Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB904 Project Name GHANA MAP II Region AFRICA Sector Health (75%);Central government administration (15%);Other social services (5%);Sub-national government administration (5%) Project ID P088797 Borrower(s) GOVERNMENT OF GHANA Implementing Agency Ghana AIDS Commission PO Box CT 5169 Ghana Tel: +233 21 782 262 Fax: +233 21 782 264 sakyi@ghana.gov.gh Environment Category [ ] A [x] B [X] C [ ] FI [ ] TBD (to be determined) Safeguard Classification [ ] S 1 [ ] S 2 [ ] S 3 [ ] S F [x] TBD (to be determined) Date PID Prepared October 29, 2004 Estimated Date of Appraisal Authorization April 15, 2005 Estimated Date of Board Approval September 12, 2005 1. Key development issues and rationale for Bank involvement The Government of Ghana has been engaged in the fight against AIDS since the 1980s. The mean prevalence rate is about 3.8 percent for the country as a whole, but reaches 8.5 percent in some areas, and is even higher among vulnerable groups such as commercial sex workers. In response to these rates, the Government established the Ghana AIDS Commission in 2000 to better mobilize and manage resources for the fight against AIDS. In 2001 the Government adopted the Ghana HIV/AIDS Strategic Framework for 2001-2005. This defines the Government’s objectives at the national level and its principal means for reaching the objectives. Importantly, the Framework establishes institutional arrangements for the coordination and implementation of multisectoral HIV/AIDS programs in Ghana. The proposed Second Ghana AIDS Response Project (FY06) is consistent with the Country Assistance Strategy discussed by the World Bank’s Board in February 2004. Specifically, the proposed project would directly support the second key objective of the Country Assistance Strategy, which is the provision of services for human development The project team completed a mid-term review of the current (and first) Ghana AIDS Response Project at the same time as a review was conducted as part of the Interim Review of the Multisectoral HIV-AIDS Program (MAP). Both reviews found that the current project has established effective capacity to fight AIDS. The reviews found that the Ghana AIDS Commission was effective in implementing the HIV/AIDS program; they found that most of the Page 2 decentralized government districts in Ghana have the capacity to conceptualize and implement good quality HIV/AIDS programs; and that over 3,200 NGOs and community-based organizations (CBOs) have made meaningful contributions to the fight against AIDS. The Ghana AIDS Commission conducted technical and financial audits for a significant number of NGOs and CBOs and the audits confirm that over 95% of the funds were used for their intended purposes. One key lesson from the on-going project is the benefit from scaling up activities in geographic areas with high prevalence rates. Another key lesson is the imperative for close monitoring. The Ghana AIDS Commission tracks the resources mobilized from stakeholders. The Commission uses an M&E system as a management and decision-making tool. This has lead to a more “hands on” dialogue between stakeholders at all levels in addition to better coordinating and targeting interventions. The key partners that support HIV/AIDS programs in Ghana are UNAIDS, DfID, USAID, DANIDA, the Global Fund, Clinton Foundation, UNICEF, and WHO. Their interventions complement Bank-supported interventions, although an overall “mapping” of the interventions remains to be completed. UNAIDS and the UN Theme Group serve as the means for regular communication among the partners. With heightened emphasis on the three “ones”, namely one national HIV/AIDS policy, one coordinating mechanism, and one M&E system, this is expected to play a heightened role in future. The continued participation of the World Bank in the struggle against HIV/AIDS in Ghana is necessary to realize the objectives of Ghana’s Poverty Reduction Strategy and to realize the Millennium Development Goal that calls for preventing the spread of the disease. Furthermore, Bank support is necessary to improve the quality of life of people living with HIV/AIDS, orphans of AIDS victims, and young children who are most vulnerable living in communities affected by HIV/AIDS. This is because the World Bank is the major source of funds for the HIV/AIDS programs and has the institutional capacity to bring partner organizations together, mobilize funds, and advise how to battle the disease using a multi- sectoral approach. In particular, the Bank has experience and a comparative advantage with Community-driven Development programs, which are relevant for activities carried out mainly through local governments and by CBOs and NGOs at the local level. The Ghana AIDS Commission and other key stakeholders are fully committed to preparing the proposed project, in collaboration with all development partners. A joint review of the national response has been completed. The recommendations of the joint review will form the basis for this follow-on operation. Development partners have also shown a high degree of commitment to supporting a Sector Wide Program (SWAp) for HIV/AIDS as a means of ensuring a coherent, more sustainable dialogue with a longer-term vision. 2. Proposed objective(s) In line with the Government’s Strategic Framework, the main objectives of the project would be to improve the accessibility and use of prevention, care, and support services Page 3 ƒ In high prevalence areas, and ƒ Among priority risk groups, and ƒ To those affected by the pandemic, especially for people living with HIV/AIDS and orphans and other vulnerable children, in particular young children (0-8)(OVC). To achieve the objectives the Project would support information, education and behavior change and communication activities. About 98 percent of the adult population of sexually active age is aware of HIV/AIDS according to the 2002 Ghana Demographic and Health Survey, and this is partially attributable to the current Ghana AIDS Response Project. Therefore, the information, education, and communication activities (IEC) would evolve and focus increasingly on behavior change and communication. The Project would also support prevention of mother to child transmission of HIV/AIDS, voluntary counseling and testing, and prevention of transmission through the medical system. It could also fund anti-retrovirals. Finally it would support PLWHAs and pilot innovative models of care for OVCs and young children infected and affected by the pandemic at the community level. The Project would enhance planning, management, and public participation at all levels to ensure its activities are successful. In particular, it would mobilize, coordinate, and target available financial resources to ensure that each district and region in Ghana