Page 1 INTEGRATED SAFEGUARDS DATASHEET RESTRUCTURING STAGE I. Basic Information Date prepared/updated: 11/09/2010 Report No.: AC5573 1. Basic Project Data Country: Madagascar Project ID: P090615 Project Name: Second Multisectoral STI/HIV/AIDS Prevention project Task Team Leader: Maryanne Sharp Estimated Appraisal Date: April 1, 2005 Estimated Board Date: July 12, 2005 Managing Unit: AFTHE Lending Instrument: Specific Investment Loan Sector: Other social services (65%);Health (35%) Theme: HIV/AIDS (29%);Population and reproductive health (29%);Participation and civic engagement (14%);Gender (14%);Other social protection and risk management (14%) IBRD Amount (US$m.): 0.00 IDA Amount (US$m.): 30.00 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: BORROWER/RECIPIENT 0.00 0.00 Environmental Category: B - Partial Assessment Simplified Processing Simple [X] Repeater [X] Is this project processed under OP 8.50 (Emergency Recovery) or OP 8.00 (Rapid Response to Crises and Emergencies) Yes [ ] No [X] 2. Project Objectives The development objectives of the MSPP II are the same as the development objectives of the MSPP, that is to support the Government of Madagascar#s efforts to promote a multisectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory. To do so, the project will build capacity and scale-up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread of HIV/AIDS. 3. Project Description PROJECT COMPONENT 1: Harmonization, Donor Coordination, and Strategies (US$1.5 million equivalent). Under MSPP I, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This component will be revised to include donor coordination, the updating of the national strategy, and a more selected support to sectors. This component will emphasize four activities: a) Harmonization and Donor Coordination: This activity will support practical mechanisms of coordination among donors to ensure better impact and cost-efficiency of Page 2 HIV/AIDS interventions. Although Madagascar has achieved two of Three principles? (One national authority for HIV/AIDS, and one strategic framework) donor coordination needs to be intensified, particularly on the M&E system. b) Updating of the National Strategic Plan. The current Plan covers the period through the end of 2006, and will need to be updated and re-validated thereafter, based on recent knowledge about the disease and the evaluation of past activities. c) Implementing the HIV/AIDS/IST communications strategy and action plan. Though knowledge of HIV and information on prevention is now relatively widespread, actual sexual practices remain risky, and stigma strong. The project will maintain mass media campaigns, but will place more emphasis on activities that facilitate dialogue and action on prevention and stigma reduction at the grassroots level. This subcomponent will also finance communication materials and toolkits for NGOs and CBOs that will implement grassroots communication sub-projects under the Fund (component 3). If needed, the existing communications strategy (October 2004) may be updated based on the evaluation of communication activities. d) Support for the development of a limited number of sector strategies and action plans (two to three). The sectors which focus on high risk groups (e.g. Education for the youth, Security for the solders, prisoners, police personnel etc.) will receive priority. If implementation progresses satisfactorily, the number or sectors may be expanded during the course of the project. PROJECT COMPONENT 2: Support for Health Sector Response (US$3.0 million equivalent). Under the MSPP I, the Ministry of Health was involved only in the implementation of a major STI program, and the implementation of the medical waste management plan. The involvement of the health sector in the fight against HIV/AIDS/IST will be strengthened under the MSPPII, which will complement general funding to the sector provided by the Second Health Support Project ($40 million for the original credit and $22 million for a supplemental credit that will be submitted to the Board in early FY06). This component will finance the revision of the health strategy for the prevention of HIV/AIDS, and will finance a range of activities of which examples are provided below. The UGP and the Health Ministry may decide together to subcontract some of these activities to NGOs and the private sector. a) Support for STI control. MSPP I made a significant effort to control STIs by financing (a) training based on the Syndromic Approach, and (b) the sale of two STI treatment kits at subsidized prices in both the public and in private sectors. MSPP II will expand these activities in high risks places or groups. b) Support for care and treatment of PLWHA. Based on the preliminary experience of the IDA-financed Regional Treatment Acceleration Program (TAP), and on the Interim Review of the MAP Program in Africa, MSPP II will help the Ministry of Health establish a range of complementary services such as: (a) expansion of the VCT centers in all district hospitals and in health centers (CSB2) in high-risk areas ; These VCT will be staffed by one nurse/laborantin and one counselor. (b) psycho-social, nutritional, and other support for persons infected and affected by HIV/AIDS; and (c) treatment of PLWHA (ARVs, CD4 count), Prevention of Mother To Child Transmission (PMTCT), and treatment of opportunistic infections (diagnosis tools and pharmaceutical products). Page 3 c) Other health sector response activities. MSPPII will provide complementary funding for other activities as needed, such as laboratories (mainly supported by the Global Fund) or blood transfusion (mainly supported by the African Development Bank), training of health staff, and medical waste management. PROJECT COMPONENT 3: Fund for STI/HIV/AIDS prevention and care-taking activities (US$17 million equivalent). Under MSPP I, some 850 NGO, CBO, and association-sponsored sub-projects have contributed to a range of preventive interventions. These local response activities will be scaled- up with a stronger focus on places where the population is at greatest risk of being infected or of transmitting the infection. Seventy five (75) percent of the Fund resources will be allocated to these places, which will be identified using the PLACE methodology (already piloted) and the LQAS. This component will finance the following activities: a) Sub-projects. Sub-projects will include (i) condom distribution through social marketing and promotional distribution ; (ii) grassroots communication activities that shift the focus from general knowledge about the epidemic to Behavioral Communication for Change; (iii) home-base care and other support for PLWHA and associations of PLWHAs, (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for HIV/AIDS services,(vi) training of peer educators and community-based counselors, (vii) activities that aim at reducing stigma and discrimination against PLWA; (viii) workplace HIV/AIDS plans for the public sector. b) Fund management. This component will finance fund management by the Financial Management Agency (AGF), the Facilitation Organizations (OF) and the Technical Review Organism (ORT). The AGF reviews sub-project proposals for the strength of financial management arrangements, and transfers funds from the project to organizations who have received approval for the sub-project proposal. The OFs will i) support the CLLS in incorporating HIV/AIDS/IST activities into their Communal Development Plans (Plans Communaux de Développement, PCDs) in the highest risk areas; and (ii) strengthen CBOs capacity to develop and implement sub-projects. This sub-component will also finance the updating of the list of the standardized activities eligible under the Fund and developed under the MSPPI. Under the MSPPI, the list of the standardized activities was used to increase the effectiveness of Fund-financed activities and to avoid over-programming of geographic areas and/or target populations. The updating will refine this instrument and its used mode so that it can be used as effectively as possible in the MSPPII#s high risk communes. PROJECT COMPONENT 4: Monitoring and evaluation system (US$3.0 million equivalent). In accordance with the "Three Ones" principle, the PMPSII project will support the national M&E plan and framework to which all HIV/AIDS partners in the country adhere. This component provides support to this single M&E system, and has three objectives: to develop a functional monitoring system (including MIS) to measure and manage the performance of the PMPSII project; to track the evolving status of the HIV/AIDS epidemic in Madagascar; and to learn how government policy can slow the epidemic and mitigate its consequences, drawing from the Malagasy experience. The monitoring and evaluation component will have three parts: monitoring; epidemiological studies, impact studies and situation analysis. Page 4 a) Monitoring: The project will support implementation of a five-part Monitoring Plan. The monitoring plan is designed to generate and/or collect key performance indicators, financial, input and operational data for the project; to consolidate this data in a fully functional management information system (MIS); and to use the data collected in project decision-making. Lot Quality Assurance Sampling will be used for quality data collection of a sub-set of key performance indicators. b) Epidemiological Surveys: The component will continue to finance a series of second generation surveillance surveys and other population based surveys. These include bi- annual behavioral surveys among high risk groups (sex workers, truck drivers, military and youth); annual sentinel surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers); The latter includes the cross- sectionnal seroprevalence study (Enquête Nationale de Sero-prevalence Auprès des Femmes Enceintes) first conducted in 2003; the 2008/09 Demographic and Health Survey; and the annual PLACES Study of high risk sites and risk behaviors there. c) Impact Studies And Consolidated Annual Report: The MSPPII will support two project impact studies, one on the cost and effectiveness of a specific prevention intervention or intervention package in high risk zones, and the second on an intervention or intervention package in a low risk zone. Each impact study will use an intervention and a control group, and will collect data before and after the intervention group participates in the project. It will also develop a consolidated annual report, in close collaboration with the CNLS. The report will provide a summary analysis of data collected in the course of the year and recommendations on re-orientation of the national HIV/AIDS program, based on the data analysis. Component 5: Project Management (US$2.5 million). MSPP II will support the institutional arrangements and operational modalities established under MSPP I, at the central level (CNLS, the PMPS Council, and UGP), and the new structures established at the regional level (BCR), following the creation of regions mid-2004. This component will finance part of each level#s staff, equipment and operating costs, vehicles, periodic technical assistance, and some training based on annual capacity building plans. 4. Project Location and salient physical characteristics relevant to the safeguard analysis National level: The project will target high-risk zones, i.e. areas where the risk of HIV transmission is greatest. 5. Environmental and Social Safeguards Specialists Mr Paul-Jean Feno (AFTEN) Page 5 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Physical Cultural Resources (OP/BP 4.11) X Indigenous Peoples (OP/BP 4.10) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: Because the project involves risks associated with the handling and disposal of HIV infected materials. These risks potentially affect personnel in hospitals, health centers and municipalities who handle waste, families whose income derive from the triage of waste and also the general public, to the extent that waste is not disposed of on-site nor safely contained in protected areas. The only safeguard issue raised by the project realates to the management of medical waste in health facilities. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: Not applicable. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. Not applicable. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. Multiple results of studies have converged in 2003 to show low consideration of medical waste management in the health facilities and public health throughout the territory and correspondingly the absence of health and environmental hazard control associates. Faced with this situation, the Ministry of Health is committed to develop a National Policy document. A participatory process work has been developed during 14 months through meetings of ad hoc technical committees, and field visits within the health centers, the document entitled #National Medical Waste Management Policy" defines the principles, adopted policies. The document develops the national action plans for the period 2005-2008. The National Medical Waste Management Policy has been finalized with the participation of civil society and various stockholders through a national workshop in July 2005. It was officially validated by Decree interdepartmental n° 2006- Page 6 680 on September 12, 2006. After eighteen months of its implementation, the National Medical Waste Management Policy was updated to improve its results and its compliance with the Development Plan for Health Sector which covers the period 2007-2011. The National Action Plans integrated into the National Medical Waste Management Policy are built around 5 strategic objectives and 51 activities. The operational activities have mainly concerned the tools dissemination such as elaboration of medical waste management plan in the health facilities, trainings in cascade at the health staffs and equipment of hospital centers in incinerators De Montfort according to an integrated approach (sensitization/ training health staff, developing medical waste management plan, storage equipments and protection hardware). To date, the implementation of the National Medical Waste Management Policy shows the following results: 200 small-scale burners to burn medical wastes in all 200 health centers rehabilitated under CRESANII; 61% of public hospitals (77 health centers) have been sensitized to the National Medical Waste Management Policy; 30% (or 37 health centers) have elaborated of medical waste management plans, 10% of the CSB (120 health facilities) have been sensitized to develop their own medical waste management plan; 44 incinerators De Montfort have been built. The National Policy and its tools have been circulated to the partners, the DRS, the DSSS and 120 public hospitals and health facilities. The training modules are available in CDs form. The cascade training processes have been led to the interregional and regional level into the hospital and health centers: 16 regions on 22, 1044 (DSS and CHD) trainers have been trained. In the health sector, a coordinator unit (SAGS), in charge of the supervision and monitoring on the implementation of the National Medical Waste Management Policy is operational. Under MSPPII project, the Ministry of Health has received the support at the implementation of the National Medical Waste Management Policy through the component 2. This support has been the construction of 22 incinerators De Montfort in health centers and the realization of cascade trainings organized in the regional level. The supervision missions have noted the strong commitment of the Ministry of Health in the implementation of the National Medical Waste Management Policy. The support of the project is satisfactory. Project restructuring scope under safeguard aspects: The PDO will remain uncharged under the proposed restructuring. The activities will be reinforced with certain components which will be reinforced with the financing reallocation. Therefore, activities proposed under the proposed restructuring are very similar to the activities already covered under the project's existing safeguards framework in the health sector under Bank's assistance. These amendments will not trigger any new safeguard policies. No new environmental risks are expected to arise under the project. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. During the preparation of original project, a National Medical Waste Management Policy was prepared through a consultative process involving all stakeholders in the regional and national level in the health sector. The Ministry of Health includes the status of implementation of the National Medical Waste Management Policy in its annual technical report of the sector. Page 7 B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Was the document disclosed prior to appraisal? Yes Date of receipt by the Bank 05/01/2004 Date of "in-country" disclosure 03/07/2005 Date of submission to InfoShop 03/23/2005 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors Resettlement Action Plan/Framework/Policy Process: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenous Peoples Plan/Planning Framework: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Pest Management Plan: Was the document disclosed prior to appraisal? N/A Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop * If the project triggers the Pest Management and/or Physical Cultural Resources, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit or Sector Manager (SM) review and approve the EA report? Yes Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes The World Bank Policy on Disclosure of Information Have relevant safeguard policies documents been sent to the World Bank's Infoshop? Yes Have relevant documents been disclosed in-country in a public place in a Yes Page 8 form and language that are understandable and accessible to project-affected groups and local NGOs? All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? D. Approvals Signed and submitted by: Name Date Task Team Leader: Ms Maryanne Sharp 07/19/2010 Environmental Specialist: Mr Paul-Jean Feno 07/19/2010 Social Development Specialist Additional Environmental and/or Social Development Specialist(s): Approved by: Sector Manager: Ms Eva Jarawan 10/13/2010 Comments: