Document of The World Bank Report No: 21458-GH PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT IN THE AMOUNT OF SDR19.6 MILLION (US$25.0 MILLION EQUIVALENT) TO THE REPUBLIC OF GHANA FORA AIDS RESPONSE PROJECT (GARFUND) DECEMBER 8, 2000 Human Development III Africa Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective 11/21/00) Currency Unit = Cedis Cedis 1.00 = US$0.0001474 US$1.00 = 6781.5 FISCAL YEAR January I December 31 ABBREVIATIONS AND ACRONYMS ACTafrica AIDS Campaign Team for Africa AIDS Acquired Immune Deficiency Syndrome CAS Country Assistance Strategy CBO Community based Organization CDF Comprehensive Development Framework CHAG Christian Health Association of Ghana CIDA Canadian Intemational Development Agency DA District Assembly DAC District AIDS Committee DANIDA Danish Intemational Development Assistance DHS Demographic and Health Survey DFID Department for Intemational Development (UK, formerly ODA) DHS Demographic and Health Survey DPP Detailed Procurement Plan DRI District Response Initiative FINMI Financial Management Initiative GAC Ghana AIDS Commission GDP Gross Domestic Product GPP Global Procurement Plan GOG Govemment of Ghana HIV Human Immunodeficiency Virus HSPSP Health Sector Program Support Project ICB International Competitive Bidding IDA International Development Association IEC Information, Education, Communication IPAA Intemational Partnership Against AIDS in Africa KAPB Knowledge, Attitude, Practices and Behavior MAP Multi-Country HIV/AIDS Program MDAs Ministries, Departments, District Assemblies MIS Management Information System MOH Ministrv of Health MOU Memorandum of Understanding MTCT Mother-To-Child Transmission NACP National AIDS/STD Control Program NCB National Competitive Bidding NGO Non-Governmental Organization OM Operational Manual PLWHA People Living with HID/AIDS PMTCT Prevention of Mother-To-Child Transmission QCBS Quality and Cost Based Selection SA Special Account SBD Standard Bidding Documents SOE Statement of Expenses STD Sexually-Transmitted Diseases UNAIDS Joint United Nations Programme on HID/AIDS UNDB United Nations Development Business USAID United States Agency for International Development VCT Voluntary Counseling and Testing Vice President: Callisto Madavo (AFR) Country Manager/Director: Peter C. Harrold Sector Manager/Director: Rosemary Bellew Task Team LeaderTask Manager: Sandra Rosenhouse GHANA AIDS RESPONSE PROJECT (GARFUND) CONTENTS A. Project Development Objective Page 1. Project development objective 2 2. Key performance indicators 3 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 4 2. Main sector issues and Government strategy 4 3. Sector issues to be addressed by the project and strategic choices 7 C. Project Description Summary 1. Project components 9 2. Key policy and institutional reforms supported by the project 10 3. Benefits and target population 11 4. Institutional and implementation arrangements I1 D. Project Rationale 1. Project altematives considered and reasons for rejection 13 2. Major related projects financed by the Bank and other development agencies 13 3. Lessons learned and reflected in proposed project design 14 4. Indications of borrower commitment and ownership 16 5. Value added of Bank support in this project 16 E. Summary Project Analysis 1. Economic 16 2. Financial 18 3. Technical 18 4. Institutional 18 5. Environmental 19 6. Social 19 7. Safeguard Policies 21 F. Sustainability and Risks 1. Sustainability 22 2. Critical risks 22 3. Possible controversial aspects 24 G. Main Conditions 1. Effectiveness Condition 25 2. Other 25 H. Readiness for Implementation 25 I. Compliance with Bank Policies 25 Annexes Annex 1: Project Design Summary 26 Annex 2: Detailed Project Description 29 Annex 3: Estimated Project Costs 33 Annex 4: Cost Benefit Analysis Summarvkc,t f- :tiveness Analysis Summary 34 Annex 5: Financial Summary for Revenue Eaming Project Entities 35 Annex 6: Procurement and Disbursement Arrangements 36 Annex 7: Project Processing Schedule 45 Annex 8: Documents in the Project File 46 Annex 9: Statement of Loans and Credits 49 Annex 10: Country at a Glance 48 MAP(S) IBRD 26553 GHANA AIDS Response Project (GARFUND) Project Appraisal Document Africa Regional Office AFTH3 Date: December 8, 2000 Team Leader: Sandra Rosenhouse Country Director: Peter C. Harrold Sector Manager: Rosemary Bellew Project ID: P071617 Sector(s): MY - Non-Sector Specific Lending Instrument: Specific Investment Loan (SIL) Theme(s): Health/Nutrition/Population Poverty Targeted Intervention: N Project Financing Data [ ] Loan [X] Credit [ ] Grant [ ] Guarantee [ ] Other: For Loans/CreditslOthers: Amount (US$m): 25.0 Proposed Terms: Standard Credit Grace period (years): 10 Years to maturity: 40 Commitment fee: 0.5% Service charge: % Financing Plan: Source Local Foreign - Total BORROWER 1.80 0.00 1.80 IDA 23.00 2.00 25.00 LOCAL COMMUNITIES 1.00 0.00 1.00 Total: 25.80 2.00 27.80 Borrower: GOVERNMENT OF GHANA Responsible agency: GHANA AIDS COMMISSION Address: Ministry of Employment and Social Welfare P.O. Box CT 5169 Contact Person: Mr. Alhaji Muhammad Mumuni, Minister of Employment and Social Welfare Estimated disbursements ( Bank FYIUS$M): . FY - ; ---2001 2002 2003 2004 2005 Annual 2.00 6.00 6.00 7.00 4.00 Cumulative 2.00 8.00 14.00 21.00 25.00 Project implementation period: 4 years Expected effectiveness date: 04/30/2001 Expected closing date: 06/30/2005 OCSPADFl, RP Md 2X0 A. Project Development Objective 1. Project development objective: (see Annex 1) The objective of the Garfund is to reduce the spread of HIV infection, and reduce thc impact of AIDS on those infected and their families by financing interventions outside the MoH's mandate. Project Purpose: The main purpose of the Ghana AIDS Response Fund (Garfund) is to support the implementation of the Government's effort to reduce the spread of the HIV/AIDS epidemic and reduce the impact on those already infected and affected as articulated in the "Strategic Framework for HIV/AIDS in Ghana." The framework enables the Government of Ghana (GoG) to implement a balanced, diversified multi-sector response, engaging all relevant government sectors, non-governmental organizations and grassroots initiatives. To date, the Ministry of Health (MoH), which is already receiving donor/IDA support through the Health Sector Program Support Project (HSPSP, Cr. 2994-GH), has led the fight against HIV/AIDS. The MoH Program of Work supported by the donor partnership supports AIDS prevention and care activities, some of which is provided through other entities. However, its contribution to engage civil society in the fight against AIDS has been insufficient. Thus, the GoG has requested access to IDA resources within the framework of the first phase of the Multi-Country HIV/AIDS Program (MAP) for the Africa Region approved by the Board of Directors of the World Bank Group on September 12, 2000, to expand its response. IDA resources would finance eligible activities conducted by civil society organizations including NGOs, CBOs, trade and professional associations, associations of PLWHAs, Districts, among others, or groups of these entities and line ministries (excluding the MoH) to complement the MoH's ongoing program and in this way ensure a rapid multi-sector scaling up of activities in all regions of the country and all administrative levels. Eligible activities include prevention, care and support activities for those affected, prioritizing community-level responses. While the fund would initially be funded by IDA, other development partners are expected to contribute. Compliance with MAP Eligibility Criteria: Ghana satisfies the four MAP eligibility criteria: (a) satisfactory evidence of a strategic approach to HIV/AIDS: Garfund is the product of a series of government sponsored actions involving all key line ministries, stakeholders and the donor partnership, under the guidance of UNAIDS. Among the GoG's efforts are the analysis of Ghana's response to the epidemic, and a draft Strategic Framework for HIV/AIDS in Ghana. The contents of the project itself include the needs and strategies identified in the documents prepared by the GoG, the comments of the GAC, and the views of stakeholders consulted. Thus, the project design is based on a broad national consensus of what needs to be done to combat HIV/AIDS. (b) the existence of a high-level coordinating body with broad representation from all sectors: The Ghana AIDS Commission has been established in the Presidency, including all key line ministries, representatives from various religious organizations, labor unions, students and women's groups as well as networks of NGOs working with HIV/AIDS and representatives of associations of PLWHAs. (c) agreement to appropriate implementation arrangements to finance activities directly in communities The project will finance activities in communities directly by financing proposals submitted by civil society -2 - organizations at the local level, and by financing District level initiatives. In order to expand access to funds to the local level more rapidly, larger civil society organizations (affiliations) will be encouraged to manage subcontracts to several communities. The Government has also agreed to contract out subproject supervision, project evaluation, training, and knowledge management in order to be more agile and accelerate implementation. (d) agreement tofiund multiple implementation entities, specially community-based and non-governmental institutions: Implementation of activities will be conducted by line ministries other than the MoH, and by the NGO/CBO sector, and a growing number of district governments. The bulk of activities are to be conducted by NGOs and civil society organizations. 2. Key performance indicators: (see Annex 1) It may be difficult to detect changes in impact indicators during the four years of implementation of Garfund. Thus, intermediate outcome measures are also included. The following indicators illustrate the three groups of core variables that will be employed to monitor the performance of the fund. A more extensive list of indicators is included in the logical framework (see Annex 1) A. Output Indicators Increase the proportion of funds awarded to CBO submitted subprojects (through windows B and C) to 20% of all subproject funding by 2005 Increase the proportion of all subprojects that develop IEC materials designed specifically for rural populations (in local dialects) to 30% by 2005 By 2005, 50% of all 1 st and 2nd cycle schools are providing HIV/AIDS education. By 2005, all line ministries (except MoH) have trained trainers at the district level on IV/AIDS. Increase by 50% the number of districts that provide community-based care for PLWHA. R Process Indicators By 2005, an adequate referral system between home-based and institution-based care has been established in 40% of Districts. Increase to 100 the number of Districts that have prepared strategic plans to confront IIV/AIDS by 2005. Increase by 10% annually the proportion of subprojects that are meeting their stated objectives in a satisfactory manner. Increase the proportion of existing affiliations (umbrellas) that are able to manage smaller civil society organizations to provide services by 30% by 2005. All Districts receive regular (quarterly) "best practice" informational materials from the Project. C. Impact /Outcome Indicators Increase the proportion of women in a union using condoms during their last intecourse from 6% to 20% by 2005. Increase the proportion of men in a union using condoms during their last intercourse from 15% to 30% by 2005. - 3 - Increase the proportion of men and women who have reduced the number of sexual partners in response to perceived risk from 60% to 80% by 2005. Increase the proportion of PLWHA that are receiving home or community based care among those PLWHA that have sought medical treatment through the MoH network to 30% by the year 2005. B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex l) Document number: 20185-GH Date of latest CAS discussion: March 30, 2000 The Ghana CAS was prepared on the basis of CDF principles, and thus also addresses the activities of other donors in its response to Ghana's development agenda. The current CAS's overriding goal is to eliminate hard core poverty. The strategy outlined by the Government specifically seeks to (i) reduce poverty in rural and urban areas, (ii) strengthen the poor's income generating capacity, (iii) reduce gender and regional disparities, and (iv) improve the health, education and productivity of the population. The World Bank Group is supporting the proposed business strategy by helping the Govemment: (i) raise the growth rate of the economy; (ii) redefine the role of the State; and (iii) implement their strategy more effectively on the ground. As part of its support to redefine the role of the State so that it can efficiently provide public goods and services and ensure an equitable distribution of benefits, the CAS specifically identifies the need to continue to provide sector-wide support to the health sector in Ghana, and the urgent need to address the spread of HIV/AIDS through a multi-sector approach before it becomes a more generalized epidemic. This proposed project specifically addresses the need to control the spread of the HIV/AIDS epidemic through a multi-sector strategy. Garfund is expected to have a direct effect in increasing condom use amongst men and women to reduce the spread of HIV, a variable which will be measured as part of the CAS performance indicators. 