Document of The World Bank FOR OFFICIAL USE ONLY '- lR-1953 -~J~ - Report No. P-4816-ZR MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 6.2 MILLION TO THE REPUBLIC OF ZAIRE FOR A NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT August 23, 1988 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ZAIRE: NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT CURRENCY EQUIVALENTS Currency unit = Zaire (Z.) US$1.00 Z. 138 (February 1988) Z. 1.00 USS$0.007 (February 1988) Z. 1,000 = US$7.25 MEASUREMENTS EQUIVALENTS Metric System GLOSSARY OF ABBREVIATIONS AIDS = Acquired Immunodeficiency Syndrome HIV = Human Immunodeficiency Virus IEC Information, Education and Communication IMR Infant Mortality Rate NACP = National AIDS Control Program NGO = Non-Governmental Organization STD = Sexually Transmitted Disease 'W=HO World Health Organization WHOIGPA = WHO/Global Program on AIDS GOVERNMENT OF ZAIRE - FISCAL YEAR January 1st - December 31st FOR OFFICLAL USE ONLY MEMORANDDUM OF THE PRESIDENT ZAIRE NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT CREDIT AND PROJECT SUMMARY BORROWER Government of Zaire BENEFICIARY Department of Health CREDIT AMOUNT SDR 6.2 million (US$8.1 million equivalent) TERMS Standard IDA, with 40 years maturity FINANCIAL PLAN Government US$1.7 million IDA US$8.1 million Other donorsl US$10.5 million Beneficiaries US$1.6 million TOTAL US$21.9 million RATE OF RETUNRN Not applicable STAFF APPRAISAL REPORT No. 7260-ZR MAP IBRD 20674 1/ Other donors include: Belgium (US$1.5 million), Italy (US$1.2 million), Federal Republic of Germany (US$0.6 million), USAID (US$1.7 million), EEC (US$2.0 million), UNDP (US$1.0 million), UNICEF (US$1.5 million), and WHO (US$1.0 million). WHO and UNDP are responsible for assisting the Government in coordinating donor support, including IDA's contribution. This document has a restricted distribution and may be used by recipients only in the penormanc of their official duties. Its contents may not otherwise be disclosed without World Bank authorizat.:m. MEMORANDUM, AND RECOHMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPHENT ASSOCIATION TO THE EXECUTmI DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF ZAIRE FOR A NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT 1. The following report on a proposed development credit to Zaire for SDR 6.2 million (US$8.1 million equivalent) is submitted for approval. The proposed credit would be on standard IDA term3 with a maturity of 40 years to help finance an AIDS Control Project. The project would be cofinanced by several donors, including Belgium (US$1.5 million), Italy (US$1.2 million), Federal Republic of Germiany (US$0.6 million), USAID (US$1.7 million), EEC (US$2.0 million), UNDP (US$1.0 million), UNICEF (Us$1.5 million), and WHO (US$1.0 million); for a total of US.$10.5 million. 2. Background. The acquired immunodeficiency syndrome (AIDS) pandemic affects millions of people in more than 130 countries worldwide. AIDS is a lethal disease caused by the Human Immunodeficiency Virus (HIV) which depresses the immune system and causes the infected person to become vulnerable to opportunistic infections. In Zaire, AIDS is mainly a Sexually Transmitted Disease (STD) among individuals with multiple sexual partners. Other STDs (through ulcers which facilitate the viral penetration) increase the risk of transmission. Other routes of transmission include transfusion of infected blood, contaminated skin- piercing instruments and motner-to-child infection. Neither a cure nor a vaccine is likely to be developed in the near future given the genetic complexity of the virus. Measures aimed at preventing the spread of the disease include the adoption of lower-risk sexual practices (limiting number of partners, use of condoms) and enhanced hygiene in health system (screening of all donated blood, sterilization of skin-piercing instruments). In Kinshasa, seropositivityl rates are alarming. In 1987, 42 to 82 of the general population, 102 of females aged 15-29, and 30X of all prostitutes were infected. The disease is spreading in most urban areas of Zaire and also to communities located near main routes. At Mama- Yemo Hospital (the largest hospital in Zaire, with 2,000 beds), 252 of the medical/surgical patients test positive and 302 of the deaths are AIDS- related. Those most afflicted with the disease (20-40 year olds) are at the most productive age. Infants die also from AIDS. World Bank projections indicate that if the transmission rate continues, the Infant Mortality Rate (IMR) would increase from 120/1,000 to 140/1,000 by the year 2005, instead of being reduced to 70/1,000. The financial consequences, in terms of direct costs (the cost of treating opportunistic infections) and indirect costs (productivity losses), will also be large. Zaire is facing a very grave public health problem with severe human, social and financial implications at a time when the country is already suffering from severe economic difficulties. The Government has shown its commitment to 1/ Seropositivityt a positive blood test showing antibodies to HIV. addressing this public health crisis by supporting the development of an AIDS research project (Proiet SIDA) in 1984, establishing a National AIDS committee in 1985, and producing with WH02 support, a National AIDS Control Program (NACP) in 1987. In February 1988, the Government and WHOIGPA organized a donors meeting that reviewed the NACP and helped prepare a preliminary financing strategy based on donors' pledges. 3. Proiect Objectives. The overall objectives of the NACP (which the project would support) are to: (a) prevent RIV transmission through: (i) sexual behavior changes; (ii) wide availability and use of condoms; (iii) adequate treatment of other STDs; (iv) donated blood screening; (v) sterilization of skin-piercing instruments; and (vi) control of perinatal HIV transmission; (b) reduce the impact of AIDS on individuals, families and communities, through: (i) special assistance to AIDS cases and seropositive patients; and (ii) information to and education of people in contact with infected persons; and (c' improve the database on AIDS in Zaire, through: (i) strengthening and developing the laboratory infrastructure; (ii) developing the AIDS surveillance system; (iii) improving the knowledge of AIDS-related behavior in the general population; (iv) developing socio-economic surveys of AIDS impact; and (v) developing operational research. 4. Project Description. The proposed project has four components: .a) Information, Education and Communication (IEC) Program Development and Condom Distribution through: (i) the development of IEC materials for the media, schools, social sector personnel and other relevant target groups, (ii) the training of health staff, social workers and teachers; (iii) the strengthening of the IEC structure with additional staff, technical assistance, equipment and vehicles; and (iv) the establishment of condom distribution networks and condom promotion programs; (b) Integration of AIDS Control Activities in Health and Social Proarams through: (i) the establishment of large scale blood screening facilities and strategies; (ii) sterilization of skin-piercing instruments; (iii) in-service training, operational support and supervision for case management, STD detection and treatment and IEC activities; and (iv) social programs at the community level through both public sector programs and NGOs; (c) Ooerational Research and Studies, dealing with: (i) contributing factors to HIV transmission; (ii) sociocultural dimensions of AIDS; (iii) cost- effectiveness of control measures; (iv) constraints on condom use; (v) case management strategies; (vi) development of diagnosis tools; (vii) economic impact of the disease; and (viii) the development of a national surveillance system; and (d) Institutional Strengthening of the NACP through: (i) support to the central coordination office by providing additional staff, technical assistance, equipment and vehicles; (ii) operational support to increase managerial capabilities at Regional, Sub- Regional and Health Zone levels, with specific training/supervision, equipment and additional operating funds; and (iii) establishment of coordination mechanisms for AIDS control activities carried out by the 2! WHO, through its Global Program on AIDS (GPA), is the leading agency in developing global control strategies and providing technical assistance and short term financial support to national AIDS control programs. - 3- governmental and n-n-governmental sectors. Project activities would be carried out by several agencies both public and non-governmental agencies, which are active in the social sectors. The National AIDS Committee. assisted by its Central Coordinating Office would provide overall guidance and ensure coordination of all activities with the support of WHO/GPA and UNDP. The project, to be carried out over three and ore-half years, would provide funds for equipment, furniture, materials, vehicles, training, technical assistance, studies, research, evaluation and incremental recurrent costs. The total cost of the project is estimated at US$21.9 million, with a foreign exchange component of US$17.8 million (812). A breakdown of costs and the financing plan are shown in Schedule A. Amount and methods of procurement and the disbursement schedule are shown in Schedule B. Bank Group operations in Zaire are given in Schedules C and D, respectively. A map is attached. The Staff Appraisal Report, No. 7260-ZR, dated August 11, 1988, is also attached. 5. Rationale for IDA involvement. Large-scale emergency efforts are required to: (a) make the NACP fully operational; (b) assist the Government in reallocating resources between ongoing health activities and AIDS control activities; and (c) coordinate donor support both financially and technically. In all these areas the World Bank could play an important role, given: (a) its expertise in large national programs, financial management, and broad-baseu economic analysis; and (b) its leading role in aid coordination as chairman of the Consultative Group. In addition, IDA's involvement would: (a) help ensure, through our continuing dialogue about the health sector, that AIDS control activities are fully integrated into the national health programs, and (b) make it easier for Zaire and WHO/GPA to mobilize and to organize the necessary cofinancing. 6. Agreed Actions. The following actions to be taken by the Government would be conditions of project effectiveness: (a) establishment of the Special Accounts (IDA revolving funds and project advance account); (b) appointment, as the central coordinating office's deputy director, of a specialist in health program management with qualifications and experience satisfactory to IDA; and (c) appointment, as the Central Coordinating Office's chief accountant, of an accountant with qualifications and experience satisfactory to IDA. Other agreements would include: (a) annual submission to IDA of project operation plans; and (b) annual project performance review, including project management, to be submitted to IDA. 7. Justification. The proposed project would respond to a public health crisis which has already a negative impact on health status, health systems, health financing and the work force and has the potential for causing severe human and economic losses in an already poverty-stricken country. The project would contribute to: (a) establishing key preventive measures aiming at protecting the most vulnerable segments of the population (10-14 year olds and women in reproductive age); (b) rationalizing the packaging of AIDS control measures; (c) making the NACP fully operational and institutionally sound; and (d) a better understanding of the AIDS epidemic, and ways to control it. The project would represent the first phase of a long-term effort aimed at protecting the majority of the population from HIV infection. Benefits would include: (a) health benefits by (i) reducing the impact of AIDS on morbidity and mortality in both adults and children; (ii) contributing to the control of STDs; (ili) assisting the health systems in coping with AIDS patients; and Civ) avoiding a major imbalance in resource allocation between priority public health programs; (b) social benefits by providing a safety net for the poorest families which otherwise would not have the means to take care of AIDS patients and lose family income earners; and (c) economic benefits by diminishing, through the reduction of HIV transmission, the direct (treatment) and indirect (loss of productivity) costs of AIDS. 8. Risks. The project's main risk concerns the weak managerial capability of DOH, particularly with regard to the complexity of the control program. The project is designed to address this risk by distributing manage.-ial responsibilities among various implementing entities and several coordinating/monitoring committees. In addition, the project's institutional strengthening component would provide training, technical assistance and operational support aimed at developing planning and managerial capabilities at both the central and peripheral levels. Finally WHO and UNDP will play a key role in monitoring project implementation. The second risk is related to the experimental nature of the control measures. Some control activities may not have the expected impact on HIV transmission. The various project-supported operational research programs are designed to respond to this uncertainty and to help adjust the NACP as necessary. The third risk concerns the potential for financing shortfalls in the long term. it is likely that the AIDS epidemic will be a long-term problem in Zaire and there is a risk of donor fatigue in financing the NACP. A joint coordinating and monitoring committee (Government, WHO, UNDP, and other major donors) has been created to address this risk. 9. Recommendations. I am satisfied that the proposed credit would comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. Barber B. Conable President Attachments Washington D.C. August 23, 1988 SCHEDL A ZAIRE NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT ESTIMATED COSTS AND FINANCING PLAN Local ForeiRn Total ------USS million-- ESTIMATED COSTS IED/Condom Distribution 1.10 4.i0 5.80 Integrating AIDS Control 0.62 8.08 8.70 Research and Studies 0.60 0.40 1.00 Institutional Strengthening 1.42 1.78 3.20 Project Preparation Facility 0.06 0.24 0.30 Total Baseline Costs 3.80 15.20 19.00 Physical Contingencies 0.03 1.27 1.30 Price Contingencies 0.30 1.30 1.60 TOTAL PROJECT COSTS 1/ 4.13 17.77 21.90 FINANCING PLAN Government of Zaire 1.67 - 1.67 IDA 0.50 7.60 8.10 other donors 2/ 0.30 10.17 10.47 Beneficiaries 1.66 - 1.66 TOTAL 4.13 17.77 21.90 1/ Inclusive of taxes and duties which are negligible. 2! Other donors includes Belgium (US$1.5 million); Italy (US$1.2 million); Federal Republic of Germany (US$0.6 million); USAID (US$1.7 million); EEC (US$2.0 million); UNDP (US$1.0 million); UNICEF (US$1.5 million); and WHO (US$1.0 million). WHO and UNDP are responsible for coordinating donor support, including IDA's contribution. SCHEDtlLE B Page 1 of 2 ZAIRE NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT PROCUREMENT METHOD AND DISBURSEMENT (US$ million) Project Element ICB LCB Other NA Total Cost - Equipment 0.94 ( .27) 0.94 ( .27) - Furniture 0.14 C .08) 0.14 ( .06) - Vehicle* 0.51 ( .32) 0.51 ( .32) - Material Dvpt. 0.59 ( .22) 0.59 ( .22) - Training/TA 2.98 (1.49) 2.98 (1.49) - Research 1.11 (0.55) 1.11 ( .56) - PPF 0.5 (0.5 ) 0.6 (0.6 ) - Condoms 4.84 (1.44) 4.84 (1.44) - Mod. Supplies 8.07 (2.70) 8.07 (2.70) - fther Op. Costs _ 2.72 C .62) 2.72 ( .62) 18.86 (4.78) 0.14 t .06) 4.88 (2.28) 8.22 (1.02) 21.9 (8.07) -I Amounts ln parentheses represent IDA ftnancing. a/Consultants will be selected in accordance with Bank guidelines. SCHEDULE B Page 2 of 2 DISBURSEMENTS CATEGORY CREDIT AMOUNT 2 OF EXPENDITURES (USS million) Equipment, Furniture, 5.0 100 2 of foreign Vehicles, Materials, expenditures and hed. supplies & Condoms 90S of local expenditure Training, Technical 1.5 1OOS Assistance Operational Research & 0.3 1002 Studies Operating Costs 0.5 50? Refunding PPF 0.5 Unallocated 0.3 TOTAL 8.10 Estimated Ir^.Disbursements (US$ million) FY89 FY90 FY91 FY92 Annual 1.0 2.5 3.0 1.6 Cumulative 1.0 3.5 6.5 8.1 SCHEDULE C ZAIRE NATIONAL AIDS CONTROL PROGRAM ASSISTANCE PROJECT TIMETABLE OF KEY PROCESSING EVENTS Time taken to pLepare: 9 months Prepared bys Deparcment of Health, WHO IGPA First IDA mission: December 1987 Appraisal mission: February 1988 Negotiations: July 1988 Board Presentation: September 1988 Planned Date of Effectiveness: January 1989 SCHEDULE D NATIONAL AIDS CONTROL PROJECT Page 1 of 2 STATUS OF BANK GROUP OPERATIONS IN ZAIRE A. STATEMENT OF BANK LOANS AND IDA CREDITS (June a0, 1986) Loan or Amount In US$ Million Credit Year number Signed 8orrever Bank IDA (1) Undisbursod Prior to Congo i Transport A June 1980 Otraco Infrastructure 91.58 (2) One Loan Fully Disbursed 100.00 Twenty six Crodits (including one SFA) Fully Disbursed 410.82 798 1978 REPUBLIC OF ZAIRE Oil Palm 7.31 1.19 1040 1980 DEPT OF AOR Small Holder Maize 11.00 1.17 1089 1981 REPUBLIC OF ZAIRE Kwllu Ngongo Sugar 26.40 0.05 1180 1962 ONATRA ONATRA Modornization 26.00 10.02 1273 1982 SOFIDE Sixth DFC 21.60 3.00 132S 1983 REPUBLIC OF ZAIRE North East Rural Dev. 18.00 6.86 1335 1983 ONATRA Ports Rehabilitation 26.00 9.80 1336 1983 CECAMINES Goeamines T.A. 7.00 0.16 1409 1983 MIN MINES AND ENERGY Petroleum Sector T.A. 4.60 1.08 1421 1984 MIN MINES AND ENERGY Ruzizi II Hydroelectric 15.00 1.56 1476 1984 SNCZ Railways Il 26.00 17.8? 1492 1984 SOFIDE Seventh DFC D8.00 3.73 1519 1984 REPUBLIC OF ZAIRE Education T.A. 9.00 4.13 1540 1985 REPUBLIC OF ZAIRE Lulua Agricultural Dev. 12.60 14.68 A 006 1986 REPUBLIC OF ZAIRE Sixth Highway 80.00 16.95 1608 1986 REPUBLIC OF ZAIRE Slxth Highway 65.00 63.87 1609 1985 REPUBLIC OF ZAIRE Seeds 14.90 13.50 168s 1986 SOFIDE Eighth DFC 50.00 47.7 1712 1986 SNEL Second Power 87.00 32.79 L2882 1988 GECAMINES Csminens Rehabilltatio 110.00 100.36 1761 1987 OVT/RVM AND RVF Novigation Improv-ment 27.60 28.42 1790 1987 REPUBLIC OF ZAIRE South Shaba Agric Dev. 4.40 4.44 1791 1987 GVT ZAIRE/SSES Small Enterprie D-v. 25.00 24.02 A 030 1988 REPUBLIC OF ZAIRE Structural Adjustment Cr. 94.Z3 47.81 1831 1988 REPUBLIC OF ZAIRE Structural Adjustment Cr. 56.00 28.28 1882 1988 REPUBLIC OF ZAIRE Econ A Fin Mgt Institutions 12.00 9.97 1839 1988 REPUBLIC OF ZAIRE Higher Eduection Rational. 11.00 10.98 **1939 1988 REPUBLIC OF ZAIRE Third Water eupply 45.00 42.73 Subtotal active projects: 110.00 701.41 546.41 Total less cancallationt, 801.58 1112.23 of whith has been repaid 117.90 7.61 Total outstnding tnel. undtsbursed: 188.68 1104.72 (3) Amount sold : 64.47 of which has been repaid 64.47 Total now held by Bank and IDA (1) 28.86 780.78 (3) Total undisbursed : 100.6 448.05 (8) -- -- -- -- -- -- - -- - -- -- -- - -- - - - -- - -- - -- -- - -- - - - - _- - - - * Not yet signed. cc Not yet effective. (1) USS amounts for credits 1089-ZR and onwards are computed at rats of negotiations dates. (2) Guaranteed by the Kingdom of Belgium. (3) Sum of Total now hold by IDA and Total Undisbursed Is highor than Total Outetanding because of depreciation of the US$. ScHEDULE 0 Page 2 of-2 ZAIRE NATIWL AIDS C ROL PROJECr STATE,MDNT OF IPC NVETSThENT (As of Febru ry 29, 1983) --------USS1 Mllion-- Fiscal Type of Aounat Year Obi loutor Business Loan Equity Total 1970 SOFIDE Development Bank - 9.8 0.6 1979 Zaire Culf Oil Co. Oil 2.5 - 2.6 1979 ZlIre Petroleum Co. Oil 1. - 1.0 1982 Alusaire Consortium Aluminium (Promotional) 093 - 9.a 1984 Sotide Development Bank - 9.5 9.5 S98s Grands Hotels du Zaire Hotel 16s0 - 16.0 1986 SOTEXKI Textils 11.8 9.4 12.2 1985 SOTEXAZ Cotton Form (Promotional) - 0.1 9.1 1987 UTEXAFRICA TextIle 14.2 - 14.2 Total Gross Commitments 45.4 1.8 47.2 Total undisbursed 14.2 0.1 14.3 IBRD 21080 MALI" NIGEO 0 4'v 6 2 //) 4 SUDAN J CENTRAL AFRICAN REPUBLIC ) 2 . NtGERIA / jJ ETHIOPIA SUDAN SUDAN / ~~~ (~~~i ~ETHIOPIAaAGI i,N )CAME00OCENTRA.A.ICN 4-1'- EQ ~~~~~~~ / ~ /CA3ekbA) KENYA |~~~~CO ZA A PtsREUa5 '0' J fi Z IRE PIIUN& TANZANIA ANJGOLA T FIIANI, ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ , UGAND~A G A B 0 N ( ~~~~PEOPLE'S REPUBUC < N ATOCANAL A0D usNRO LRO TANZANIA o 100 200 ~~~~3100 a.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Ll NATIONAL AIDS CONTROL PROGRAM M ASSISTANCE PROJECT POPULATION DENSITY: - Paved Roads n] above 40 bm, - Main Earth Gravel Roads -15-40knl -- Raikioad r bt-z2 b- pWW by 0-15 kn3 t Airhelds ANGOLA KOLWOZ, a r' ay 2 below5km. ' NabooaICaa - -.f Ma 0 Region Capflals ! '5iC KteUeStLUMA t/ _n ln , 2 - Rrve3rs 12- 1d .p at be V aldpara _ _Zone Boundaries PWi