-ont contribution to an HIVJAIDS activity or program, primarily in-kind. The SNIM example has clearly had broad local coverage and acceptance. Although federations may not have the cash to take them very far, employers may. One o fthe issuesdiscussedwith federationofficials was the matter o fprivate health insurance for their members. All formal sector employers interviewed said that they contribute to the Caissenationale de sdcuritd sociale, which provides retirement pensions and health benefits for hospitalization and office visits. An Administrator o f the Caisse indicated that-as is the case in many developing countries-the Caisse needs management strengthening. It also covers relatively few members o f the economically active population, inparticular women and youth who are employed inthe informal sector andlor the unemployed. 5. Collaboration between modern and traditional health sectors. It is difficult in many developing countries, includingMauritania, to extend modem health services to poor populations in -111 - rural areas. Traditional health practitioners represent the most widely distributed and most affordable health services for many people. Collaboration between the modem and the traditional health sectors i s therefore increasingly perceived as an important component in HIV/AlDS prevention, treatment, and counseling. Traditional health practitioners' capacity was assessed to support the communities inthe fight against HIVIAlDS.The findings andthe ongoing preparationo f a training program for traditional healthpractitionersare described inAnnex 20. 6. Female Genital Cutting. According to the DHS, 71 percent o f women have had a Female Genital Cutting(FGC) performed. Almost the same proportion o f 15-19 year-old girls (65.9 percent) have been cut as women aged 4549 (68.6 percent). There are considerable differences between ethnic groups with regard to the practice o f FGC. The lowest proportion o f women cut i s in the Wolof population (28 percent). Among the Soninke, 92 percent are cut, while 72 percent o fPoulaar and 71percent o fMaures are cut. There is no formal law against FGC inMauritania. Currently discussions are ongoing inthe country concerning potential changes in the International Convention on the Rights o f the Child, whereby FGC would be defmed as a method o f hanningchildren physically and mentally and would carry a monetary punishment. The World Bank and UN agencies have adopted policies aimed at reducing the practice o f FGC, which WHO and others consider to be a potential risk factor for HIV/AIDS. Furthermore, the MACP promotes a range of behavioral changes and can also be an excellent opportunity for advocating the reduction o f FGC. The UNagencies, with UNFPA in the lead, have collaborated with some national NGOs to start a network in Mauritania with the objective o f reducing the prevalence o f FGC. The network includes representatives from SECF, Female Genital Cutting practitioners, and Imams, and has the capacity and interest to implement new projects and scale-up existing initiatives. The perceptions andpractices relatedto FGC andthe ways inwhich the project can collaborate with the existing network are described inAnnex 19. 7. Women's cooperatives. The women's cooperative is a relatively modem type o f organization that i s well-known and which operates inmany parts of the country. The SECF estimated that more than 12,500 cooperatives areofficiallyregistered inMauritania. (Unfortunately, anupdatedfigure of the Cooperatives that are active was not available at the time o f the social assessment.) Inthe region o f Brakna, it has been estimated that, out o f 800 registered cooperatives, 400-500 are currently active. Women's cooperatives are administered by the SECF, with regional representatives maintaining direct contact with some of the cooperatives. Inaddition, cooperatives in the cities of KaCdi, Rosso, andNouakchott are organized through unions. Focus groups discussions were carried out in 12 women's cooperatives, including the participation of 50 cooperative presidents. One o f the main results is the need to recognize the diversity in size, activities, and socioeconomic status among the cooperatives. For example, the number o f women in eachcooperative varied from 10to 80; the most common size is 20 or 25. The main activities are, in order o f importance, agriculture (production o f vegetables and rice), handicrafts (production o f mats and tents, coloring of textiles, and sewing), and trade (primarily through small convenience stores). The extent and combination o f activities vary with location. Rice production i s only seen inthe areas very close to the Senegalriver, the productiono fmats are mostly done inthe region o fTraza, andthe Gorgol region is famous for the coloring o ftextiles. The participants mentioned several problems that women's cooperatives face with regard to their economic activities. In order o f importance, these included lack o f access to water, insufficient - 112- fencing to protect gardens fiomcattle, the highcost o fmaterial for coloring, lack o f garden tools, the absence ofday care for children, and inadequatetransportation. The largest variation among the visited cooperatives regards socioeconomic conditions. Cooperative members range from extremelypoor divorcedwomen to marriedwomen whose husbands work inthe highend o fthe regional administration. The resourcesavailable vary interms of economic capacity, literacy level, social networks, and access to information on available resources (e.g., micro-credit schemes). At the other end o f the scale, well-functioning cooperatives exist through which women receive a profit apart from their own consumption o f vegetables and cloth. Several o f these cooperatives hadreceivedmicro-credit support and tended to be located inregional capitals. The majority o f women's cooperatives function without any or very limited support from the SECF, international NGOs, andthe regional administration. A few cooperatives participate indevelopment projects supportedby Oxfam, World Vision, FLM,PNUI), UNICEF, andthe World Bank. Cooperatives create important sources o f income for many women. It appears that especially vulnerable, divorced, or widowedpoor women tend to be organized incooperatives. The capacity o f the majority of cooperatives was weak in terms o f economic resources, management and financial skills, technical skills and tools, and diversification o f production. Many o f the members' and their children's basic needs (for example, health care) are not, however, met, a problem which substantially increases their level o f vulnerability. The motivation for working in cooperatives was stronger, and it was clear that the cooperatives are recognized as useful and supportive for women, particularly inrural areas. Empowerment strategies that enable women's cooperatives to gain access to increased opportunities and economic autonomy, incombination with information on HIVIAIDS, FGC, and other health risks, will be addressed in the project through the Grassroots Management Training (Annex 15 andsub-component 1.4). 8. NGOsand local civil society organizations. International and local NGOshave been active as stakeholders inproject preparation. The assessment team met with key localNGOnetworks that will be proposing sub-project activities, some o f which will, in turn, be implemented with CBOs. These networks offered opportunities to the assessment team to hold directed group discussions with community-level groups whose members are likely candidates for IEC or CCB outreach, and with small groups of clients that represent the communities of interest and at-risk groups they already serve. Most network members admit that their scope o f action is limited to the Nouakchott urban and peri-urban areas. Although some have started outreach programs about 30-50 kilometers outside the metropolitan area, most are not yet at that stage o f development. The team visit to Nouadhibou substantiatedthis impression o fa limitedpresence o fNGOs outside the capital. All NGOlCBO staff interviewed agreed that they were inneed o f capacity andmanagement strengthening ifthey were to better serve existing and potential beneficiaries, and that they hope to receive such strengthening under the IvlACP. At least two NGOs stand out in terms o f experience and capacity to sensitize and develop interventions together with base- or community-level groups. One is the Lutheran World Federation (LWF), which has already begun working with SOS, Pair Educateurs, and the other i s Stop-SIDA. GRET, a French NGO that has beenworking to develop housing for the poor, includingimmigrants livinginperi-urbanslums, is one o f the sub-contractors under the IDA-fmancedUrbanDevelopment Project (PDU). In addition to providing construction credit, local GRET agents have successfully - 113- organized local water user management committees, youth associations, women's productive associations, and other self-sufficient community-based organizations in the urban quarters where they work on housing. These activities will eventually become available to all communes in the periphery (Sub-component 2.2. and component 4). The Commissariat aux droits humains, d la lutte contre lapauvrett, et d 1'insertion has also worked with the mayor of Nouakchott, GRET, private and semi-private structures inNouakchott, including women's cooperatives and associations, to implement a series o f pilot projects in potable water distribution, urban and peri-urban waste collection, and micro- and SME credit, Some o f these activities are funded under the Urban Development Project, while others are funded by Cooptration franFaise, UNDP, andGTZ. The assessment team visited Darbella, which is one o f the original slum areas selected for housing credit schemes by GRET prior to the start o f the PDU. A meeting was held with male and female community leaders and GRET-trained graduates who are based in the community to develop additional socio-cultural and productive activities with the local level groups o f men, women, and youth, The members o f a youth association working on a tree plantingproject (who also make up a local sports team) were also present. When the topic o f HIVIAIDS was raised, all group members and representatives agreed that this is a very important issue. Community agents pointed out that they already have a sensitization program on health and nutrition, and they have wanted to receive training andmaterials inorder to include HIVIAIDS under that program. They also mentioned that their youth theater troupe, which has already traveled to other quarters o f the city andregions o f the country, could provide an excellent venue for disseminating IEC or CCB messages. When an earlier visit to the "red-light" district where an internationalNGO is doing peer education with sex workers was mentioned, the Darbella group said that they saw many possibilities for replicating these activities intheir own quartier andinother PDUareas usingtheir network o fCBOs. Another meeting was held at the water distribution point ~orne-fontai~e~. Discussions with water carters reflected interest in sensitization training on HIVIAIDS and, following the peer-education model, to then be able to pass on the messages during water delivery routes among households, There are probably 5,000 or so o f these carters already influenced by other donor-funded activities, and even more carters who remove household and other waste on a regular basis. The water carters are often in-migrants from rural areas who live inthe slum areas, stay for perhaps six months o f the year to accumulate cash, and then go home to plant their crops. They are archetypical o f the mobile male communities o f interest who are themselves at risk and who are also highlylikely to put women andchildrenat riskwhen they retumfrom their stay inthe city. Furthermore, whenthis group returns to their villages, they are seen as influential and as potential leaders due to their having been to the city and having disposable income. The participation o f migratingmen inpeer-education programs in both the city and the rural areas could therefore achieve a dual positive impact: fostering information dissemination andreducingthe likelihoodthat they will themselves become seropositive and a vector o fHIVIAIDS transmission. Such a pilot project could also include VCT. - 114- Additional Annex 12 Assessment of NGOs MAURITANIA MULTISECTORHlVlAlDS CONTROL PROJECT The purpose o f this annex is to present the major conclusions on the situation o f Civil Society Organizations (CSOs), the types o f contracts signed with such organizations and, to make recommendations: 1. Generaloverview of CSOs The fabric o f associations inMauritania i s still embryonic andvery diversified. It comprises (i) national NGOs or development associations, (ii) international NGOs ,(iii) Community-based organizations, (iv) socio-professional organizations, (vi) religious associations. There are several legal frameworks which govem CSOs: (a) Development associations These are based on the 1901 law on associations and are governed by the following insmments: (i) Law No. 641098 o f 9 June 1964 o f the Ministry o f the Interiorrelating to associations, as amendedby LawNo. 731007 o f 1973 andLawNo. 731157 o f 1973; (ii) Law No. 20001043 o f July 2000 and implementation decree No. 20021030 f February 2002: This law creates a new legal framework for NGOsldevelopment associations. Approval i s granted bythe C o ~ ~ ~ s s aonthe r ~ a tbasis o fpredetermined criteria. (b) Community-based associations vary widely and are governed by several legal frameworks, like: (i) cooperatives (law o f 1967 on cooperatives updated in 1973 and 1993), EIGs (law on EIGs), (ii) Community development associations (CDAs, Law No. 2000/043), (iii)solidarity groups o f family or village members, or producers, for example groups ina "tontine", etc. (c) Socio-urofessional organizations (SPOs). Under the umbrella o f trade unions (workers' unions, the bar council, farmers and stockbreeders groups, the medical council, etc). Some o f these organizations are governed by Law No. 701030 to organize professional groups and trade unions and others bythe labor code or the law o f 1964. The profile o f civil society organizations i s characterized by: (i) a lack o f reliable and standardized information sources; (ii) a proliferation o f organizations o f all kinds; (iii)lack o f a focus in activities, which results inan absence o f specialization; (iv) a multiplicity o f networks (over ten networks o f NGOs and associations, which are theoretically operational but for which infomation on objectives, activities and composition is scanty); (v) a lack o fqualified staff; (vi) a lack o f financial and material resources; (vii) a low organizational capacity o f CSOs, (viii) poorly implemented capacity building programs; (ix) a coverage o f the national territory; (x) underdeveloped entrepreneurship which affects the quality o f services provided. Generally, existing data on the sector remain inaccurate and unreliable as shown by: (i) the few reliable studies and surveys (whether sectoral or comprehensive) conducted during the recent years, (ii)the difficult access to information, particularly at the Ministryo f Interior which does not even have a list o f approved organizations; (iii) aninability to verify informationfurnished byNGOdassociations insurvey forms; (iv) repeatedmention o fthe needto identify specialized, qualified and credible organizations by interlocutors met. Institutional partners also noted the - 115- absence of data (list, categories) on NGOs involved in the various programs or projects with development partners, the absence of a clear policy, plan o f action and of a management mechanism, the lack of maturity and a strategic vision, multiplicity of the missions. These difficulties exist at the network level as well as at the levelof individualNGOs. The directories o f NGOs available are: (i) CYBERFORUM directory (2002); (ii) the the directory o f the Humans Rights, Poverty Reduction and Integration Commission (CDHLCPI), (iii) directories of NGO networks; (iii) directory of the Interior Ministry, and (iv) the the directory which appears inthe document Evaluating national NGO capacity, CDHLCPI, 2000. All these directories provide contrasting, inconsistent and incomplete data. There is little agreement between two directories ,for example: 12 international NGOs inthe health sector appear inthe directory o fthe Commissariat, while only 1is inthe CyberForumdirectory . 2. CSOinvolvedincombatingAIDS Some o f these challenges, though not specific to NGOs of any given sector, seem to be compounded with regard to HIVIAIDS. An analysis of information on NGOs and associations which purport to be involved in healtWHIVlAIDS activities shows that NGOslassociations o f diverse sizes, areas of expertise and capacity cohabit in a disorganized manner. When they are compared, the comparison further illustrates the existing confusion. A review based on the number of NGOs per list, included herein as an attachment, shows that: (i) profilesof the NGOsIassociations inhealth andHIVlAIDS are varied; (ii) CSOs, particularly with regardto the actions inhealth/HIVlAIDS are young; (iii) the specialization andtechnical skill of specialized NGOs, especially for their founding members and volunteer staffs (not only o f salaried personnel); (iv) scanty resource base, particularly with regard to the organization's own assets, since associations hardly benefitedfrom contracts which would have facilitated the acquisition o f more significant equipment; (v) the multisectoral approach towards which it could advance in conjunction with civil society. The true size of the health/AIDS sector is difficult to assess: For example, 12% o f NGOl CyberFonun identify health as a sector of activity, inwhich 37% are considered as specialized in HIVIAIDS. This percentages drop to 20% and 15%, respectively, on the list of the Commissariat. The study on the evaluation ofNGO capacity found that there are 45% o fNGOs in health, but does not identify the organizations. The various directories do not contain the same organizations. Assembling andcross-checking showed that only 0.05% (that is, 4 out of 70 NGOs) appear on bothCyberForum andthe Commissariat directories . Also, 10ofthe 11NGOs involvedin AIDS control on the Interior Ministry's list are not on any other list, Itcan also be observed that there are many NGO networks involved inAIDS control (1 international network FOM and 3 national networks: RESEAU SIDA, ROMASIDA, RONASIMA) compounded by the lack o f linkages between networks and directories : only 33% of member NGOs of one network are listed inthe directories (CyberForum and Commissariat). The situation o f NGOs in A I D S control i s nearly impossible to assess: only 33% o f members o f the 2 networks are listed inonedirectory orthe other. 3. Generalrecommendations 3.1 Capacity building: It is important to resort to competent organizations, since the envisaged AIDS control actions will be conducted in a context o f emergency in which time for buildingcapacity is limited. On the other hand, ifthe future Project also seeks to strengthen civil -116- society's entrepreneurial fabric with regard to HIVIAIDS, contracts would have to be provided for all the categories o f stakeholders; international NGOs should also be required to partner with national NGOs to make any proposal. Within this framework, knowledge (categorization) and consideration of specificities (competence level, specialty, target group reached, potential impact, etc.) which would permit the determination o f the contract size, budget types, parallel assistance, etc., which will be accessible to them. This should also foster better control o f (i) geographic coverage (ii) diversity and (iii) profile o f people involved(men, women, sectoral the children, HIV-positive persons, patients, etc). 3.2. Involvement of networks inthe operationalphase should be considered. Their concrete involvement in the Project could be ensured particularly through support to the following standard activities: (i)planning o f support and supervision activities for member NGOs providing services under the Project, (ii) monitoring activities following network and Project criteria; (iii)disseminatingltraining the NGO themselves (reducing effect), etc. The types o f partnerships, the roles and responsibilities should be defined by mutual agreement. Budgets to support the operation o f a network and to pay for services required mustalso be considered. 3.3. Sector specific procedures. To ensure a maximum level o f impact for activities financed and to avoid the gaps or the deficiencies in the content provided, the operational modalities should guarantee that certain inescapable priorities (e.g. sensitization, screening, etc.) automatically figure among the activities to be conducted. Contrary to several other sectors wherein communitydesired projects constitute a determining priority, it i s highly improbable that this sort o f mechanisms will generate high demand at the base, or at least a demand for essential activities. Policies on sub-project fmancing and channeling o f funds should consider these issuesanddevelop strategiesaccording to the partners and constraints involved. 3.4. Forecasts based on an efficient functioning. This could be facilitated particularly by adopting the following measures: (i) clarification o f Project implementation procedures. This could be achieved through a brief manual or guide made available to the various implementing bodies and CSOs. It shouldbe prepared through a process o f consultationand validated through a participatory process. Subsequently, training should be ensured at various operational levels accordingto their mandates; special attention should be paidto defining clear policies as regards the fmancing o f activities and contract award procedures; (ii) simplification o f procedures for compilingdocuments through a decentralized mechanism for providingmodel terms o freference and invitations to tender for activities which are either identical or frequent; (iii) maximumlevel o f decentralization o f funds and management thereof (approval, administration, etc). This will (a) reduce administrative redtape, (b) speedup processing o ffiles and (c) endup ina gradual but greater empowement o f the populations. The population, therefore should be involved in all implementationphases. 4. Specific recommendations 4.1. Survey on CSOs. To quickly obtain a clear profile o f the pool of CSOs working inthe healthkIW1AIDS sector, an inventory o f NGOslassociationdother CSOs operating in Mauritania, with special emphasis on that sector, is recommended. This study could be undertaken locally under the supervision o f the Commissariat, with the technical support o f a committee comprising representatives o f relevant organizations. It should include a svstematic visit to all organizations seeking registration. -117- 4.2. Categorization of CSOs. By comparing several identification forms used within the framework o f Projects (e.g. NUTRICOM) or by various national authorities over the past years, it canbe observedthat most o fthese forms are concise and provide selective information which does not necessarily reflect the current needs for the Project andor HIVlAIDS control action. It would be useful that documents already proposed locally should be (i) reviewed, supplemented and validated before they are (ii) integrated into a common system o f CSO classification and categorization. Categorization should be based on 2 types o f information: (i) specialty and nature o f activity, and (ii) level. The evaluation suggests the following classifications, capacity which were discussedwiththe parties concerned: Functional categorizationby nature of activity: 4 categories: 0 Category I: includes only NGOlassociations specialized in STDsfHIVlADS, with 2 subcategories: organizations primarily conducting preventive actions (1.1) and those which focus onprovidingsupport for patients (1.2, which at the present time are fewer). 0 Category 2: comprises NGOlassociations involvedinhealth, that is, those for which health i s the principal activity (e.g., up to 50 % o f their operations). Here, there are 2 distinct profiles: health organizations with an AIDS component (2.1) and those which conduct general activities (2.2). 0 Category 3: covers all the other sectors, including: NGOlassociations for which AIDS control activities constitute a secondary component (3.1, for example, environment/AIDS), and possess a highgrassroots outreach capacity, andthose organizations that focus on target groups at risk which are concerned by the Project (3.2) and whose specialty could be requiredfor specific actions (e.g., capacity building). 0 Category4 is reserved for NGOs o fpersons livingwith HIV(PWlH). Categorization by capacity level: Sub-project promoters (CBOs and NGOs) will be ranged by categories according to their financial capacity as follows: 0 Category A: International NGOs andnational NGOs with a solid institutional set-up and a good long-termtrack record: sub-project amount up to US$30,000; 0 Category B: nationalnocal NGOs with a good institutional set-up and limited sub-project experience: sub-project amount up to US$lO,OOO; 0 Category C: emerging NGOs with little to no previous experience: sub-project amount up to US$5,000; 0 CategoryI): local grassroots CBOs, such as Parents' Associations, Women's Cooperatives: sub-project amount up to US$l,OOO. These thresholds may be subject to revisions during MACP annual reviews onthe basis o f experience. 4.3. Computer data base on CSOs. The need for a reliable directory was mentioned by all partners who were met duringthe evaluation. The results of the survey mentioned above should be stored inan electronic medium (data base) which could be localized in CyberFonun, in such wise that it is consistent with current data bases. It will permit (i) the maximization o f available resources in CSOs, (ii) an equitable distribution o f financing between NGOlassociations o f various dimensions, (iii) provide greater implementation prospects, (iv) a better assessment o f NGO capacity building needs by competence level (function: creation of a viable pool of NGOsJassociationsand promotioncapacity on a higher operational level). This data base would permit sorting out the followingbases: 0 Overall identification bycategories (usingthe 2 categories above) 0 Identificationby geographic region (usingdefined zones): - 118- Identification o f organizations based in rural areas for each region and for all regions combined, as well as those inurban andlor peri-urban areas, Identification o forganizations with branchoffices inone or more areas other than the main office. 4.4. Current situation of types of contract signed with civil society. Several forms o f contracts are usedwith CSOs andCBOs: (i) Subcontracting (provision of services) between a project or government department and civil society NGOslassociations for the performance o f specific activities; the provision o f services is based on (i) terms o f reference which define the activities to be performed and expected results (ii) a clear definition o f the service provider's responsibilities (with limits), and (iv) a simple, short-term contractual relation. Evenifthe requirements vary, it i s generally required that the NGO providing the services should, (i) and be in contact know with the beneficiaries, and (ii) the technical and managerial skills for that level o f have operation. (ii)Fullimplementation. ThistypeofcontractonlyappliesheretosomeNGOs with high capacity andexperience levels (GRET, World vision, FLM, Espoir, Terre vivante, Tenmiya, etc) and to some projects (PDU with GRET, Nutricom for CNC, CDHLCPI, etc.) It entails recruiting a subcontractor to implement the entire range o f activities comprising a "program" whose (predetermined) budget andimplementationschedule are relatively significant. (iii)Partnership agreement between a national NGO and an international NGO. For the sake o f complementarity or for capacity buildingpurposes, this process encouragesthe pairingo f an experienced international NGO with a national NGO (for transfer o f knowledge, sharing expertise and cooperation). The experiment undertaken by NUTRICOM currently enhances the capacity o f national NGO partners in developing, managing, and efficient and participatory implementationo f interventions inthe CNC. GRET, with the low-cost housingprogram, World vision and Espoir on social mobilization, FLM and Tenmiya, etc., are all examples o f such partnership arrangements. (iv) NGO/project responseto community demands: Financing c o ~ ~ u n i ~ ~ r o j e cHere,. t s the community i s pro-active: it makes a needs and priorities assessment, makes a request, for each activity or for a range o factivities, managesthe h d s granted and ensures the sustainability o f the services it has acquired. If its capacity i s weak, it may partner with a service NGO to submit its file, but it remains responsible for the implementation. Under its project, the community may also resort to subcontracting to NGOslassociations for performing certain tasks, but the onus remains on the community to place the order. The model applied by PGRNP (the community conducts a participatory diagnosis o f development objectives, problems and priorities. It establishes guidelines for desired actions which it proposes and for which it negotiates contractual arrangements once approval i s given. The implementation is entirely in the handso fthe community, which managesthe funds and the subcontracting arrangements. - 119- List of NGOdAssociations inthe areaofhealth/HIV-AIDS identifiedby alphabeticalindex Acronym 8 I Area Area Origin 1Index Title I I I -120- ROMASIDAmember;5 RONASIMAmember; 6 Interior Ministry;7 FSNAMnetwork;8 PLWHAAssociation - 121 - Additional Annex 13: Assessment of the Line MinistryAction Plans MAURITANIA MULTISECTOR HI!//AIDS CONTROL PROJECT The purpose o f Component 2 is to initiate, facilitate andlor incorporate HIV/AIDS control activities in sector ministries in a bid to further knowledge and ensure needed changes in the behavior o f the personnel o f such ministries and o f their clients. The public sector should play a leadership role by way o f defining strategic guidelines and disseminating basic information on the subject, In this sense, the project will contribute to the strengthening o f the capacities o f sector ministries inthe implementationof their sector plans and activities deemed to be priority and necessary for the attainment o f the set objectives o fthe plans. Aside from the Ministryo f Health and Social Affairs (MOHSA), the following seven sector ministries have so far submittedaction plans: e MinistryofCulture andIslamicOrientation(MCOI) e Ministryof National Education(MEN) a MinistryofRuralDevelopment andthe Environment(MDRE) a Ministryof National Defense(MDN) a Ministryof Public Service, Youths and Sports (1MFPJS) a MinistryofCommunicationandRelations withParliament (MCRP) a Secretariat o f State for Women's Affairs (SECF) Those Sector Action Plans were reviewed and assessed during the project appraisal mission, making it possible to define those activities that will be funded by MAP-IDA under the resource distribution, as follows: MINISTRY US DOLLARS MCOI 310.000 SECF 440,000 The Sector Action Plans comprise activities that are relatively standard for all ministries, particularly as concerns training and awareness-building activities for ministry personnel and their clients, as well as activities geared toward strengthening the management capacity o f each ministry, both at the central and regional levels, Standard training and awareness-building activities intended for internal clients (ministry personnel) and external clients (ministry's target groups) of the ministry and the management capacity-building activities, as discussed and agreed upon during project appraisal, are described in chapters Iand 11below. Chapter IIIsummarizes the sector action plans by breaking down the standard activities carriedout byministries andthe actions that are specific to each sector. -122- I. Methodologyforstandardtrainingandawareness-buildingactivities(acrossMinistries) The administrative, technical and support staff (internal clients) o f each ministrywill have the benefit o f awareness-building sessions on W / A I D S once a year. Such sessionswill be referred to hereafter inthe document as "Advanced training on HIV/AIDS" (see 1.b). Those sessions will be conducted by trainers (educators) from the ministries concerned who will be trained for the purpose by experts in the area. Extemal clients o f the ministry will take part in awareness-building sessions that will be referred to hereafter in the document as "notions on W / A I D S " (see 1s). Such sessions will be held once a year. The training sessions will be conducted by personnel designated as outreach workers once they have received training from the educators. Intemal and external clients o f the ministry shall also be provided sustained assistance in information and counselling by persons who will be referred to inthe rest o f the document as "STOP-AIDS Personnel" or SAP (see 1.c) and will come from the ministry concerned. Women and persons from various age brackets should be sufficiently represented among the trainers on the basis o f the number o f persons being given the training. These activities would require the creation, within each ministry, o f the following pools o f specialists on HIVIAIDS: (i) resource persons, (ii) peer educators, (iii) educators, (iv) outreach workers, and (v) counsellors. The following stages and activities will therefore be implemented with the objective to reach, first, the entire personnel o f ministries inthe central andregional services, andthen the external clients o f the saidministries. La. Activity One: Identification andtraining of educators The first task o f each ministry is to train, from among its own personnel, W/AIDS trainers, hereinafter referred to as educators. The training and retraining o f educators is intended to make them equipped to discharge their duties as trainers o f intemal clients, resource persons and outreach workers. The mandate andprofile of educators as well as their training course shall include the followingkey elements: Identificationof Educators Mandate Selection criteria Educators1 PersonnelRatio Offers his services to Respected person. Has close relations with colleagues. Has 1:200(indicative) internal clients, but experience in the training o f adults. I s able to draw up a simple may also offer them to curriculum. Good communicator. Uses simple and clear terms, Each training and extemal clients; recognizes and accepts his limitations, is committed to helping his retraining session provides training and colleagues, is keen on improving his knowledge. Neither shall involve retrainingto intemal judgmental nor is apt to impose his own views. 25-30 persons to clients, resource ensure efficiency. persons. I - 123- Training of Educators Type Coursecontent Purposeoftraining Duration of Training 1. Broad HIVIAIDS The diseaseandthe syndrome This training is intended to [nitial course: :oursefor educators Concept o fhealthy carrier informtrainees onHIVIAIDS 15 days; Opportunistic diseases andonhowto obtain Modes o ftransmission additional information. Italso rrainingby Methods o fprotectionl touches on elements o f Reftesher course: nbcontracting prevention behavior change and 1 daylyear STI and their links with empowerment o feachand HIVIAIDS everyone inthe fight against HIVIAIDS. A specific 0 Importance o f STI treatment and notification o fpartners module for communication Dangers o f stigmatizing techniques andpromotion o f HIV-infected persons (PWA) condomuse will be included Importance o fa healthy lifestyle as well as a module on for persons livingwith or affected androgenous techniques. byHIV Epidemiologicalsituation Communication techniques Condompromotion and use Androgenous techniques 1.b. Activity Two: BuildingAwareness inInternalClients The awareness-building programme for administrative, technical and support staff (internal clients) will be conducted by educators who would have been trained for the purpose. The awareness-building course will also afford the opportunity to identify persons suitable for playing a supporting role for staff designated as "STOP AIDS personnel (SAP)" as defined inparagraph 1.c. The programme will deal with key elementso f HIVlAIDS domains as follows: Type Purposeoftraining Coursecontent Duration of Training Advance Training This course is intended for The disease andthe syndrome Initial onHIVIAIDS persons with little or no Concept o fhealthy carrier course: 2 (elaborate level) knowledge on HIVIAIDS; Opportunistic diseases days; it encourages participants Modes o ftransmission Trainees: all to seek more information Methods o fprotectionlprevention Refresher ministrypersonnel and shows them how to STI and their links withHIVIAIDS course: obtain it. It also touches 1daylyear Trainer: the on elements o f behavior Importance o f STI treatment and educator (see 1.a) change and empowering notification o fpartners each and everyone to play Dangers o f stigmatizing HIV-infected a role in the fight against persons (PVVA) HIVIAIDS. Importance o f leading a healthy life for P W A Epidemiologicalsituation - 124- I.c. Three:IdentificationofSTOPAIDSpersonnel(SAP) Activity The "STOP AIDS Personnel" will be identified under the awareness-building programme intendedfor the internal clients ofthe ministry as defined inparagraph 1.b. They shall comprise: (i) resource persons; (ii) outreach workers; (iii) educators; (iv) counsellors. It should be noted, however, that certain peer ministries already have certain staff categories in them (e,g., peer helpers in the Ministry o f Defense; outreach workers in the Ministry o f Rural Development and Environment) who may play some o f the roles assignedto the various categoriesmentionedabove, Beneficiaries of SAP services :Internal clients Category of Mandate Selection criteria Trainerltrai SAP neesratio 1. Resource Offers hisservices to intemal Respectedperson, good communicator, 1: 50 person clients; provides informationon all uses clear and simple language; employees aspects ofHIVIAIDS; Refers cases recognizes and accepts his limitations; is (indicative) to the appropriate services, does not committed to helpinghis colleagues, is deal withpsycho-social cases; does keento leammore on the subject; does not offer moral advise, works notjudge others nor impose his moral according to demand. views. 2. Peer educator lffers hisservices to intemal clients; I s trusted by his colleagues; good 1:30- 1:50 istens to persons withHIV/AIDS listener and communicator, discrete (indicative) ,elatedproblems; analysis the (ensures confidentiality o fcases); iituationwiththe person; gives emotionally stable; uses clear and tdditional informationto help him simple language; recognizes and accepts inda solution andtake a decision. his limitations; is ready to withstand loes notjudge others; works upon violent reactions and emotions; can `equestbut may be proactive, i.e. he empathize, is committedto supporting nay approachother where necessary. colleagues, is keenon learning more on 3. Counselor Offers his services to internal IIMature the subject; neitherjudges nor imposes his moral views. person discrete (ensures 1: 100-200 (Counseling) supervisespeer educators. reactions; can empathize; Keenon leamingmore onthe subject ; Beneficiaries of SAPservices :External clients Category of Mandate Selection criteria Trainerltrai SAP neesratio 1. Outreach Offers his services to external Respected person, friendly to his peers. 1: 50 worker clients; gives informationon all Good communicator. Uses clear and aspects o fHIVIAIDS; refers cases to simple language, recognizes and accepts the appropriate services; does not his limitations; is committedto give moral advise. Works upon supporting his colleagues; keen on request but may be proactive. leaming more. Neitherjudges nor imposes his moral views on others. -125- 1.d. Activity four: TrainingofSTOP-AIDSPersonnel(SAP) Duringthe frst year of program implementation, initial training adapted to the duties assigned to each category of personnel is envisaged in a bidto harmonize the SAP training program. The same personnel will undergo annual refresher courses. Type of Course content Course objective Duration training 1. Broad Disease and syndrome The course will give nitial HIVIAIDS Concepto fhealthy carrier .dormation onHIVIAIDS raining: training Opportunistic diseases mdlay downguidelines for 5 days Type I Mode o ftransmission Furtherinformation. It also Protectionlpreventionmethods iffects aspects relating to iefresher Beneficiarvo f :hange o fbehaviors and :ourSe: training course STI and their relationto HIV/AIDS Zmpowerment o f everyoneto Idaylyear (i)Resources Role o f treatment o f STI andnotification o fpartners get involved inHIVIAIDS persons Dangers o f stigmatizing persons livingwithHIVIAIDS :ontrol. A special module on (ii)Outreach (PLWHA) :ommunication and condom workers Importance o fa healthy life for PLWHA Isepromotion techniques Trainer: Epidemiological situation will be included. Educator (see 1.a) Communicationtechniques Promotionanduse o fcondom. 2. Broad Diseaseand syndrome n additionto the points nitial HIVIAIDS Concept o fhealthy carrier ientionedin 1above, a .aining: training Opportunistic diseases iodule will be introduced 0 days Type 2 Mode o ftransmission npsycho-social care, Protectionlpreventionmethods iter-personal . Lefresher Beneficiary: ommunication and ourse: Peer educators STI andtheir relationto HIVIAIDS Role o ftreatment o f STI andnotification o fpartners emonstration o f condom daylmonthl Dangers o fstigmatizing persons infectedwithHIV ear Importance o fa healthy life for PLWHA Epidemiological situation Communication techniques Promotionanduse o fcondoms including demonstration o f use Psycho-social care Inter-versonal communication and counseling 3. Broad Disease and syndrome [nadditionto the points [nitial HIVIAIDS Concept o fhealthy carrier nentionedin 1and2 raining: training Opportunistic diseases ibove, which will be 12 days + Type 3 Mode o ftransmission Furtherperfected, a module nternship Protectionlpreventionmethods 3 nadvanced counseling n Course nethods will be offered. iub-region: beneficiaq: STI and their relationwith HIIAIDS rrainingwill be I4days Counselors Role o ftreatment o f STI andnotification o fpartners Dangers ofstigmatizing persons infectedwithHIV supplementedby a *efreshercourse inthe iefresher Trainers Importance o f a healthy life for PLWHA Oegion. :ourse: Sub-contracted Epidemiological situation L days every institution Communication techniques Promotionanduse o fcondoms including demonstration o f l monthper use ,rear Psycho-socialcare DInter-personalcommunication and advanced counseling Inductioncourse inthe sub-region - 126- Le. Activity five: BuildingAwareness of ExternalClients Outreach workers trained by educators will buildthe awareness o f external clients o f the ministry. Two aspectso f the approach adopted are worth consideration: 1) variables specific to each ministry inrespect o f its functioning and which are not necessarily the same for all ministries (e.g. type o f external clients, ongoing awareness-building activity, etc); and 2) an approach which forms part o f the routine activities o f outreach workers with ministry external clients. HIV/AIDS related awareness campaigns organized one day per year will thus form part of the regular activities of outreach workers. There will be budgetary allocations for the five years to facilitate awareness-building activities. Each ministrywill therefore have to use these resources, depending on its specificity, according to the functional mode already adopted for ongoing similar activities. Ministry external clients will also be given information and continuing counseling by outreach workers as part o f their regular duties. Evaluation of the sound use of resources will thus depend on the numbero fexternal clientsreached, ontheir levelofknowledge of STIIHIV/AIDS and also on the number of sub-projects initiated and implemented (under Component 4 of the MACP) by such clients on account o fthe catalyst andpromotion education they have receivedthrough the approach. Type oftraining Course content Course objective Duration 1. Notions of HIVlAIDS (basic *Disease and syndrome This training course is 1 daylyear level) Concept of healthy carrier targeted at people with Beneficiary of sensitization: oopportunistic diseases very little knowledge o f ministry exteinal clients .Mode oftransmission HIVIAIDS. It aims to give ~~~i~~~~ for awareness-buildinq: Protectiodpreventionmethods basic information, arouse Outreachworkers as part o ftheir oEPidemiological Situation curiosity and prompt a regular activities desire to know more and to share information. 11. Standard activities inbuildingmanagement capacities(component 1) The study conducted on sector action plans has revealed a high level o f similarities among the capacity-building activities of the HIVlAIDS Control Sector Committee (CSLS). Furthermore, given the absence o f specific activities on monitoring and evaluation, such aspect should be included in the component. The following basic activities have therefore been included as part o f the action plans of the ministries concerned with component 1 ofthe project. - 127- Activity Target group Duration A. Monitoringand evaluation 1. Half-yearly meeting on experience with recommendations Designatedpersonnel 1day for the future 2. Quarterly meetingon programmonitoring, evaluation andCSLS members, Coordinator and sectod 1day management methods Irepresentative 3. Annual meeting on lessonsinspired bythe experience and CSLS; Coordinator; CSLS representative;/ 2 days withinCSLS planof activities for the fallowing year intemal and extemal clients- (total: 50 persons). B. Management of sector program 1.Recruitment o f a secretary oncontract CSLS Full-time 2. Recruitment ofa driverlmessenger on contract CSLS Full-time 3. Acquisition o f office fumiture, a computer unit (fix and Coordinator (acquisition at central level) laotod. 14WD vehicle 4. Internet access Coordinator Continuous 5, Runningexpenses: travel expenses, consumables, etc. CSLS + sector representative at regional Continuous level 6.Preparation o fannual progress report (national consultant) CSLS 15 dayslyear 7. Support for implementation o f action plan: specific area CSLS 2 monthslyear to be determined according to needs (national consultant) 111. Specificities of action plans of sector ministries The following tables summarize the key aspects specific to each o f the seven sector ministries excluding health. The plan is to finance, for each ministry, not only the usual activities such as training, awareness-raising andbuildingo f management capacities, as above described, but also specific activities under sector plans where there is a comparative advantage. e MinistryofCulture andIslamic Orientation (MCOI) 0 MinistryofNational Education(MEN) e MinistryofRuralDevelopment andthe Environment (MDRE) e Ministryo fNational Defense (MDN) e MinistryofPublic Service, Youths and Sports (MFPJS) 0 MinistryofCommunicationandRelationswithParliament (MCRP) e Secretariat o f State for Women's Affairs (SECF) For the Ministryof Health and Social Affairs, the standard training for its internal clients (the MOHSA's staff, i s similar to the other Ministries. Its specific activities are detailed inComponent 3 (see Annex 2). - 128- Ministry of Culture and Islamic Orientation(MCOI) Background: The MCOI oversees two separate sectors: culture (arts, heritage, documentation, etc.) and Islamic affair: (Islamic education, Imams, Mosques, etc.). Given the special nature o f its double mission, the MCOI is concerned no only with its own direct staff (civil servants and employees) but also with the general public through religiou pronouncements, the arts and theatre. For its HIV/AIDS control drive, the MCOI will take advantage o f the importan role played by Imams in sending messages to the public in general. The MCOI has the duty to build the awareness o religious leaders inthis field. Imams are approved by the ministry before assuming duty, and are subject to ministeria regulations. They are not State employees, but some o fthem receive a symbolic annual grant from MCOI, which plays i guideline role and is committed to undertaking lasting actions, an experience which could be extendedto other countries. The standard training and awareness-building program shall be fine-tuned to MCOI's special needs and religiousmission Considering the already established experience o f Imams in conveying messages, they will be given similar training ai outreach workers, educators and counselors, but specially adapted to the religious context. The plan is to have fou counselors represented byImams. The roles o fpeer educators andresource persons shall not be applicable to MCOI. Potential Targetgroups: a. intemal clients: 360 ministry civil servants andemployees; 3,000 Imams (560 Imams from Nouakchottt; 2,440 Imams at regional level); b. extemal clients: 1500 students from religious schools; 630 artists; 550 persons from associations and clubs; 10000 Oulemas andFaghih. Targetgroup within MAP context: C. intemal clients: all the 360 ministry civil servants andemployees; halfo fthe Imams, Le. 1500 Imams o fwhom 280 from Nouakchott and 1,220 from regional level through usual and specific MCOIactivities; d. extemal clients: at central andregionallevel: 1500 students from religious schools, 500 artists; 550 persons fron associationsandclubs; 10.000 Oulemas and Faghihthrough standard and specific MCOIactivities. e. Stop AIDS Personnel to be trained: 4 Counselors, 14Resource Persons, 40 Educators. MCOIspecific activities: a. Prevention: holdingo f advocacy seminars for the Grand Oulemas and LeamedPersons; holding o fmeetings withImamsonout-of-wedlock sexualrelationships; culturalparties onHIVIAIDS; awareness-buildingsessionfor the public inthe mosque; specializeddocuments inthe national and regional libraries; debates onthe HIVIAIDS theme on radio andTV; theatre and awareness campaigns; b. preparationand productiono finformation and teaching aids; publishing o fpreventionguides for Oulemas, Fighihand other members o f civil society; yearly giant concerts on the HIVIAIDS theme. I. Policies: holding ofmeetings devoted to the learning o finstrumentsrelatingto desired attitudes; holding o f :olloquiums for opinion leaders to teach them instruments relatingto desired attitudes; conferences to popularize instruments; d. Capacity-building: evaluationo f impact o fefforts madebythe culture sector: conduct o f studies and surveys ini bidto draft instruments and set up a data bank, training o fCSLSmembersinmanagement; conduct o fa survey to identif) :he culturalbases o f behaviors that constitute animpediment to AIDS control. lnitial capital and existingfacilities: 4n awareness seminar on the theme "Islam and HIVIAIDS"was organized in2001 with the participationo f40 Imams Eight other similar seminars were organized for 240 Imams. With the collaboration o f the NGO Stop SIDA, a trainini md communication handbook for religious leaders was prepared and tested. Some fatawas (Islamic law consultation were held on this issue. VAPbudget: About US$310,000 equivalent -129- Minktry of National Education (MEN Background: Given its mission, the Ministry o f National Education (MEN) has a prime role to play inthe Government' HIVIAIDS control drive. The education sector has to grapple with three types of problems, namely: vulnerability o students and teachers to HIVIAIDS; the tendency for HIVlAIDS to spread among teachers, especially those living fa from their families, and students including teenagers and young adults. Although there are no data on HIV prevalence ii the school milieu, HIViAIDS i s a real danger to the school system since it reduces the number o f both teachers anr students. MEN has several opportunities to identify Stop AIDS Personnel (SAPs). Teachers for example have the necessq teaching skills and can as such aptly play the role o f educators among SAPs. Secondary school students adequate\ represent youths ingeneral and young women inparticular inthe transmission o f STIiHIVIAIDS related messages. It i necessary to highlight personnel mobility, including SAPs educators. There is therefore need for these persons to bi settledinorder to better performtheir duty. Potential Targetgroups: a. internal clients (inyear 2003-04): a total ofabout 15,000 persons comprising: 344 administrative and support civil servants (central level); elementaryeducation: 9,600 teachers; secondary education: 2742 teachers and 1123 supervisors; higher education: 282 lecturers and 570 administrative staff; technical education: 213 trainers and 103 supervisors. b. external clients: about 255,000 persons: Elementary education: 40,600 6-grade pupils, secondary education: 80,000 students; higher education: 7,700 students; technical education: 1,850 students; 5,000 Parent-Teacher Associations (PTA) withabout 25 members each. Targetgroup within MAP context: C. internal clients: all personnel o fcentral offices (344); and about 113 o fall school staff (elementary, secondary, vocational training and higher education (4,900). d. external clients: about 75,000 comprised of: Elementaw education; half o f 6-grade pupils (20,000; secondary education; halfof secondary students (40,000); all higher education students (7,700); and halfo fthe PATSwith about 10 members per PTA. e. StoD AIDS Personnel to be trained :Peer educators: 120; vulgarisateurs: 60; resourcepersons: 66. MEN specific activities: a. Prevention: Inclusioninschool curricula o f a STLrHIVlAIDS module, productiono f teaching aids, introduction o fmodules and supports inschools, training o fteachers incharge o f introducingmodules and supports, monitoringand evaluation o fthe introduction o fmodules and supports at all levels (elementary, teacher training, generalsecondary, higher teacher training, technical education, CSET, university. b. Policies: Make the HIVIAIDS Control Sector Planpart o fthe MENannual activity program; foster effective collaboration betweenthe education sector and other stakeholders as part o fthe national and intemationalpartnership to combat HIVIAIDS inAfrica; promote the rights o fpersons infected withHIVIAIDS among teachers and students inorde to protect them against discrimination and exclusion. C. Capacity-building: Conducting a "CAP" study inschools; introduce a STIJHIVIAIDS component instudents' memoire; create a magazine on HIVIAIDS inschools, give assistancefor researchon the HIVlAIDS problem inschool; organize study trips for CSLS members, coordinator andCRLS sector representativeinthe sub-region; participate in intemational meetings onHIVIAIDS inschool (e.g. AIDS and migration). InitiaE capital and existingfacilities: Certain preventive activities were carried out, notably: introduction o f an AID module in Form 4 and Form 1 (AS) curriculums, holding of workshops on management and health education an nutrition for teachers and PTA; introductiono f STIIAIDS notions inelementary 6th year and TTC curriculums. Partner and main funding sources for AIDS control in the sector include UNFPA; WFP; FAO; World BankIADBIIDE WHOIUNAIDS; NGO (ADRA-M); PTA and professional associations. No survey has yet been conducted inthe fielc though the findings of the population and health survey o f 2001 reveal a STI prevalence rate o f 2.3 percent and 0. - 130- Ministry of Rural Development and theEnvironment (MDm) Background MDRE's mission consists in formulating, implementing, monitoring and evaluating rural development ani environmental protection and management policies adopted by Government. Inthe discharge o f its duties, MDRE relie on ministerial services and departments as well as on MDRE regional delegations which are in turn structured inti services. There are also several projects and project units under the ministry. One special aspect o f MDRE is that it ha grassroots extension workers who are particularlyvulnerable to HIVIAIDS hazards. Itmay also bementioned that MDRl gives access to coordination facilities (rural radio) and training structures (Centre National deRechercheAgronomique e de Dheloppeinent Agricole -CNRADA; Centre National d 'Elevage et de Recherche Y&rinaire -CNERV; Ecol National de Formation et de Vulgarisation Agricole -ENFVA ;Feme M'Pourik ;and other institutions (SONADER National Park o f Diawling ;Centred~pprov~ionnementdes Intrants de I'Elevage ;SocibtbNationale des Abattoirs d Nouakchott). There is also a wide network o fexperienced monitors and extension workers. MDRE offers a range o f opportunities for the identificationof "Alerte SIDA" Personnel (PAS), for example, grassroot extension workers can appropriately serve as outreach workers among PAS. MDRE coordination and training facilitie also make it possible to easily identify PAS personnel among people with basic knowledge o f teaching ant communication methods. Potential Targetgroups: a. intemal clients: at central level: total o f 1,705 persons, o fwhich 437 supervisory staff and 108 support staff; at regional level: 160persons (72 extensionworkers and 88 support staQ inthe Ministry,and 1,000 public establishment employees including training institutions. b. Extemal clients: about 120persons at the central level, working inthe offices o f 7 federations, 6 stockbreeders' association; 2 farmers associations, 10 cooperative unions, and 2 development projects; and about 15,000 persons at the regional levelworking in4,500 cooperatives, 295 community associations (natural resource management inrainfall areas and 192NGOsinvolvedwiththe environment and poverty alleviation),. Targetgroup within MAP context: C. intemal clients: at central level: all above mentioned. d. extemal clients: all above mentioned external clients. e. Stop AIDS Personnelto be trained : 1Counselor; 19Educators; 34 Peer Educators; 76 "Vulgarisateurs", and 3f Resource Persons. MRLIE specijic activities: a. Prevention: Produce and duplicate brochures and leaflets on STVHIVIAIDS to serve as teaching supports; prepare awareness-buildingtools the prevention and transmission o f STIII-IIVIAIDS adapted for use bynomad stockbreeders and farmers; hold inter-country meetings to raise the awarenesso f officials o fnomad stockbreeders to modes o fpreventing and transmitting STVHIVIAIDS; train outreachpersonnel insafety at work; design and distribute tools to raise the awareness o fpersonnel to the benefits of screening for AIDS for PAS and their clients; organize a weekly radio program on the need for voluntary screening (inassociationwithMCRP); promote responsible sexual behavior amongMDREstaff, especially among extension workers through PAS duties; distribute 10.000 condoms to MDREstaff. b. Policies: Popularize the rightsand instrumentso fPLAVinthe work setting (inassociationwithMFPJS). C. Capacity-building: Conduct a "CAP" study on perceptions o fAIDS amongMDREstaff; study trips for 3 CSLS members and coordinator to trade experiences incountries o fthe sub-region. Initial cavital and existinp facilities: No HIVi'AIDS controlrelatedactivity has beenorganizedto date. MAP budget: about US$430,000 equivalent - 131- I Armed and Security Forces (FAS) Background: The Armed and Security Forces are considered to be the total o f servicemen, gendarme officers, guards an1 police officers working interritorial command units, in specialized services and police stations. They also include civilia personnel serving invarious services inministries (MDN and Ministry o f the Interior). They comprise the National Arm) the National Gendarmerie, the National Guard, the Directorate General for National Security (DGSN, police) and th Directorate o f Civil Protection (DPC). These categories o f staff are vulnerable to infection by the nature o f their duties mobility, young age, separation o f couples; low awareness o f condom use; tattooing, unprotected sexual relations Healthwise, the Armed ForcesHealth Service covers the National Gendarmerie andthe National Army, while the Nationz Guard and DGSN each have their own health service. The Army has a military hospital in Nouakchott, 19 garriso infirmaries and several secondary health posts including two mobile posts for the nomadic squads (meharists). The polic has 7 health centers and the National Guard 6 health facilities, Healthpersonnel includes 35 medical officers, pharmacist and dentists, and about 400 nurses. N o study has so far beenconductedto determine the HIV prevalence rate. The FAS has a range o fopportunities to identify Stop AIDS personnel. FAS assetsincludepeer assistant and its experienc acquired through campaigns targeted on uniformed personnel. With its action plan, FAS will make sure young girls (3C are well represented as educators both at central level and inthe 4 regional camps for couples. The planis that initially, th number o fpersons inproject target groups will be adjustedproportionately to the budget. Activities targeting other group could be funded from other sources (e.g. Global Fund). Potential Targetgroups: a. internal clients: about 80,000 persons from the army, guard, police, gendarmerie, fire brigade and civilian personnel, including 200 highlyranked officers and480 personnel incamps for married staff. b. Externalclients: about 300,000 persons from (FAS) families and their associations, PLWHA. I Targetgroup within MAP context: a. internal clients: 48000 persons, that is, 60 percent o fthe above internal clients ; b. external clients: 26000 persons, that is, 10percent o fthe above external clients. C. Stoo AIDS Personnel to be trained :400 peer educators; 930 "vulgarisateurs"/"voltigeurs"; 1,090 Resource Persons. FAS spec@ activities: a. Prevention: Prepare andpublish a handbook on STIIAIDS; design andpublishmodules on STVHIVIAIDS for FAS centers and schools; provide all FAS facilities with condoms; systematically screen all recruits for HIVJAIDS; provide the military hospitalwitha blood bank andmedical consumables; provide the facilities concernedwithprotection and disinfection equipment; produce FAS specific supports; set upFAS monitoring centers; set up a voluntary anonymous STIMIVIATDS screening andtreatment center (Nouakchott); b. Treatment and social protection: Organize home visits for PLWHA; give PLWHA andaffectedpersons material support; boost STI care at boundaryposts; supply ARV and STUOI essential drugs; C. Capacity-building: Organize two 2nd generation epidemiological surveys (2004 to 2008); organize training workshops for medical officers on medical care o finfectedpersons; train laboratory technicians inscreening and STIMIV reinforce the capacities o fthe 4 laboratories inNouakchott with STI detection equipment; supply health facilities with notification supports, forms, registers, etc; supply laboratories with STIMIV reagents andproducts; set up 4 community-basedbodies. Initial capital and existing tools: Monitoring o fscreening at the military hospital and duringrecruitment has revealedvery rapid spread o fthe HIV infectioi 2000: 1.42 percent; 2001: 2.22 percent; 2002: 4 percent. One out o f five servicemen has an STI, particularly hepatitis ' (16.2 percent prevalence rate). About 400 peer educators have already been trained in2003 inNouakchott and a handboa on "Services for Uniformed Officers: Initiative o fHIVIAIDS Care Providers" has beendeveloped (September 2002). MAPbudget: aboutUS$460,000. - 132- Minktry of PublicService, Youthand SportsWFPJS) Back.wound The Ministry o fPublic Service, Youth and Sports overseestwo separate sectors: the public service (general regulations o fthe public service and implementationthereof, management o fcivil servants, auxiliary State employees and foreign contract workers, general labor policy and implementation thereof) and youth and sports (formulation anc implementation o f national policy on youth and sports). Given this double mission, the ministry in its HIVlAIDE sensitizationltraining drive has to address not only its direct staff (civil servants and employees) as well as public civil servants in general but also the youths who make up 50 percent o fthe population ingeneral, and sports meninparticular The sportsmen are mostly single and highly mobile, with the tendency to migrate towards other countries in the sub-region, constituting vulnerable groups to the HIV/AIDS hazards. With its youth intake facilities, MFPJS offers opportunities for these vulnerable groups to serve as supports to combai STI/HIV/AIDS. The ministry can also use sports events to effectively convey messages. The key facilities o f MFPJE include 25 youth centers, 7 vocational training centers, 1youth training center and sports stadiums. MFPJS has wide chances to identify SAP,s for example, the youth (young girls and men), sportsmen and members 0: ports associations make it possible for youths in general and young women in particular to be well represented in thi conveying o f STI/HP?/AIDS control messages. Potential Targetgroups: a. intemal clients: total 2,500 civil servants, including 700 administrative staffand 800 technical and support staff at the central level and 100 staff inthe regions, andpublic establishments including the CaisseNationale de Skcuritk Sociale, the Olympic Complex Authority, ENA, 7 vocational training centers, andYouth Centers (one ineach region); b. Extemalclients: all sportsmen; members o fassociations (e.g. scouts in 13 Wilayas, sports women, youths); professionalorganizations and federations; workers' familymembers. Target group withinMAP context: a. intemal clients: 1,500 civil servants at the central level and 160 inthe regions. b. external clients: 50,000 young persons (<20 years) including: sportsmen, members o fassociations (e.g. scouts ir 13 Wilayas, sportsmen, youth) professional organizations and federations; 1000persons from MFPJS workers' families. C. Stov AIDS Personnelto be trained :2 Counselors; 15 Educators; 25 Peer-Educators; 25 "Vulgaxkateurs"; 50 ResourcePersons. MFPJS specificactivities: a. Prevention: Preparation o fbillboardsandstickers on STVHIVlAIDS targeted on internal clients; survey o f condomperception byministry personnel; survey o f sexual behavior o fyouths; organization o fa "compac" for youths (3( million: other fundingsources); provisiono fcondoms to counseling and monitoringcenters; cultural and sports activities to rally youths and sportsmen behindthe STVHIVlAIDS control drive; awareness-building campaigns, equipment of medical sports center; contest on condom use amongyouths. b. Policies: Create conducive work conditions for PLAV; prepare instruments relatingto protection o fpatients and PLAV; conduct a study onthe puttinginplace o fanassistance and integration fund, its hnctioning and sustainability, foi public sector workers. Initial capital and existingtools: Several HIV/AIDS awareness activities have been camed out to date, chief among which are: a survey o f youths ani parents on the needs and desires o f youths (1994); 13 regional week activities on AIDS with the distribution o f 120r "savoir pour savoir" (knowing to know) booklets (1995); three cultural days on AIDS (1998, 1999, 2002); trainin; workshop for directors o fyouth centers on STVHIVlAIDS prevention. MAP budget: about US$500,000 equivalent. -133- Ministry of CommunicationandRelations withParliament(MCRP) Background: MCRP's mission consists in formulating and implementing national policy on information and communication, and monitoring relations between the various government services and the two chambers of parliament: the Senate and the National Assembly. The Minister is government spokesman and is member o f the National HIVIAIDS Control Committee (CNLS). Apart from ministry services, MCRP supervises the Mauritanian Information Agency (AMI), Radio Mauritania (RM), Mauritanian television (TVM) and the National Printing Press (IN).Atregionalandlocallevel, MCRPhas 12regionaloffices affiliatedwithAMI, aregionalradio stationand4local radio stations controlledby RMwith assistance from the IntegratedCommunication Poles (PCI). MCRPpersonnel comprise mainlyjournalists, communicators and communication technicians who, bythe very nature o f their profession and the duties assigned them by their media employers, are required to inform and sensitize the general public about various development-related issues, including HIVIAIDS. MCRP therefore has a major role to play in HIVIAIDS control not only in conveying messages, but also on account o f its relations with members of parliament whom it can actively involve inHIVIAIDS control. MCRPpersonnel are particularly vulnerable because 75 percentofmediaworkers are young people under 30 years, who are very mobile on account o ftheirjobs. MCRP should not face any problem in identifylng `Wo to AIDS Personnel" (PNAS) on account o f its skills already acquired through communication and information techniques. In this respect, journalists, communicators and communication technicians constitute a precious asset. An added information access opportunity comes from the Integrated Communication Poles whose duty is to conduct inter-personal communication activities in support o f the communication drive carried out by radio stations at the grassroots to sensitize the people to local development issues Furthermore, because o f its supportive association with the PCI and the networks o f journalists and communicators, MCRP can play the role o f catalyst and promoter. It can guide its units to gain access to the funds allocated under the civil society component. Potentia2Targetgroups: a. internal clients: at central level: a total o f 1,400 civil servants, with 800 supervisory staff and 600 support staff, including the ministry, TV, national radio, rural radios andprintingpress; at regional level: 400 civil servants with300administrative staffand 100supportstaff; b. extemal clients: the entire population: 2.5 million people; PCI (9 towns inthe country including4 regional capitals); networks of developmentjournalists and communicators; private media; members o fparliament. Targetgroup within MAP context: a. internal clients: halfo fthe above internal clients. b. external clients: 687 persons from the central level; networks o f development journalists and communicators (100); private media (300) andmembers o fparliament (137); at regional level: PCI(150). C, Stou AIDS Personnel to be trained : 1Counselors; 2 Educators; 3 "Vulgarisateurs"; 14Peer-Educators; 14 Resource Persons MCRP specific activities: a. Prevention: Prepare messages; produce educational supports; conduct media campaign onTVM, caravans on rural TV; spot, sketchreports; serial reports; brochures, folders; articles, reports; duplicate writtenvisual supports; radio campaigns; HIV/AIDS control campaigns withprivate newspapers. b. Policies: Development o fa communication strategy (withassistancefrom a communication expert-consultant recruitedunder the PPF project). Initial capital and existing tools: Existence o f a select group o fjournalists who have been trained inthe field o fHIVIAIDS control. Experience acquirec byvarious ministrystakeholders inthe productiono f STIiIlIVlAIDS educational supports. MAP budget: about US$320,000 equivalent. - 134- Secretariatof Statefor Women'sAffairs {SECF) Backrrround: SECF is in charge o f advancing the cause o f women, ensuring their full participation in economic and social development and fostering the safeguard o fthe family and the welfare o f children. Inthis respect, and intune withHIVIAIDS control, SECFhasamajorrole to playinthe MauritanianGovernment's efforts to get the National HIVIAIDS Control Strategy Framework underway. SECF will thus, through awareness-building activities and the involvement o f women and children in its facilities, make sure they are protected against transmission risks. SECF will also guide NGOs and associations, and sensitize them to the problem o f STIMIVIAIDS affecting their clients. Inidentifymg "No to AIDS Personnel" (PNAS) for routine training and awareness activities, SECF should take into account the need for women and young girls to be well represented in order to make it easy to convey STID-IIVIAIDS-related messages to internal and especially external clients. It should envisage involving 1,700 female monitors as "Vulgarisateurs" as well as 80 percent o f the 2,000 women's cooperatives that have contact withthe SECF, onthe basis ofone womanper cooperative, Potential Targetgroups: a. intemal clients: 380 civil servants o fthe ministry (central and regional level), including ministry services, the Information and Documentation Centre onWomen, the Familyand Children, the 16 training centres for the advancement o fwomen (4 at Nouakchott and 1ineach o fthe 12regions). b. external clients: 5,000 female genital cutting (FGC); about 280,000 persons representing the following groups: householdheads; 12,500 women's cooperatives; (100,000) women affiliated to the nine Nissa Banque; 8 savings-and-loans groups in 17 divisions from 6 regions o fthe country; women affiliated with socio-professional groups (80,000), traders, Gorgol women's bank, andassociations o fmother educators; (32,000) women affiliatedwithwomen's micro-credit networks and CNC, AGRlliteracy (5,000) and artisanal fishing (500), 79 nurseryschools (12 ownedbygovernment and67 private onesmanaged byNGOs. Targetgroup within MAP context: a. internal clients: 100percentministry civil servants. b. external clients: 50,000 women (component will help increase the number o f women targeted). C. Stor, AIDS Personnelto be trained : 1Counselors; 7 Educators; 7 Peer-Educators; 7 Resource Persons; 1,700 "Vulgarisateurs". SEW spec@ activities: a. Prevention: Campaigns to building-awarenesso fwomen o fchild-bearing age andmothersto the dangers o fgivingbirthat home and o f FGC, radio programs on STIlllIVIAIDS targeted on women; creation o f information booths at regional branch level, including Nouakchott; b. Policies: Inclusiono fthe STIlllIVIAIDS dimension inthe National Advancement o f Women Strategy 2003-2007; C. Capacity-building: Conduct o fa study on reproductive health for young girls aged 10-14 years; study on socio-cultural behaviors conducive to HIVIAIDS control. initial capital and existing tools: Identification o f key indicators through surveys: Survey o f HIV prevalence among pregnant women, 2002. Population and health survey, 2000-01. Kev indicators: HIV prevalence rate among pregnant women: 0.57 percent; Births out o f health facilities; 51 percent; Birthsat home (rural areas): 77 percent; FGC: 71 percent. MAP budget: about US$440,000 equivalent - 135- AdditionalAnnex 14 Project ImplementationArrangements MAURITANIA MULTISECTOR HIV/ADSCONTROL PROJECT General structure of institutional arrangements The general structure o f project institutional arrangements i s perfectly consistent with the National Strategy Framework document adopted inAugust 2002, and includes: e the NationalHIV/AIDSControl Committee (CNLS); e the NationalHIVlAIDS Control Executive Secretariat (SENLS); Regional HIVlAIDS Control Committees; e Regional HIVIAIDSControl Executive Secretariats; e sector ministries; e "Projects"; e the corporate private sector; e NGOs; e Community-Based Organizations (CBOs). The respective roles o f these organs andtheir relations with the other partners o f the private and public sectors andcivil society are as follows. National HIV/AIDS Control Committee (CNLS). The CNLS is responsible for combatingHJY/AIDS inMauritania. Itcoordinates strategy andpolicy, advocacy, resource mobilization for implementingthe National Strategy Framework for HIV/AIDS control (CSNLS), and supervises the execution o f the national HIV/AIDS control multisectoral program, and inparticular, the PMLS (Multisectoral HIV/AIDS Control Project) financed by IDA, The draft decree defines these missions clearly. For this reason, the CNLS i s responsible for: (a) supervising the development, approval and review o f the national strategy and the action plan, includingthe preparation o f the IDA-financed PMSS project; (b) laying down the policies necessary for strategy implementation, (c) examining and approving annual plans o f action and budgets; (d) monitoring andevaluating the progress made inprogram implementation; and (e) playinga central role in combating the HIV/AIDS epidemic. With regard to the IDA-financed PMLS, the CNLS is responsible for: (i) approving the project document and procedures manual as well as for reviewing them periodically; (ii) approving sectoral plans o f action; (iii) monitoring and evaluating the progress made inproject implementation; (iv) evaluating, with development partners (inparticular, IDA), during annual program reviews, achievements o f the previous year's action planandapproving the plan for the coming year. The CNLS is assisted by the SENLS (see below). The Procedures Manual under preparation will specify the practicalmodalities for CNLS's performance o fits duties. Judging by the number o f its members, the CNLS i s a rather unwieldy committee. To ease its work during the period between general meetings, as well as to ensure regular liaisonbetween the CNLS and the SENLS and its external partners, the CNLS, will appoint a Restricted National HIVlAIDS Control Committee (CNRTS) o f 8 members, also chaired by the Prime Minister and comprising 3 other Ministers, 1representative o f the private sector, 2 representatives o f Civil Society and 1representative o f the ONUSIDA Thematic Group. National Executive secretariat. The duties o f the National HIV/AIDS Control Executive Secretariat (SENLS) may be summarized as follows: (a) assist the CNLS and provide it with secretarial services; (b) follow up and coordinate all activities in Mauritania relating to HIV/AIDS, as well as compiling - 136- information on these activities andon HIVlAIDS prevalence trends inthat country; (c) manageresources -under the authority o f the CNLS, in particular, the 2 special accounts (CS): (i) first CS for the financing Non-health Sector Action Plans ; consultant services relating to the execution of the above-mentioned activities; the award o f contracts for construction works and supply o f goods and services; for training and capacity building; coordination o f IECICBC; Monitoring and Evaluation; research, and inparticular, operational research; and the fmancial and accounting information system, quality control and audits; and (ii) second CS for financing private sector and Civil Society the Initiatives; (e) ensure that all partners comply with the Procedures Manual. The list o f SENLS experts working under the Executive Secretary i s as follows: 0 Assistant Executive SecretarylCoordinator o f Civil Society Initiatives; 0 Coordinator o f Sector MinistryAction Plans; 0 Capacity BuildingandTraining Specialist; 0 Information, Education and Communication (IEC) and Communication for Behavioral Change (CBC) Specialist; Monitoring& Evaluation (M&E) Specialist 0 Specialist inPublic Procurement Contracts, Specialist inFinancial Management and Accounting, and accounting staff. Regional HIVIAIDS Control Committees (CRLS). CRLS are provided for in the National Strategy Framework. Ineach region, a Regional HIVIAIDS Control Committee (CRLS) will be set up according to the CNLS format: under the chairmanship o f the Wuli, the members shall be: (i) regional representatives o f sector ministries, (ii) locally-elected officials, (iii) private sector representatives active in the area, (iv) representatives of local religious organizations, (v) representatives of NGOslCBOs operating in the area, (vi) representatives o f the regional association o f people living with HIVlAIDS. The duties o f the CRLS will be as follows: (a) coordinating, at the regional level, the sectoral action plans o fthe various sectors involved inthe national plan; (b) approving sub-projects submittedbyLocal Communities, local NGOs and CBOs, on the basis of eligibility criteria contained in the Procedures Manual, for their financing by the PMLS; (c) monitoring andevaluating progress incombating AIDS in the area -- including regional activities o f sectoral plans andcivil society sub-projects inthe area -based on performance indicators. CRLS will be assisted in their work by a Regional HIVIAIDS Control Executive Secretariat . RegionalHIVIAIDS Control Executive Secretariats (SERLS). To facilitate effective implementation of the project at the regional level, it was agreed that each Regional HIVlAIDS Control Committee will be assisted by a SERLS, which will perform the following duties: (a) assist the CRLS and provide it with secretarial services; (b) monitor all HIVIAIDS-related activities at the regional level and, in particular, regional activities of various sectoral plans and sub-projects of civil society and compile regional information on these activities and on HIVlAIDS prevalence trends in the area; (c) manage funds inRegional Accounts earmarked for financing civil society sub-projects; (d) ensureprovision of the required assistance to civil society organizations in the execution o f their sub-projects; (d) ensure that all the partners in the area comply with the requirements o f the Procedures Manual. The composition o f SERLS shallbe as follows: 0 a Regional Executive Secretary, accountable to the National Executive Secretary, who shall managethe regional team andbe responsible for executingthe mandate o f SERLS; 0 a regional accountant, incharge ofthe Regional Account, placedunder the Financial Specialist o f SENLS, 0 a regional public procurements specialist, placed under the SENLS Public Procurements Specialist, responsible for providing technical support to NGOs and CBOs in the award o f Community-based contracts. - 137- Non-Health Sector ministries. They are responsible for preparing and implementing Sectoral Action Plans. That i s the condition and the guarantee for real ownership o f the HIVI'AIDS control effort at the sectoral level, which i s the purpose o f the multisectoral approach, To that end, the following provisions are envisaged: (i) Fundingagreement.SectoralActionPlansthathavebeenfinalized,quantifiedandphasedinan annual schedule, will be the subject o f a funding agreement between each Ministry concerned and the SENLS. Under the terms o f the Convention, the Ministry shall pledge to carry out activities defined in the plan o f action, while SENLS shall pledge to finance the plan by sections, each o f which will correspond to a number o f physical objectives to be attained (number o f persons trained or quantities o f IEC materials distributed, for example). The relevant Ministry will be responsible for all Convention implementation tasks, including, where its capacity so permits, financial management and awarding contracts for the supply o f goods and services stipulated inthe Convention, while SENLS will disburse payments for the sections o f the Convention and monitor the execution o f the Ministry's commitments under the Convention. The Convention will include: (i) the plan o f action, (ii) contracts award plan, a (iii)a list ofperformance indicators for the implementation, and(iv) a payments schedule ofthe Convention. (ii) Role of Departments and Coordinators of Non-Health sector responses. Experience has shown that, ina ministry, HIVI'AIDScontrol is not the business o f one department or the other, nor is it a separate activity from the other activities o f the Ministry.Rather, each department has a role to play in executing a sectoral HIVIAIDS control plan. Therefore, plans o f action must clearly define, for each action to be carried out, which d e p m e n t or organ o f the ministrywill be assigned the execution o f that action. This cannot be left to the Coordinator, whose only duty will be that o f coordinating the other officials. The mission noted that, inall ministries (excluding the Ministry o f Health), the function o f the Focal Point or Coordinator was assigned to a highofficial inthe ministry,to be heldconcurrently with his other duties. It drew the attention o f the authorities to the fact that the function o f Coordinator is a full-time function That already holds true for the preparation o f the project, and will be the more so for its implementation. The Prime Minister gave assurances that this concem will be taken into account. The Coordinator should be attached to the Minister's Cabinet. The group o f all coordinators o f the Ministries (including that o f the Ministry o f Health) should constitute, with the Executive Secretary, a working party which meetsregularly to finalize the preparation o fplans o f action (components 2 and 3 o f the project) and, later on, to coordinate andfollow up their implementation. (iii) Responsibilitiesforfinancialmanagementandprocurement. TheexecutionofConventions will involve transferring SENLS resourcesto each Government ministrywhich will have to cany out the Sectoral Plan o f Action which i s the subject o f the Convention. Two scenarios are possible: (a) the relevant ministry already has the capacity and experience to manage external funds, in particular, IDA funds. Inthat case, the missionexpressly recommendedthat the Ministryusesthis capacity for managing the funds o f the Convention. This could be, for example, "projects" like the DPEF for MEN, the Nutricomproject for SECF. Inthat case, the "project" would ensure for the relevant Ministrya financial management service. Ifnecessary, the capacity o f the project unit could be strengthened to take on the additional workload. This solution makes it possible to refrain from buildinga second capacity where one already exists. Then, the relevant ministry would be totally incharge o fprocurements related to the Convention; (b) the ministrylacks the capacity or experience to manage external funds. Inthat case, the mission recommended that its finance department be strengthened for the purpose o f handling expenditure relatingto the Plano f Action, up to a ceilingabove which the SENLS would act on behalf o f the Ministry. - 138- Health sector. The Ministry o f Health i s responsible for preparing and implementing the Health Sectoral Plano fAction. Inthat regard, the following provisions were discussedand agreedupon: (i) Special account. It was agreed that the MSAS should have a special account for financing expenditure relating to component 3, for the following reasons: (i) the strategically important role o f the MSAS in the HrV/AIDS control program; (ii) the high level o f financial requirements for the Health sector's response; (iii) the capacity o f the DGI o f MSAS to manage external funds, and (iv) the importance of integrating the PMLS financing for the Health sector response to HIV/AIDS into the sectoral approach developedbythe MSASwithin the POAS framework. (ii) FocalPointlCoordinationoftheHealthsector. The accepted organizational arrangement concerning the implementation o f the plan o f action i s an "integrated" approach, in which each department i s responsible for its own part o f the program, with a light coordination structure (coordination unit).Thus, the Health sector response inHIV/AIDS control would be implementedby the MSAS in an "integrated" manner, following a horizontal approach which integrates all MSAS departments inHIV/AIDS control efforts, byusingtheir specific capacities. This would make it possible to avoid creating a "vertical" program for HIV/AIDS control, with the traditional disadvantages o f this type o f approach: duplication between Services and Programs; transfer o f qualified personnel from departments to program coordinationunits, which weakens the departments responsible for actions. Each department and institution i s thus fully responsible for its part o f the Plan o f Action and is prepared to execute it. According to this scenario, coordinationwill be light: an official reporting to the Minister's Cabinet, who will be assistedby support staff and will have a budget. The coordinator will be responsible for: (i) monitoring the performances o f various components o f the sectoral plan, (ii) and liaising mobilizingthe various actors, (iii) with SENLS, (iv) providing the Ministerwith all information liaising necessary on progress o f the sectoral plano f action, (v) conducting the necessary studies and research. At the regional level, it was proposed that each Regional Department shouldhave a regional coordinator to ensurethe "integrates' implementationo fthe program at that level, under the supervision o fthe DR. "Projects". Several projects have a "community-driven development" approach (CDD) or development initiated at the grassroots level, such as SECF's Nutricom project or MDRs Natural Resource Management Project (PGRN) for rural communities, both o f which are financed by IDA, or CDHLCPI's "T'wizb" program for urban grassroots communities. These projects can be used as effective channels to reach grasroots communities, to inform and mobilize them with a view to giving them access to MPLS funds to finance community HIV/AIDS control sub-projects, and to provide technical assistanceto communities andensuremonitoringlevaluation tasks for sub-projects implemented by communities. To that end, it is possible to consider funding agreements between SENLS and the projects (component 2.2), along the same lines as those which govern the links between SENLS andthe public sector (component 2.1). The corporate private sector. The missionjudged that the most effective channel to reach the private sector was through employers' unions which are organized by sector. The Secretary-General o f the National Confederation o f Employers o f Mauritania proposed that all Federations, and key industrial sectorpartners come together to discuss the HrV/AIDS problemandreach agreement on a plano f action. Following these meetings, a strategic plan will be developed to allocate resources to support their individual andor collective initiatives. Major NGOs.Major NGOs (category A according to the survey) would be able to submit to the national level proposals whose scope goes beyond the regional level. Inthat case, they will submit proposals for - 139- sub-projects in accordancewith the Procedures Manual for financing civil society initiatives. They also will act as service providers for SENLS. In that connection, they could be selected as Consultants following competition. They could also be used as supervisors for the budding local NGOslCBOs in designingandplanning activities to be carried out. Local NGOs and CBOs. Small NGOs and CBOs will forward sub-projects to access PMLS resources to finance grassroots HIVlAIDS control activities. These NGOlCBOs will be responsible for implementing their sub-projects, includingmanaging the funds placed at their disposal for the execution o f sub-project activities, as well as the award o f contracts for the acquisition o f goods and servicesunder the sub-project. The procedure for preparing, submitting, evaluating, financing, implementing, reporting, monitoring and evaluating sub-projects will be described in detail in the Project Procedures Manual for Civil Society Initiative component. To facilitate access to PMLS funds and speed up disbursements to local communities and NGOs, the system will be decentralized to the regional level. The sub-project cycle is summarized as follows: SENLS and SERLS shall use all possible channels, including contracting the provision o f information services to inform communities about project benefits, including standard submission documents for sub-projects; interested local CBOs or NGOs, which may be assisted by a support NGO, are responsible for preparing and submitting sub-projects; a technical evaluation committee coordinated by SERLS will be responsible for the technical evaluationo f sub-projects; the Regional HlVlAIDS Control Committee (CRLS) shall approve sub-projects, following eligibility criteria; the SENLS and CBOsINGOS concerned shall signature the funding agreement o f sub-projects approved by the CRLS; the agreement will contain the sub-project objectives, activities, costs and ,schedule, links model, as well as objective and measurableindicators o fperformance; local CBOsfNGOs concerned, signatories to sub-project agreements, will be responsible for implementing sub-projects, including managing subvention funds for financing activitiesunderthe sub-project andawarding contracts; SERLS will finance sub-projects, by successive disbursements on the basis o f supporting documents on the advancement o fthe sub-project; the NGOslCBOs concerned will provide evidence o f the advance of progress in the execution o f sub-projects, on the basis o f performance indicators stipulated in the sub-project agreement; the CNLS will monitor andevaluate sub-projects usingM&Eoperators on contract. Regionalaccounts. Financialflows to civil society will be characterized by a large number o f sub-projects for financing, each o fwhich will require a small amount o f funds and these sub-projects will be spreadover the entire country. This configuration requires a degree o f decentralization inmanaging -140- financial flows. The CS2 funds managedby SENLS will replenish Regional Accounts managedby RegionalExecutive Secretariats for HIVlAIDS control (SERLS), These accounts will be replenished throughfundadvancesto cover estimated costs ofactivities over periods of 3 to 4 months, andwill be usedto finance sub-projects proposed by civil society organizations approved bythe CRLS. Sub-projects will be fmancedbyinstalments, on the basis o fjustificationof"results" rather than onjustification of transactions. More than for the sectoral plans, this approach will require a significant effort infinancial supervision which couldbe ensured fkomthe level of SENLS and SEES. - 141- AdditionalAnnex 15 CapacityBuildingof Communities,CBOs and NGOs: The GrassrootsManagementTraining(GMT) MAURITANIA MULTISECTORHlVlAlDSCONTROL PROJECT Generalinformationon GMT. GMT is a training methodology developedby the World BankInstitute (WBI) andthe country partners since 1990 through pilotprojects mainly inAfrica. The goal of the pilot program was to strengthen the management and marketing capabilities o f poor rural women and their counterpart in the formal urban sector, taking into account their current illiteracy level. Over five years, women from six developing countries (Burkina Faso, Nigeria, Malawi, Tanzania, Senegal and India) participated and developed the GMT program. The topics that are addressedinthe GMT include: human resource management, financial management, micro-project management, credit management, and marketing. GMT programs are often linked with literacy and health programs as will be the case in the Mauritanian MAP. As a training methodology, GMT targets communities andNGOs with a participatory approach. The curriculum reflects the reality o f life, the opportunities and the constraints that the communities face in their businesses. GMT trainers do not lecture; they provide case studies, ask for questions and facilitate the discussions among participants, assuming that by sharing their experiences, and drawing out from their knowledge, participants will find better solutions to the problems they are facing, Then, the facilitator can provide information and some theoretical inputs. GMT i s adapted to illiterate communities and is also designed to take gender dimensions into account by determining how, when, and where training delivery and follow-up have to be organized to ensure that women will not be excluded and increase their participation. The training material i s developed on the basis o f a local Training Needs Assessment (TNA) and is designed to address the specific problems and needs in each type o f community. The training material i s gender-sensitive and it offers training in local languages, using drawings, figurines, films, role plays, dramas, andproverbs. GMT assumes no literacy and no numeric skills. Specific modules can be based on topics such as Hlv/AIDS and Female Genital cutting, other modules are oriented to community-based decisionmaking, financial management, or community-base procurement. There are good reasonsto apply the GMT approach to this project. The evaluation o f GMT initiatives in Africa and in India has proven that it made an impact on the lives o f those who benefited from GMT projects. It has helped to improve team work inlocal groups andto have a better division o f work, make better business decisions, select and manage their activities in a better way, runtheir collective projects with more transparency, increase their incomes and savings, develop self-esteem and raise the social status o f women in the community, improve their living conditions and assume better control o f their lives. GMT is expected to buildthe requested capacity o f CBOs for a full benefit of the Component 4 o f the MACP. GMT principles. The GMT approach is based on: (i) participation: training needs identification, evaluation and translation into training programs and modules are executed with the effective participation o f all stakeholders: grassroots population, Junior and Senior trainers as well as national program managers; (ii) ownership : all stakeholders have some responsibilities; (iii) experience : the methodology andthe problem-solving techniques are based on beneficiaries' knowledge andexperiences; (iv) bottom-up c~mmunication:prior to their implementation, all activities are expressed, analyzed, and prepared by grassroots population; (v) adult-spec~ctraining cycle; (vi) multisec~oralapproach ;(vii) a~aptationof existing training materials prior to their use innew sites. - 142- GMT role inthe MACP. Grassroots-level communities (CBOs andlocalNGOs) are expectedto play a key role inthe fight against HIVIAIDS for reasons detailed in sub-component 4.2: ExpandCivil Society Organization Initiatives regarding HIVIAIDS. However, their capacity is weak, as assessed inthe social assessment (see Annex 11) andthe NGOassessment (see Annex 12). Buildinglenhancing capacity o f the grassroots level organizations o f the civil society is the objective o f sub-component 1.4: Institutional Capacity Buildingo f Communities, CBOs and NGOs for HIVIAIDS responses. For reasons explained above, GMT was selected as the preferred approach to build the grassroots level CSO's capacity under this sub-component. Assessment of current training practices. Duringproject preparation, an assessment of the ongoing initiatives to train communities was carried out. Meetings were held with various NGO networks and intemational organizations, which conclusions are the following: (i) illiteracy is considered a major handicap for training institutions when they intend to select grassroots trainers in villages or urban suburbs for IEC activities; (ii) illiteracy is a major obstacle for targeted audiences to understand the documentation proposed to them by trainers. According to an international institution operating in the area of HIVIAIDS, dynamic people or groups are generally the only ones to be effectively reached by activities targeting grassroots communities, leaving the others out o f the reach o f the information, and consequently reducing their chance to participate to development activities including HIVIAIDS. It is therefore necessary to help these less-dynamic peoplelgroups to enhance their capacity to become dynamic ones. This is one o f the main objectives o f GMT which has designed its methodology and training tools for this purpose. The assessmentreveals that institutions operating inthe area o f HIVIAIDS generally use techniques with limitedparticipatory content which are not conducive to general public and more specifically illiterate groups. Traditional knowledge o f targeted population i s often not considered as a training resources. Illustrations centrally designed are used as training support regardless the geographic location where they are used. By contrast, the GMT uses training techniques that are familiar to the trainees, androotedintheir cultural heritage (stories, songs, sketches, etc.). Buildingon existingFGBcapacities: Status ofFGBinMauritania. Existing Human Resources. Mauritania has participated to almost all training-of-trainers workshops organized by WBI. Overall, 15 persons have benefited o f these training sessions and apply the acquired skills in their work, in "projects", in NGOs, or in the public service. In addition, Mauritania sent representatives to the workshop regarding N the design and appraisal o f GMT-Project preparation and appraisal )>held inWashington DC in May 1998. As a follow-up to the training-of-trainers workshop in Rabat (February 1997), the Mauritanian participants created a GMT Group to: (i) promote and disseminate the GMT approach; (ii) test and adapt what they learned during the training; (iii) provide information about existing experience; (iv) act as communication relay for WBI and the other networks (in West and North Africa); (v) organize training-of-trainers sessions to increase the number o f the participants to the GMT Group. Information and sensitization activities have been carried out by the Group towards potential clients or partners, such as the institutions where the GMT Group members work, the World Bank country office, UNICEF, SECF, CDHILCP, etc. The GMT Group has organized trainingsessions inthe Guidimakha, Hodh and Nouakchott regions, with financing from GRDR, AFVP, GTZ and UNICEF, through which a total o f 42 persons were trained in the regions. Other training sessions were organized in various structures, leading to an estimate o f about 60 trained across the country. Training Modules. Several modules have been developed on various themes such as : drinking-fountain management, village-based store management, dyeing, community-based management o f saving and credit, cattle-feeding, cereal-bank, andfinancial management. SomeNGOs andgovernmental institutions - 143- e have adapted these training modules as well as the training tools for their specific needs. Some modules were translated inPulaar. , Implementation of the GMT program in the MACP. The implementation o f the GMT program will include the following steps: (i) recruitment o f the GMT Program Coordinator; (ii) inventory o f agencies implementing (some) GMT; (iii)selection o f field-operators as contractual partners; (iv) capacity-building o f NGOs; (v) organizational analysis; (vi) training needs assessment; (vii) training needs analysis; (viii) inventory o f training materials; (ix) training-module development; (x) training o f junior-trainers ; (xi) translation o f training modules in national languages; (Ai) training-material tests; (xiii) training o fgrassrootscommunities; (xiv) monitoring-support; and (xiv) programevaluation. Recruitment of the GlcllT Program Coordinator. The ProgramCoordinator will be a GMT expert, selectedamong the senior-trainers on a competitive basis with predetermined specific criteria. Inventory of agenciesimplementing (some) GMT. This work will allow a databaseto be set up on related competences. It will also include a file on partner structures related to training. These structures will be contracted (through competition), for program implementation in the field, (while ensuring geographic coverage o f the country starting from previously defined criteria), to lead training workshops, or to elaborate modules. The National Program Coordinator will take an inventory o fthe available structures. Selection of field-operators as contractual partners. To ensure effective and efficient implementation o f the training program, the MACP Project will select "support-structures" with which itwill include contracts/conventionsfagreementso f collaboration to execute the program at the level o f the moughataas. It will be particularly important to give preference to NGOs, because they are generally close to basic populations and, more importantly, because their training staff is stable. Incase one moughataa would not have any NGO capable of doing the work, the NGOs operating elsewhere inthe country will be encouraged to work there according to arrangements which need to be defined between the respective NGO and SENLS. The "support-structure" will need a senior-trainer who will be responsible for a team o f junior-trainers. The training staff o f partner structures will not necessarily need to work full-time on the FGB program. The junior trainers provided by NGOs will be composed o f women and men who will facilitate and promote the participation o f female citizens. The selection o f the FGB National Program Coordinator will be responsible for the selection o f"support structures". Capacity-building of NGOs. This assignmentwill consist of: the identification ofmissing capacities o f NGOs, the development (conception or adaptation) o f NGO training modules and programs, the trainingofNGOsrunby Specialist (Senior FGB trainers inthe FGB approach, MARF' Specialist on training according to this method). The FGBcoordinator will be responsible for this assignment. Organizational analysis. This assignment will consist in making an inventory o f all traditional and modem organizations, of the intervention structures as well as o f the religious institutions (Imams, Muslim Brothers, heads o f villages, etc) and traditional institutions. Each o f these organizationsfinstitutions will need to be involved during the next stages o f the program. This particular stage will be implementedbyNGOs. Training needs assessment. This assignment will be performed at the NGO level by a consulting firm, while partner-NGOs will do this for CBOs at the moughataa level. CBO needs will be identifiedby all identifiedgroups at the previous stage (economic andsocial activities) as well as the - 144- fight against AIDS. This assignment will be performedby a professionaladult trainer, especially in ruralareas. It will need to be performed as carefully as possible, as the success of future trainings depends on it in terms o f participation and motivation. Several techniques (CEFE, MARP, SARAR types) are generally basedon questionnaires and needto be as participative as possible. 0 Training needs analysis. This activity consists indefining precisely the needs o f target audiencesin terms o fknowledge andknow-how which they must acquire within the context o f the training session to be given through a module to be elaborated. Itwill be executed bytraining NGOs. 0 Inventory of training materials. This assignment consists inresearching, collecting andcentralizing all existing training materials in the area o f FGB as well as in related approaches (CEFE, MARF', SARAR). This assignment will be all the more useful that it will allow to avoid duplications; it will also make it possible to save time and money during the development o f training modules. This assignment will be givento a Consultant. e Training-modules development. Training modules will be developed onthe basis o f training needs identified and analyzed at the previous stage. They will be executed during specific workshops during which several modules may be elaborated at the same time. Untrained trainers in the FGB approach may be associatedinthe elaboration o f modules, provided that they have a good command of adult training techniques. In addition, each workshop will have as many resource-persons as necessary, depending on the themes (for example, on awareness or information o f AIDS transmittal modes, on the basic vocabulary o fthe pandemic, on financial management, etc), andon the assistance of a health specialist to provide the technical contents as related to HlV/AIDS. The FGB training specialists will be responsible for the adaptation according to pedagogical needs. The ideal team would be composed o f two adult trainers (among which a senior- and junior-trainer who are very familiar with the particular environment) and o f a resource-person. Several teams may share the same graphic communication specialist (or illustrator). The following areas should at least be covered by training modules: (i)the organization and management o f organizations o f basic populations; (ii) leading discussions on health (or IEC for health), in general and IEC in the fight against W / A I D S inparticular ;(iii) productive activities; (iv) management o f productive activities and (v) social dimensions and development gender in general, especially as related to the fight against HIV/AIDS; (vi) Female Genital Cutting, (vii) financial management at the community level, (viii) procurement at the community level, and(ix) conflictresolution. e Training of junior-trainers. These trainings will especially aim at developing general pedagogical capacities, particularly inrelation to the FGB approach among future trainers o f basic populations. The workshop will last no more than one week and will allow participants to get familiar with the FGBmaterialbefore starting usingit ona live sca1e.k assignmentwill be givento a Consultant. 0 Translation of training modules in national languages. For the training o f basic populations, modules will be translated into local languages before being used by junior-trainers. However, should translation problems arise, very experienced junior-trainers may be solicited to start the trainingofpopulationspriorto the translation. e Test of Training Materials. After modules have been developed and before they are used for training, they will need to be tested to ensure that behind each visual instrument, the target audience understands the message which i s intended to be effectively conveyed. Thus, it will be possible to avoid the frustrations o f the audience who, for cultural reasons or others, may not welcome certain - 145- images, figurines, etc. Training of grassrootscommunities. As for investments, training will be given a-la-carte and will be ledbyjunior-trainers inCBO villages or districts. At the beginning, junior-trainers maybe helped bysenior-trainers who aremore familiar withthe instruments. ~onitonng-support,Training supervision and support to junior-trainers will be organized by the supervisor at the rate o f two supervision sessions per year. The National Coordinator will perform less frequent supervision sessions. An ideal supervision team will consist o f a senior-trainer and o f a junior-trainer, preferably those who attended the elaboration o f the module for the first supervision sessions. The aim i s to improve the achievement o f pedagogical objectives assigned to various trainings. Program evaluation. The assessment o f the FGB program must fit into the general system o f supervision-evaluation o f the Project, and the National Coordinator o f the FGB must actively participate inits elaboration. Financial management. Each "partner-structure" will develop an annual activity plan which will be translated into quarterly technical and financial implementation programs. When these programs are adopted, "partner- structure^" are responsible for their implementation at the moughataa level as well as at the village level. Program coordination and management. (i) the national level: the program will be coordinated by At the National FGB Coordinator under the responsibility o f the Coordinator o f the Civil Society Initiatives who will report to the National Executive Secretary o f the M A P Project; (io at the level of each moughataa: one NGO-partner will be chosen to implement the program (one NGO may cover several moughataas. This structure will providejunior-trainers who will train basic populations; (iii) the level at o f each village or group o f villages or district inurbanareas: Shift trainers will ensure that, once training is received, it i s restitutedto other members o fthe respective groups. Shift trainers will be supported by junior-trainers. - 146- Additional Annex 16 PrivateSector Initiative MAURITANIA MULTISECTORHIV/AIDSCONTROLPROJECT Context. The private sector in Mauritania is relatively small and scattered throughout the country. Principle industries are Mining, Fishing, Agriculture, Transport and Construction. There are very few large companies in the country, other than the SociCtk Nationale Industrielle et Minikre (SNIM), the National Telecoms company, Sonelec, Air Mauritania, and the National Bank o f Mauritania. A majority o f industry and enterprise has less than 50 employees, and a considerable amount o f private sector activity can be categorized as informal, such as markets, boutiques, and independent businesses and trade. The private sector is organized through a sectoral Federation structure, centralized under the umbrella o f a Confederation (the Confidiration ~ a t ~ o n adu l ePatronat de Mauritanie). The Federations of key sectors play a leadership role inthe national economy and represent, collectively, a large number o f employees, eg. the Federation o f Industry and Mines has approximately 50 company members, representing 5000 employees; the Federation o f Boulangerie represents 700 bakeries, with 4000 employees; the Federation o f Transport has approximately 20,000 members including transport companies and independent and small trucking groups, buses, and taxis; the National Federation o f Fishinghas 30,000 members, andthe FederationofTraditional Fishinghasanother 15,000 members. Despite a recognition that HIV/AIDS is a critical issue for businesses inMauritania, there has been very limited attentionpaid to addressing the issue through the private sector. There is no national workplace policy, and none o f the Federation organizations have started any programs to provide information to their constituencies, offer seminars in which to raise questions, provide condom distribution, discuss risks associated with behavior, or consider the option o f a sectoral or national workplace policy on the issue. However, the largest employer inMauritania, SNIM, has launched an extensive program for their employees, and they have done so with their own financial resources, andonly limited external technical assistance. The S N I M program includes awareness campaigns, youth programs, expert seminars and speeches, peer education and counseling (in partnership with SOS and FLM), VCT, and treatment - it should be notedthat SNIM i s the only employer that provides treatment for employees with HIV/AIDS, though they do so outside the country. They do not, however, have a workplace guideline on HIV/AIDS since they do not differentiate HIV from any other life-threatening diseaseo ftheir employees. In general, because o f the very low prevalence rate (.56 percent - 1.0 percent)of HIVAIDS in Mauritania, companies have not felt an urgent need to address the issue. But, there is a growing understanding that the key players inthe private sector inMauritania are inhigh-riskcategories -fishing, transport, agriculture and therefore there is a need to catch the disease before it becomes an epidemic. - The leadership o f the Federations appear to understand this, though there is a needto provide assistance to the organizations to sensitize and engage their large memberships especially given the cultural and religious challenges associatedwith addressing the diseaseina highlypublic way. Leadership in private sector involvement in the national response to HIVIAIDS. Currently, the CNLS, the Confederation, and the Federations do not have focal points to work with the private sector response. The CNIS does have plans to hire a person into a position to manage the involvement o f the civil society, including the private sector. The Secretary General o f the Confederation does sit on the NAC and has expressedinterest intaking a leadership role inworking with the Federation members and the Parliament. Inmeetings with the Secretary Generals o f several Federations, there was a willingness to identify an appropriate focal point to manage activities related to HIV/AIDS, though at the moment there is no general terms o f reference for what these representatives might do or what resources might be *147- available to them. There i s no central location for information, or a forum in which companies or associations are able to come together to discuss studies, data, issues, andlor solutions. SNIM has clearly demonstrated a leadership role inmitigating the impact o f HIV/AIDS for their own employees, and the company has expressedinterest and willingness to expand their programs, and share their advocacy and technical materials. The international NGO, Federation Luthkrienne Mondiale is the only organization that i s currently working with the private sector, conducting large peer education programs through their partnership withthe localNGO and peer counseling organization, SOS. Available Data. There is no data available on the impact o f HIVlAIDS on the productivity and profitability o f businesses inMauritania. The mission was unable to identify any comprehensive studies that addressed HIVIAIDS prevalence rates in companies, an accurate measure o f levels o f HIVIAIDS knowledge, attitude and practices among company employees, or the impact o f HIV/AIDS on productivity andprofit margins for businesses. Action Plan. Based on discussions with private company representatives and business association officers, and several NGOs, a consensus emerged that the following steps constitute the core o f a short term action planto mobilizeprivate sector involvement inthe fight against HIV/AIDS: 0 Convene a meeting under the leadership o f the Confederation o f the Secretary Generals o f National Federations and SNIM; Create a fiamework for private sector involvement by reviewing, revising and confirming eligibility criteria andapplication package for access to financial resources to support private sector lead HIVAIDS programs, includingcounterpart fundingrequirements; 0 LaunchHIV/AIDS Prevalence andImpact Analyses; 0 Consider and determine plan for disseminating research findings, information and other resourcesavailable for the private sector; 0 Review and consider options for crafiing a workplace guidelines for Federationmembers; 0 Consider the option o f identifymga focal point for HIVIAIDS inkey organizations, inparticular, the CNLS, the Confederation, andFederation members; 0 Buildcapacity ofthe private sector to planandimplementHIVIAIDS proposals andprograms; e Implement two to three programs inkey areas inorder to pilot approach andprocess o f working with the private sector. Eacho f these steps i s discussedbriefly below. Meetingof Federations. The following organizations have agreed to participate inleading a meeting of Federation representatives: The Confederation, Federations o f Industry and Mines, Transport, Fishing, SNIM, andFLM. The Secretary Generals o f these organizations have agreed to act as an advisory group for the CNLS to launch a comprehensive program on behalf o f the private sector. All Federations that express interest should be included. The mission recommends that the Federations o f Construction and Tourism also be invited. The objectives o fthe meetingwill be: Outline the fill range o f constituencies included inthe private sector - large companies, SMEs, Micro-enterprise, non-foml sector including commercial sex workers, independent truckers, shop keepers, open markets, etc; e Determine levels o f awareness o fthe Federations andtheir members; 0 Strategiesfor disseminating infomtion about consequences o fthe epidemic; 0 Presentation o fthe SNIM experience; Facilitatingthe coordination andjoint action among and betweencompanies on HIVIAIDS; 0 Buildingthe capacity oftheprivate sectorto mobilize resourcesfor the businessresponse; 0 Discussing the development o f a national workplace guideline - content, review process, implementation; -148 - 0 General discussion o f common program targets, ie. communications plan, advocacy campaign, awareness raising, training, peer education, condom distribution, materials development and distribution, actionplanning, technical assistanceneeds. 0 Determining ifgroup i s interested inmeetingregularly andplayinga leadership role inincluding the private sector ina national response; 0 Prioritize actions Creating a framework for private sector access. The CNLS agreed to allocate approximately 10 percent o f the total civil society budget to the private sector. As such, CNLS will be responsible for implementing and managing a framework for private sector access to the new grant facility being designed to support the their participation in the National AIDS agenda. There will involve the following: 0 Builda menu of options for private sector participation, ie. workplace programs, peer education andcounseling, condomdistribution, etc; 0 Establisha core team to discuss with the CNLS the grant application "rules" for private sector access andreflect decisions inoperations manual 0 Develop criteria, application forms, review, selection and disbursement process to facilitate companies accessthe available grant facility (using existing templates) 0 Develop a mechanism for fast tracking o f funds to companies including the Small and Medium Enterprises (SME) e Identify strategies to ensure the access and participation o f high-riskpopulations o f the private sector, ie, micro-enterprises, private truckers, market workers, andthe non-formal private sector (includes outreach campaign, proposal preparation support, capacity building,other) 0 Identify other sources o f funding for the strengthening and scaling up private sector HIVlAIDS programs All application relatedmaterials mustbe agreedto andapproved bythe CNLS. Impact Assessment. During preparation, there will be an HIVIAIDS Prevalence survey and impact analysis. The research findings would be used to sensitize business managers on the direct link between HIVlAIDS and business operations and the importance o f mainstreaming HIVlAIDS inbusiness plans. The US Embassy has expressedinterest incofinancing this study. Dissemination of research findings and sharingof knowledge and information. Iti s usefulto provide a central point to collect and compile information and from which material can be accessed and distributed to the private sector. Several locations for such materials can be considered and include the CNLS, the Confederation, an NGO, a Facilitating Agent, or another entity. Time and resources will be necessary for any organization to develop the capacity to receive, manage, update and disseminate new information. Options for workplace guidelines. The development o f a national workplace guideline for employees affected by HIVlAIDS will be considered. There i s strong evidence that the introduction o f guidelines to protect the rights o f workers and avoid the tragic consequences o f stigmatization o f people has positive effects on both the lives o f those affected by the disease, and the perception and understanding o f HIVlAIDS. Itwouldbeusefulto identifya championcompany, organizationor Federation that wouldbe willing to leadthe discussion onthe value o f implementing such guidelines inMauritania. Though SNIM does not have guidelines and at the moment does not see the need for one, it would be useful to discuss with the company the idea o fintroducinga policy as a way o fleadingthe rest o fthe private sectoron this issue. Samples o fguidelines will be made available to the CNLS. - 149- Support focal points. Working effectively with and taking advantage o f the power o f the private sector will require focused attention on the part o f key organizations, chief among them, CNLS and the Confederation. In order to do this, identify and support focal points will be identified in both organizations. Capacitybuildingfor boththese resourceswill receive highpriority. Build and scale-up capacity of the private aector to plan and implement HIVIAIDS programs. Based on the experience o f FLMand SOS inworking with various parts o f the private sector, there i s a great demand to scale up training o f peer educators and to provide information, education and communication materials for workplaces, However, there are significant gaps in the capacity o f all private sector groups to plan, manageandintegrate these types o f programs. There is therefore a need for a coordinated communications effort and support to companies and Federations to help them with reaching their employees and their target audiences in the communities where they operate. Strengthening andscaling upprivate sector participationinthe responseto HIV/AIDS include: e Trainpeer educator and Peace Corpsvolunteers inproject preparation; e Work with NGOs to identify programs that mitigate issues o f stigma and denial incommunities and explore how they might be appliedto private sector environments; 4 Identify and scale up S N I M program to expand their activities to work with families and communities; e Provide focused programs to train senior managers, Federation management, business leaders, andline staff; 4 Train Federation and CNLS key personnel in identifying opportunities to suggest a variety o f interventions such as training o f peer educators, sensitization o f managers, workplace programs, options for resources, and other Implementingpilots. Severalprograms mightusedas pilots for engaging the private sector. 4 S N I M case study - identify a consultant to do a written review and case-study o f the SNIM experience. 4 SNIM flyer and other materials to be modified for different sectors (Fisherman, transport workers, other) anddistributed-possible partners World Vision, FLM, Stop SIDA. -Based onmaterials for flyers, posters, t-shirts, stickers, condoms e FLMpeereducationtrainingfor shopkeepers Critical path to launch the private sector involvement inthe national response.The following steps have been identified as critical path for the strengthening and scaling up o fprivate sector participation in the implementationo f the National Strategy: Phase I:(i) consultant for implementing and managing private sector outreach; (ii) consultation and needs assessment o f the private sector; (iii) coalition building-develop agenda and schedule meeting o f Federation representatives; (iv) identify focal points in Federations and the CNLS; (v) impact assessment; (vi) confirm process for determining eligibility, application, review and disbursement of funds from the grant facility andprocessandmanagement; (vii) collect samples o fworkplace policies in other countries; (viii) identify all partners that may have resources, including materials, technical assistance, commodities, additional funds; Phase 11: (i) prevalence study and other research; (ii) execute defmelidentify strategy for data and information dissemination; (iii) study o f organizations and NGOs working with the private sector; desk (iv) collection o f W A D S training materials targeting different groups and communities that mightbe useful for the private sector in Mauritania; (v) identify and collect capacity buildingprograms focusing on target groups from organizations andgroups aroundthe Region- including peer education, awareness - 150- raising, condom distribution, programs involving PLWHA; (vi) initiate support to the private sector for proposals preparation; (vii) select and fund pilot projects using the PPF; (viii) develop and set up monitoringandevaluation system; (x) launchprogram o f information sharingthrough Confederation and Federations; (xi) conduct consultations on the introduction o f a workplace policy on HIVAIDS in the Workplace Phase 111: (i)test funding mechanisms for private sector lead projects; (ii) up private sector scale programs ensuring participationo f a broadrange o f companies andFederations insuringrepresentation o f sectors, size andgeography. - 151- Additional Annex 17 Bio-MedicalWaste ManagementPlan MAURITANIA MULTISECTORHIWADS CONTROL PROJECT 1. Introduction The Republic Islamic o f Mauritania covers an area o f 1 030 700 km2, with a saharian and sahelian climate. In 1996, the population i s estimated to 2 346 752 inhabitants. The RIM counts 13 Wilayas, 53 moughataa and 208 local communities. The country i s ranked among the poorest countries inthe world 56 percent o f the population amounted poverty line. Health indicators revel a globally fickle situation. Life-expectancy is reportedto be o f 51.3 years. There is a 0.6 percent HIVJAIDS prevalence rate within adult people. 2. Objective The present project constitutes a component o f the World Bank Multisectorall HIVJAIDS Program for Africa (MAP)which objective i s to contributeto the reduction o f the HIVJAIDSprevalence and to reduce the impacts o f the HrVJAIDS on the infectedandaffectedpeople, through a community an multisectorial approach. The objective o fthis study is to elaborate a HealthCare Waste Management Plan appropriately assessed, with clear institutional dispositions for its implementation. 3. Main acknowledgements of the study The health system comprises three levels: the Central level (national), with 5 reference hospitals; the medium level (wilaya), with 10 regional hospitals; the first level (moughataa), with 55 health centres and 243 health posts. Health system also includes health military services and para public institutions. The private medical sector i s relatively developed and comprises: 12medical clinics ;22 medical cabinets ;15 health care cabinets; and 14 dental cabinets. In2002, the health staff comprises 3542 agents, with :438 doctors; 271 nurses, 1648 paramedical agents; 1185 other agents. The production o f solid wastes are estimated to 3304 kgper day, among which 678 kglday o fHCW and 144 kglday o f sharp objects. The main problems in HCWM globally are: an absence o f a working national strategy in HCWM; a deficiency inthe legal framework inmatter o f HCWM; a lack o f quantitative andqualitative information on HCW; an insufficiency o f knowledge and behaviors in the HCWM; the non implication o f private companies inthe HCWM; an insufficiency o f financial resources. The institutional and legal framework i s deficient in HCWM : HCWM i s not a priority in the national policy : the institutional framework is marked by a lack o f national strategy, specific guidelines and procedures in HCWM. HCWM organization andplanning is not performing. Inspite o f the remaxkable efforts insome health centres, the organization o f the H C W M through health structures leaves some to be desired absence o f reliable data on the produced amounts; no responsible always designated ;the majority o f health centres do not have protective equipment for the staff; absence o f a selective collection andthe HCW are mixedup with the home refuse insufficiency o f pre-collection, collection and storage dustbins as well as a lack o f adequate protection equipment for the health care waste managing staff. Inthe health facilities, various HCWM and elimination procedures are used; insufficiency o f financial resources. Knowledge, attitudes and behaviors in the H C W M are globally insufficient. At the level o f knowledge, attitudes and practices, several socio-professional categories (hospital staff; the collection staff; the informal scavengers; the people using recycled objects are directly concerned (in term o f risks) by the H C W M and axe liable to HIV/AIDS contamination. Generally, medical staff are relatively conscious o f the risks linked to the -152- HCWmanipulation, eventhoughmost o fthemwere not trainedto the charge o ftheir management. There is, among the helpers or caring-aids responsible for the removal and emptying wastes dustbinswithin the health centres, little consciousnesso f the impacts and effects o f bad HCW management. Agents charged to the collection, permanently incontact with the infected wastes, are generally without qualification and have a very low level o f education. Most o f them work in shaky hygiene and protective condition: not enough and safety equipment, etc. Informal scavenging andrecycling activities inthe garbage dumps are opportunities and sources o f income for the poor people. Owing their very low level o f education and shaky living conditions, they difficulty succeedinperceiving the dangers relatedto the waste scavenging and manipulation. Public opinion needs information about the dangers related to the objects collected in the HCW, especially people using recycled products and those giving andlor receiving health care at home. Private companies are a little involvedinHCWM. For external transportation, the non-existence o f HCW collection specialized companies constitutes A major constraint for the health centres in need o f external treatment. Financial resources allocated to H C M activities are insufficient: they are generally allocatedto healthcare activities the health facilities. 4. Main recommendations 4.1. Plano fAction Measures advocated inthe HCWMplan shall be structured around the following components: Objective 1:Improvethe institutionaland legalframework inHCWM - Activities: Set up a structure for coordination andfollow upo f HCWMplan Develop a nationalpolicy onpublic hygiene and environmental health develop rules andregulations linkedto HCWM develop technical guidelines inHCWM Objective 2: ImproveHCWMinhealth facilities - Activities: Regulate HCWMwithin the health centres Set up a hygiene committee and appoint a responsible incharge o fH C W M issues andfollow up Providethe health facilities with materials andequipment for HCWM Conduct a systematic selection and rationally manage sharp objects -- Promote the use o frecyclable materials Determine HCW treatment and final disposal for any type ofhealth facility Estimate financial resourcesinorder to fundH C W Mactivities Objective 3: Train the hospital staff andthe waste operators Activities - Elaborate training programmes andtrain the trainers Train all the operators acting inthe H C W M system Evaluate training programmes Objective 4: Sensitizepopulations on risks relatedto HCWM Activities Informpopulations on dangers relatedto HCW and the use o frecycled objects Ensure a soundHCWMinthe households after medical care at home Objective 5: Promote implication of private companies inthe HCWM Activities implement a partnership framework between public, private andcivil society sector reinforcemanaging capacities o fprivates societies inH C W M - 153- Objective 6: SupporttheimplementationofHCWMplan Activities validate the HCWMplan prepare the operational activities follow up the implementationandevaluate the HCWMplan 4.2. Treatment and elimination systems Regarding the treatment system, inaccount o f the socioeconomic context inMauritania, the comparative analysis allows to recommend : - - the modem incinerator seemingly appropriate to the national (central) hospitals; the one-combustion room incinerator (home-made incinerator), which is appropriate for regional hospitals andhealthcentres, and; stabilized side andbottompitsfor healthposts. Meanwhile, inappropriate incinerators or the combustion o f waste unable to get incinerated (plastic, chemical andradioactive products, mercury, heavy metals, etc.) can generate polluting effects inthe air. For this reason, the model o f incinerator recommended inthe action plan lies within the strategy mainly based on waste segregation at the source, inorder to greatly reduce the infectious wastes and restrict the contamination o f the other non contagious wastes (papers, plastics, pipes and syringes, etc.). All types of wastes shall not be incinerated. The selective sifting shall help send all non contaminated wastes towards more classical treating systems (disinfection, burial, garbage dumps) and only incinerate the contaminated or risk-based wastes (needles, etc.). Now, these categories o f wastes do not emit (or very few) targeted toxical produces, especially dioxins andmercury. Moreover, the system allow total melting o fneedledwhich are the most feared vectors for the accidental transmission o f the HIV/AIDS. Inthehealthcentres locatedinregionalandruralareas, thequantities ofhealthcarewastesproducedare very small. Ifsegregation i s respected, the volume to be incinerated will be insignificant. Inaddition, the promotion o f the use of non-chrorinated plastic containers will help reduce pollutions stemming from incineration. Incase of institutional obstacles should be met with the use of incinerators, the following alternative options are proposed: chemical disinfection; piling in garbage dumps or burial within the hospitals if appropriate area i s available. The other systems(autoclaving, microwaves) are not recommendedbecause they are very expensive andrequire highlyqualified stafffor operating, For liquid wastes, chemical disinfecting is, for sure, the most effective one for treating o f infectious wastes. It is the reason why it shall be given priority in this project centered around fight against HIV/AIDS. In so doing we could contemplate a combinated system (disinfecting and septic tank) for provincial and rural. Inthe central hospitals, owing to the important volume o f waters, it preferable to choose a physico-chemical treatment which include a disinfecting post. However, this system requires more detailed study interm o f faisability. 5. Action Planfor theimplementation Concerning the institutional arrangements for the implementation, the Ministry of Health and Social Actions will be responsible for the improvement o f the legal and regulatory framework, especially the Hygiene national Centre (CNH), in the first year o f the program. Withon the health care facilities, HCW regulationandregimentationshouldbe conducted byDMP, DPS and CNH. Training activities in the heath centres (implemented in the two first years on the program) could be monitored by the Direction of Human Resources (DRH) with the supply o f CNH. In the Wilaya, the -154- controlandachievement o factivities shallrealizedbyRegionalHealth Directions. As far the population, ingeneral, are concerned, sensitizing actions shall be conducted and supervised, nationwide and during all the program, by the National service o f Health Education (SNES) with the supply of CNH. Inthe Wilaya, Regional Health Directions shall ensure the control and achievement of the activities and assess and follow up reports. The set up o f the coordination structure o f H C W M plan and launch seminars (for starting the project) should be organized at the beginning o f the first year, in form o f national and regional forum by the Ministry of Health and Social Actions. The beginning assessment shall be ensured by local consultants, under supervision o f the RegionalHealth Directions. Locally, it i s advised that the control be ensured by Regional Directions. Monthly, following-up shall be achieved in the health centres, whereas the annual yearly follow up will be achieved bythe central services o f CNH,incollaboration with the services o f the MinistryofHealth. The assessmentshallbe done mid-way (late inthe secondyear) and at the endofthe project. Locally, control and supervision shall de assured by the Health Directions, while, nationwide, supervision will be carried forth by the CNH and National Commission for fight against AIDS, in collaboration with the services of the Ministry o f Health, the Ministry of Environment and the local collectivities. 6. Cost of the HCWMplan The cost o f the HCWM plan, which exclusively comprises activities for the reinforcement of the institutional and legal framework, for the training and public awareness, is estimated to 832 800 US$, dividedas follows: - --- Improvemento f institutional andlegal framework 55 200 US$ training 540 800 US$ sensitizinglpublic awareness 187 600 US$ Implementationo fHCWMplan 49 200 US$ As regards complementary measures aiming to improve the HCW collection and treatment inthe health facilities, the costs o finitial devices (as anindicator) are amounted to 195 600 US$. - 155- Additional Annex 18 Monitoringand EvaluationSystem MAURITANIA: MULTISECTORHlVlAIDS CONTROL PROJECT 1.Introduction. The projectwill bea "leaming bydoing" process,therefore a solidM&Esystemwill be a key feature of the project design. An overall project M&E system will be established containing (i) activity monitoring and evaluation, (ii)monitoring o f the epidemic and its impact (iii) financial monitoring o f all the financed action plan and sub-projects, in order to identify emerging problems in execution o f activities and (iv) social monitoring impact, to assess the impact o f the project on the vulnerable groups insociety 2. Participative approach. Ownership o fthe system, felt by all stakeholders, is vital andall levels down to the communities shouldbe involvedinthe development o f the procedures, culminating ina manual o f M&Eprocedures. Structuredfeed-back andregular contact bysupervisory visits will beamainfeature of the M&E system. The M&E system will establish data-bases on past activities, experiences and results (both national and international), as well as for epidemiological data, that should be readily accessible at different levels, so that people will be able to learnform others' experiences. 3. Implementation arrangements. Monitoring and Evaluation in the National AIDS program o f Mauritania is the ultimate responsibility o f the NAC, the daily management will be inthe hands o f the M&E specialist in the NAES, this specialist coordinates the M&E system, but does not execute the activities. During the preparation phase a consultant will assist inthe setting up o f the system. After the formulation o f a M&E action plan, the first issue to address i s advocacy, not everybody is convinced o f the importance andappropriatenesso f a M&E system and its funding. Secondly, staff o f every levelhave to be trained indata collection andanalysis. Tools and forms have to be developed andfinally a decision has to be made about the flow o f information, The GAMET Global AIDS Monitoring & Evaluation Support Team supported by the World Bank and UNAIDS will participate in the supervision o f the project to provide support. 4. Monitoring of activities. Experience has taught that program activities have not been sufficiently followed inthe past. Inthe Mauritanian HIV/AIDS project this will now get ample attention. Activities on any level will be monitored following a relatively simple format, so that even the most peripheral levels are able to keep records o f activities; therefore the collection andreporting procedures must be as simple as possible. It should contain standardized core; if each implementing partner uses different systems or tools, it will be impossible to analyze or summarize the data. However, this does not preclude partners from collecting additional, situation-specific data. Core data will be requested from all actors, and will be incorporated into the standard form for Action Plans and Sub-Projects. This will be done internationally, to allow ditto comparison betweendifferent countries: 1.Number of mediaHIV/AIDSradioltelevision programs producedandnumber o fhoursaired 1.a Radioprogramsproduced 1.bNumberhours radioprograms aired 1.c Television programsproduced 1.dNumber hourstelevision programs aired 2.Number of HIVlAIDS preventionbrochureshooklets developed andnumbers distributed 2.a Number print brochures produced 2.b Numberprintbrochures distributed - 156- 3.Number o fHIV preventionstaff andvolunteers trained 3.a Number staff trained 3.b Numbervolunteers trained 4.Number o fHIV preventionmeetings heldand medwomen reached 4.(a) Meetings held(b) number o fmenattending (c) number o fwomen attending 5.Number o f condoms (a) sold (b) given free &(a) Number and (b) percent o f health facilities providing STI care with both trained staff and uninterruptedsupply o fdrugs 7.Number o f (a) men(b) women receiving HIV testing and counselling 8.Number o fwomen tested duringpregnancy andreceiving PMCT ifHIV-positive 9.Number o fHIVcare staff andvolunteers trained 9.a Number staff trained 9.b Number volunteers trained 1O.Number o fPLWHA support groups and number o f (a) menand (b) women enrolled 11.Number o fcommunity AIDS careprojects andnumber o f(a) men(b) women enrolled 12.Number o f community orphan support projects and number o f (a) boys and (b) girls supported 13.Number o f(a) boys and(b) girls receiving support for school fees Explanation o fthe content o f indicators andproposed collecting forms are presented inthe appendices 1, 2 and3. 5. Flow of data. Data will be collectedmonthly from community level andafter analysis presented on a three-monthly basis to regional level, which has the task to evaluate the level o f progress, but also has to assess the coverage inthe region andto assure that the various activities have reachedthe largest possible number o f people. From there, it will be presented (again 3-monthly) to national level where the NAES M&E person will do the final analysis, assess the progress and identify the areas where corrective measures have to be taken. Finally the N A C will use the half-yearly reports to address strategic and conceptual question andtake decisionon approaches to abandon or to develop. Onall levels feed-back is essential, both as an encouragement as well as a possibility to improve. As there will be a large volume o f data to be collected a specialized entity (inthe flowcharts called Agence de collecte et traitement des donnkes)will be contracted to collect and organize (andpossibly pre-analyze) the data before presenting the processed data to the NAES. The data on activities will be linked by triangulation to disbursement and to the contracts with the executing organizations, in order to follow up the equilibrium between funding andnumber and quality o factivities executed (example o f flow charts can be found inappendix V.). 6. Use of data. The collected data should be usedfor the improvement of the execution of the activities, it is therefore important, starting with the communities, to develop the capacity in collecting and analyzing data, necessitating adequate community training andappropriate tools like self-assessment and auto-evaluation, so that communities will be able to estimate the effectiveness o f the ongoing activities. And similarly, training and capacity-building for higher echelons, wherever activities are executed. External supervision is important to confirm or adapt the findings o f the self-assessment o f the executing agents or communities, and at the same time formative supervision can improve the quality o f the activities and services offered. On higher levels (regional and national), analysis will be more comprehensive and must enable the verification of the completeness andaccuracy o f collected data. The system should be able to distill on a short time basis what activities seems to be effective, in order to adapt strategies. It i s essential to have a bidirectional flow o finformation; to reinforce easy access to new information the M&E coordinator is responsible for the creation o f a data-base, that can be easily consulted, regular feed back and updates both about the activities as well as scientific information is an essential feature of a proper functioning M&Esystem. - 157- 7. Monitoring of the epidemic. Another aspect o f the M&E system is the monitoringo f the epidemic; this will be done by national biological and behavioral surveillance o f STL"/AIDS/TB, to be translated in sexual behavior rates and trends. To this end the MAP will support Mauritania in implementing every 2-3 years, a survey o f "second generation" recently developed by WHO and UNAIDS, combining biomedical and behavioral surveillance, targeted to vulnerable groups. Every 5 years a larger nation wide s y e y will be executed with financial and technical assistance from other donors. The social impact evaluation will be part andparcel o f the monitoring o f the epidemic, done by intermittent surveys. The MOHSA has a specific role to play in the follow up o f activities that are executed under their responsibility. Duringthe appraisal, specific indicators will be developed for the monitoringo f The treatment o f STIs bythe syndromic approach The prevention o fthe transmission o fHIVfrom mother-to-child Condomdistribution (specifically the supply chain logistics) Treatment o fTB and other opportunistic infections Treatment o fPLWA The supply of safe blood Some but not all o f these indicators will be usedinthe overall Project M&E system, the majoritywill be usedwithin the MOHSA to improvethe programs for which they bear the responsibility. 8. Financial monitoring. Financial management monitoring o f NAC's, the public sector and civil society's utilization of resources and funds is necessary to establish the relation between disbursement and activities. Combining financial andprogrammonitoring provides a basis to cross check financial and activity data and to ensure sound finance-program data cross-verification. Financial Monitoring & Evaluation will not touch audit procedures, but will be used as a management instrument, usingtools like cost analysis. Accurate andfull cost information is crucial for evaluating the current level o f resource use and assessingopportunities for future expenditures on the control o f the AIDS epidemic inMauritania. It can make future budgeting more accurate and will also allow project planners to project the financial requirements necessaryto continue, expand, or replicate an ongoing activities. Inthe contracts with the executing agents details are given about type and quality requirements o f the activities, to take all these aspects in account, a triangular connection between these items (contract-activities-disbursement) must be created. A dr& financial monitoring form can be found inappendix IV. 10. Social impact. Social impact monitoring has to assess ifthe project does not influence negatively the social tissue o f the society, there are several sensitive areas to be monitored; what happens to the people that have been tested positive for AIDS? Their gain will be access to specialized care, but this can be counteracted by increased discrimination. This danger lurks specifically for pregnant women who are identified HIV positive during the PMTCT program; she can encounter adverse reactions from her environment. Inthis program ceasing breast-feeding i s offered as an option; again, the community can stigmatize the women who does breast feed her child. How will people perceive actions to assist Men who have sex with Men? Social impact monitoring should also look into equity: do women have access to AIDS services, do the poor have easy access to condoms, do illiterate people have access to information about the preventiono fAIDS, do prisoners have the possibility to protect themselves against KNinfections. These questions will be addressedinsocial impact monitoringand specific objectives andindicatorshave to be developed. 11.Objectives andIndicatorsofthe program. The followingtablepresentsthe General Objectivesand Indicators. Itwill be finalized duringthe appraisal mission. - 158- A. Impact Indicators l T ~ e Col- Perio- Measurement unit Goal lecting dicity agent 1. %o fHIV/AIDS Sentinel X H Yearly % o fpregnant women < 1%seropositivebythe end prevalence among surveillance o fProject pregnantwomen age 15 to pregnant women 19remains below 1capacity-building (May: 2002 0.69%) 2. % o fHIV/AIDS prevalenceSurveillance MDN Yearly % o fmilitary, police and < 0.5% seropositivebythe amongthe militaryrecruits military, recruits gendarmerie recruits endo fProject remainsbelow 0.5% (2003: 0%) 3.60% o ftuberculosis Administrative dat DPCS Yearly % o fall identified TB 60 % o fTB patients patients having completed patients that are correctly :ompletedDOT at the Directly Observed Treatment treated :ndo fProject Strategy (DOTS) B. Outcome indicators 4. Percent o frespondents DHS+ Sexual CNH Four % o fpersonthat can 80% o fthe populationcan (general adult population) Behavior Survey yearly correctly identify 3 ways identify 3 ways o fprevention who both correctly identify general o fpreventing HIV 80% o fthe populationcan ways o fpreventingthe population infectionandthat can identify 3 misconceptions o f sexual transmission o fHIV correctly identify 3 HIVinfection from alist and reject major misconception o fthe bythe end o fthe Project misconceptions about HIV HIVinfection transmissionor prevention IFHI I 5. Safer sexual practices: Sexual CNH Two )/o declaring having Age o f sexual inception men youth (15-19): ia) increased Behavior Survey Yearly initiated sexual raised by 1year, women by age o fsexual inception young people intercourse year at the end o fthe and Project (b) reducedoccurrenceo f idem CNH idem % declaring using 30% decrease o fmenand unprotected sexual :ondoms duringlast 20% o fwomen declaringnot intercourse `non-union' sexual usingcondoms with last intercourse casual partner at the end o f Project 6. Safer sexual practices: DHS+Sexual CNH Two )/o declaring using 30% decrease o fmen and adults (20-49): Reduced Behavior Survey yearly :ondoms duringlast 20% decrease o fwomen occurrence o funprotected generalpopulation `non-union' sexual declaring not usingcondoms sexual intercoursewith .ntercourse with last casual partner at the endo fProject Output Indicators Collec Periodic Measurement unit Goal ting ity agent NAES Once Vumber o f contracts All contractswithstaffo f procurement, implementation, withNAES signed NAESsigned technical support andM&E VAES Once qumber and %s o f all 10 ministrieshave submitted percentage o fline ministries `VfinistrieslSecretariatso f AIDS action plans for their withHIV/AIDS workplans 'ublic sector that have employees by the end o f and budgets for employees ipproved HIV/AIDS Project year I iction plans for their - 159- 2. (a) Number and (b) Administrative data VAES 3nce 11 Number employees and %s o f all IO ministries have submitted ,ercentage o fline ministries Ministrieslsecretariats o f \IDS action plans for their KithHIVIAIDS work plans Public sector that have :mployees bythe end o f indbudgetsfor external approved HIVIAIDS 'roject year I1 :lients actionplans for their external clients LO. (a) Number and (b) Report VAES 3nce Number and %o f 4 regions have a Jercentageo fregions that regions that have a mnalized committee lave establishedHIVIAIDS formal committee with ythe end o fProject :ommittees appointed president ear I 11. Number andpercentage ofReport VAES 3nce Number and %o f 50% o fthe Moughataas have Nulayas withHIVIAIDS Moughataasthat have eceived fundingbythe end Narkplans andbudgets received fundingfor ifProject yearI ipproved and funded their work plan 12.Number andpercentage Report VAES 3nce Para-statal, Civil, Private \114 sectors have a Ifallsectorsthat havea Religiousbased sectors hctional coordinating bnctional HIVlAIDS Group HIVIAIDS groups 3IVlAIDS group ?ordesigning, implementing indmonitoringtheir Sector ?lan 13. (a) Number and Survey MEN Yearly (a) Number and (b) 100% o f all institutions have :b)percentage o f percentage o fprimary/ istarted anHIVIAIDS ximary/secondary/tertiary secondary/ tertiary :urriculum :ducational institutions with educational institutions 50% o fall institution have HIVIAIDS programs for theii with anHIVIAIDS started extra-curricular students curriculum and ictivities bythe end o fthe extra-cumcular activities ?roject. for their students 14.Number o ftrained peer Report VAES Yearly Number o f 500peer educators are active :ducators active intargeted peer-educators o f ~yProject Year I1 targeted groups inall sectors who havebeen active for at least 5 days duringthe pastmonth 15. Number o fpersons jAdministrative data VAES rhree-m Number o f all persons 1.OOO.OOO persons reached eeachedbyCCB activities in mthly attending IEClCCB 3ythe end o f the Project :argetedgroups sessions 16.The second generation !Report 2NH h c e Number o f surveillance Everytargetedgroup ~ per targeted group mderwent at least two xgeted groups functional Targeted groups: 1. jurveys bythe end o f the CSW, 2. Miners, 3. Project Fisher- andboatmen, 3 Truck drivers, 4. Uniformed services 1 5.SchooI drop outs. Other groups canbe added but will not be counted inthis indicator.: 17. Percentage o foverall IAES 3nce Percentage o ftotal 50% o fall fundingfor kndinggranted to civil fundingfor activities ictivities went to civil and society services allocatedto civil society xivate society bythe end o f and private sector .heProject -160- 18. Total AIDS services kdministrativedat NAES Three Number o fPLWAthat %5000 This includes delivered: monthly was offered, medicalor multiple services to the same P u b l i c ~ G O / C B O ~ B O ~ v ~ psychosocial care by any person. PLWA havebeen te sector offered services by the end of the Project 19.Number o fVoluntary ,dministrative dat NAES Three Number o fany person 4000 people have be Testing and Counselling monthly counselled Whether the counselled byend o fProject canters established personwas actually year I1 tested is not to be considered. onHIV testing by a qualified ( 2 week training) counsellor 20. Number o fCommunity .eport NAES Three Number o f community At least 400 CBO received (based) HIV/AIDS monthly based organizations that fundingbyend o fProject Committees receivingsuppor haveactually received year I1 to implement their action funs for HIVlAJDS plans activities 21. Number o fHIVlAIDS ,dministrative dat NAES Three Number o f educational 1. 150different educational preventionbrochureslbooklet monthly supports (1) produced materialshavebeen (a) developed and (b) and (2) distributed by all developed byendo f Project numbers distributed sectors year I1 ?.15,000 educational naterials have been listributedby end o f ?rojectyear I1 22. Number o f condoms dministrative dat NAESl Three Number o f condoms (1) Bythe endofthe Project 1 soldgiven SNIS monthly sold and (2) handedout million condoms per year are for free byall sectors distributed (includingprivate pharmacies) 23. Number o fmedwomen idministrative dat SNIS Three qumber o f (1) women ant :to be developed) receiving STI care from Repro monthly 2) men treated following heaith facilities withtrained ductiv :tandardsyndromic staff anduninterrupted supplj ipproach algorithms and o fdrugs Health reatment Progra m 24. (a) Number and (b) idministrative SNIS Three (a) Number and (b) 50%o fallthe pregnant percent o f women tested and lata Repro monthly percento fwomen tested seropositive mothers receive receiving PMCT if ductiv positive and actually ARV HIV-positive receive at the Health appropriate time ARV Progra for herself and her baby, m - 161- Circuit de I'infwmationentre SELNS et secteur public 12 Donnies 1 1 3 I I DmcJramariqu 2' PTME,CNEf l4 I Financement- / let -------; 9 15 -162- Circuit de I'infirmatition secGur entre SENLS socibtb civilelsrcteur privb - 163- AppendixI:Planning, MonitoringandEvaluationForm Indicators Data Column4 Ratingof Progress 1.Number o fmediaHTVIAIDS 1.aRadioprograms radioltelevisionprograms producedand produced number of hours aired 1.b Number hoursradio programs aired 1.c Televisionprograms uroduced 1.dNumber hours I television programs aired 2.Number o fHTVIAIDSprevention 2.a Number print brochureshooklets developed andnumbers brochuresproduced distributed 2.bNumber print brochures distributed 3.Number of HIV prevention staff and 3.aNumber staff trained vohnteers trained 3.b Number volunteers trained 4.Number o fHIVprevention meetings held 4.a Meetings held and medwomenreached 4.b Menheld 4.c Women held 5.Number o fcondoms soldgiven 5.a Condoms sold 5.b Condoms given free 6.Number andpercent o f healthfacilities 6.a Number health providing STIcare withbothtrained staff facilities anduninterruptedsupply ofdrugs 6.b Percenthealth facilities - 164- Indicators Data Column2 Column3 Column4 Agreed Progress Ratingof Targets Towards Progress Targets 7. Number of merdwomenreceiving HIV 7.a Number o fmen testing and counseling 7.b Number women &Number o fwomentested andreceiving - 8.aNumber women PMCT ifHIV-positive 9.Number o f care staff and volunteers Number staff trained 1I 9.a I I I 9.bNumber volunteers 10,Number of PLWHA support groups 10.a Number support and number o fmerdwomenenrolled groups 10.bNumber men 1O.cNumber women 11,Number o f community AIDS care 1l.a Number community projects andnumber o fmenlwomen AIDS care projects enrolled 11.bNumbermen 1l.c Number women 12,Number o f community orphan support 12.aNumber community projects and number o fboys/girls orphan support projects enrolled 12.bNumber boys 12.cNumber girls 13.Number o f boys'girls receiving 13.a Number boys support for school fees 13.b Number girls -165- Partner Project 1 Month,Year I 1 Name I Signature Indicator Activity Number 1.Number o fmedia HIVIAIDS radioltelevision 1.aRadioprogramsproduced programsproduced and number o fhours aired I.bNumberhoursradioDroeramsaired 1.cTelevisionprogramsproduced 1.dNumber hours television programs aired 2.Number of HIvlAIDSprevention 2.a Number printbrochuresproduced brochureshookletsdeveloped andnumbers distributed 2.bNumber printbrochuresdistributed 3.Number o fHIV prevention staffand 3.aNumber stafftrained volunteers trained 3.b Number volunteers trained 4.Number of HIVpreventionmeetings held and 4.a Meetings held menlwomen reached 4.b Men held 4.c Women held 5.Number of condoms soldgiven 5.a Condoms sold 5,b Condoms givenfree 6.Number andpercent o f health facilities 6.a Number healthfacilities providing STI care with bothtrained staff and uninterrupted supply of drugs 6.b Percent health facilities 7.Number o fmenlwomen receiving HIVtesting 7.a Number men and counseline 7.b Number women &Number o f women tested andreceiving 8.aNumber women PMCT ifHIV-positive 9.Number o f care staff andvolunteers trained 9.a Number staff 9.b Number volunteers 10.Number o fPLWHA support groups and 10.aNumber support groups number ofmenlwomen enrolled I I IO.b Number men I I IO.c Number women ~ 1I.Number o fcommunity AIDS care projects 1l.aNumber communityAIDS care projects and number o fmenlwomen enrolled 11.bNumber men ~ 1l.cNumber women I2.Number o f community orphan support 12.aNumber community orphan support projects andnumber of boyslgirls enrolled projects 12.bNumber boys 12.cNumber girls 13.Number o fboyslgirls receiving support for 13.aNumber boys school fees I 13.bNumber girls - 166 - Appendix I11 ProgramActivityMonitoringFormInstructions Administrative details Partner. Fillinthe name ofthe implementingpartner completingthe report Project Fillinthe number andnameofthe project, as itappearsinthe contract Month. year. Fillinthe monthandyear coveredbythe report Name Fillinthe nameo fthe officialresponsible for the report Signature Pleaseensure the report is signed by the official responsible for the report 1.Number ofmediaHIVIAIDSradioltelevision programsproducedandnumber o fhoursaired l.a Radio programs produced This is the number of discrete radio programs producedbythe implementing partner duringthe reporting period, includingdocumentaries, drama, talk shows andadvertisements, that include significant reference to AIDS l.a Numberhours radio programs aired This is the total number o f hours that radio programs, including documentaries, drama, talk shows and advertisements, that include significant reference to HIVIAIDS,have beenaired 1.c Televisionprouams produced This is the number o f discrete television programs produced by the implementing partner during the reporting period, includingdocumentaries, drama, talk shows andadvertisements, that include significant reference to AIDS 1.dNumber hours television Dromams aired This is the total number o f hours that television programs, includingdocumentaries, drama, talk shows and advertisements, that include significant reference to HIVIAIDS,have been airedduring the reporting period 2.Number o fHIVIAIDSPrevention brochureshooklets developed andnumbers distributed 2.aNumber ofHIVIAIDS preventionbrochureshooklets developed This is the number of HIVIAIDS prevention brochureshooklets developed by the implementing partner duringthe reportingperiod 2.b Number ofHIVIAIDS preventionbrochureshooklets distributed This is the number o f HIVJAIDS prevention brochureshooklets distributed by the implementing partner duringthe reportingperiod 3.Number ofHIV prevention staff andvolunteers trained 3.aNumber stafftrained This is the number of HIV prevention staff trained by the implementing partner during the reporting I - 167- period 3.b Number volunteers trained This is the number o f HIV prevention volunteers trained by the implementing partner during the reportingperiod 5.Number o fcondoms soldgiven 5.aNumber condoms sold This is the number o fcondoms soldby the implementingpartner duringthe reportingperiod 5.b Number condoms given free This is the number o fcondoms given free bythe implementingpartner duringthe reportingperiod 6.Number and uercent o f health facilities providing STI care with both trained staff and uninterrupted suuplv ofdrugs 6.aNumber healthfacilities This is the number o f healthfacilities managed by the implementing partner during the reporting period which are providing STIcare with bothtrained staff anduninterruptedsupply o f drugs 6.b Percent health facilities This is the percentage o f health facilities managed by the implementing partner during the reporting periodwhich are providing STI care with both trained staff and uninterrupted supply o f drugs, inrelation to the total number o f facilities supported by the implementing partner during the reporting period providing STI care. That is, o f all health facilities supported by the implementing partner during the reportingperiod, what percentagehave bothtrained staffanduninterrupted supply of drugs 7.Number o fmenlwomenreceivingHNtesting and counseling 7.a. Number men This is the number o fmenwho have receivedHIV testingAND counseling 7.b Number women This is the number o fwomen who have received HIVtestingAND counseling &Number o fwomen tested andreceivingPMCT ifHIV-positive 8.a Numberwomen This is the number o f women tested AND receiving PMCT if HN-positive from the implementing partner duringthe reportingperiod 9.Number ofHIV care staff and volunteers trained 9.a Number staff trained This is the number o fHNcare stafftrainedbythe implementing partner duringthe reportingperiod 9.b Numbervolunteers trained This is the number o f HIV care volunteers trained by the implementing partner during the reporting period I0.Number o fPLWHA support mouus and number o fmenlwomen enrolled - 168- 1O.aNumber PLWHA support groups This is the number o f support groups formed or formally supported by the implementing partner during the reportingperiod 1O.bNumbermen This is the number o f men participating in support groups formed or formally supported by the implementing partner duringthe reportingperiod 1O.cNumber women This is the number of women participating in support groups formed or formally supported by the implementingpartner duringthe reporting period 1l.Number o f community AIDS care proiects andnumber o fmedwomenenrolled 1l.aNumber community AIDS careprojects This is the number o fcommunity AIDS careprojects initiatedor formally supported bythe implementing partner during the reporting period 11.b Numbermen This is the number of male clients enrolled in community AIDS care projects initiated or formally supportedbythe implementingpartner duringthe reportingperiod 11.cNumberwomen This is the number o f female clients enrolled in community AIDS care projects initiated or formally supported bythe implementingpartner during the reportingperiod 12.Number of community orphan supportproiects andnumber o fbovslgirls supported 12.aNumber community orphan support projects This is the number o f community orphan support projects initiated or formally supported by the implementing partner duringthe reporting period 12.bNumber boys This is the number o fboys enrolled incommunity orphan support projects initiated or formally supported bythe implementingpartner duringthe reportingperiod 12.cNumber girls This is the number o fgirls enrolled incommunity orphan support projects initiated or formally supported bythe implementingpartner duringthe reportingperiod 13.Number o fboyslgirls receiving support for school fees 13.a Number boys This is the number of boys receiving support for school fees from community orphan support projects initiated or formally supported bythe implementing partner duringthe reportingperiod 13.b Number girls This is the number o f girls receiving support for school fees from community orphan support projects initiated or formally supported bythe implementing partner duringthe reportingperiod - 169- Appendix I V Financial MonitoringForm Consultancy 3 Consultancy 4 Consultancy 5 sub-total Transport/ wransport Accommodation Accommodation Sub-total Training !Activity 1 hctivitv 2 Activity 4 Activity 5 Sub-Total External Audit Total - 170- Additional Annex 19 Reductionof Female GenitalCutting MAURlTANIA MULTISECTORHlVlAlDS CONTROL PROJECT Diagnosis Inattemptingto reduce thepractice offemale genitalcutting(FGC), itiscriticalandyet difficult toreach bothwomen who have been cut andwomen who performthe ritual. The practice o fFGC posesa range of healthproblems for girls andwomen and i s perceivedas a potentialriskfactor for HIVIAIDS. The Demographic HealthSurvey o f 2000-2001indicates that 71percent o f Mauritanianwomen have had some form o fFGCperformed. The processto reduce FGC requires takinga long-term perspective, Ithas been determined through the social assessmentthat there i s some levelof acceptanceinthe communities to address the pros andcons o fFGC. FGC is performed bywomen, but to some extent mostly for the benefit o fmen. The involvement o fmeninthe debateover the impacts andfuture practice o fFGC i s therefore critical. Perceptions andpractices o f FGC For most girls inMauritania, FGC is performed duringthe first weeks o flife. The proportion o f women who have had a complete clitoridectomy compared to partial removal is undocumented. Infibulation is rarely practiced in Mauritania. More than half o f girls (52 percent) have at least one medical complication after the procedure, according to the DHS. The procedure is most often carried out by a FGC practitioner, who usually i s an older woman, Typically a razor blade and a needle are used for the procedure. Inthe rural areas, a small gift i s sometimes given to the woman performing the FGC, but the practice does not provide an important source o f income. Inthe urban areas, cutting tends to be more commercialized. The skills o fcutting are most often passedon from mother to daughter. Some ethnic variations were noted inthe justification o f the practice o f FGC. The most frequently cited reasons mentioned by the Maures were that the religion obliges them to cut in order to secure the virginity of the girls untilmarriage; cutting reduces girls' sexual desire; and cutting is aesthetic because the clitoris is ugly and therefore should not be visible. Discussions took place in several focus groups about the role o f religionindetermining whether FGC i s practiced. Several Maure women claimed that the religioninfact does not require the practice o f FGC andinstead said that it was a matter o f tradition. The women from the ethnic groups PouEaar andSoninkedescribed FGCas a cultural tradition that serves to defend the honor o f the family. The body is a source o f dishonor and needs to be controlled. Early marriage o f girls, for example, i s seen as a method to defend family honor by securing the virginity o f girls untilmarriage. Other reasons mentioned included that girls would not find a husbandifthey were not cut, and that FGC is a way to avoid pregnancy before marriage. The participants generally agreed that the practice o f FGC continues but is becoming rarer. One reason for the decrease i s that midwives and nurses at health centers do not agree with the practice due to the health-related dangers it poses for girls. As a result, FGC is not performed at health centers anymore, according to interview statements. In each focus group with young women, at least one participant expresseddoubt about or a negative view o f FGC. Some mentioned that they had not wanted their own daughters to be cut, but that their grandmothers had taken the girls to be cut without the mothers' knowledge. A few husbands were mentioned as being opposed to FGC and had requested that their daughters not be cut. Among the girls not yet married, a few mentioned that they had told their grandmother that they would not let their future daughters be cut. A more diverse view o f FGC was noted among the girls interviewed inNouakchott, where a few participants were not cut and rejected the -171 - ritual as something o f the past. At the same time, other women inthe same focus group stated that they wanted to cut their baby daughtersbut were not allowed to bytheir husbands. FGC i s deeply rooted in Mauritanian society, with the exception o f the Wolof population. FGC is perceived, especiallyby older women, as an integral part o f their way o f life. FGCi s collective innature since it i s considered to be a prerequisite for marriage. A decision to abandon the practice i s therefore not only an individual decision, but rather one for communities and society as a whole to make in order to avoid stigmatization o f girls who are not cut. Such cultural and social factors are important to acknowledge when choosing strategiesto addressFGC. Strategv The UnitedNations Fundfor PopulationActivities (UNFPA) hasbeengiven a mandate bythe System o f the UnitedNations (SUN) to ensurethat the question o f FGC i s integrated into the gender-related aspects o f development programs. The UNFPA thematic group on gender issueshas therefore developed a strategic national approach to FGC, inwhich consensushas beenreachedbetween the government and the partners involvedindevelopment projects. The UNFPA strategy focuses on four areas o f intervention: legal protection; socio-cultural determinants; conversion o f FGCpractitionerswith the help o fpeer educators; and medical aspects(Le., the health relatedrisks o fFGC). Inthe last several years, UNFPA has launched initiatives to collaborate with both NGOs andFGC practitioners. A range o f activities have subsequently been implemented, including studies and campaigns to promote the reductiono fFGC andthe mobilization o fa network o faround ten national NGOs. On the basis o f such experience and in collaboration with the NGOs active in the area, SUN and its development partners, under the leadership o f UNFPA, plan to implement new activities using a village empowerment approach. This approach, developed bythe NGO "TOSTAN" inSenegal, aims to buildthe capacity o f communities to prepare sub-projects as part o f a comprehensive training program implemented throughout the Senegal River Valley. Included in the training program is training in the "public declaration" model, whereby villages decide to announce a collective abandonment o f FGC. The general approach taken in the program i s that facilitators do not impose their beliefs on village population, but present information andencourage the villages to make their own informed choices. Collaboration between the partners active inthis areaandthe MACPproject will elucidate the importance o f combining experiences and resourcesto create synergy around the complex problem o f FGC. Imdementation To reach the target groups, ensure their participation, and facilitate the establishment o f sub-projects, UNFPA can provide technical assistancebased on a protocol o f collaboration with the NAC. A protocol serves to specify the roles andresponsibilitieso fbothparties. The UNFPA's responsibilitieswill be as follows: e Facilitate contact betweenthe NAES/RAES andthe NGOlCBO active inthe area. e Support beneficiaries inthe identification o fneedsandthe formulation o f sub-projects (based on the procedures for sub-project application delineated inthe MACP). e Securefinancial coordinationbetweenthe SUN andpartners active inthis area, under the auspices o f -172- the UNFPA thematic group on gender. 0 Elaborate the terms ofreference for studies that are determined to be necessary. The responsibilitieso fNACfNAES will be as follows: 0 Provide the UNFPA withan Operation Manualfor the preparation o f sub-projects that serveto reduce FGC throughout Mauritanian Communities. 0 Finance sub-projects that addressFGC. - 173- Additional Annex 20 Collaborationwith Traditional Health Practitioners MAURITANIA MULTISECTORHIV/AIDSCONTROL PROJECT Assessment Throughout Mauritania, traditional health practitioners play central cultural andhealth service roles, and can therefore serve as an important resource for responding to the spreado fHIVIAIDS inbothurban and rural populations. As a part o f the social assessment interviewed practitioners from large clinics were chosen through a participatory method in which they were asked to identify other practitioners whom they thought should be interviewed. Five large clinics were identified and interviewed, all o f which are recognized as belonging to old, highlyrespected Marabou families. They runtraditional clinics where apparently hundreds o fpatients are treated on a dailybasis. The clinics are all located inNouakchott; one practitioner also operated clinics inother partso fthe country. Collaboration between the modernandtraditional health sectors is currently very limited, although a few meetings with traditional health practitioners have been held by the Ministry o f Health and Social Affairs. The traditional health practitioners expressed some skepticism towards the Ministry based on four key factors: 0 Marginalization because they are not represented at the Ministry o f Health and do not have the rightto atrade union(for example ashairdressersandrestaurant owners do). 0 Criticismo ftraditional methods bythe Ministryo f Health. 0 The claim that traditional healthpractitionershave few patients. 0 Modemdoctors discretely seek treatment at traditional healthclinics. The number o fpatients that go to traditional clinics i s not known. However, it was claimed ininterviews that up to 80 percent o f the population seeks services from traditional health practitioners. Interviews with women suggest that this health-seeking behavior is complementary, with patients seeking both modem and traditional treatment untilthe patient improves. The traditional health practitioners interviewed were familiar with HIVIAIDS and recognized the main paths o f transmission and prevention. They had treated a few AIDS patients at their clinics, but the patients hadbeen inthe terminal stage o fthe disease andthe practitionershadnot beenable to help them. One o fthe clinics had written a paper on HIVIAIDS that includeda discussion on the possibility that the disease has similar symptoms as an old diseasenamed yarkhane sawdawi. The paper recommended HIV testing before marriage and the use o f condoms, which are interesting examples o f the potential complementarities of modemand traditional medical methods. The traditional clinics visited during the assessment showed a significant capacity in terms of being well-established with highnumber o f patients; having a closely knit network with other traditional health practitioners; maintaining a good level o f knowledge of the risks o f HIVIAIDS; having interest intaking a leading role inmobilizing other practitioners; andbeing willing to seek collaboration with the modem health sector. However, some risks are associatedwith such collaboration, which ishighlyexploratory in the Mauritanian context; in addition, the development o f mutual respect between modem andtraditional practitioners i s a processthat can take time. Strategic Auuroach A number o f traditional health practitioners have expressed great interest in participating in activities related to HIVIAIDS based on mutual respect for modem and traditional health services and a concrete - 174- plan of action. During 2002, a small group o f traditional health practitioners agreed to select one practitioner to serve as an official representative, and launched the Association de Tradi-praticien en Mauritanie (the Association o f Traditional Practitioners in Mauritania) in February 2003. The first working meetingwith the Association de Tradi-praticien en Mauritanie was held during the appraisal mission. Among other subjects, potential collaboration between the N A C and the Association was discussed. A training curriculum developed in Uganda was considered as the central learning material; the strategy contained inthis curriculum i s to provide training during a relatively long period (two days per month for one year) in order to ensure common understanding o f the role o f practitioners in HIVIAIDSprevention, The training addresses several important topics: transmission andprevention o f HIVIAIDS; diagnosis of AIDS; referral o f patients to the modern health sector for testing and treatment; counseling o f patients; design o f communication messages to women and men; gender roles; the humanrights o f infected and affected people; female genital cutting; prevention o f HJY infection during work by traditional health practitioners; and religious and cultural aspects. Implementation The Association de Tradi-praticien en Mauritanie has begun to prepare a sub-project proposal for the development o f a training program for traditional health practitioners. It is anticipated that 40-50 traditional healthpractitionerswill be trained inNouakchott duringthe first year o f the sub-project. The selection o fparticipants will be carried out by the practitioners themselves. It i s anticipatedthat training will be expanded to other regions inthe next four years, andwill possibly includeupto a 100personsper year. - 175- AdditionalAnnex 21 Supply Chain Assessmentof HealthCommodities MAURITANIA MULTISECTORHIVIAIDSCONTROL PROJECT The Assessment of the Health Commodity Supply Chain for the Mauritanian MACP i s composed of 4 parts: (i) the first partprovides an Overview of Procurement, Storage and Distribution issuesfor Health CareProductsfor theImplementation of the Map Program, while the following 3 partsprovide specific assessmentsfor: (ii) Logistics Issuesfor the Voluntary CounselingC? Testingprogram; (iii) LogisticsIssues related to the Treatmentprogramfor "PersonsLiving WithAIDS (PLWA); and (iv) LogisticsIssues related to theprogramfor "Center National de Transfusion de Sang (CNTS,. I.OverviewofProcurement, StorapeandDistributionissuesforHealthCareProductsforthe ImDlementationofthe M a p Program 1.1. Background. An assessment o f the CAMEC (Centrale d'Achat des Midicaments Essentiels, Matiriels et Consommables MCdicaux), an autonomous body established by the Ministry o f Health in mid-2002 as the central procurement office for all public sector medical needswas conducted bythe EU. The assessment concluded that the CAMEC was functioning very poorly. A World Bank assessment conducted during project preparation confirmed these findings. On this basis it was agreedthat CAMEC was not ina position to meet the procurement needso f the MACP, particularly inthe short term. Instead, procurement should be done through UN agencies. CAMEC acknowledged the findings o f the assessment and has begun work to address the issues. The bank is providing support to CAMEC through the health sector project. Inthe medium to longer term, it i s therefore envisioned that CAMEC will be handlingthe MACP health care procurement and distribution. However, since the MACP is fast-tracked and becausemuch o fthe programdepends on the reliable availability o f the pharmaceuticals andmedical supplies, alternative mechanisms mustbe identified for the short term. 1.2. Objective. The objective o fthe HealthCommodities Supply Chain Assessmenti s to: e Undertake an assessment o fcapacity on all levels o fthe supply chain e Assist inselection o fhealth careproducts e Develop initial forecasting o fproduct needs e Do an assessmento fthe feasibility o fa social marketingeffort for Condoms Specifically, the assessment focuses on identifying alternative mechanisms, including (i) assessing the strength and weaknesses o f the storage, distribution and logistics management capacity (ii) recommending an action planto ensure reliable supply andquality o f all products needed for the MACP programs underthe Ministry o f Health. 1.3. Strategy. Identifying established entities to ensure simple, reliable procurement and storage o f quality products at a reasonable price, to meet the needso fthe MAP inthe short term. 1.4. Key Assessment Issues.Itwas determined that: e UNFPA, WHO andUNICEF can meet all o frequirements for products neededbythe MAP; however, careful attentionmust be paidto lead-times, particularly for WHO. e Not usingCAMEC results ina fragmentation o fthe procurement, storage, distribution and logisticsmanagement. Although informal cooperation i s taking place, each programis runningits own - 176- systemat every level. e However, procurement, storageanddistributionneedsare initially very modest. This can therefore, with some support, be managedbythe programs themselves without involvement o f CAMEC. e Since the bloodbank, VCT, AIDS treatment andsocial marketingprograms are to be build virtually from scratch, there is little institutionalexpertise insuchprograms, includingall aspects o f logistics management e The coordinating function within the M O Hneed strengthening andtechnical assistanceto (i) serve as the coordinating linkbetween service delivery sites andthe procurement agencies, and (ii) managethe logistics anddistribution system, ensuringcontinuous, reliable supply o fproducts to service delivery sites. e That a carefully crafted, low-profile, educationally focused andculturally sensitive social marketingprogramhas significant potential for buildingthe comfort level and use o f condoms over time 1.5. Key Recommendations. Itis recommendedthat: e NAES has a full time distribution andlogistics management specialist on staff for two years to assistthe MOHwith the new programs. e Training and technical assistancebe providedto the MOHCoordinator to overseeboththe procurement anddistribution. e An agreementwithProgramme Elurgi de Vuccination(PEV) be established for useoftheir cold storage facilities. e Necessary agreementsbe establish between i"and UNFPA,WHO andUNICEF. e A follow-up assessmento fCAMEC isundertaken within one year, . e An order isplaced, on atrial basis, withthe localdistributor o frapiddiagnostic tests to assess that capacity inaction. e A social marketingmanagerbehiredbythe NAES to coordinate andoversee a social marketing program for condoms. 11. Assessment ofLogisticsIssuesfor the VoluntarvCounselinp & Testinp Dropram (Project sub-component 3.2: PreventionandVoluntary Counseling) 2.1 Rationale. The project includes a program for expanding the access to Voluntary Counseling & Testing (VCT) for the general population, i.e. as a prevention strategy for the spread for HIVIAIDS through people unknowingly spreading the HIVIAIDS virus. While the programmatic effort to expand public awarenessi s a prerequisite for this effort to succeed, the non-availability o f relatively inexpensive test kits will effectively render those efforts useless if people cannot be tested reliably. Specifically, quality Elisa and rapid tests must be available where and when they are needed. The Elisa test kits require cold storage and have a relatively limited shelf life (5 months), whereas the rapid test do not require cold storage andhave shelf life o f over one year. None o fthe other supplies require cold storage andhave long shelf life. Since significant effort andresourceswill be invested inencouragingpeople to be tested, stock-outs may have significant impact on the pay off o f these investments andundermine the entire strategy o f awareness raising, behavior change andprevention. Other supplies are all standard and for this assessment and are assumed to be available through central MOH stock. As mentioned earlier, CAMEC is not functioning effectively at this time. Given the consequenceso f not having continuous and reliable supply o f high quality tests, the focus o f this assessment is to identify, assess and recommend ways to meet the needs o fthe VCT program inthis regard. 2.2. Objectives. The objective o f logistics i s to assurethat the tests and other supplies that are needed for the CNTS programare continually andreliably available to the program, its donors and its patients, -177- The focus o fthe assessment is therefore to: (i) identifyand evaluate alternative procurement, storage, distribution andlogistics managementcapacity onall levels of the supply chain withregards to VCT testing; (ii) recommend an actionplanto ensure reliable supply andquality of all products; (iii) develop initial forecasting o fproduct needs; and(iv) assist inproduct selection; 2.3. Diagnosis/Assessment.-CurrentlyVCT is done only inNouakchott, Kiffa (runbythe Croissant Rouge with support from Croix Rouge) and some private facilities. The VCT roll out plan focuses on upgrading existing MOHSA facilities: one in each regional hospital, two in Nouakchott, two in SNIM and one the Army. Two or three additional unitsmay be added. 0 Issuesto consider: (i) o fPrivate sector inVCT and supplyo fVCT tests throughMOHSA; role (ii) ofCivilsocietyinVCTsupplyofVCTteststhroughMOHSA;(iii) ofAnnyinVCTsupply role role o fVCT tests through MOHSA; 0 Product selection: The testing algorithms have already been determined -with one algorithm for the central site andone for the regional sites. These algorithms confirm with WHO recommended approaches. Only the central sites will use Elisa (two per client), which is the only product requiring cold storagewhereas the regional sites will use rapidtest (two per client). 0 Forecasting: The forecasting is attached at the end o fthe document. As VCT services at the MOHSA have been offered only inone central location andnot offered before at the regional level, the estimates mustbe adjusted as the programrolls out and experience i s gained. As the programi s inits infancy stages, it i s difficult to determine how quickly the programwill actually expand. A simple but well functioning LMIS systemi s absolutely key to capturing datato allow better forecasting as experience i s gathered. 0 Procurement. Due to lack o fdata anda very new service programwithno historical track record, the forecast are liable to significant corrections. It is therefore important that the procurements are plannedwith maximumflexibility, particularly for Elisa. This may include a general contract with orders placed every 3 -6 months or puttinginplace staggereddelivery withthe option of changing the date of delivery. Itwas determined that WHO can serve as a procurement agent for all test. However, note must be made o fWHO'Sleadtimes o f3-4 months. The staff for the VCT programhasnot yet been selected. It can therefore not be determined what capacity will be available inthis regard. However, the MOHSA has experience procuring from WHO. 0 Storage/warehousing~The CNHhave a small cold storagechamber, but incomplete disarray, as i s the rest o fthe warehouse. Inventorymanagement is a serious issue. Unlessthe CNTS can get sole use o fthis chamber, it shouldnot be considered at thistime. Elisa tests: PEV's cold storage i s very well organized, storagearea i s clean, inventory clearly labeledandmanagedwith a LMIS software system. Basedon the forecasts, the small number andvolume (since only test usedat central sites require cold storage) o fthe Elisa tests anddiscussion with the PEV, the current cold storage spaceat PEV is adequate inthe immediate to short term. The PEV agreedthat its facility will beingbe usedfor VCT needs, providedthat the volume does not overwhelmtheir capacity andthat the MACPlVCT program would pay for additional cold storage capacity (refrigerators), ifneeded. Rapidtests: For the sake o f easy stock management, andkeeping inmindthe problems at the CNH storage, the rapidtests shouldbe kept inor near the VCT unit. 0 Distribution. Withthe relatively small number o f service delivery sites (1 central, 5 regional) in the first two years, all o fthem locatedinmajorurbanareas, there is no need for intermediate warehousing -products shouldbe delivered directlyto the service delivery places. The VCT program budget includes vehicles. Giventhat it i s expectedthat staff will visit regional sites regularly for training, supervision andmonitoring, they shouldbe able to easily handle the delivery o ftest andother supplies themselves. 0 LMIS.There iscurrentlynoLogisticsManagementInformation System(LMIS) inplace. The systemneedsto be driven byinformation. This requires that early on inthe project, anLMIS is put in - 178- place that captures consumption data. The systemwill bringtransparency as to where the inventory i s and improve the forecasts for future commodities. Lack, o f data, and use thereof, will result inexpired product andpurchase o f commodities that is either too muchor too little. 2.4. Recommendations for Implementation andNext steps. Product selection. Since the tests are already relatively inexpensive, priority shouldbe on quality andreliable delivery; Forecasting. Ongoingreview o fthe forecasts as the number o f sites grows andthe caseload expands is critical to meet the needs o fthe program and avoid waste. Procurement. (i) WHO as the supplier. The emphasis on thispoint is onreliability o f Select supplyandquality; (ii) establish general contracts withWHO with flexible arrangements for order frequency andvolumes, for example with orders placed every 3 -6 months or staggereddelivery with the optiono fchanging volumes anddateso fdelivery; (iii) specifications for the first order with submit WHO as soon as possible; (iv) sometime inYear 1, place anorder with the local distributor ofrapid diagnostic tests to assess that capacity inactionandto develop a channel for back-up supply (local importersldistributorsare part o f local capacity); Storagelwarehousing. (i) an agreementwith PEV to use their storage space for the Develop Elisa tests; (ii) for products that do not require cold storage, determine the storage location inor close to the central unit itself, andconstruct a safe area that meets the storagerequirements for the products. LMIS. Implement a simple LMIS system. The VCT programbudgetincludesresourcesfor computers andtraining, andan LMIS system shouldbe an integralpart o fthat. A consultant shouldbe brought inearly on to set the systemup correctly. 2.5. Monitoring & Evaluation. (i) Forecasting: the inventory and consumptionrates o f the various products shouldbe monitoredvery closely vis-a-vis delivery times andexpiration dates; (ii) Procurement: Assess WHO'Sperformance vis-a-vis the needs o fthe programs. Alternative channels for supply may be exploredonce the program is "settled"; (iii) m:Anoutside consultant should be brought into evaluate the useo fthe L M I S system andto suggestways to improve. 2.6. Cost and Financing.-The preliminary forecast for the tests neededfor the VCT programi s in Annex 22. 111. Assessment of LoPistics Issues related to the Treatment Dropramfor "Persons Livinp With AIDS (PLWAI"(Project sub-component 3.3: Care andtreatment ofPLWAs) 3.1. Rationale, The project includes a treatment program for People LivingWith Aids (PLWA) that is heavily commodity dependent. One key to success of the program will depend on whether the right health supplies are available at the right time, place and quality. The ARV drugs do not require cold storage. However, stock outs will quickly undermine the program. Since significant effort andresources will be invested inencouraging people to seek care and services for this highly stigmatized disease, stock outs m y have significant impact on the pay off of these investments - not to mention the severe impact on the affected patients. As mentionedearlier, CAMEC is not functioning effectively at this time. Given the consequenceso f not having continuous and reliable supply of highquality products the focus of this assessment is to identify, assess and recommend ways to meet the needs o f the ARV program in this regard. 3.2. Objectives. The objective o f logistics is to assure that the antiretroviral drugs that are needed for treatment of PLWA are continually and reliably available to the program and its patients. The focus o f - 179- this assessment is therefore to: (i) andevaluate alternative procurement, storage, distribution and identify logistics management capacity on all levels o f the supply chain with regards to ARV drugs; (ii) recommend an action plan to ensure reliable supply and quality o f all product; (iii) develop initial forecasting o fproduct needs; (iv) assist inproduct selection. 3.3. DiagnosislAssessment. 0 ' Product selection and forecasting. The basis for product selection andforecasting i s the treatment algorithm. However, since treatment for HIVIAIDS has never been offered inMauritania before, this algorithm i s only now under development.An additional complication i s the absenceo f consumption data andeven the level o fprevalence o fHIVIAIDS is only an estimate. Iti s therefore also difficult to determine how quickly the caseloadwill expand. As i s often the case inthese situations, forecasts are strongly basedon experience, inother countries andfrom other situations. The forecasts are attached inannex 22. Estimated cost o f drugs (about. $350-700 per patient per year) are basedon documentation fromMdecins SansFrontiGresandassume the use o fFixedDose Combinations (FDC), which are significantly cheaper than individualdrugs. The drugNevarapin is provided free bythe manufacturer Bohringer Ingleheim, but only for MTCT treatment. For other uses, there is preferential pricing through the Access Initiative. The above issuesalso apply to the treatment o fopportunistic infections (01)associatedwith HIVIAIDS. However, the costs o fmost drugs neededare very low, the forecast includes a few drugs that certainly will be needed. Others will have to be added, but costs are expected to be relatively low. All drugs that have not previously beenused inMauritania mustbe registeredwith the DPL. 0 Procurement. Due to the lacko f data ina new service programwith no historical track record, the forecasts maybe markedly different from actual use. Iti s therefore imperativethat the procurements are plannedwith maximumflexibility. Through aninternational effort, known as the Access Initiative, the extremely costly ARV drugs can be purchased at sharply reduced prices for eligible countries. However, Mauritania i s not approved for this mechanism at this point. Itwas determined that WHO can serve as a procurement agent for the ARV drugs as well as those neededfor opportunistic infections. However, note mustbe made o fWHO's leadtimes o f3-4 months. The stafffor the ARV programhas not yet been selected. Itcan therefore not be determined what capacity will be available inthis regard. 0 Storagelwarehousing. With only one treatment site there i s no needfor intermediate warehousing -products shouldbe delivereddirectly to the service delivery place, CNH. Because o fthe extremely highvalue o fthe drugs they shouldbe stored separately ina locked-of area with very restricted access. Forthe sake of easy stock management, drugsneeded for 01shouldalso be kept here. Also note, that a shortage o fthese inexpensive drugs can effectively render the expensive ARV treatments moot. None o fthe drugs require cold storage. 0 Distribution. With only one treatment site andstorage on-site there i s no need for distribution capacity. 0 LMIS.There isnoLMISinplacethat canbeusedfor this program. Withonly 3-4 drugs,alimed number o f01drugs, plus a few regular supplies (which canbe supplied from general hospital supply), the complexity o fthe LMIS systemwill be limited. However, with the highcost o fthe ARV drugs, the relatively short shelf life, the criticality o f drug availability for treatment-inventorylevels, consumption rates and order leadtimes shouldbe monitoredvery carefully. 3.4. Recommendations for Implementation andNext steps. 0 Product selection. (i) the treatment algorithms for bothHIVIAIDS and01; (ii) the complete start registrationprocesswith the DPL as soon as product selection is completed. Althoughthe Director o f DPLindicatedher support for speedyregistration, it is only prudent to allow ample time for this process; 0 Forecasting. Revise the forecastings basedon the treatment algorithm andthe actualprices 0 Procurement. The MOHSA should (i) immediately beginthe process o f gettingapprovedfor the -180- Access Initiative, and inthe most preferential category; (ii) WHO as the supplier; the emphasison select this point i s on reliability o f supply andquality; (iii) general contracts with WHO with flexible establish arrangements for order frequency andvolumes, for example with orders placed every 3 -6 months or staggereddelivery with the optiono f changing volumes anddates o f delivery; (iv) submit specifications for the first order with WHO as soonas the algorithms have beendetermined; (v) contact Bohringer Ingleheim soonestpossible to ensure drugavailability intime for programlaunch. The manufacturer must be contacted directly bythe MOH; (vi) ensurethat customswaivers andother permissions are in place before initiatingprocurement e Storagelwarehousing. Determinethe storage location inor close to the treatment unititself, and construct a safe area that meets the storagerequirements for the products. e LMIS. Installandimplement a simple LMIS software system. Provide training inLMIS to the personincharge and to the back-person. 3.5. Monitoring & Evaluation. (i)-: the inventory and consumption rates o f the various drugs should be monitored very closely vis-a-vis delivery times; (ii) for supply should be explored once the program is "settled"; (iii) m:an Procurement: alternative channels outside consultant may be brought into evaluate the use o fthe LMIS systemandto suggest ways to improve 3.6. Cost and Financing. The preliminary forecast for the ARV drugs i s attached. In contrast to many other health care programs the costs o f the ARV drugs make up a substantial portion of the total project cost. IV. Assessment of Logistics Issues related to the Dropram for "Center National de Transfusion de Sang (CNTS) n (Project sub-component 3: Expand Health Sector Responses for Prevention, Treatment and Care o fHIVIAIDS) 4.1. Rationale. The project includes a program for securing safe blood, i.e. as a prevention strategy for the spread for HIVIAIDS through tainted blood in transfusions. While the programmatic effort to expand the donor base is a prerequisite for this effort to succeed, the non-availability o f a small number of products will effectively render those efforts futile as the safety o f the blood cannot be assured, Specifically, quality reagents, test kits and blood bags must be available where and when they are needed. The Elisa test kits require cold storage and have a relatively limited shelf life (5 months). None of the other tests and supplies require cold storage andhave a longer shelf life. However, stock outs will quickly undermine the program. Since significant effort and resources will be invested in encouraging people to donate blood, stock-outs may have significant impact on the pay off o f these investments. Usingun-screenedbloodis not an option -it wouldruncounter to the entire strategy o fprevention-not to mention the risk to the bloodrecipient. For example, from 1997-2000 the two facilities inNouakchott and Kiffa suffered from several stock outs with serious effects on their ability to provide safe blood, As mentioned earlier, CAMEC i s not functioning effectively at this time. Given the consequences o f not having continuous and reliable supply o f high quality test, the focus o f this assessment is to identify, assess andrecommendways to meet the needso f the CNTSprogram inthis regard. 4.2. Objectives. The objective o flogistics i s to assure that the tests andother supplies that are needed for the CNTS program are continually and reliably available to the program, its donors and its patients. The focus o f this assessment i s therefore to: (i) identify and evaluate alternative procurement, storage, distribution and logistics management capacity on all levels o f the supply chain with regards to CNTS reagents, test and supplies; (ii) recommend an action plan to ensure reliable supply and quality o f all products; (iii) develop initial forecasting o fproduct needs; (iv) assist inproduct selection - 181- 4.3. DiagnosislAssessment. Product selection: The testing algorithms have already beendetermined -with one algorithm for the central site andone for the regional sites. These algorithms c o n f mwith WHO recommended approaches. Only the central site will useElisa (andeventually western Blot), which is the only product, apart for the collectedblood, requiring cold storage Forecasting: The forecasting was done by the CNTS. As neither donor nor CNTS services have not been offeredbefore at the regional level, the estimatesmustbe adjusted as the programrolls out and experience i s gained. As the programi s inits infancy stages, it is difficult to determine how quickly the program will actually expand. A simple but well functioning LMIS system i s absolutely key to capturing data to allow better forecasting as experience i s gathered e Procurement. Due to lacko fdata anda very new service programwith no historical track record, the forecast are liable to significant corrections. It is therefore important that the procurements are plannedwith maximumflexibility, particularly for Elisa andthe other products with short shelf life. This may include a general contract with orders placed every 3 -6 months or puttinginplace staggered delivery with the option o f changing the date o f delivery. Itwas determined that WHO can serve as a procurement agent for all products. However, note mustbe made o fWHO'Sleadtimes o f 3-4 months. The staff for the CNTSprogramhas not yet been selected. Itcan therefore not be determined what capacity will be available inthis regard. However, the CNTS, has experience procuring fromboth WHO anda localimporter. e Storagelwarehousing. Basedonthe forecasts, the small volume o fthe Elisatests anddiscussion with the PEV, the current coldstorage space at PEV is adequate inthe immediateto short term. The PEV has offered that his facility may be usedfor CNTS's needs, provided that the volume does not overwhelm their capacity andthat CNTS would pay for additional cold storage capacity (refrigerators), if needed. The CNHdoes have a small cold storagechamber, but it is incomplete disarray, as i s the rest of the warehouse. Inventory managementi s a serious issue for them. There, unless the CNTS can get sole use o fthis chamber, it shouldnot be consideredat this time. PEV's cold storage is very well organized, storagearea is clean, inventory clearly labeledandmanagedwith a LMIS software system. However, it i s questionable whether the storage space maybe adequate for future CNTS requirements. CNTS has included their own coldstorage facilities intheir budget which will be needed for storage ofblood. Distribution. With the relatively small number o f service delivery sites (1 central, 4 regional) in the first year, all o fthem locatedinmajor urbanareas, there i s no need for intermediate warehousing - products shouldbe delivereddirectly to the service delivery places. The CNTS programbudget includes 4 vehicles. Giventhat it i s expected that staffwill visit regional sites regularly for training, supervision, monitoring andcollection o fblood, they shouldbe able to easily handle the delivery o fproducts themselves. LMIS. There i s currently no LMIS inplace. Lack o f data will result ininaccurate forecasts, expiredproduct andpurchase o f commodities that is either too much or too little. 4.4, Recommendations for Implementation and Next steps Product selection. Once program is "settled", review product selection with a view to less expensive products. However, since most o fthe products are already relatively inexpensive, priority shouldbe on qualityandreliable delivery. Forecasting. Ongoing review o fthe forecasts as the numbero f sites grows andthe caseload expands. Procurement. The MOHSA should (i)select WHO as the supplier. Althoughthe processmay not be ideal, the emphasis on this point i s onreliability o f supply and quality; (ii)establish general contracts with WHO with flexible arrangementsfor order frequency and volumes, for example with orders placed every 3 -6 months or staggereddelivery with the optiono f changing volumes anddates o f - 182- delivery; (iii) specifications for the first order with WHO as soon as possible; (iv) sometime in Submit Year 1, place an order with the localdistributor o frapiddiagnostic tests to assess that capacity inaction andto develop a channel for back-up supply(local importersldistributorsarepart oflocalcapacity). e Storagelwarehousing. Develop anagreementwith PEV to use their storagespace for the Elisa tests andbloodbags. Forproducts that donot require coldstorage, determine the storagelocation inor close to the centralunititself, andconstruct a safe areathat meetsthe storagerequirements for the products. e LMIS.The systemneedsto bedrivenbyinformation. Thisrequiresthat early onintheproject, an L M S be inplace that capturesconsumption data. The systemwill bringtransparency as to where the inventory is and improve the forecasts for future commodities. The CNTSprogrambudget includes resources for computers andtraining, and anLMIS system shouldbe an integralpart o fthat. A consultant shouldbe brought inearly on to set the systemup correctly. 4.5. Monitoring & Evaluation: Forecasting: the inventory and consumption rates o fthe various products shouldbe monitored very closely vis-a-vis delivery times and expiration dates; Procurement: Assess WHO'Sperformance vis-&vis the needs o fthe programs. Alternative channels for supplymay be explored once the program is "settled"; m:,Anoutside consultant maybe brought into evaluate the use o fthe LMIS system and to suggestways to improve 4.6. Cost and Financing.-The preliminary forecast for the CNTSproducts is attached inannex 22. - 183- AdditionalAnnex 22: Forecast of HealthSupply MAURITANIA MULTISECTORHlVlAIDSCONTROL PROJECT Activities. Total $59,089 Total Product coat $88,815 Assumptions: Central level algorithm: Two ElisaTests; Regional sites algorithm: two different rapidtests, plannedin 16 sites; WestemBlot test notused; Pricesbasedon WHO quotes; All regular consumablesprovidedbythe MOHSA; Baselinecaseloadfor new central levelcenter: 600; Baselinecaseloadfor new regional levelcenter: 300; Caseloadincreasingby 20 percentperyear. basedon LJNFPAquotes. Treatmentwith ARV Total Drug Cost par patientpar ye6 650 Grand Total: I 372,0801 Assumptions: 10,000peopleHIVpositive; Prevalence0,57 percent; Assuming Senegalesealgorithm(many Mauritanians alreadytreatedin Senegal); Number ofpatientstreatedincreaseby20 percent per year; Total numberoftreatments distributedoversites; The prices herearebased on FixedDoseCombinations (FDC) which arefar lesscostly than individual drugs; 50 percent ofcaseswill useFDCandone supplementary drug; Wces basedon Doctorswithout Bordersestimates; All laboratoryequipmentandinfrastructure is inplace. Assumptions: All regularconsumablesprovidedby the MOHSA; STIneeds anddrugs arenot included. - 184- MotherTo ChildTransmission Total ProductCost: av.074 GrandTobl $26,165 Assumptions: Regionalsites algorithmtwo differentrapidtests; RegionalsitesNouadhibouandKiffa; WesternBlot Test not wed;Prices based on WHO quotes; Nevirapinedonatedfor free to programby BohringerIngelheim, ifapproved;Tabletform for mother, oralsuspensionfor child; Allregular consumablesprovidedby theMOHSA, Baselineis atotalof2,000 women visitingthe two sites. BloodTransfusion $284 649 Grand Total $828 8991 Assumptions: CentrallevelalgontbmElisatest: one site, BackupWestem Blood; Periphericlevel(Bloodbank): two rapidtests; Fundingsource for this budgetis the PASS; Onebloodgroupingkitusedfor 30 donors. - 185- Consumables Anllceptlu usage per facility, Total Antiseptics Total Product cost $68.250 Assumptions: all other regularconsumablesprovidedbythe MOHSA. Research Assumptions: AlgonthmOnerapidtest; Eachstudywill compnse 1000clients; Pnces basedonWHO quotes; All regularconsumablesprowded bythe MOHSA, Sentinel Surveillance Assumptions: AlgonthmOne rapidTest; Eachyear will survey20 groups of 100peopleeach;PncesbasedonWHO quotes ;All regular consumablesprovidedbythe MOHSA. - 186- AdditionalAnnex 23: Supervision Pian MAURITANIA MULTISECTORHlVlAlDSCONTROL PROJECT The project will needintensive supervision givenits fast-track preparation, the large spano factivities from the community to the national level, its blendo fpublic, private andcivil society implementation agencies, whose experience with HIVlAIDS programs varies considerably, andits multisectoral nature. The range o factivities inprevention, care, treatment andmitigation is complex andwill be implemented bymanyentities, whose capacity will needstrengthening. The Bank's supervisioneffort inthe first year will focus onthe following strategic areas. Comprehensive Approach to HIV/AIDS. Funding and executing a broad range o f HIV/AIDS activities across many sectors by multiple implementation agencies at the national and local levels, with a particular emphasis on scaling up existing programs and buildingcapacity, will require consistent and sustained support and coordination, including learning from other MAP and HW/AIDS programs from around the world. Ownership and Stakeholders. Experience has shown that the commitment and enthusiasm shown by stakeholders during project preparation needs to be maintained during early project implementationby accelerating funding o fprojects inboththe public sector andcivil society. While the Implementation Manual has been prepared in Mauritania with involvement of some stakeholders, this needs to be expanded, and supervision should focus on constantly adjusting the Implementation Manual to local realities. New Institutions. The SENLS is designed to facilitate and coordinate rather than to control and implement. Any new institution, however, implements its mission through actions. Supervision will focus, in particular, on assisting the SENLS to: (a) contract out key services and functions; and (b) empower the implementing agencies in the public sector and civil society by allowing them to make decisions onprogram activities andto participate inadjustingproject processesbasedon early lessonso f implementation. FiduciaryArchitecture. Financialmanagement, procurement, monitoringand evaluation, and implementation channels represent the core fiduciary responsibilities that need to be assessed and enhanced during supervision. The principle that program monitoring and evaluation i s part o f the fiduciary framework o f the MAPapproach i s new for Mauritania andwill require special attentionduring implementation. Objectivesand Scheduleof SupervisionMissions Duringthe first 12 months o f implementation, the project will have three formal supervision missions in addition to ad hoc visits by Bank staff in the Mauritania Country Office (on financial management and procurement) and from the UNAIDSlWorld Bank evaluation support unit in Washington (on monitoring and evaluation). The members o f the UNAIDS Thematic Group in Mauritania may also assist with supervision on an ad hoc basis in addition to: (a) assisting government ministries and civil society organizations to enhance project preparationto access MAP funding; and (b) improving the efficiency and effectiveness o f HW/AIDS programs through specialized technical expertise. - 187- The first supervision mission will be scheduled within the following few months after the Board approval to review the new staffing of the SENLS, and to participate in a formal project launch aimedat accelerating the preparation and funding o f first-year programs by public sector institutions and the submission o fproject proposals by civil society organizations. The second supervision mission will focus on providing assistance to ensure that: (a) the Implementation Manual has been adapted to early implementation experience; (b) existing programs are being scaled up and funded, especially in core public sector ministries and civil society organizations already working on HIV/AIDS; (c) capacity buildinghas started for agencies that require it; and (d) the SENLSi s operatingeffectively. The third supervision mission will focus on assisting Mauritania to hold an annual partnership review o f the project that would involve donors, the UNAIDS Thematic Group and stakeholders in the country. The review would (a) assess the performance o f the project during the first year o f implementation andmake any necessarydesign adjustments; (b) preview the programof activities for the second year; and (c) ensure that appropriate finding is available from the international community and from local resources. TheBank's SupervisionEffort The joint UNAIDSlWorld Bank progress review o f MAP Iin mid-2001 concluded that MAP projects require intensive supervision using multi-sectoral teams that can provide implementation assistance in a variety o f sectors, The Bank preparation team will be carried over into the first year o f supervision, enhancedby: (a) increased reliance on the Country Office for periodic visits between formal supervision missions; and (b) the possibility o f support from the members o f the Mauritania UNAIDS Thematic Group as it adds capacity. It i s expected that the supervision budget for the first 12months will exceed the Bank norm. Indicative cost o f supervision for the first 12months o fthe project is estimated at US$200,000 andhasbeen incorporatedinto the CD's budget for FY04. Each mission i s expected to last for two weeks or more and comprise between four and six members. About 25-30 total staff weeks will be required for the first three supervision missions, in addition to approximately eight non-mission staff weeks. Technical skills required by a mission will depend onrelevant implementation issues each time, The necessaryspecialists are likely to include: First supervision mission: TTL, procurement, financial, M&E,health, civil society expert Second supervision mission: TTL, civil society expert, education, institutional capacityexpert Thirdsupervision mission: TTL, health, social, financial, procurement Financial management, procurement, and civil society support from the Bank's Mauritania Country Office will be on anad-hoc basis inadditionto scheduled missions. - 188-