2. Main sector issues and Government strategy: The Dimensions of the HIV/AIDS Epidemic in Ghana It is estimated that about 4.6 percent (1999 NACP) of the adult population of Ghana is infected with HIV. At least 400,000 Ghanaians are estimated to be living with HIV. Prevalence almost doubled between 1994 and 1998. At current rates of infection, it is estimated that 1.2 million Ghanaians will be infected by the year 2005. Prevalence rates are highest among commercial sex workers, with rates as high as 82 percent in Kumasi in the Ashanti region. The actual number of AIDS cases is difficult to estimate given the strong stigma associated with the disease and the culture of silence it imposes. While the epidemic has not reached the crisis dimension evident in other African countries, a failure to act now could have serious consequences as HIV prevalence rate has been known to accelerate rapidly once it reaches 5 percent of the population. Without concerted intensified action to reduce its spread now, Ghana's recent benefits from improved macroeconomic performance will be diminished. Even now, at current levels of infection, HIV/AIDS has had a serious impact on families and communities, with concomitant repercussions on the wider economy. The primary mode of transmission of HIV in Ghana is heterosexual, accounting for 80 percent of the cases. Vertical transmission accounts for 15 percent and transmission through blood and blood products accounts for another 5 percent of cases. While the male to female ratio was 4:1 in 1996, the gap closed considerably to 2:1 in 1998. -4 - Most of the people infected with HIV are young. Peak ages for reported AIDS cases are 25-29 for females, and 30-34 for males. Ninety percent of all reported AIDS cases occur to adults aged 20-49, the most economically productive years of life. This represents economic losses in terms of productive labor days lost due to increased absenteeism and reduction of the labor force, eroding the social and economic development accomplished in recent years. Added to this is the increased burden on the Ministry of Health budget and the strain on families and communities resulting from expenditures incurred in taking care of the ill and the increasing number of orphans left behind. There are an estimated 126,000 orphans in Ghana, and the figure is estimated to increase to over 250,000 by 2004. The context and manner in which HIV infection occurs and the long delay in the onset of full blown AIDS make it a complex illness to address. The fact that HIV/AIDS is sexually transmitted makes it difficult to address modes of prevention publicly. And, because onset of visible symptoms is so delayed, individuals are often unaware they are infected, infecting others unintentionally. Moreover, its invisibility makes the community unaware of the extent of the problem. The considerable stigma associated with the disease only serves to complicate matters as it forces many people living with HIV/AIDS (PLWHA) to remain silent and hidden from the community and sometimes their own family and to not seek care when needed. The stigma imposes extreme hardship on those infected as they lack economic and social support. Women are particularly vulnerable as a result of their position in society (both economic and cultural), the culture of silence surrounding the disease making it impossible for women to negotiate safer sex, their desire to bear children, and limited information on sexuality and disease. The fact that 3 percent of the reported AIDS cases among females are to girls aged 15-19 only serves to underscore this point. Women are also more affected in that the burden of caring for the sick generally falls on them. The Response to the Epidemic to Date As has been clearly demonstrated by some countries in Africa and in other parts of the world, it is possible to prevent an explosive growth in the HIV/AIDS epidemic and limit its adverse impact. While the national response to the epidemic has improved, the Government recognizes that it is still inadequate, as it is too focused on health sector interventions and insufficiently funded. The response to date has been primarily the responsibility of the Ministry of Health (MoH). The MoH is currently receiving support through the Health Sector Program Support Project (Cr. 2994 -GH) which became effective on June 18, 1998. The total program cost is estimated at $824 million. The program is co-financed by the GoG and partners including DFID, DANIDA, the Nordic Fund, the Netherlands, the European Community and IDA, with a credit of US$35 million equivalent. Additional earmarked funds are available from USAID and CIDA. The Credit supports the Ministry of Health's sector-wide reform program, financing a time-slice of the combined Govemment and extemal assistance budgets for developmental and operational activities. The Plan of Work (POW) of the Ministry of Health identifies HIV/AIDS as one of the key/priority services, along with immunization, management of malaria, TB, maternal and reproductive health, and the eradication of the Guinea Worm. While the health sector response to the epidemic needs to be strengthened, it has made some notable advances. Training for syndromic management of STDs has been carried out widely and effectively, all blood for transfusion is being screened, providers are improving infection prevention practices including use of clean needles and sterilization practices and the sentinel surveillance system is functioning well. However, there are some weaknesses that need to be addressed. With respect to the MoH's clinical response, STD management, and clinical care for PLWHA, need to be strengthened, access to TB drugs improved, and the process of implementing activities to prevent mother-to-child transmission (MTCT) accelerated. On the prevention side, Voluntary Counseling and Testing (VCT) - 5 - services must be expanded, including adequate supply of HIV diagnostic tests. IEC materials need to be more plentiful and accessible, and efforts on peer and group counseling should be strengthened. Condom use should be more strongly promoted. As for home-based care and social support for PLWHA, efforts conducted primarily by the Christian Health Association of Ghana (CHAG) need to be expanded. It is important that the MoH scale up its current response in order to ensure it can address demand for prevention and care generated by a multi-sector effort. Government Strategy National awareness of the spread of HIV/AIDS dates back to the mid-eighties when the GoG established the National Technical Committee on AIDS. Soon after, the National AIDS/STD Control Program (NACP) was established within the MoH to coordinate the national response to the epidemic. However, its impact has been limited. Part of the reason is that prevention works primarily through behavior change, and the NACP/MoH has focused more on medical/clinical aspects and less on IEC and community initiatives. An October 1999 mission of the International Partnership against HIV/AIDS in Africa noted the need for a multi-sector approach to increase the effectiveness of the GoG's response. The GoG established a multi-sector national commission to coordinate all HIV/AIDS activities in the country. It also assessed the adequacy of its response to the epidemic to date and based on the results, developed a National Framework for HWV/AIDS in Ghana. The objectives of the Strategic Framework for HIV/AIDS in Ghana (Sept, 2000 draft) are to: (a) reduce new HIV infections by 30 percent by 2005; (b) improve service delivery and mitigate the impact of HIV/AIDS on individuals and families; (c) create an enabling environment for the implementation of the strategic framework; and, (d) establish a multi-sector and multi-disciplinary institutional framework for the coordination and implementation of HIV/AIDS programs in Ghana. The guiding principles for this effort include: (a) the adoption of a multi-sector public and private partnership approach; (b) respect for fundamental human rights and appropriate cultural norms and practices; (c) access to appropriate information and comprehensive basic services; (d) decentralized implementation, community participation and individual responsibility in all HIV/AIDS programs; and, (e) mobilization of adequate financial and human resources to implement the framework. This project would provide support in the financing of a fund to assist in the expansion of the GoG's response to the HIV/AIDS epidemic by financing eligible activities conducted by civil society organizations including NGOs, CBOs, trade and professional associations, associations of PLWHAs, and line ministries (excluding the MoH) to complement the MoH's ongoing program, through a rapid multi-sector scaling up of activities nationwide. While the fund would initially be funded by IDA, other development partners are expected to contribute. The fund will implement the part of the National Strategic Framework for HIV/AIDS that is not being implemented by the MoH. Partnership. Garfund was born out of a series of consultations between the GoG and the donor partnership. UJNAIDS has been the main force behind the multilateral collaboration with the GoG, and has been instrumental in securing government commitment. Working with the HIV/AIDS thematic group, UNAIDS has guided the work of the inter-ministerial task force that was set up to assess the HIV/AIDS situation in Ghana and define a framework to confront the epidemic. The donor partnership is already financing a number of activities to combat HIV/AIDS in Ghana (refer to section D) and is currently - 6 - assessing how best to ensure the success of Garfund. DFID has already committed to finance technical assistance to help line ministries develop their action plans for HIV/AIDS well before effectiveness, as well as to assist in the expansion of the District Response Initiative to enable more districts to access funds at project start-up. USAID will support the equipping of the Secretariat's premises. 3. Sector issues to be addressed by the project and strategic choices: Given the complex nature of HIV/AIDS, the context in which it is spread, and the rapid growth of the epidemic, the response needs to be broad-based, including all relevant levels and sectors of govemment and society, rapid and flexible. While a freestanding project to fund HIV/AIDS initiatives from all sectors including health was initially considered, it was discarded as it would seriously undermine the spirit of the ongoing Health Sector Program Support Project and the partnership arrangements in the health sector. Recognizing the emergency nature of the problem, and the need for flexibility. Garfund will be managed as a fund. To ensure a broad-based response the fund will finance eligible activities proposed and conducted by civil society organization;, districts and line ministries (excluding the MoH) to complement the MoH's ongoing efforts to reduce the spread of HIV/AIDS. Community-based responses will be prioritized. Issues to be addressed by Garfund comprise two general groups: institutional/logistic issues, and programmatic issues. On the institutional aspects, three key issues being addressed are: the difficulty of coordinating multiple executors to ensure synergy; low implementation capacity in some line ministries, districts and smaller civil society organizations; and, ensuring the active participation of grassroots organizations and districts. On the programmatic side, two issues need to be addressed: increasing awareness of personal risk and encouraging adoption of safe practices in light of the invisibility and culture of silence, and the provision of care and support to PLWHA and their families in light of scarce resources and the stigma that prevails. Coordination of a Balanced Multi-sector National Response: Ensuring an effective, balanced, and truly multi-sectoral approach entails close coordination between the health sector and other sectors participating in the national initiative. Duplication of efforts needs to be avoided and gaps in coverage need to be minimized. Inputs by all relevant sectors need to be adequate and timely both in terms of their involvement in the strategic coordination of the national response, as well as in the implementation of their individual sector commitments. Adequate timing of interventions is key to ensure synergy and a maximized response. The GoG has already taken a number of steps in this direction: (a) it has developed a Strategic Framework for HIV/AIDS in Ghana based on a situation analysis and a response analysis conducted by multi-sector teams employing a participatory approach, with constant interaction with HIV/AIDS Oversight Committee set up by the GoG; and (b) it has established the Ghana HIV/AIDS Commission in the Presidency which includes high level representation of all key sectors and an executive arm to implement the Strategic Framework. However, a solid and balanced multi-sector response also requires a stronger and more focused response from the health sector to ensure the necessary synergy will be generated. IDA will continue to support the MoH's efforts to improve access to HIV/AIDS prevention, care and treatrnent of opportunistic infections, provide better quality of care and improve the overall efficiency of its efforts. Assurances will be obtained from the MoH that it will give greater priority to HIV/AIDS in its annual POW and that it will increase its budget allocation to HIV/AIDS interventions. An action plan of the activities to be scaled up will be prepared and discussed as part of the discussion of next year's POW. Areas where the MoH needs to improve its response have been identified in the "Response Analysis". They include increasing access to voluntary counseling and testing services (VCT) including in terms of physical availability and cost, defining a policy on prevention of mother-to-child transmission (MTCT) and implementing it, increasing - 7 - access to condoms, and increasing coverage of treatment of opportunistic infections and other clinical needs of PLWHIAs. Low Implementation Capacity of Executors. Implementation capacity is uneven across line ministries, and the majority have not worked on WHV/AIDS in the past. In the case of small NGOs, CBOs and districts, implementation capacity can be even lower. Garfund would provide, when needed, technical assistance and training support on basic project management, techniques to improve IEC effectiveness (including interpersonal communication skills) and induce behavior change, approaches to home-based care, and basic knowledge on HIV/AIDS prevention and care, among others. Umbrellas and large civil society organizations with solid implementation capacity will be able to work with groups of small NGOs, CBOs and districts with lower capacity which will, in the process of subproject execution, slowly strengthen their capacity. Working with group subprojects will also allow for a more rapid response to HIV/AIDS. Ensuring active participation of grassroots organizations, districts, and civil society. A broad-based response implies action on every front, particularly at the grass-roots level where links with the community are strong. Their participation is crucial as they can best address delicate, taboo subjects and can work with farnily members in the community to reduce the stigma and the barriers to "coming out" about HIV/AIDS status. Civil society organizations also have the added benefit of being more flexible and innovative in their approaches to the epidemic. Garfund will ensure participation of the smaller organizations by actively seeking proposals from them and providing technical support in their preparation. A communications campaign describing the purpose of Garfund, how to access financing and what may be financed will be implemented early on and before each funding cycle. More targeted carnpaigns will be carried out to reach CBOs in specific areas. To encourage participation, the smaller groups would get some seed funds to initiate some activities which could be expanded through a subsequent more formal proposal at a later date. Working through umbrella organizations (affiliation networks), Garfund will facilitate access to associations that may be otherwise difficult to reach. Encouraging Adoption of Safe Practices. The culture of silence and the fact that the onset of AIDS takes place many years after infection contribute to the general population's lack of awareness of the extent of the epidemic and the risks they, as individuals, actually face. Without the awareness of personal risk of infection, behavior change will be