Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2642 Project Name Multi-sector HIV/AIDS Project II Region AFRICA Sector Health (75%); Central government administration (15%);Other social services (5%);Sub-national government administration (5%) Project ID P096056 Borrower(s) GOVERNMENT OF BENIN Implementing Agency National HIV/AIDS Control Committee (CNLS) P.O. Box 01-6930, Cotonou, Benin Tel. : 229 32 2727 Fax : 229 322727 Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared October 30, 2006 Date of Appraisal Authorization November 27, 2006 Date of Board Approval March 29, 2007 1. Country and Sector Background Country and sector issues. The Republic of Benin is located between Togo, Burkina Faso, Niger and Nigeria, and it has a coastline of 120 km in the Bay of Bengal of Atlantic. The total land area is 114,763 Km2. In 2005, the population of Benin was about 7.5 million persons. Benin is one of the countries that are still relatively lightly attacked by the HIV/AIDS virus. The prevalence rate of HIV/AIDS among the adult population from 15 to 49 years is estimated to be 2.0 percent, meaning that among this group there are about 66,000 seropositive persons. There are strong differences between the regions, where the prevalence rates varied from 0.3 percent to 3.3 percent in 2004. This rate was highest in such vulnerable groups as commercial sex workers and persons with tuberculosis, 30.5 and 16.3 percent, respectively. Government Strategy. The Government’s strategic plan for HIV/AIDS (2001-06) is being updated for the period 2006-10, but the objectives are not expected to change essentially. In brief, the objectives aim to (a) strengthen the prevention of sexually transmitted, blood-transfusion- and drug-injection-induced, and mother-to-child- transmitted infections of HIV; (b) improve the medical and psychosocial treatment and care of people infected with and affected by HIV/AIDS, including orphans and other children; and (c) reduce the economic and social impacts of HIV/AIDS among the population. HIV/AIDS Issues. A special feature in the Government’s strategy is that it has opted to provide antiretroviral medication (ARV) free of charge to all seropositive persons who need such medication. The main problem in this respect, as well as for all other strategies of prevention, treatment and care, is that the Government must rely on external funds to finance the necessary purchases and activities, because the Government itself can only provide a very modest contribution amount of funds for that purpose (equivalent of US$3.6 million in 2005). Page 2 2. Objectives The development objectives of the proposed project are derived from the country’s strategic plan for fighting HIV/AIDS and its effects and for preventing the further spread of HIV/AIDS by means of a multisectoral program approach. They are essentially similar to those under the predecessor project. Thus, complementing the activities financed by other sources, the project would help Benin Government implement its new 2006-2010 National Strategic Framework for boosting its national response to HIV/AIDS by contributing to increasing and improving the coverage and utilization of prevention services, treatment and care for specific high-risk and vulnerable groups. More specifically, the project will contribute to (a) strengthening access to and increasing utilization of prevention services for vulnerable groups (women, youth, etc.) and the high-risk groups such as the commercial sex workers and staffs of some key ministries; (b) improve access and utilization of treatment and care services for HIV/AIDS infected and affected persons, notably the persons living with HIV/AIDS (PLWHA), and orphans and vulnerable children (OVC); and (c) consolidate the coordination, management, and the monitoring and evaluation of the national response to HIV/AIDS for its sustainability. 3. Rationale for Bank Involvement The World Bank has been the single largest source of funding for HIV/AIDS prevention and care over the past four years, and has accumulated more experience in dealing with the many facets of this work than any other support program. Although the Global Fund will provide more funds in the coming years, the Bank’s comparative advantages--particularly in working with the non-health sector and in mainstreaming and unifying the coordination arrangements of HIV/AIDS—are likely to continue. Furthermore, with the experience gained in the region, especially in the multisectoral approach during the first MAP as well as in community-based operations, the Bank, in collaboration with UNAIDS, can help Benin harmonize donor contributions, develop and consolidate a multisectoral approach, promote strong coordination under CNLS, and support development of unified monitoring and evaluation arrangements. The Bank would therefore be instrumental in assuring the effectiveness of the “three ones” principles. In addition, the World Bank’s experience gained in community mobilization would help accelerate the prevention activities, especially among young people, high-risk groups, and vulnerable populations. Although the partners have been important in financing the fight against HIV/AIDS, commitments beyond the year 2006 are