designs, implements, and monitors a strategy to prevent HIV infection. It would also provide treatment, care, and support to PLWHAs and OVCs. Young children (0-8) have distinct early child development (ECD) needs, which would be addressed under the proposed project. The Project would monitor implementation by commissioning independent evaluations of the efforts of implementing partners, through biological and behavioral surveillance, and through routine reporting on the accessibility, coverage, and use of essential HIV/AIDS services. The Project would then use the M&E system for strategic decision making and in particular for planning purposes. Moreover the Project would stimulate participation in the fight to stabilize the pandemic among CBOs, NGOs, ministries, departments, and agencies, and in the private sector, and promote the exchange of information among these organizations. Since this project is being designed as a SWAp, development partners and other stakeholders will reach a consensus on one set of performance indicators to be monitored for 2006-2010. This indicators would be fully consistent with the overall direction and scope of Ghana’s National Strategic Framework which is currently being revised for the 2006-2010 time frame. These indicators would be selected from such HIV/AIDS program indicators as mobilization of resources, coordination and targeting, participation, prevention (e.g., percentage of commercial sex workers targeted by the project who report using condoms during their last sexual encounter), treatment and care, mitigation of impact, and monitoring and evaluation. 3. Preliminary description The proposed project would contain three broad components, which embrace closely related subcomponents. Page 4 (a) Support for Multisectoral HIV/AIDS Responses . The public-sector response. The Ministry of Health (MOH) was excluded from the on-going project because it received funds from other sources. The proposed Project would enable the MOH to deliver services to people identified through the voluntary counseling and testing and prevention of mother to child transmission programs --which are supported by the Health SWAP. The proposed Project would also fund other ministries, departments, and public agencies so that they can continue IEC activities and prepare or implement workplace HIV/AIDS policies and action plans. It would also support, when requested, care for ministry and public agency staff infected with HIV, and voluntary counseling and testing. The decentralized government response. The proposed Project would work with Ghana’s decentralized governments: the district assemblies. In particular, the Project would help districts prepare their own AIDS plans and help build the financial, managerial and technical, capacity to implement community based activities initiated during the on-going MAP. Moreover, the Project would support piloting of conditional cash transfers for the basic education and health needs of orphans and other vulnerable children, such as those under eight years of age.. The nonpublic-sector response. Under the proposed Project, NGOs, CBOs and faith-based organizations would continue to engage in prevention and care activities, such as IEC, VCT, prevention of mother-to-child transmission, early child development interventions, peer education, organizing associations of PLWHAs, and providing training, and hospice care. With project support, traditional leaders and faith-based organizations could implement mid-size pilot programs for orphans and vulnerable children, including young children (0-8). The proposed Project would also include funds for HIV-AIDS activities in the private sector, which started late in the implementation of the predecessor project, as well as for preparation of a well-articulated private-sector strategy. (b) Capacity Building and Knowledge Management . The Ghana AIDS Commission has been successful in engaging thousands of stakeholders in the public and nonpublic sectors and in disbursing funds. Nevertheless, the Commission must continue to provide training and enhance the communications network on HIV/AIDS (including Web sites). The Project will support the Commission’s effort to create a platform for sharing experiences and best practices and to provide incentives to expand effective programs. (c) Coordination, Administration, and Monitoring The Ghana AIDS Commission is responsible for coordinating the activities of the proposed Project and of donor HIV/AIDS efforts (with support from the Ministry of Health) . The project Page 5 team will look for ways to ensure that the Commission does not continue to be overburdened by implementation related matters at the expense of the coordination of the National Response. The Commission will continue to focus on partner coordination in many ways (dissemination of information on the various partner programs, agreement on annuals work programs and budgets for the Commission, etc.) Thus, one option under consideration is to revisit the Commission’s organizational structure, which could be divided into two units: coordination of the national response and program implementation. The proposed Project would finance most of the Commission’s activities. Increased resources would be made available for M&E at all levels to ensure that it can continue to provide timely disaggregated information on the types of sub-projects, service providers, etc. 4. Safeguard policies that might apply [Guideline: Refer to section 5 of the PCN. Which safeguard policies might apply to the project and in what ways? What actions might be needed during project preparation to assess safeguard issues and prepare to mitigate them?] The only safeguard which could be triggered is the Environmental Assessment. An Environmental Assessment of the Health Sector (which included HIV/AIDS) was carried out as part of the preparation of the IDA financed Health Sector Wide Support Project (SWAP). It will be re-disclosed for this Project. This Environmental Assessment included the preparation of a Waste Management Plan. This Plan includes specific actions which need to be carried out in terms of medical waste disposal and management for the various types of health facilities in Ghana. In addition, specific training programs are recommended for the various health workers. The implementation of these new policies and actions for waste management are expected to begin in September 2005. 5. Tentative financing Source: ($m.) INTERNATIONAL DEVELOPMENT ASSOCIATION 25 BORROWER/RECIPIENT 2.5 LOCAL COMMUNITIES 4 UK: BRITISH DEPARTMENT FOR INTERNATIONAL DEVELOPMENT (DFID) 10 Denmark: DANISH INTERNATIONAL DEVELOPMENT AGENCY (DANIDA) 10 TOTAL 51.5 6. Contact point Contact: Eileen Murray Page 6 Title: Sr Operations Off. Tel: 5337+3106 Fax: (233-21) 227887 Email: Emurray@worldbank.org Location: Accra, Ghana (IBRD)