difficult. While awareness of AIDS is universal in Ghana, knowledge on how to avoid HIV/AIDS is not. Moreover, over half of all men and women (DHS, 1998) did not perceive any risk of getting AIDS, with women perceiving themselves to be at lower risk than men. And, of those perceiving high risk, 20 percent did not modify their sexual behavior. Increasing awareness of personal risk and existing prevalence will both, encourage adoption of safe practices, and reduce the stigma attached to the disease. Garfund would support IEC initiatives employing some mass media, but focused primarily on interpersonal communication through peers, small groups or other one-on-one encounters, which tend to be more effective in transmitting sensitive messages. Messages would include the promotion of VCT and prevention of MTCT, and the need to seek diagnosis and treatment of STDs. This would complement the MoH's strengthening of its VCT capability. Garfund would also support advocacy in various contexts to ensure the message is disseminated. Work with the Ministry of Education would provide another venue to raise awareness and inform youth. Work with the Ministry of Food and Agriculture would work with extension workers to reach farmers. Condom promotion and distribution would also be supported. Provision of care and support to PLWHA and theirfamilies: The stigma attached to the disease and the insufficient knowledge about how AIDS can be prevented pose unnecessary hardship for PLWHAs and their families. They represent important barriers to seeking care, and the abandonment by their families and - 8 - loss of employment can leave individuals destitute and without any psychological and social support. Illness and death leave many children orphaned in practical and real terms. Garfund will encourage IEC activities to dispel misconceptions about HIV/AIDS, and educate family members and the community about how to care for PLWHAs in their own homes or community hospices. It will support initiatives to mobilize the community to provide social support and the creation of income generation initiatives for PLWHA and their families. Garfund will also provide support to community initiatives to care for orphans, and provide counseling for PLWHA and their families in their homes. Home care, including some nursing services would also be covered. Garfund would also support training tmditional healers and traditional birth attendants to teach them how to protect themselves and their clients, and how to ensure their current practices are safe. Garfund will also finance initiatives designed to protect PLWHAs rights, including the definition of policies against discrimination in the work place and with regard to access to care. C. Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown) Indicatie , . a __... % Of .-- . ==Compon .. . Secfor 'C % of inancg B-nk- =.__________ _ = . US$M)< Total (US$M)... i,y.fi fitacin9 Prevention and Care Services AIDS, STDs 21.00 75.5 18.90 75.6 Strengthening Public/Private AIDS, STDs 2.40 8.6 2.40 9.6 institutions for HIV/AIDS Control Knowledge Management AIDS, STDs 1.40 5.0 1.00 4.0 Project Management (Incl. M&E) AIDS, STDs 3.00 10.8 2.70 10.8 Total Project Costs 27.80 100.0 25.00 100.0 Total Financing Required 27.80 100.0 25.00 100.0 The Project, Garfund, would finance a US$25.0 million, 4-year component of the Government's Strategic Framework for AIDS, and would cover all activities not within the MoH's mandate (refer to annexes 5 and 6 for procurement and disbursement, and financial management). Garfund's objective is to intensify multi-sector activities designed to combat the spread of -HV/AIDS and to reduce its impact on those already affected. To achieve its objective, the project includes support for the following activities: Prevention and Care Services by financing governmental (excluding health) and civil society7 entities to provide a broad spectrum of preventive and care activities at national, regional and local levels. Seventy percent of funding will be allocated to these activities out of which approximately 75%, or US$15.0 million, will be earmarked for non-governmental and community-based initiatives. The size of any single activity financed under the fund is not expected to be large (generally less than US$100,000). Prevention activities are designed to reduce high risk behavior and exposure to risk, and to reduce the vulnerability of those who are unaware of their risk by raising their awareness, and "de-stigmatizing" the disease so as to increase access to prevention and care. For families affected by HIV/AIDS, Garfund would reduce their vulnerability by financing services to protect their rights, income generation activities, care for orphans and home-based care for the ill. -9- Access to funds for the financing of proposals would be available through three windows, each with slightly different access rules. The first group (Group A) includes proposals from line ministries, and will finance activities for internal and external clients. The second group (Group B) includes financing for proposals from civil society organizations including NGOs, CBOs, trade and professional associations, associations of PLWHAs, Districts, among others, or groups of these entities, including affiliation networks (umbrella organizations). The third group (Group C) would provide seed money for activities conducted by very small CBOs and associations. not to exceed $2500 up front to engage in activities defined in a letter of irtent. Strengthening Public/Private institutions for HIV/AIDS Control and Care Giving by supporting training and technical assistance for institutions on technical and practical aspects of working with HIV/AIDS, and when required, some training on community participation and project management. Only entities implementing subprojects are eligible for training. The training will be subcontracted to NGOs and line ministries with expertise on the issue in question. Financing of this component will strengthen the impact of activities financed under Component 1. Knowledge Management by providing support for the establishment of a mechanism/strategy to collect, organize and disseminate up to date information on AIDS prevention and care, best practices of existing projects, research results, and any reports that would be useful to implementing entities. It would also finance activities to bring together subproject representatives to share experiences with subprojects with similar orientations. Financing of this component will strengthen the impact of activities financed under Component 1. Project Management. See Annex 5 for details. Garfund will also have a Monitoring and Evaluation subcomponent that will assess the progress attained in the fight against AIDS nationwide on the basis of the targets defined in the Strategic Framework and will monitor the advance of Garfund financed activities. (Refer to annex 4 for details). 2. Key policy and institutional reforms supported by the project: Ghana AIDS Response Fund (Garfund) is a multi-sector operation designed to support the implementation of the Government's effort to reduce the spread of the HIV/AIDS epidemic and reduce the impact on those already infected and affected as articulated in the "Strategic Framework for HIV/AIDS in Ghana". The operation does not intend to address long-term sector and institutional reforms within any one sector, nor to include conditions linked to macroeconomic or sector policies. However, Garfund will strengthen several key policy and institutional changes, i.e. it will: (a) establish the National HIV/AIDS Program coordination, under the Ghana AIDS Commission under the office of the President, making it more independent of the Ministry of Health, and giving other sectors, including civil society, a greater role. The institutional arrangement should strengthen the GoG's capacity to implement a balanced. diversified multi-sector response, engaging all relevant government sectors. non-governmental organizations and grassroots initiatives; (b) mainstream HIV/AIDS control into the action plan of everv of Government agency, at National and District levels; (c) strengthen the public private partnership in HIV/AIDS control; and (d) empower communities to be key players in HIV/AIDS control. - 10- 3. Benefits and target population: The proposed project is expected to: (a) reduce the risk of contracting HIV in both the population at large and vulnerable and high-risk groups by seeking to induce behavior change through the personalization of risk and increased access to information (including both HIV and STD infections), and the provision of condoms. The benefit to women will be greater, given their greater lack of information on HIV/AIDS and their inability to negotiate safer sex in a context of the culture of silence that prevails and traditional role expectations; (b) reduce rates of mother to child transmission by providing information on its prevention and alternatives to breast feeding (c) improve the quality of life for those living with AIDS by providing care and support in the community, working with the community to reduce stigma, and ensuring a closer link with the health sector; (d) provide support to families affected by AIDS by providing access to income generating activities, support for orphans, among others; (e) improve the ability of civil society, including communities, NGOs, trade and professional organizations, etc. to respond to the epidemic and strengthen prevention efforts; (f) mainstream HIV/AIDS into line ministry work programs to ensure long term, sustainable change, and, (g) reduce future costs of care, treatment, and orphan care. 4. Institutional and implementation arrangements: Institutional Arrangements: Garfund is expected to be implemented within a four-year period. The proposed project would be placed under the authority of theGhana AIDS Commission (GAC) which would be in charge of the definition of broad priorities for action, the selection of eligible proposals (through a technical subcommittee), and the monitoring of the performance of the project. The Secretariat of the GAC would implement the GAC's decisions. The GAC includes high level representatives of all line Ministries that can play a role in the fight against HIV/AIDS, religious, occupational, NGO affiliations, women's and student organizations and other interest groups. It is located in the Presidency under the chairmanship of the President. The vice-chairmanship of the GAC will rotate every year. The current vice-chair is the Minister of Employment and Social Welfare. The Secretariat of the GAC would be responsible for the financial and administrative aspects of Garfund, as specified in a detailed operational manual. It would contract the necessary technical support to guide executing entities support in preparing proposals and implementing subprojects. The Secretariat would provide entities awarded contracts under Garfund with basic training on financial management and procurement procedures in order to ensure compliance with Bank procedures. It would prepare and administer contracts to selected executing entities and monitor their technical and financial performance. The Secretariat would provide financial and technical reports on a quarterly basis to the GAC, and prepare annual reports for financing agencies. The Secretariat would also ensure annual audits are carried out in accordance with agreements with IDA and ensure the use of funds follows procedures agreed upon with IDA as specified in the Credit Agreement and the operational manual. - 11 - To be responsive and agile, it is important that the staff be composed of highly qualified and politically neutral professionals. For the purposes of administration of the project, the Secretariat would need a coordinator, a finance and administration division with 34 key staff including procurement capacity, and a technical division including 4-5 full-time specialists, and support staff, to provide technical guidance in the day-to-day issues of implementation, monitor technical aspects of the project, identify technical assistance needed to ensure adequate support to subprojects, oversee the knowledge management activities, keep the GAC informed about key technical issues that arise during implementation, and be responsible for the overall monitoring and evaluation of the project. With regards to the finance and administration division, it is expected that the financial component will be larger than the procurement aspects as most procurement will be some limited goods, and many contracts for services and technical assistance. the majority of which are expected to be small. Implementation Arrangements: Garfund will employ a fund mechanism to finance subprojects executed by a wide range of organizations at the national, regional and local levels. The GAC will select atechnical subcommittee to review and select subproject proposals on a semiannual basis and to submit its recommendations to the GAC for their final endorsement. The membership of the subcommittee will be public and will rotate on an annual basis. The Secretariat would call for proposals, receive and assess them for completeness, and, once selected by the technical subcommittee with the endorsement of the GAC, would process and finance the contracts. In the case of line ministries, they would submit proposals based on previously prepared action plans to address HIUV/AIDS. To access funds, line ministries will have to have had defined a line item for HIV/AIDS in their budget and contribute their own matching funds. To ensure subprojects address local needs and minimize duplication, all implementing entities (NGOs, civil society, CBOs) need to secure the endorsement of the Districts they are working in. To streamline project selection and to ensure local needs are addressed, proposals in Group C will be reviewed and selected by District authorities (eventually the District AIDS committees once they are established) who will submit their recommendations to the Secretariat. When the Secretariat makes the call for proposals it will inform Districts approximately how much they may have available to finance subprojects. The indicative amount would be population-based, and would not be disbursed unless letters of intent/proposals have been submitted. Districts would submit their recommendations for funding to the Secretariat who would issue the necessary contracts. As implementation proceeds and the capacity of districts is ascertained, the process could be further decentralized by having the Secretariat transfer the total amount of funding for the proposals submitted to each District Assembly to disburse and supervise. Given that project activities need to be demand-driven, the funding amounts available to each District are only indicative. Should some Districts be submitting an insufficient amount of proposals, the Secretariat would reallocate the extra funds to other Districts. If the Secretariat is overwhelmed with the number of contracts it needs to process, altemative arrangements will be sought. To ensure transparency and encourage accountability, the names of entities or associations receiving awards and the amount of the award would be listed in a local paper of broad circulation. The members of the technical subcommittee will be technically qualified to evaluate subproject proposals. They will meet twice a year for a period of 3-5 days to assess proposals. Garfund will be managed from Accra, and, with the exception of Group C proposals, all subproject funding decisions will take place centrally by the GAC. Garfund will conduct a wide communications campaign to inform potential implementing entities about the nature of the fund, what it can finance and how to apply for funding. A specific campaign will be conducted prior to each call for proposals, with specific messages targeting civil society organizations in areas and or populations that need to be targeted. - 12- D. Project Rationale 1. Project alternatives considered and reasons for rejection: Three project design altematives were considered and rejected. A stand-alone HlV/AIDS Prevention and Care project, incorporating all sectors including health, was initially considered. However, it was thought that financing health expenditures in parallel to the HSPSP would go against the spirit of the HSPSP and undermine its effectiveness. The HSPSP finances a time slice of the combined GoG and extemal assistance budget for developmental and operational activities of the MoH. Consideration was also given to topping up the MoH's budget so that they could finance additional activities and subcontract NGOs to conduct them. However, the MoH is already working at full capacity and would be unable to adequately expand its activities to include actors outside the MoH. Moreover, they would be unable to finance activities in other line ministries. A structured project with clearly defined actors and activities, and plans of action for each one was considered but rejected in favor of a fund financing mechanism. A fund structure is more flexible, allowing for a more rapid response and is open to more innovative proposals as the content of the activities is not previously defined except generally. Fuithennore, a fund-like approach allows for modifications in funding priorities, the timing of financing, and the amounts to be supported. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned).completed, ongoing and planned Latest Supervision Sector Issue Project (PSR) Ratings (Bank-financed projects only) Implementation Development Bank-financed Progress (IP) Objective (DO) Health sector-wide support Ghana Health Sector Program S HS Support Project AIDS and STD control Brazil AIDS/STD S S Brazil Second AIDS/STD S S Control Project Argentina AIDS/STD S U Control Project Kenya Decentralized STD/AIDS and Reproductive Health Project (Approve but not yet effective) Ethiopia Multisectoral HIV/AIDS Project (Approved but not yet effective Other development agencies - 13- USAID IEC, STD management training, MTCT, VCT, condom distribution, NGO support, advocacy, workplace programs, surveillance CIDA CSW. IEC, STD management, support for PLWHA GTZ TA to integrate HIV/AIDS into district PHC DANIDA PLWHA DFID Reproductive Health; EU Support for NGOs, STD management UNAIDS Advocacy, resource mobilization, training traditional healers and physicians, planning UNICEF IEC, peer education to adolescents. CSW UJNDP Home based care UNFPA Training, support for NGOs, peer education, IEC, advocacy WHO Surveillance, training on STD and counseling, IEC, home-based care, support to NACP IPWDO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: Several design features of successful AIDS/STD programs in Africa and other regions are reflected in the design. These examine the overall approach of Garfund and the content of the interventions. In Uganda political leadership was a key factor in the success of the program. The high level of the GAC members under the chairmanship of the President gives the program the visibility it needs. In Brazilfhuilding a constituency for AIDS/STD program early on at local, regional and national levels are key. Garfund will conduct a communications campaign early on to inform potential actors about its objectives and strategy. A coordinated multi-sector approach has also been found to be the most effective in addressing the epidemic. Garfund is ensuring that the GAC designate a technical subcommittee to which it will delegate many of its advisory tasks to avoid delays in implementation caused by competing opportunities for GAC member's time. An annual half-day workshop will be held with representatives of sector ministries once their work plans for HIV/AIDS are developed in order to ensure coherence, coordination and reduce duplication of efforts. NGO and CBO participation is critical for project success. In both Brazil and Uganda these organizations were the most effective in reaching high risk groups and in delivering IEC messages through less formal channels. In Uganda they were more easily mobilized to provide care in the community (in the broadest sense, ranging from providing home-based care of AIDS patients and also supporting income generating - 14- activities for those who are still strong enough to work). NGOs are very effective in peer education, which has been shown to be cost-effective in modifying community and individual norms and attitudes in the United States and Zimbabwe. NGOs can more easily address cultural and ethnic issues to care and prevention. NGOs also have the added value that they are more innovative and flexible in their approaches and already have an infrastructure in the communities where they work. A communications campaign will be carried out to inform and encourage civil society organizations to participate. Targeted campaigns will be conducted in areas with low coverage to encourage CBOs and NGOs in the area to participate prior to each funding cycle. Their participation in the GAC will be encouraged. The targeting of specific high risk groups has been shown to be very effective in reducing the spread of the epidemic (United States, Brazil, Uganda). While Garfund intends to have nation-wide coverage, specific activities will target high risk groups, including, the police, army, prisons, commercial sex workers and truck drivers, all of whom were among the first to be hit by the epidemic. Youth need to be targeted as well, as HIV is on the rise among them and they have demonstrated the greatest capacity to adopt safer sex practices. In Uganda, HIV growth rates have declined the most in this age group. While there are subgroups of women who are more vulnerable, WHV has increased significantly among women in general and targeting them will be crucial to reduce the spread of infection. High risk groups will be mapped and their coverage will be carefully monitored. Coverage attained by each funding cycle in terms of number and groups reached will be assessed through the MIS prior to the call for proposals to define funding priorities for the subsequent funding cycle. Capacity building was found to be a key feature of the program in Uganda. A phased approach was employed in the implementation of district level activities, beginning with those districts most affected by the epidemic. Within three years, all the districts were covered. This project will provide implementing entities with funds to contract technical assistance and training when necessary. It will also phase both the implementation of district activities, beginning with those that have already completed district level strategic plans, allowing the others to prepare their own. It will also permit the incremental implementation responsibilities of umbrella organizations over subsequent funding cycles. Monitoring and evaluation are necessary components of any strategy to combat AIDS. Ghana has a reasonable surveillance system which can give some estimates of prevalence among women receiving antenatal care, and on women seeking STD diagnosis and treatment. Data from these specific groups will be employed to assess prevalence. However, data on prevalence need to be complemented with population-based information on Knowledge, Attitudes, Practices and Behavior (KAPB) regarding HIV/AIDS to be able to assess what interventions have had the greatest effects and define where future priorities need to be placed. Some baseline information is already available. A Demographic and Health Survey (DHS) was conducted in 1998 which can be used as baseline information for Garfund activities. Another DHS is planned for sometime around 2003/2004 and can be used to measure population-based indicators of program impact. Moreover, some information will be available on knowledge, attitudes and behavior for high risk groups including youth (both males and females aged 18-24), commercial sex workers, miners and police. The survey is being conducted now (October 2000) in Accra, Kumasi and Obuasi by Family Health Intemational. An endline survey will also be conducted. In addition, the project will monitor process and outcome indicators, and will also involve civil society in monitoring and ensuring accountability at the grass roots level. - 15 - 4. Indications of borrower commitment and ownership: In early 1999, the GoG set up a multi-sector task force to assess the status of the epidemic and to make recommendations to reduce its spread. Based on its recommendations, the Vice-President called on the International Partnership Against AIDS in Africa (IPAA) to assess its readiness to join the Partnership. It was the first African country to do so. In his endorsement of the recommendations of the task force, the Vice-President expressed the governrnent's concern with the status of the epidemic and recognized HIV/AIDS as a priority health and development issue. In response, a mission of the IPAA visited Ghana in October 1999 and recommended the establishment of a special fund to scale up the fight against AIDS through a multi-sector effort. Since early 1999 the GoG has conducted a Situation Analysis of HIV/AIDS, a Response Analysis examining its achievements to date and gaps, and has developed a Strategic Framework for the next five years. In addition, it has established a high level multi-sector commission (the Ghana AIDS Commission, GAC) and is in the process of setting up its executive arm, the GAC's Secretariat. 5. Value added of Bank support in this project: Availability of sufficient funding for HIV/AIDS. Many donors are supporting both the Health Program Support Project and Ghana's efforts to step up efforts to combat HIV/AIDS. However, no donor alone is able to mobilize the amount of resources necessary for a fund which could finance the efforts of non-governmental and community-based groups as well as public agencies. Cross country experience: The Bank is the largest financier of HIV/AIDS and STD control projects and has ample experience in the design, implementation and evaluation of these programs in all continents the Bank works in. Through its regional AIDS Campaign Team for Africa (ACTafrica), the Bank is well-positioned to make available regional experiences to Garfund. Moreover, the Bank has ample experience in the management of investment and community development funds all over the world in which implementing entities are largely organizations of civil society and local district governments. Analytical capacity. The Bank has authored numerous studies analyzing HIV/AIDS and its impact, drawing upon knowledge in epidemiology, public health, and economics in order to make recommendations on defining priorities, strategies to confront it, and the measurement of its impact. The Bank can provide added value in its technical assistance on monitoring and evaluation. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): * Cost benefit NPV=US$ million; ERR= % (see Annex 4) O Cost effectiveness O Other (specify) Economic: A very detailed economic analysis of the impact of MAP activities on the HIV/AIDS epidemic and the economic benefits of these activities was conducted for the preparation of the Multiple Country HIV/AIDS Program for the Africa Region (MAP). A summary of that econometric analysis is included here with a focus on Ghana. For illustrative purposes, it was assumed that some eight representative African countries (including Ghana) would have access to the financing provided by the MAP. These countries include some 280 million people, just under half of Sub-Saharan Africa's population. The cost of implementing comprehensive, national HIV/AIDS programs in full in these countries was estimated at US$575 million per year. - 16- If such nationwide scale could be achieved quickly, the MAP would help reduce the HIV prevalence rate in these countries from 7.9 percent in 1999 to 5.6 percent over ten years and below 4 percent over 15 years. The driving force would be the reduction by half in the number of new HIV infections among 15-24 year-olds over the next decade. This is an ambitious but achievable goal that has been met in some parts of Uganda and Zambia in the 1990s. For the rest of the adult population, new HIV infections would decrease in a similar fashion, but because of the stock of existing HIV infections, the adult HIV prevalence rate would fall by only 25 percent over ten years period. The rate of return on HIV/AIDS prevention activities for the eight countries was estimated to range from 22% to 13%. The benefit was an increase in the rate of growth of GDP per capita of about 0.35 percentage points per year. The economic benefits would be manifold. The fall in new HIV infections would reduce the number of new AIDS cases. Over the next 20 years, some 6.7 million adult deaths would be averted. In economic terms, this would result in lower costs of treatment and care of HIV/AIDS patients, which would offset part of the MAP costs. The macroeconomic benefits, while intuitively compelling, are difficult to quantify. Data constraints and the wide variety of ways through which the epidemic affects development limit the types of analysis that can be done. Cross-country analysis has produced estimates broadly consistent with those of other methods, but the limitations of this approach should be borne in mind. That said, on the basis of existing evidence as discussed in Annex 5 of the MAP, the fall in the HIV prevalence rate would likely increase the growth rate of GDP per capita. In addition, the reduction in AIDS-related deaths would increase labor force growth, further raising GDP growth. In total, the rate of growth of GDP would increase gradually by about 0.2 percentage points per year in 2007-2015 and 0.5 percentage points afterwards. Calculating the net economic benefits that would result from the combination of output increase and the different assumptions conceming costs is necessarily speculative. The estimated intemal rate of return is, however, quite similar under the two cost assumptions, at around 30 percent. Ghana has made great improvement in macroeconomic policy (its CPIA rating rose substantially between 1995 and 1999). This can explain the increase in per capita growth from - 1.1 % per year in the 1980s to 1.5% in the 1990s. Without a strong HV/AIDS program, the benefits from improved macroeconomic performance are going to be undermined by the spread of HIV. According to UNAIDS data, the estimated HIV prevalence rate rose from 2.38% (1997 UNAIDS estimate) to 3.6% (1999 UJNAIDS estimate). The estimated impact is a reduction in the rate of growth of GDP per capita of about -0.4 percentage points per year. Put differently, Ghana's per capita GDP would have increased by 1.9% per year instead of 1.4% per year in 1990-97 if the HIV prevalence rate had been zero. There are clear benefits of acting early. The estimated cost of a national-scale prevention and care program amounts to 1.2% of GDP per year. This is low compared to other countries. One reason is that the cost of treatment and care of AIDS is a small share of total cost because few people have AIDS. But if one waits, the cost will rise quickly and reach a point where the increased number of AIDS cases result in a total cost that cannot be afforded by countries. For a typical African country with a per capita income of US$300, the cost of prevention and care increases from 1% of GDP (HIV rate below 5%) to 5.7% of GDP when the prevalence rate reaches 25%. At current prevalence rates (less than 5%) implementing an WHV/AIDS control program would amount to 1.0 percent of GDP. Should action be delayed until prevalence reaches 25 percent, the budgetary costs of the program are estimated at 5.7 percent of GDP. Thus, the timing of the program is paramount in significantly containing costs in the medium and long term. Compared to the average African country, Ghana is well placed as concerns gender inequality and income inequality (both are much better than Southern Africa). But it is not well placed as concems ethnic fractionalization, (which may worsen the allocation of public expenditures across ethnic groups). This - 17- could be addressed by focusing on community-based organizations, which are quite strong in Ghana, and can offset the potential adverse impact of ethnic fractionalization. 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) Not applicable. Fiscal Impact: No civil works nor medical equipment will be procured and thus the project is not expected to generate additional recurrent costs. 3. Technical: The activities financed under Garfund follow intemationally accepted best practice for HIV/AIDS responses, as validated by UNAIDS. The project was prepared in close collaboration with the GoG and UNAIDS, and contains the input of the donor partnership working on health and HIV/AIDS in Ghana. Several key line ministries have been involved in the preparation of project components and implementation arrangements to ensure consistency with national technical standards and procedures. Given the key role of the MoH in HIV/AIDS activities and the need to ensure adequate coordination between Garfund and MoH activities, the preparation team included someone from the Policy Planning Monitoring & Evaluation Division and the head of the National AIDS Control Program from the MoH. Standard protocols, as recommended by UNAIDS or the World Health Organization will be used for the provision of voluntary counseling and testing, and counseling in other contexts. Training will be provided as required to address the handling and disposal of medical equipment, supplies, and waste technology. 4. Institutional: The Ghana AIDS Commission, located under the Office of the President, is well placed for coordinating the National HIV/AIDS program and the project, and to provide a multi-sector perspective. Coordination of all sectors financed by Garfund with MoH activities will pose an important challenge. Ensuring active participation of the MoH in the GAC will be crucial. Implementation capacity differs by implementing agency. TheGhana AIDS Commission has just been established, as has its Secretariat, and therefore lacks project implementation experience. However, the Secretariat includes some staff who have had prior experience with implementation of large donor/IDA financed projects. Included is at least one key staff from the MoH, which has had a close relationship with IDA and a satisfactory implementation record. IDA will work closely with the GAC to ensure they have the necessary financial management and procurement skills.Line ministries differ in the extent to which they have taken HlV/AIDS into account and their implementation capacity. Several line ministries including the Ministries of Education, Communications, and Agriculture have prepared draft action plans. DFID has already committed to finance technical assistance to help line ministries develop their action plans for HIV/AIDS well before effectiveness.Districts also have differing implementation capacity and levels of planning for HIV/AIDS. To date, 22 districts have prepared strategic plans to integrate HIV/AIDS into their work plans. DFID has also committed to assist in the expansion of the District Response Initiative to enable more districts to access funds at project start-up. As foLcivil society. NGOs and CBOs, Garfund will finance technical assistance to strengthen their capacity. -18 - 4.1 Executing agencies: Not applicable. 4.2 Project management: Not applicable. 4.3 Procurement issues: Not applicable. 4.4 Financial management issues: Not applicable. 5. Environmental: Environmental Category: C (Not Required) 5.1 Summarize the steps wudertaken for enviromiiental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. It is expected that the program activities would not generate any adverse environmental effects. Guidelines will be prepared as part of the procedural manual to ensure that environmental considerations are taken into account in all subprojects supporting home based care and the training of traditional birth attendants and healers, to ensure the proper disposal of medical waste. When needed, training will be provided. 5.2 What are the main features of the EMP and are they adequate? Not applicable 5.3 For Category A and B projects, timeline and statLs of EA: Date of receipt of final draft: Not applicable 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? Not applicable .5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? Not applicable 6. Social: 6.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes. Garfund is expected to have a very positive social impact by assisting and empowering people and institutions to deal more effectively with the HIV/AIDS epidemic. Garfund activities will deal with a broad and sensitive range of social issues conceming HLV/AIDS. Opposition may arise to providing assistance and empowerment to some vulnerable groups such as youth and women, and especially socially marginalized groups such as commercial sex workers, men having sex with men, and inmates. Issues such as distribution of condoms to youths and to married women may raise cultural and religious sensitivities. The project will involve key stakeholders who are experienced in dealing with these issues (i.e. civil society organizations and people living with HIV/AIDS) to help overcome such barriers in locally appropriate ways and ensure that no groups are excluded in program implementation. In addition the -19- project will carry out a series of advocacy, inforrmation, education and communication activities to create awareness of the legal rights of PLWHA. 6.2 Participatory Approach: How are key stakeholders participating in the project? key stakeholders, how involved, and what they have influenced; if participatory approach not used, describe why not applicable Garfund is the product of a series of government sponsored actions involving all key line ministries, stakeholders and the donor partnership, under the guidance of UNAIDS. Stakeholder consultation (including NGOs. civil society, PLWHAs and Districts) was conducted at key moments of the process. The GoG established a multi-sector HIV/AIDS Oversight Committee which has coordinated and supervised two important activities: (a) a draft Strategic Framework for HIV/AIDS in Ghana, and (b) and a response analysis conducted by multi-sector teams employing a participatory approach. The recommendations of the response analysis, and of the consultations with the donor community under the guidance of UNAIDS, were to establish a mechanism that would allow the GoG to implement a scaled-up multi-sector response to the epidemic. This led the GoG to establish the Ghana HIV/AIDS Commission in the Presidency which includes high level representation of all key sectors, including line ministries and civil society (church, professional and trade groups, and NGOs working on HIV/AIDS), and to seek financing for this scaled up response. Several members of the donor partnership have responded in addition to IDA, including DFID and USAID. As part of the process of project preparation, meetings were held with the broader group of members of the GAC to obtain their feedback. Actual preparation was conducted with staff from the GAC's secretariat. The donor partnership was also consulted. The contents of the project itself include the needs and strategies identified in the documents prepared by the GoG, the comments of the GAC, and the views of stakeholders consulted. Thus, the project design is based on a broad national consensus of what needs to be done to combat IV/AIDS. During project implementation, a number of beneficiary assessments will be conducted to obtain feedback on the nature and quality of services being delivered to monitor quality through the eyes of beneficiaries. The process will contribute to raising awareness amongst both beneficiaries and the project implementation team. Project supervision and oversight also involves stakeholders. Subproject activities financed under Group C would be supervised by District teams. And, a hotline will be established for the stakeholders to be able to report irregularities. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? NGO's and other civil society group are eligible for such project financing. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development ouitcomes? The institutional arrangements envisage collaboration with civil society in project supervision and through beneficiary assessments. 6.5 How will the project monitor performance in terms of social development outcomes? Beneficiary assessments as well as specific monitoring indicators. - 20 - 7. Safeguard Policies: 7.1 Do any of the following safeguard policies apply to the project? PoIc: ApIC.b- Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) 0 Yes 0 No Natural habitats (OP 4.04, BP 4.04, GP 4.04) 0 Yes 0 No Forestry (OP 4.36, GP 4.36) O Yes * No Pest Management (OP 4.09) 0 Yes 0 No Cultural Property (OPN 11.03) O Yes * No Indigenous Peoples (OD 4.20) 0 Yes 0 No Involuntary Resettlement (OD 4.30) O Yes * No Safety of Dams (OP 4.37, BP 4.37) O Yes * No Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) 0 Yes 0 No Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60) 0 Yes * No 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. Not applicable - 21 - F. Sustainability and Risks 1. Sustainability: The project is built upon the strong government ownership and supports the national program. Institutional capacitv building to be provided at national and local level would enhance the sustainability of the project and its local sub-projects. Moreover, many project management functions will be slowly decentralized to the Districts Nxhen capacity is assessed as adequate. 2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1): Risk Risk Rating Risk Mitigation Measure IFrom Outputs to Objective !Garfund institutional arrangemenits mav S Obtain assurances from the GoG as to the be cumbersome autonomy of the Secretariat. Provide ample supervision support in the first year or two The MoH mav be unable to scale up its S Obtain assurances from the MoH that the share of HIV/IAIDS activities I budget for HIV/AIDS will be increased in the next POW. Additional financing for health would be considered by IDA From Components to Outputs An insufficient amount of Garfund S Action plans submitted by line ministries must resources will flow from central line detail how the funds will reach the districts. .minisries to the districts This will be carefully monitored. Districts will be encouraged to submit proposals for funding There will be insufficient NGO/civil M |The project will work closely with Districts that socicty participation are not opening the door to NGOs/civil society Smaller CBOs in more rural districts will S The project will seek proposals from the more be too hard to reach and may lack remote CBOs and assist them in proposal capacity, leaving large areas uncovered preparation when needed. They will be targeted by the communications campaign Slow disbursement due to limited Most procurement will be done through financial capacit-. procuremenit capability! subprojects and will be for small contracts. and/or project management Assistance from Ministries receiving IDA funding will be sought Overall Risk Rating i S Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk) - 22 - 2. Risks A well-balanced multisector response requires astronger and more focused response from the health sector to ensure the necessary synergy will be gencrated. A less than adequate response from the MoH could greatly limit and possibly have a detrimental effect on the project as Garfund will generate demand for MoH services, including VCT, prevention of MTCT, condoms and clinical care, and a failure to respond will lead to a loss of credibility in the GoG's effort. This poses an important risk to project success as the MoH is currently not focusing sufficiently on HIV/AIDS. IDA will continue to support the MoH's efforts to improve access to HIV/AIDS prevention, care and treatment of opportunistic infections. provide better quality of care and improve the overall efficiency of its efforts. Assurances will be obtained from the MoH, that it will give greater priority to HIv'/AIDS in its annual POW and that it will increase its budget allocation to HIV/AIDS interventions. An action plan of the activities to be scaled up will be prepared and discussed as part of the discussion of next year's POW. Areas where the MoH needs to improve its response have been identified in the "Response Analvsis". Should additional funding for the health sector be required. IDA will be willing to reconsider it Ensuring achive participation of grassroots organizations, districts, and civil .society. An important risk to Garfund is that capacity is so low at the grassroots that it would be difficult to encourage a strong grassroots response. Garfund will ensure participation of the smaller organizations by actively seeking proposals from them and providing technical support in their preparation and implementation. A communications campaign describing the purpose of Garfund, how to access financing, and what may be financed, will be implemented early on and before each funding cycle. More targeted carnpaigns will be carried out to reach CBOs