insufficient, leaving a large gap between the needs as estimated in the draft Strategic Plan 2006-10 and the funds committed (the need estimates, which exceed US$150 million for the period, will be further analyzed during project appraisal). Except for the Global Fund, which has committed a total of about US$68 million until 2010, only two small contributions are certain: about US$4 million per year until 2008 by AfDB and US$500,000-US$600,000 per year by the Lagos-Abidjan Corridor Project, until 2007. Thus the gap amounts to some US$75 million for the period 2006-10. Because the Global Fund plans to finance mainly the activities of the Ministry of Heath (and cannot cover them all), the gaps appear in all other activities, such as the public-sector, private-sector, and community- based programs to prevent HIV/AIDS; the psychosocial, economic, and physical care and support of persons infected and affected and of vulnerable groups (including sex workers, orphans, and children in general); national and local-level coordination and programming; and monitoring and evaluation. The most critical gaps will be identified and quantified during project appraisal. With the planned IDA financing of US$35 million over the next four years, the proposed project would fill n early 50 percent of the gap in necessary funding estimated in the national strategic plan. As has Page 3 occurred in the past, the World Bank Group’s funding and involvement in the fight against the pandemic would attract additional funds from other development partners. 4. Description The MAP II would contribute to the national program within the annual action plan and budget, using subproject grants and quarterly allocations, as appropriate. The project would act as “the lender of last resort,” that is, the project support would be provided to activities in the national strategic plan that are not covered by other financiers or are covered only partially. In the allocation of funds, the comparative advantages of the Bank-financed HIV/AIDS projects would be taken into account (see Section A.2). Although preventive and support actions are necessary for the entire population, the project would specifically reserve some funds for targeting high-risk and vulnerable groups such as orphans, children, and sex workers. On this basis the project would contain the following components (details of the project components that are similar to those in MAP I are described in Annex 4): Component 1: Social mobilization The project would provide funds to help prevent HIV/AIDS, particularly for activities relating to information, education, and communication (IEC) for behavioral change, and for care of infected and affected persons, and for the social marketing of condoms. The activities would be carried out by civil society organizations (CSOs), community-based organizations (CBOs), nongovernmental organizations (NGOs), and the private sector, as support to persons living with HIV/AIDS (PLWHA); as subprojects for vulnerable groups such as the orphans; as psychosocial and economic support to infected and affected persons; and as support to programs by the public sector (key agencies and ministries such as the Ministries of Defense, Education, Youth, Social Protection, and Agriculture). Component 2: Access to treatment and care The project would also seek to enhance access to treatment and care for HIV/AIDS-infected persons. With additional funding for the National HIV/AIDS Control Program of the Ministry of Health (PNLS/MOH) to supplement the financing provided by the Global Fund and others, access to testing, ARV medication, treatment of opportunistic infections, sexually transmitted infections (STI), prevention of mother-to-child transmission (MTCT), and second-generation sentinel surveillance would be improved. Subprojects initiated and operated by faith-based and other organizations dealing with treatment, care, and support, and potentially with nutritional issues (to be looked into during appraisal), also would contribute to improving access. Component 3: Coordination, management, and monitoring and evaluation Various studies have concluded that the coordination mechanism under the SP/CNLS has had insufficient staff and resources to lead the nationwide fight against HIV/AIDS. The project would provide funds to strengthen the SP/CNLS to allow it to carry out its role, especially in implementing “the three ones” principles. For one element of the “three ones”—a nationally functioning monitoring and evaluation system--UNAIDS and GAMET have jointly financed development of an M&E system that was completed in early 2006. The proposed project would help finance the implementation of this system at all levels in the country. Furthermore, the project would support capacity building in CNLS and decentralized units (regional and local committees). This component would also support project administration and management, including capacity strengthening and policy and technical support, management and advocacy training. The project would also finance the operating expenses of the Project Management Unit (PMU), which will be placed under the direct tutelage of the Secretary Permanent of CNLS, and recruitment of a financial management