Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB4078 Project Name Swaziland HIV/AIDS Project Region AFRICA Sector Health (60%); Other social services (23%); General public administration sector (10%);Central government administration (7%) Project ID P110156 Borrower(s) KINGDOM OF SWAZILAND Government of Swaziland Swaziland Implementing Agency Ministry of Health and Social Welfare P.O. Box 5 Mbabane H100 Swaziland Tel: 268 404 2431 Fax: 268 404 2092 National Emergency Response Council on HIV/AIDS P.O. Box 1937 Mbabane H100 Swaziland Tel: 268 404 1708 Fax: 268 404 1692 Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared September 15, 2008 Estimated Date of Appraisal Authorization January 26, 2009 Estimated Date of Board Approval July 2, 2009 1. Key development issues and rationale for Bank involvement: Swaziland is a unique lower income IBRD country that is facing tremendous development challenges particularly in the area of HIV/AIDS. The scale of the HIV/AIDS epidemic and its social and economic implications are unprecedented and devastating, with a magnitude comparable only to a natural disaster or a civil war, and is now the country’s single greatest challenge. Swaziland’s HIV/AIDS adult prevalence is the highest ever recorded anywhere in the world since 2004. It now stands at 32.4 % (2006) (Annex 1). A staggering 49% of women aged 25-29 are HIV positive. The raging epidemic has affected all aspects of society, including: (i) Swaziland’s death rate is the highest in the world as the result of the epidemic; (ii) its population size has shrunk to less than one million; (iii) life expectancy has dropped to an astonishingly low 31 years, the lowest in the world; (iv) based on the current trend, the epidemic may claim the lives of two thirds of all 15 year olds; (v) more than 31 percent of children are orphans and vulnerable children (OVCs), and every other household hosts at least one orphan; and (vi) it is estimated that 32% of all staff in central government agencies will be lost to AIDS over the next 20 years. Page 2 The epidemic has overwhelmed the country’s obsolete health systems, contributing directly or indirectly to the other worsening health indicators in the country. Swaziland has the highest TB incidence rate in the world, with a TB-HIV co-infection rate as high as 80 percent. The maternal mortality ratio is 589 per 100,000 live births (2007 Demographic and Health Survey) against the MDG target of 140 per 100,000 live births. The under-five mortality rate is 120 deaths per 1,000 live births, indicating that one in every seven children born in Swaziland dies before reaching the fifth birthday. Nutrition is also a problem and 42 percent of children aged 6-59 months have some degree of anemia. Anemia is also prevalent among pregnant women and breastfeeding women. In summary, the country is off track in meeting the MDG targets. This situation is exacerbated by a dire social and economic situation. GDP growth has slowly declined from an average of 6 percent in the 1970s, 3.7 percent in the mid- and late 1990s, to 1.7 percent in 2006. 69 percent of households live in poverty. The unemployment rate is as high as 32 percent. 20 percent of the population live on food aid. With a Gini coefficient of 0.61 percent, Swaziland reports the 7 th most severe income inequality in the world. In summary, the HIV and health situations as well as the some of the social and economic indicators are worse than in many IDA countries. National response to the epidemic : Swaziland declared the HIV/AIDS epidemic as a national disaster in 1999. The National Emergency Response Council on HIV/AIDS (NERCHA) was established in 2003 to coordinate and facilitate the national multisectoral response to HIV/AIDS. The National Multisectoral HIV and AIDS Policy, issued in June 2006, is a call to arms to fight the epidemic. Drawing on the HIV and AIDS policy document, the Second National Multisectoral HIV and AIDS Strategic Plan (2006-08) was also issued in June 2006. Although the country, together with its partners, has made great efforts and invested heavily to control the pandemic, clearly large critical gaps remain which require further assistance. To a significant extent, the middle-income country label has limited Swaziland from receiving the much needed financial and technical support from the international community. It is estimated that, even after receiving a significant new Global Fund grant (Round 8), Swaziland will need an additional US$170 million in the next 5 years to be able to fully implement its national HIV and AIDS strategic plan. The funding that Swaziland received from the three major donors (PEPFAR, Global Fund, and the World Bank) is significantly less than some IDA countries with much lower HIV prevalence rates (e.g. Zambia). As a result, there is no evidence to show signs of declining prevalence rates in the country. Based on the Government’s own assessment, among the five thematic areas of the country’s HIV/AIDS program- prevention, care & treatment, impact mitigation, system strengthening , and cross-cutting issues (such as capacity and M&E), prevention and care & treatment have received sufficient funding to finance planned interventions for the next five years. HIV/AIDS related social protection as part of impact mitigation requires renewed attention. System strengthening is the weakest area and also suffers from lack of funding. The health service delivery system, which was designed before the HIV epidemic, is overwhelmed by the magnitude of the epidemic. There is an urgent need to expand and upgrade the health system network to provide preventive and treatment services. Implementation and management capacity is another challenge which requires urgent support. Page 3 Relevance to CAS objectives : The Bank and the Government did not have a CAS from 1994 to 2007. However, the Bank remained engaged in Swaziland via one IBRD financed project (Urban Development), a US$ 500,000 IDF grant for strengthening the HIV/AIDS M&E system, and a number of small-scale and demand-based technical assistance and analytical work during the non-CAS period. This situation changed recently when the Government asked for a strategic re- engagement with the Bank. The re-engagement process was intensified following a visit to Swazila nd by the Bank’s Vice President for Human Development in late 2007 and the drafting of an Interim Strategy Note (ISN). The ISN was approved by the Board in March 2008, marking a historic step toward renewed commitment and improved cooperation between the two sides. The ISN outlines three strategic areas for the Bank increased support to Swaziland: (i) fighting HIV/AIDS; (ii) improving governance; and (iii) increasing competitiveness. This proposed project, the centerpiece of the Bank’s assistance to the country’s efforts to fight HIV/AIDS, has been explicitly included in the ISN. Other partners’ activities and coordination : Only a few donors are supporting Swaziland in the area of HIV/AIDS and health. Major external financiers include the Global Fund to fight AIDS, Malaria and Tuberculosis (GFATM), US President’s Emergency Plan for AIDS Relief (PEPFAR), and European Commission (EC). The UN family (including UNAIDS, UNDP, UNFPA, UNICEF, and WHO) are active in providing technical support. In addition, the African Development Bank (AfDB) is preparing a health sector project with a focus on health infrastructure. The task team has actively engaged partners in harmonizing support to the country, and significant progress has been made as follows: (i) the EC has agreed to jointly prepare and finance the proposed project with the Bank. The Government has endorsed that the EC channel about 17.5 million Euro to the Bank through a trust fund arrangement to co-finance the project; (ii) Partners supporting the health sector have agreed to help the health sector move toward a Sector-Wide Approach. The proposed project will support the building blocks of the SWAp; (iii) the Bank and AfDB reached a consensus to establish and use a common fiduciary system, and (iv) the Bank and GFATM will work closely to complement support particularly in the area of social protection. 2. Proposed objective(s): The overall objective of the project is to assist the Government of Swaziland in fighting HIV/AIDS by addressing the major gaps in implementing its HIV/AIDS national strategic plan, particularly in health system strengthening and HIV/AIDS related social protection. Specifically, the project aims at improving accessibility and efficiency of health and social protection services for HIV/AIDS affected population particularly the poor and vulnerable. 3. Preliminary description: To achieve the project objective, the project will adopt the following guiding principles: The project will be in alignment with the overall national strategic plan and adopt a gap-filling approach; it will complement the government and development partners’ ongoing programs and efforts; and it will finance capacity-building and avoid ambitious design in dealing with the weak capacity on the ground. Based on these principles and the unique situation in Swaziland, the project did not follow the typical design of the Bank’s MAP. It rather plans to direct most of the resources to support the Page 4 two weak areas identified by the Government and the Bank team, namely the health system and HIV/AIDS related social protection. The investment project instrument is deemed the most appropriate given the fact that: (i) weak capacity in the country that requires flexible and targeted implementation support; and (ii) the clients are not familiar with the Bank operational procedures and more complicated instruments (e.g. APL, SWAP, etc.) would affect the implementation. However, the project will support the country’s long-term efforts to move to a SWAp in the health sector. The project includes four proposed components with an estimated cost of US$ 50 million (in which EC will contribute about 17.5 million Euro, equivalent to about US$ 27 million) Component 1: Health system strengthening . The health system is the one major weak area in responding to the unprecedented epidemic, with its insufficient capacity, inadequate management, and unmotivated staff. The component intends to provide support to fill in the gaps in management, service delivery, and human resources in the health system, and also to improve performance by introducing a performance-based grant facility. Specifically, this component will: (i) introduce a performance-based grant facility to improve efficiency; (ii) provide technical assistance to the key functions of the MOHSW (including planning, HR management, procurement and financial management, M&E, HIV/AIDS and TB programs; (iii) support the completion and commissioning of three problematic projects: the TB hospital, the national referral laboratory, and the central medical stores; and (iv) address the capacity gaps for those providers who do not qualify for performance grants. Component 2: HIV/AIDS related social protection . The unprecedented increase in the number of PLWAs, and particularly OVCs, coincides with the deterioration of the country’s social fabric and informal social safety nets. The Government is struggling in developing a social protection system that can provide an appropriate and adequate response to the increasing level of national destitution and vulnerability. Although significant external resources have been invested in scaling up the overall impact mitigation of the epidemic, social protection of the vulnerable populations remains a major challenges. This component will support strengthening the social welfare system by: (i) creating a simple and efficient system to implement grant-based interventions with a focus on the demand side (e.g. a unified “Child Support Grant”); (ii) strengthening and expanding the reach of service-based social risk programs; and (iii) helping building an efficient policy-making and administration system to implement social welfare strategies. Component 3: Public-Private Partnership (PPP) for improving health care services . The Government acknowledges that PPPs are being widely used in the health sector and for HIV activities by governments worldwide and in the southern Africa region, specifically South Africa and Lesotho. Several public-managed and financed projects have run into problems due to reasons mostly related to lack of adequate capacity and efficient coordination in the public sectors. The Government has decided to explore the PPP options for improving health services. This component includes support to: (i) identifying and implementing pilot PPP projects that will be jointly assisted by IFC and (ii) building capacity needed in the Government to plan and manage PPP projects. Page 5 Component 4: Institutional rebuilding . Efficient institutions and their sufficient capacity are a must in making the fight against HIV/AIDS effective and implementing the proposed project. The project will be doomed to failure if institutional capacity issues are not carefully considered. This component details the capacity needs for public sector organizations, public sector staff and private sector organizations (including NGOs) and includes specific supports to fill in the major gaps. 4. Safeguard policies that might apply: In view of the proposed project’s activities under Component 1, (including support to the completion of the TB hospital, national referral laboratory, and central medical stores, and the need for medical waste management), the OP/BP 4.01 “Environmental Assessment” will apply. To meet the requirements of this policy, an Environmental Analysis will be carried out during project preparation to assess the potential environmental impacts and a National Health Care Waste Management Plan will be prepared. The document will be approved and disclosed in-country and at the Bank's Infoshop prior to appraisal. 5. Tentative financing Source: ($m.) Borrower 3 International Bank for Reconstruction and Development 20 EC: European Commission 27 Total 50 6. Contact point Contact: Feng Zhao Title: Sr. Health Specialist Tel: (202) 458-7772 Fax: (202_ 473-8299 Email: fzhao@worldbank.org