in specific areas. To encourage participation, the smaller groups would get some seed funds to initiate some activities which could be expanded through a subsequent mnore formal proposal at a later date. In the case of line ministries, there is a danger that funds destined to reach the district level will do so very slowly or not get there at all. Garfund will seek local initiatives., particularlv from districts that have already prepared a strategic plan to confront HIV/AIDS. DFID will finance the provision of technical assistance to Districts to ensure a substantial number of them have prepared a strategic plan to confront HIV/AIDS prior to pro ect start-up. A related risk is that Government, at national and district levels may not be as willing as necessary to finance civil society organizations to provide ser-vices. The current distribution of funds amongst the three windows in component 1 is designed to encourage more civil society participation. Institutional arrangements need to be agile. Given the Secretariat's lack of experience in implementation of IDA-funded projects it is expected there will be some disbursement delavs initiallv. Both financial management and procurement need to be carefully supported through supervision and technical assistance. IDA will recommend the contracting of someone with prior Bank procurement experience. Should the financial management system not be adequatelv established to permit smooth implementation. the need to subcontract that function will be considered. Delays can also result from the politicization of the project. The Secretariat must be staffed by politically neutral professionals and must have sufficient independence from the GAC to not delay implementation. Moreover, the subcomniittee selecting proposals to be funded will have a rotating membership. On IDA's side Given the multi-sectoral nature of the project, the limited capacity of the newly formed Ghana AIDS Commission and its Secretariat, the number of players involved, and the agility required to disburse rapidly, the supervision of the project will require greater-than-standard effort. IDA will have to ensure the necessary financial management and procurement support are available to the project, and that supervision - 23 - staff comprise specialists from several sectors. Higher than average supervision coefficients need to be provided particularly during the first year of implementation. 3. Possible Controversial Aspects: Activities to be financed by Garfund have been amply discussed in the Govemment and with members of the GAC who include NGO, religious, trade representatives, among others and thus are not expected to spark controversy. - 24 - G. Main Loan Conditions 1. Effectiveness Condition There are five proposed conditions of effectiveness for the credit: (a) adoption by the Government of the operational manual for the Project; (b) establishment of a financial management system for the Project acceptable to IDA; (c) establishment of GAC the Secretariat with appointment thereto of staff with qualification and experience satisfactory to the Association; (d) the adoption of a legal framework for the management and operation of the AIDS Response Fund; and, (e) the selection of auditors for the Project with qualifications and experience satisfactory to IDA. 2. Other [classify according to covenant types used in the Legal Agreements.] Grants for the financing of sub-projects shall be awarded in accordance with the policies and procedures set forth in the Operational Manual. H. Readiness for Implementation [D1 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. Z 1. b) Not applicable. C: 2. The procurement documents for the firstyear's activities are complete and ready for the start of project implementation N 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. Z 4. The following items are lacking and are discussed under loan conditions (Section G): *. Compliance with Bank Policies Z 1. This project complies with all applicable Bank policies. F 2. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. Sandra Raenhouse Rosemary Bellew Peter C. Harrold Team Leader -Sector Manager Country Director - 25 - Annex 1: Project Design Summary GHANA: AIDS Response Project (GARFUND) ...... ..e . ...r anc Sector-related CAS Goal: Sector Indicators: Sector/ country reports: (from Goal to Bank Mission) Reduce the spread of Increase the proportion of men Ghana Demographic and The supported programs will HIV/AIDS through a in a union using condoms Health Survey (GDHS) enable the mobilization of multisectoral approach during their last intercourse sufficient financial and human from 15% to 30% by 2005 resources to support a multi-sectoral and sustainable Increase the proportion of national response to the women in a union using epidemic condoms during their last Ghana Demographic and intercourse from 6% to 20% Health Survey (GDHS) by 2005 Project Development Outcome / Impact Project reports: (from Objective to Goal) Objective: Indicators: To reduce the spread of H1V Maintain prevalence of HIV of HIV/AIDS surveillance Multi-sectoral activities infection pregnant women at or below 6 financed will lead to percent by 2005 attitudinal and behavior change regarding prevention. Close coordination with health sector activities designed to reduce the spread of HIV/AIDS and its impact. The Secretariat will have sufficient autonomy to operate in an agile manner Reduce the prevalence of HIV Special Studies (CIDA Idem infections to 75% among financed) commercial sex workers in Kumasi by 2005 Increase the proportion of men Demographic and Health Idem and women who have reduced Survey (GDHS) the number of sexual partners in response to perceived risk from 60% to 75% by 2005 Increase the median age at Demographic and Health Idem first intercourse from 17 to 18 Survey (GDHS) years of age by 2005 Reduce the impact of AIDS on Increase the proportion of Macro systems Services Multi-sectoral activities those infected and their PLWHA that are receiving Survey, Special Study based financed will reduce the families home or community based on sample of Districts stigma associated with care among those PLWHA HIV/AIDS and lead to that have sought medical attitudinal and behavior treatment through the MoH change regarding care-giving network to 30% by the year to PLWHAs 2005 - 26 - Provision of Prevention and Increase the proportion of Project Data Civil society organizations Care Services funds awarded to CBO know about Garfund, are submitted subprojects interested in participating, and (through windows B and C) to the Garfund is agile in 20% of all subproject funding responding to them by 2005 Increase to 100 the number of Project Data Districts will have the capacity Districts that have prepared and interest to carry out plans to address HIV/AIDS activities and are implementing part of their plans by 2005 Output from each Output Indicators: Project reports: (from Outputs to Objective) Component: Increase the % of Ghana Demographic and Information about condom males/females who know they Health Survey availability is transmitted and can avoid HIV by using will be absorbed and condoms from 40% to 75% understood (males) and from 22% to 50% (females) by 2005 Increase the % of Ghana Demographic and Sufficient information about males/females who know they Health Survey HIV transmission is provided, can avoid HIV by restricting absorbed and understood sex to one partner from 60% to 90% by 2005 Increase the proportion of all Project Data Civil society organizations subprojects that develop IEC working in rural areas see IEC materials designed specifically as a priority for rural populations (in local dialects) to 30% by 2005 By 2005, 50% of all 1st and Ministry of Education, Project There is no public opposition 2nd cycle schools are data to providing AIDS training to providing HIV/AIDS students education By 2005, all line ministries Project data Line Ministries are interested have trained trainers at the in receiving training and the district level on HIV/AIDS training is adequate By 2005, 30% of districts have Project data Willingness of NGOs and civil organized care of AIDS society to participate orphans By 2005, 50% of districts have Project data Willingness of NGOs and civil comnuunity-based care for society to participate. PLWHAs Stigma is reduced, and individuals are not afraid of AIDS By 2005, an adequate referral MoH statistics, Project Data Adequate collaboration system between home-based between the MoH and the rest and institution-based care has of Garfund exists been established and is functioning in 40% of districts - 27 - Strengthening Public/Private The funding received by Project Data A sufficient number of Institutions for HIV/AIDS affiliations (umbrellas) that existing affiliations are willing control are able to manage smaller to manage funds for their civil society organizations or members or other affiliates to provide services organizations will increase to 30% of funds /associations disbursed by component I by 2005 The proportion of subprojects Project data The training and TA provided implemented effectively, by Garfund is adequate to meeting their stated objectives meet the needs of will increase by 10% every implementing entities year Knowledge Management 100% of Districts regularly Project reports, random Access to rural Districts is receive information on "best site-visits, supervision available by mail practice" examples of HIV/AIDS interventions Project Components I Inputs: (budget for each Project reports: (from Components to Su b-components: component) Outputs) A. Prevention and Care US$2 1.0 million Project information system The purpose of the project is Services adequately disserminated B- Strengthening US$2.4 million Project infonration system There is ample participation Public/Private Institutions for by grassroots organizations HIV/AIDS Control C. Knowledge Management US$1.4 million Project information system The materials and information generated by the project are utilized at the local level D. Project Management and US$3.0 million Project information system Line ministry allocations Monitoring and Evaluation reach the districts The institutional framework for the Garfund is agile Procurement procedures are implemented smoothly - 28 - Annex 2: Detailed Project Description GHANA: AIDS Response Project (GARFUND) The Project, Garfund, would finance a US$25.0 million, 4-year component of the non-MoH mandated activities of the Government's Strategic Framework for AIDS. Garfund aims to intensify multi-sector activities designed to combat the spread of HIV/AIDS and to reduce its impact on those already affected. To achieve its objective, the project includes support for the following activities: By Component: Project Component I - US$21.00 million HIV/AIDS Prevention and Care This component would employ a fund mechanism to solicit, evaluate and fund service provision subproject proposals to carry out activities in prevention of HIV transmission and care of PLWHAs and their families. Access to funds for the financing of proposals would be available through three windows, each with slightly different access nies. The first group (Group A) includes proposals from line ministries, and will finance activities for intemal and external clients The second group (Group B) includes financing for proposals from civil society organizations including NGOs, CBOs, trade and professional associations, associations of PLWHAs, Districts, among others, or groups of these entities, including affiliation networks (umbrella organizations). The third group (Group C) would provide seed money for activities conducted by very small CBOs and associations, not to exceed $2500 up front to engage in activities defined in a letter of intent. Garfund will encourage group proposals to scale-up the response more rapidly. Affiliation networks that do not possess sufficient capacity to subcontract and manage smaller entities will be encouraged to submit proposals that include training and TA to strengthen their capacity and allow them to scale up in subsequent funding cycles. Likewise, Districts will be encouraged to present proposals for activities to be conducted by several civil society organizations in their district. Proposals will indicate the activities to be conducted and can include up to 10 % for TA to be received by the implementing entity to improve the entity's ability to provide the proposed services. The maximum duration of contracts is to be one year. Each funding cycle is expected to disburse approximately US$2.5 million. The amounts to be allocated to fund proposals under each group are set initially as described below but will be adjusted as needed as implementation proceeds. Calls for proposals will take place on a semi-annual basis. The selection of proposals to be funded for Groups A and B will be carried out by a technical subcommittee of the GAC. Proposals for Group C would be selected by the Districts and sent to the Secretariat for the processing of contracts. Line Ministries (Group A) will be able to submit proposals once: (a) they have included a line item in their budget to work on HIV/AIDS activities; (b) have prepared an action plan to address HIV/AIDS. A ceiling for the amount of funding allocated to Group A will be defined for each funding cycle. Initially it will represent about 25 percent of the funds available for that cycle, i.e. approximately US$625,000. Line Ministries will have to provide matching funds of up to 10% of the proposed activities, and the maximum amount to be requested will not exceed US$100,000. Garfund would finance only those activities considered eligible for funding (as described below). Line Ministries will primarily need financing for sensitizing/training their own staff at all levels), for developing policies and guidelines to address HlV/AIDS and its consequences, and some sector-specific interventions involving extemal clients. District-level interventions/proposals involving work with extemal clients will be funded through group B. Activities eligible for funding in Group A include, among others: - 29 - (a) advocacy to increase political support and mobilize the community. (b) targeted messages to captive homogeneous audiences such as schools, unions, and other organizations with large membership on promotion of safe practices, and to dispel misconceptions about HIV/AIDS. (c) policy development (d) preparation of guidelines and manuals related to confronting AIDS in their sector. (e) sensitization and training of ministerial staff centrally and training of trainers at the District level on HIV/AIDS (f) preparation of strategic plans at the district level to combat AIDS (g) technical assistance required to provide that service more effectively Proposals from Group B will be selected on a competitive basis. Group proposals would be encouraged. Proposals would be assessed on the basis of their technical merits and on their fulfillment of some basic eligibility requirements. The latter are more stringent for large contracts. The criteria are specified in the Operational Manual. Less than 5 percent of proposals are expected to be for contracts over US$100,000. Group proposals that include the subcontracting of other smaller entities will have to include information on how the funds will be managed and the activities supervised. It is expected that close to two-thirds of each funding cycle will go to Group B (approximately US$1.6 million). Included in this group would be Districts submitting proposals on the basis of Strategic Plans prepared under the District Response Initiative. These may or may not include activities executed by local civil society organizations. Recipients of grants under Group B would have to make in-kind contributions of up to 10% of subproject costs. To ensure subprojects address local needs and minimize duplication, all implementing entities (NGOs, civil society, CBOs) need to secure the endorsement of the Districts they are working in. Approximately 11 percent, or US$275,000 will be available per funding cycle initially for funding small contracts under $2500 (Group C). Proposals from Group C would require a statement of intent, a guarantee in the form of a declaration of joint liability signed by at least 5 unrelated community members, and some very basic information (this has worked very well in other settings). The details of the requirements are spelled out in Garfund's Operational Manual. Activities eligible for funding by Groups B and C include, among others: (a) advocacy to increase political support and mobilize the community; (b) local campaigns to raise awareness and understanding about HIV/AIDS, its mode of transmission and its consequences; (c) interventions targeting high risk groups to encourage low risk behavior and voluntary counseling and testing of both HIV and STDs. High risk groups include commercial sex workers and their clients, truck drivers, the prison population, the army and youth; (d) targeted messages to captive homogeneous audiences such as schools, unions, and other organizations with large membership on promotion of safe practices, and to dispel misconceptions about HIV/AIDS; (e) peer education in the community, schools, workplace, etc. to promote safe practices, encourage voluntary counseling and testing for both HIV and STDs, and to encourage community-based care of PLWHAs; (f) counseling; (g) condom distribution combined with information about safe practices; (h) home-care for PLWHAs including nursing care and support in daily routine activities; (i) community care for orphans; (j) income generation activities for PLWHAs and their families; (k) legal advice and information for protection of PLWHA; - 30 - (1) activities designed to prepare legislation to protect PLWHAs, and; (m) technical assistance required to provide that service more effectively. A broad communications campaign will be conducted to inforn potential executing entities about the objectives of Garfimd, how to access funds, and on activities that may be financed. Brief campaigns would be held at the time of each call for proposals. Prior to each cycle, analyses of coverage will be conducted to identify areas that are insufficiently covered to target them through a targeted communications approach. Accountability and transparency will be promoted by establishing a hotline for reporting fraudulent practices, and advertising in the newspapers of the widest circulation, the names of the entities receiving awards, the amount of the awards and the activities financed. CBOs and NGOs would be expected to submit evidence of their prior work in the District. All subprojects must be endorsed by the Districts they are proposing to work in. Calls for proposals will take place semiannually. Proposals for groups A and B will be reviewed by a rotating subcommittee of the GAC, who will select those to be funded and obtain the GAC's endorsement. The composition of the subcommittee will be public. To streamline project selection and to ensure local needs are addressed, proposals in Group C will be reviewed and selected by District authorities (eventually the District AIDS committees, once they are established) who will submit their recommendations to the Secretariat. When the Secretariat makes the call for proposals it will inform Districts approximately how much they may have available to finance subprojects. The indicative amount would be prevalence and population-based, and would not be disbursed unless letters of intent/proposals have been submitted. Districts would submit their recommendations for funding to the Secretariat who would issue the necessary contracts. The funds would go directly to the entities submitting the proposals. As implementation proceeds and the capacity of districts is ascertained, the process could be further decentralized by having the Secretariat transfer the total amount of funding for the proposals submitted to each District Assembly to disburse and supervise. As Regional AIDS Committees are established and possess the necessary capacity, they will be given a role in subproject supervision and dissemination of information. Participating entities will have to meet pre-defined eligibility criteria specified in the Operational Manual to receive funding. The Secretariat will prepare the contracts and work with the implementing entities on all the implementation arrangements. The project will provide orientation on how to prepare proposals, and once awards are made, it will provide training on basic project management, bank procurement procedures, and financial management. Technical training on HIV/AIDS prevention and care issues, community participation techniques, home-based care, and in technical areas specifically addressing HlV/AIDS will be available. Implementing entities receiving funding will be requested to coordinate with local health authorities or other local health services when relevant to ensure coordination. The funding cycle process allows for a phased implementation and will allow for a more rapid start-up by allocating resources to those who are ready to go first. It also allows the flexibility to modify funding priorities each cycle to reflect the perceived needs. The first cycle will target greater Accra and Kumasi, and the Eastern region which, in addition to being more accessible, allowing project staff to work out unforeseen implementation issues and ensure all arrangements are in place, are also the areas of the highest incidence of HIV/AIDS. In order to ensure high risk groups and vulnerable groups are being prioritized, a careful mapping of the location of these groups will be prepared when Garfund is established, and the coverage attained through each funding cycle will be assessed prior to each subsequent funding cycle to define funding priorities for the following call for proposals. The proposed fund would be placed under the authority the GAC, which would be in charge of the definition of broad priorities for action, the selection of eligible proposals (through the subcommittee), and - 31 - the monitoring of the performance of those receiving funding (with inputs from the Secretariat). The fund would not finance drugs, civil works nor any physical rehabilitation, vehicles, overseas training, laboratory or medical equipment. Project Component 2 - US$2.40 million Strengthening Public/Private institutions for HIV/AIDS Control (Capacity Building) Capacity building is essential to improve skills and strengthen structures to help achieve the Garfund objective of scaling up the national HIV/AIDS response. The purpose is to enhance both the technical and managerial capacity of implementing entities to implement projects as well as sustain the process of scaling the WHV/AIDS response. Both technical assistance to specific projects (not previously defined in subproject proposals) as well, as training to groups of implementing entities will be provided. Although implementing entities will have identified some TA in their proposals, it is expected that through project supervision and the entity's experience in the implementation of subproject activities, additional needs would be identified. Only entities implementing subprojects are eligible for training. The training will be subcontracted to NGOs and line ministries with expertise on the issue in question. The project will keep a live list of pre-qualified TA/training providers on hand and contract them as needs arise. The Secretariat will contract TA/training providers directly. Feedback from beneficiaries will be obtained on a regular basis to monitor the quality of the services provided. Random site visits will be made by Garfund. Project Component 3 - USS 1.40 million Knowledge Management The project will set up and maintain an information clearing house/data base on HIV/AIDS relevant to implementing entities to improve their effectiveness. The purpose is to provide implementers with the latest information on HIV/AIDS prevention and care, best practice examples from other countries, research results, and any other reports that would be useful to them. In addition it would provide a forum for information and experience exchange by implementing entities, and access to technical information on the project itself Information would be disseminated in various mediums, including newsletters, copies of published papers, meetings to exchange information and via the intemet. It is expected that umbrella organizations could have a key role as vehicles of dissemination of information. Once the Regional AIDS committees are all established, they will also serve as focal points for dissemination. Project Component 4 - US$3.00 million Project Management and Monitoring and Evaluation Project Management. (Refer to Section C, Implementation Arrangements). The Garfund will have a strong Monitoring and Evaluation subcomponent that will assess the progress attained in the fight against AIDS nationwide on the basis of the targets defined in the Strategic Framework and will monitor the advance of Garfund financed activities. - 32- Annex 3: Estimated Project Costs GHANA: AIDS Response Project (GARFUND) Local Fodreiga Totat Project Cost By omone.nt Us S $miW1n US $mRilo- Component 1 (Prevention and Care Services 20.00 1.00 21.00 Component 2 (Strengthening Public/Private Institutions for 2.10 0.30 2.40 HIV/AIDS Control) Component 3 (Knowledge Management) 0.90 0.50 1.40 Project Management (mcl. M& E) 2.80 0.20 3.00 Total Baseline Cost 25.80 2.00 27.80 Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 25.80 2.00 27.80 Total Financing Required 25.80 2.00 27.80 1. .P r.ojectCost.Byvate; ory -US $I us - mil S U Goods 0.50 0.50 1.00 Consultant Services & Training 4.00 0.50 4.50 Subproject 20.20 0.80 21.00 Operating Costs 1.10 0.20 1.30 Total Project Costs 25.80 2.00 27.80 Total Financing Required 25.80 2.00 27.80 Identifiable taxes and duties are O (USSm) and the total project cost, net of taxes, is 27.8 (IJS$n) Tlherefore, the project cost sharing ratio is 89.93% of total project cost net of taxes. - 33 - Annex 4: Cost Benefit Analysis Summary GHANA: AIDS Response Project (GARFUND) Summary of Benefits and Costs: Not applicable. Main Assumptions: Not applicable. Sensitivity analysis t Switching values of critical items: Not applicable. - 34- Annex 5: Financial Summary GHANA: AIDS Response Project (GARFUND) Not applicable. - 35 - Annex 6: Procurement and Disbursement Arrangements GHANA: AIDS Response Project (GARFUND) Procurement General Although the specific type of activities to be financed under the project have been defined, it is not possible at this stage to determine the exact mix of goods and services which will be procured as most will be procured through demand driven subprojects (Component 1, Prevention and Care Services). Part of Component 2 (Strengthening Public/Private Institutions for WHV/AIDS Control) will also be based on perceived need and thus is difficult to forecast. Guidelines All goods financed under the IDA credit would be procured in accordance with theGuidelines: Procurement under IBRD Loans and IDA Credits, January 1995 and as revised in January andAugust 1996, September1997 and January 1999. Consultants will be selected in accordance with theGuidelines: Selection and Employment of Consultants by World Bank Borrowers, January 1997 and as revised September 1997 and January 1999. National Competitive Bidding (NCB) procedures will include: (a) an explicit statement to bidders of the evaluation and award criteria; (b) national advertising with public bid opening; (c) award to the lowest evaluated responsive and qualified bidder and (d) foreign bidders would not be precluded from participation in NCB. The Bank's Standard Bidding Documents (SBD) will be used for all ICB (and with appropriate amendments for all NCB) for goods. However, no ICB is envisioned at this stage. The Bank's Standard Request for Proposals (SRFP) would be used for all consulting assignments. GAC may not use less competitive bidding and selection procedures only as an expedient to by-pass more competitive methods or fraction large procurements into smaller ones solely to allow the use of less competitive methods. A Project Operational Manual (OM) has been prepared which describes the procurement procedures to be followed under the project, including the Bank's Guidance on Shopping. Procurement Notices A General Procurement Notice (GPN) is mandatory and will be published in the UN Development Business. The GPN would show ICB contracts- if any- and a list of expected consulting assignments, and would be updated on a yearly basis. Specific Procurement Notices (SPN) will be required in UNDB for contracts to be procured under ICB and consulting assignments estimated to cost above US$ 200,000, and in the national press for NCB. Consultant contracts with an estimated cost of US$ 100,000 or more will also be advertised in the national press prior to the preparation of the shortlist. Very small contracts will be advertised either in the national press or by other practical means. Procurement Capacity The GAC secretariat has yet to be made operational and a procurement capacity assessment was, therefore, not possible. Since other than one or two vehicles for project management, the project will not finance vehicles, drugs, nor civil works, the Secretariat would only require one procurement specialist who is - 36 - familiar with Bank procurement guidelines and who will be contracted through an open competitive process. Procurement capacity is needed mostly for the selection of consultant services and drafting and management of their contracts, and for monitoring the procurement process for subprojects. Goods to be purchased are minor, including a small number of computers for knowledge management (Component 3) and possibly some minimal equipment for project management. Processing of these contracts is not likely to cause delays as the GAC Secretariat can seek procurement support from specialists of ongoing Bank-financed operations or the services of a procurement agent to be hired under the project. This would be balanced with the presence of a strong financial management team. It is expected that the procurement staff could work together in the same unit with the financial management team. The presence of a qualified team, acceptable to the Bank, would be a condition of effectiveness. Once staff have been selected, an orientation workshop would be held. Topics to be covered include Bank procurement and disbursement procedures. Institutional Arrangements The responsibility for procurement under the project will be with the GAC Secretariat. The Secretariat is expected to process primarily contracts with NGOs and CBOs to finance subprojects and contracts for a variety of consultant services to conduct Garfund's capacity building activities (Component 2), subproject supervision, and Garfund's evaluation. The GAC Secretariat will monitor the procurement workload and when required will use the above mentioned procurement agent/or an individual to provide short term support on specific assignments such as preparation of procurement plans, preparation of bidding documents and Requests for Proposals and assistance in preparing evaluation reports Procurement Plans Only an indicative Global Procurement Plan (GPP) for the procurement of goods and selection of consultants and training for project components I and 2 will be prepared because it is difficult to determine the exact mix of goods and services, in particular for the subprojects (component 1) where procurement is vet undetermined. Procurement planning will only be possible, at this point, for activities in the Knowledge Management (Component 3) and Project Management and M&E Components (Component 4). As for component 2 (Strengthening Public/Private Institutions for HIV/AIDS Control), it is likely that once project implementation gets under way, some forecasting will be feasible. The procurement plan for the first year will be based on the needs of the GAC Secretariat for project management, including monitoring and evaluation, and Knowledge Management. Procurement plans for subsequent years will only be indicative, based on subprojects submitted on each round and an estimation of training needs. Where possible, a Detailed Procurement Plan (DPP) will be prepared for the first year of the project showing contract packages, the estimated cost for each package, and the procurement method and processing times till completion. When subproject proposals have been approved by the GAC technical subcommittee, the GAC Secretariat will submit up-dated versions of the GPP, and the annual DPPs. PMRs At the end of each quarter the GAC will send to IDA a Project Management Report which will include but will not limited to the following information. (i) Financial Management Report (ii) Progress Monitoring Report and (iii) Procurement and Subproject plans for the following six months. PMRs will be prepared - 37 - from the beginning of the project, but moving to PMR-based disbursement will not take place before the first fourteen months of implementation and before a satisfactory assessment has been made that the financial and procurement management systems meet IDA PMR requirements. Goods, Vehicles and Equipment (USD l.Om) The project would finance one or two vehicles, office equipment and supplies for the GAC Secretariat, and computers for both project management and knowledge management. No ICB is expected under the project. However, where goods and equipment to be purchased under the project could be grouped into packages estimated to cost the equivalent of US$300,000 or more, they would be procured under ICB procedures using Bank Standard Bidding Documents. To the extent possible and practicable, goods and equipment to be purchased under the project would be combined into packages worth at least US$ 100,000 and procured under National Competitive Bidding (NCB). Contracts for goods estimated to cost between US$30,000 and US$300,000 each would be procured through NCB, using procedures acceptable to IDA, to an aggregate amount not to exceed US$500,000 equivalent. Vehicles estimated to cost less than US$50,000 equivalent per contract, up to an aggregate amount of US$100,000 equivalent, may be procured on the basis of National Shopping Procedures (NSP) using shopping procedures as described in the Bank's Guidelines on Shopping Procurement for readily available off-the-shelf goods that cannot be grouped, or standard specification commodities for individual contracts of less than US$30,000 and not exceeding an aggregate amount of US$400,000, would be procured on the basis of national shopping procedures as described in the Bank's Guidelines. The GAC secretariat will maintain records to advise IDA prior to when these aggregate limits may be exceeded. If these goods are not available in the country, intemational shopping procedures would be followed. Requests for such quotations will include a clear description and quantity of the goods, requirements for delivery time, if they are not immediately available, and the place of delivery. Consulting Services/Training, Audits (US$ 4.5m) As a rule, consultant services will be selected through the Quality and Cost Based Selection (QCBS) or Least Cost Selection (LCS) method if appropriate. For assignments up to US$ 100,000, the shortlist may consist entirely of national consultants, provided that at least three qualified national consultants are available in the country and foreign consultants who wish to participate are not excluded from consideration. Consultant services estimated to cost less than the equivalent of US$ 50,000 may be contracted by comparing the qualifications of consultants who have expressed an interest in the job or who have been identified. Auditors would be selected using the Least-Cost-Selection method. Training programs and workshops, which are designed to familiarize entities conducting subprojects on IDA procurement and financial reporting and to improve subproject management will be carried out on the basis of approved semi-annual programs that will identify the general framework of training activities for the following six months, including the nature of training/workshops, the number of trainees, and cost estimates. The training institutions for all workshops/training with costs exceeding US$ 5,000 should be identified within the semi-annual program; where the training cost exceeds US$ 15,000, the selection of the training institution should be based on a competitive process preferably using a quality-based method of selection. In the case of training on technical skills of entities (NGOs, CBOs etc) implementing subprojects, needs will be initially difficult to forecast as the needs will vary with the type of subprojects being financed and the capacity of the implementing entities. However, as project implementation proceeds, i.e., after the first 12 months of implementation, those needs would be more easily estimated up-front and included in tie semi-annual plans. - 38 - Subprojects (US$ 21.0m) Entities proposing Subprojects, which are not expected to exceed US$100,000 per project, will handle their own procurement. When subprojects selected for funding include significant procurement or selection of consultants, an assessment will be made of the entity's ability to carry out procurement. In the case of govemment entities, Ministries, Departments, District Assemblies (MDAs) are currently implementing Bank Projects and have the basic knowledge in public procurement. In addition, the subproject application package will include a write up on procurement procedures to be followed. Procurement is expected to include small purchases such as supplies, such as video equipment, and other products easily available in the local market through local shopping procedures as specified in the OM. Entities will also contract technical assistance for very specific needs identified such as learning how to manage people living with AIDS, how to prepare better educational material, etc. Items will be procured under simplified procurement procedures similar to those applicable to social funds. Arrangements for selecting and funding subproject proposals are detailed in Annexes 2 & 5. GAC will sign a Memorandum of Understanding (MOU) with each MDA and a contract with each NGO/CBO whose proposal is chosen for funding under the program. The MOU/Contract will detail the deliverables expected from the MDA/NGO/CBO as well as the schedule of payments to be made by GAC in relation to the deliverables. The OM will specify at what level these contracts would be signed and supervised. All subproject proposals costing US$ 100,000 or more will be subject to IDA prior review. The MOU/Contract will include an explicit statement that (i) proceeds of the fund will be used solely for the intended purposes; (ii) any procurement of any goods, equipment, materials or services will be done in accordance with good public procurement practice and in accordance with the thresholds and procedures in the DCA and Table 5B below; (iii) The MDA/NGO/CBO will maintain proper accounting and procurement records of all inputs for the implementing the subproject; (iv) The implementing entity shall at all times exercise procurement in the best interest of the Client and any discounts or commissions obtained by the entity in the exercise of such responsibility shall be for the account of the Client; and (v) The MDA/NGO/CBO will permit independent auditors and or Bank staff to inspect their accounts and records relating to the performance of the MOU/Contract. During appraisal, IDA reviewed formats for inviting subproject proposals in national newspapers, MOUs and sample Contracts prepared by GAC and has found them acceptable. Every six months GAC will publish in at least one newspaper of nation circulation all subproject awards together with the names of the beneficiaries. IDA Review With the exception of vehicles, all goods contracts estimated to cost US$ 100,000 or more will be subject to IDA review of bidding documents including draft contract and technical specifications prior to inviting bids, and IDA review of bid evaluation prior to contract award. Contracts for vehicles estimated to cost more than US$ 50,000 will also be subject to prior review. All subproject proposals and contracts for subprojects above US$ 100,000 will also be subject to IDA review prior to contract award. For subproject contracts estimated to cost between US$ 50,000 and US$ 100,000, one subproject proposal and its corresponding contract for each of windows A and B for each funding cycle will be subject to prior review. In addition, one subproject proposal and contract will be reviewed for window C each funding cycle. - 39 - The TOR for all consulting assignments irrespective of value will be subject to IDA prior review. For consultant contracts with firms costing US$ 100,000 or more, and US$ 50,000 or more in the case of individuals, the draft Request for Proposals (RFP) and the shortlist of consultants must be cleared by IDA prior to inviting proposals from consultants. In addition, the evaluation of technical proposals must be cleared with IDA before financial proposals of the qualifying firms are opened and the negotiated contract will require IDA no objection before the final version is signed. All procedures in Appendix I of the Consultants Guidelines would apply. Contracts which are not subject to prior review will be selectively reviewed ex-post by the Bank during project implementation and will be governed by the procedures set forth in paragraph 4 of Appendix I to the Guidelines. Monitoring and evaluation of procurement performance at all levels (national, district and community) will be carried out through annual ex-post procurement audits and regular ad-hoc reviews. Such audits would: (a) verify that the procurement and contracting procedures and processes followed for the projects were in accordance with the Development Credit Agreement (DCA); (b) verify technical compliance, physical completion and price competitiveness of each contract in the selected representative sample; (c) review and comment on contract administration and management issues as dealt with by participating agencies; (d) review capacity of participating agencies in handling procurement efficiently; and (e) identify improvements in the procurement process in the light of any identified deficiencies. Procurement methods (Table A) Table A: Project Costs by Procurement Arrangements (US$ million equivalent) Expodit ue Categ 1. Works 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 2. Goods 0.00 0.50 0.50 0.00 1.00 (0.00) (0.45) (0.45) (0.00) (0.90) 3. Services 0.00 0.00 4.50 0.00 4.50 Consulting/Training and (0.00) (0.00) (4.50) (0.00) (4.50) Audits 4. Miscellaneous 0.00 0.00 21.00 0.00 21.00 Subprojects (0.00) (0.00) (18.70) (0.00) (18.70) Operating Costs 0.00 0.00 1.30 0.00 1.30 (0.00) (0.00) (0.90) (0.00) (0.90) Total 0.00 0.50 27.30 0.00 27.80 (0.00) (0.45) (24.55) (0.00) (25.00) Figures in parenthesis are the amounts to be financed by the IDA Credit. All costs include contingencies Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services. and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units. Figures in parenthesis are the amounts to be financed by the Bank loan. Figures in Goods includes vehicles and equipment. - 40 - Table A1: Consultant Selection Arrangements (optional) (US$ million equivalent) COasoftant election Mto Servloe --ture NF - S - - - c Total Cost; A. Firms 2.20 0.00 0.00 0.20 0.30 0.00 0.00 2.70 _ (0.00) (0.00) (0.00) (0.00) (0.00) (0o00) (0.00) (0.00) B. Individuals 0.00 0.00 0.00 0.00 0.12 0.60 0.00 0.72 (0.00) (0.(00) (0. 00) (0.00) (0.00) (0.00) (0,00) (0.00) Total 2.20 0.00 0.00 0.20 0.42 0.60 0.00 3.42 (0.00) - (0.00) (0.00) (0.00) (0.00) (0.00) (0.00) L (0.00) 1 Including contingencies Note: QCBS = Quality- and Cost-Based Selection QBS = Quality-based Selection SFB Selection under a Fixed Budget LCS Least-Cost Selection CQ = Selection Based on Consultants Qualifications Other = Selection of individual consultants (per Section V of Consultants Guidelines), Commercial Practices, etc. N.B.F. = Not Bank-financed Figures in parenthesis are the amounts to be financed by the Bank Ctedit. - 41 - Prior review thresholds (Table B) Table B: Thresholds for Procurement Methods and Prior Review' 1. Works N!A 2. Goods >US$ 300,000 ICB All contracts Vehicles US$ 50,000 Shopping All contracts Other US$ 30,000 NCB All contract above US$ 300,000 US$100,000 3. Services >US$ 100,000 QCBS, LCS (UNDB and All contracts Consulting/Training National Advert) US$ 50,000 QCBS/LCS/CQ/CV All contracts with US$ 100,000 (National Advert) individual and first two contracts with finn First two contracts '.cUS$5,000 LCS.CQ_CV 4. Subprojects >US$100,000 See Note 1 All MOUs/Contracts US$ 50,000 One grant agreement US$ 100,00 under group C during each funding cycle \ 0 DISTRICT CAPITALS Nodowl / ) I . @ REGION CAPITALS Walewal A.~~~~~~~~~ NATIONAL CAPITAL - DISTRICT BOUNDARIES - REGION BOUNDARIES - INTERNATIONAL BOUNDARIES W 10~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1 _-nk- Eu \ a,S 0 Ao ongSokoeGushiegu >. 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