unit to ensure effective flow of funds to subprojects. Page 4 5. Financing Source: ($m.) BORROWER/RECIPIENT 2.45 IDA Grant 35 Total 37.45 6. Implementation Much of the project would be implemented through subprojects initiated by CSOs, CBOs, private-sector entities, faith-based organizations, and others engaged in fighting HIV/AIDS. ARV medications and medical supplies would be purchased through a central procurement system supervised by MOH. The project would contract out to a local financial management firm the entire process of financial assistance to CBOs that implement social mobilization activities, and this agency would act as a financial intermediary. Other project activities would be carried out by the beneficiary agencies, such as selected ministries, subproject units themselves, or their support organizations that have been granted funds from project resources. Subprojects in the field would be approved and implemented in accordance with the following procedures developed and fine-tuned during the predecessor project: Interested organizations (village organizations, NGOs, civil-society organizations, etc.) would draft a community action plan or subproject plan and financing application. Regionally experienced NGOs, confessional agencies, traditional associations, and private-sector organizations could provide technical support for these tasks, if necessary. The applications would be reviewed and approved or rejected by th e CNLS’ decentralized units (village, communal, or regional HIV/AIDS committees) in accordance with the size of the proposed subproject and the authorization level of the respective CNLS unit. The regional staff of the financial management firm mentioned above would provide assistance in program/subproject development, accounting, disbursement of funds for community-level plans, financial reporting, and perhaps even monitoring of implementation of subprojects or community action plans. As mentioned, the organizations that initiate the action plans or subprojects would be responsible for implementing them. PMU would assure that all participants in the process follow the procedures of the Operation Manual and agreements with the World Bank. Other implementation aspects. Modalities for carrying out finance, procurement, and disbursement activities are detailed in Annexes 6, 7, and 8 and the respective sections of the Operations Manual. 7. Sustainability Government commitment and ownership. The Government and other stakeholders are strongly committed to fighting the threatening HIV/AIDS pandemic. In recent years, the Government has increased its budgetary allocation for the fight against HIV/AIDS to about US$3.6 million--still a modest amount compared with the needs in this sector. For the predecessor project, Benin met the conditions of participation in the World Bank’s multisectoral program for Africa, and it has now met the conditions set for repeater projects in the sector (see Section A.1), including development of a unique, national, fully functional M&E system, which is ready to be implemented for MAP II and other donors’ projects and programs. The national strategic framework for 2006-10, along with an operational plan in the form of a national program with unified M&E indicators, also is ready. Page 5 Although the Government has been committed to fighting HIV/AIDS, two main problems remain: (a) insufficient funding to the Permanent Secretariat of CNLS at both central and decentralized levels and (b) insufficient coordination of all HIV/AIDS-related activities by the Permanent Secretariat of CNLS although it has been recognized as the sole authority. An institutional analysis has been done as part of the revision of the national strategy framework, and recommendations to correct identified weaknesses would be acted on under the MAP II. Sustainability. The extensive capacity and institution building that took place during the past four years, largely facilitated by MAP I, provides a basis for organizational and institutional sustainability, provided that continued financing for it is forthcoming. However, because Benin is one of poorest countries in the world, its Government is able to provide only a fraction of the costs needed to effectively fight HIV/AIDS. For the foreseeable future, there is general understanding within the international community that an effective and sufficient response to the epidemic depends largely on the sustained financial support of multilateral and bilateral agencies. However, as noted earlier, the Government has already started to increase its own financial contributions for the fight against HIV/AIDS. During review and approval of the National Strategic Plan for HIV/AIDS, the Government indicated that it will further increase its funding for the purpose. 8. Lessons Learned from Past Operations in the Country/Sector Main lessons from Analytical and Advisory Activities (AAA) . In 2005 the World Bank’s Operations Evaluation Department (OED) carried out an evaluation of multisectoral HIV/AIDS projects (MAP) in Africa. OED concluded that the MAPs had, in general, played an important role in scaling up the fight against HIV/AIDS. It also pointed out that the MAPs had contributed to setting priorities among the national HIV/AIDS strategies and in emphasizing a need for cost-effectiveness and results. The report also revealed that the individual country MAPs had been based on insufficient analytical work, and that coordination and monitoring and evaluation (M&E) were weak. (Guidance presented in the World Bank’s Turning Bureaucrats to Warriors has also been followed in this document.) Experience from the Benin social sector has shown that strong coordination and comprehensive and systematic monitoring and supervision are particularly essential because there are so many participants in the health and HIV/AIDS sectors (i.e., public, private, and religious sectors, external donors, local leaders, beneficiary groups, and decentralized civil servants). Lessons from the previous project. The Analytical and Advisory Activities (AAA) studies conducted in Benin and other studies, including the project ICR, have confirmed the positive impact of PPLS in Benin. An important lesson is that persons infected with and affected by HIV/AIDS can be reached through community mobilization and use of multiple channels. The process is demanding, as hundreds of civil society organizations must be involved and trained (652 in Benin), thousands of community-based groups established (3,137 in Benin), national and local associations for people living with HIV/AIDS (PLWHAs) established and supported (33 in Benin) and nearly all of the government’s administrative infrastructure engaged, but it can be done with good planning and management and with innovative approaches. MAP I was the main financing source for HIV testing in the whole country, facilitating that 202,000 persons were tested (1,223 of them seropositive). It supported capacity building in the health sector, provided equipment for health centers, and toward the end of the project even financed Page 6 provision of ARV drugs. The same component also provided sensitization and other services to the staff infected with or affected by HIV/AIDS in 40 non-health public ministries and agencies. Africa-wide studies and Benin-specific assessments, including ICR on the predecessor project, have pointed out the weaknesses in coordination and M&E. The PNLS (MOH) and various bilateral agencies and NGOs implemented their own programs without coordinating them with the National HIV/AIDS Control Committee (CNLS), while the Global Fund program was supervised by a separate Global Fund committee (CCM). Developing a unified M&E system for HIV/AIDS took the whole project period (but is now ready for taking into use). In addition, whereas responses by some public-sector agencies, such as those of the Ministries of Defense and Youth, were effective, responses by others were weak. All these shortcomings are either being corrected or will be addressed by the follow-on MAP. Although project results were encouraging, it is too soon to assess their impact. However, the ICR mission carried out in September 2006 confirmed that on the basis that the project development objectives were attained and outcome and output objectives reached or exceeded, the pre decessor project’s impact is promising. During MAP II impacts of MAP I should be possible to assess better, partly because of the new nationwide M&E system and because the indicators under MAP II the result indicators would be similar to those used under MAP I. 9. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP 4.01) [ ] [x] Natural Habitats ( OP / BP 4.04) [ ] [x] Pest Management ( OP 4.09 ) [ ] [x] Physical Cultural Resources ( OP/BP 4.11 ) [ ] [x] Involuntary Resettlement ( OP / BP 4.12) [ ] [x] Indigenous Peoples ( OP / BP 4.10) [ ] [x] Forests ( OP / BP 4.36) [ ] [x] Safety of Dams ( OP / BP 4.37) [ ] [x] Projects in Disputed Areas ( OP / BP 7.60) * [ ] [x] Projects on International Waterways ( OP / BP 7.50) [ ] [x] 10. List of Factual Technical Documents · Projet multisectoriel de lutte contre les VIH/SIDA (Benin): Operations Manual, French Version · Projet multisectoriel de lutte contre les VIH/SIDA (Benin): Operations Manual Annex II · République du Benin, Ministère Chargé de la Planification et du Développement, CNLS: Monitoring and Evaluation Manual (national M&E system) · CNLS: Draft Annual Work Plan for the First Project Yea r · République du Benin, Ministére du développement, de l’économie et des finances, CNLS : Cadre Strategic National de Lutte contre le VIH/SIDA/IST 2006 – 2010. * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 7 · République du Benin, Ministére du développement, de l’économie et des finances, CNLS : Plan Operationel pour Cadre Strategic National de Lutte contre le VIH/SIDA/IST 2006 – 2010. · République du Benin, Ministére du développement, de l’économie et des finances, CNLS : Rapport de la Préparation de la phase II du MAP (Project Plurisectoriel de Lutte contre les IST/VIH/SIDA II) du Benin · The World Bank: Implementation Completion and Results Report (ICR) of PPLS · The Wordl Bank: Turning Bureaucrats to Warriors. Preparing and Implementing Multi-Sector HIV/AIDS Programs in Africa. 11. Contact point Contact: Nicolas Ahouissoussi Title: Sr Agric. Economist Tel: (202) 473-2794 Fax: Email: nahouissoussi@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop