Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB2445 Project Name Cameroon - Multisectoral Contribution to HIV-AIDS National Program Region AFRICA Sector HIV-AIDS (100%) Project ID P100656 Borrower(s) Government of Cameroon Implementing Agency CNLS Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared June 20, 2006 Estimated Date of Appraisal Authorization June 11, 2007 Estimated Date of Board Approval September 11, 2007 1. Key development issues and rationale for Bank involvement Status of the HIV-AIDS epidemic. DHS data from 2004 estimate that about 5.5% of the population in the 15-49 years age group are infected with the Human Immunodeficiency Virus (HIV). In 2004 the Demographic and Health Survey (DHS), based on a wide national sample, reported an average national prevalence rate of 5,5% , but still high enough for HIV/AIDS to be classified as a generalized epidemic in Cameroon. The national average rate masks wide variations by province (from 1.7% in the North to 11.9% in North-West), by gender (1.4% for men and 4.8% for women in the 15-24 age group), by area of residence (with higher rates in urban areas), and by high risk groups. UNAIDS estimates that in 2005 about 470,000 adults and 35,000 children had contracted the virus, that in the same year 48,000 adults and 10,000 children were newly infected, that Cameroon has about 122,670 AIDS-related orphans and that close to 50,000 people have died from the Acquired Immune Deficiency Syndrome (AIDS) since the onset of the epidemic. Better access to treatment is allowing more patients to live longer. This positive outcome increases the number of People Living with HIV/AIDS (PLWHA) but simultaneously increases the number of people living with the infection. This increase in number of infected people because of more accessible treatment can be countered by decreasing new infections. Fewer new infections would initially stabilize the prevalence rate and deeper reductions in new infections would slowly decrease the national prevalence rate. Health Indicators and Health Sector Financing . The HIV/AIDS epidemic, combined with the resurgence of TB and malaria, runs the risk of further undermining health outcomes which have deteriorated dramatically during the past decade. Life expectancy at birth was 48 years in 2003, infant mortality stood at 95 deaths per 1,000 live births, under-five mortality at 166 per thousand, and maternal mortality is estimated at 730 maternal deaths per 100,000 live births in 2000 (WDI 2005). Cameroon is seriously off track for reaching the child mortality and nutrition MDGs. The public health system suffers from poor physical access; deteriorated facilities; shortages of staff, essential drugs, and basic medical equipment; low productivity; and a skewed geographic distribution of staff and resources. Cameroon spends on average about five percent of GDP on Page 2 health of which only one percent is public sector spending. Overall per capita spending of about US$31 is close to the average for sub-Saharan Africa but low in comparison to countries at similar levels of GNI per capita. Government commitment to a National Program and a National Strategic Plan. Between September 2005 and July 2006, the National HIV/AIDS Committee (Comité National de Lutte contre le SIDA or CNLS) evaluated the results of the 2001-2005 National HIV/AIDS Strategic Plan (NHASP). It then elaborated a National HIV/AIDS Program (NHAP) for 2006-2010 and defined a five year achievable NHASP. The 2006-2010 Strategic Plan is based on data from various studies. It prioritizes the needs stated in the NHAP, and develops a set of key performance indicators in order to monitor its implementation. The National Strategic Plan aims to: (i) reduce the number of new infections in the general population; (ii) achieve universal access to treatment and care for PLWAs including children; and (iii) reduce the impact of HIV/AIDS on orphans and vulnerable children. It would do so by addressing seven priority areas: (a) Voluntary counseling and testing; (b) Prevention and management of STIs; (c) Promotion of condom use; (d) Blood safety; (e) Scaling up HIV prevention among youths; (f) Prevention of new infections among women; and (g) Scaling up prevention of mother to child HIV transmission. Ownership and participation. The participatory process involved provincial and national workshops attended by about 1,200 participants from civil society, government and development partners. CNLS had disseminated in the 365 municipalities of the country a comparison of local results with provincial and national results. The municipalities used these results to target the most vulnerable groups. In March 2006, the Prime Minister officially launched the 2006-2010 NHASP. In May 2006, CNLS organized a workshop with participation by Civil Society, PLWHA representatives and the public sector in order to establish priorities for implementing the 2006-2010 National HIV-AIDS Strategic Plan. The Minister of Health, who is also the President of the CNLS, organized a donor round table in June 2006 to harmonize actions for implementing the national strategic plan . National stakeholders and donors approved the principles of the national program and the proposed strategic plan to carry out the program, and agreed to prepare specific implementation arrangements with CNLS during a joint mission in November 2006. MAP 1 and MAP 2 Criteria. Cameroon met the conditions of participation in the Bank’s Africa MAP I for the predecessor project, and has now met the criteria to access MAP II funds. The criteria are: (i) evidence of a participatory strategic approach to combating HIV/AIDS; (ii) agreement to consolidate all M&E systems into one national M&E system; (iii) a high-level HIV/AIDS authority and coordinating body with representation of key stakeholders from all sectors that would be accountable for implementing the national HIV-AIDS strategic plan; (iv) willingness to use exceptional implementation procedures to achieve a satisfactory pace of fund disbursements; and (v) willingness to integrate performance considerations into fund allocation and disbursement decisions. Page 3 Coordination of Activities with other partners. Numerous partners have joined to fight the HIV/AIDS epidemic including UNAIDS, GFATM, KFW, UNICEF, and UNFPA. Coordinating national and international partners would be a primary focus of project preparation. Some critical coordination steps have already been taken. The 2006-2010 National Program and Strategic Plan have been approved by all donors. Following a donor roundtable in June 2006, all development partners have approved the proposed M&E results framework and have approved the principle of improving harmonization inside the NHASP. They should all plan and report activities and results against agreed core indicators of the NHASP. CNLS and key stakeholders will present the specific contributions in one annual action plan and work program, submitted to the CNLS general assembly in November each year. IDA is engaged in pro-active consultation with GFATM and other donors to prepare: (i) common implementation channels; (ii) joint annual reviews; and (iii) joint fiduciary assessments. IDA, GFATM and other donors are planning to conduct a joint mission in November 2006. Rationale for Bank involvement The GOC has prepared a detailed financing plan for the years 2006-2008 and has provided a rough estimate for five years (2006-10). The three-year national program would cost US$191.3 million. Financing sources have been identified for funding US$81.2 million or 42% leaving a 58% or US$110.2 financing gap. Among the already identified financing of US$81.2 million, the two largest sources are the Global Fund accounting for more than half (53.4%) and IDA (9.7%). The state budget would contribute 2.6%. The cost of financing the five-year program has tentatively been estimated at US$376 million and will be reviewed and needed adjustments made during a proposed roundtable meeting in November 2006. This round table will also provide the opportunity to discuss and sign a Memorandum of Understanding between the government and development partners and to reach agreement on medium term financial contributions. The Bank uses a multi sector approach to combat the spread of HIV/AIDS and has been the major source of funding in Cameroon over the past four years. The Bank has access to and works with non-health line ministries, has the ability to unify coordination arrangements and convene donor meetings, and has experience in working in decentralized settings that strengthen the local responses. The Bank is also a major actor in strengthening health systems. The Global Fund will provide more funds in the coming years but the Bank’s support is will be needed. Development partners are counting on the Bank to continue supporting CNLS in order to achieve programmatic coordination, to ensure a unified M&E results framework to monitor and evaluate multi sector activities, to strengthen health systems, and to bolster local responses for prevention activities and to support using competitive results-based grants. 2. Proposed objective(s) The objectives and outcomes of the National Program are clearly articulated and have been quantified in the National Strategic Plan as follows: (i) reduce the number of new infections by encouraging and assisting 3 million people to get tested and to manage their status; (ii) achieve universal access to treatment and care for PLWAs including children by helping 300,000 PLWHA to access care and treatment and to benefit from psychosocial and economic support, mainly through associations of PLWHA; and (iii) reduce the impact of HIV/AIDS on 100,000 Page 4 orphans and vulnerable children by assisting communities in identifying the most dramatic situations and accompanying them to access care and support. The overall goal of the proposed operation would be to assist the GOC in implementing the National HIV/AIDS Strategic Plan. The Project Development Objectives are: (i) preventing the spread of HIV/AIDS in the general population and reducing transmission among the high-risk groups by supporting community-based responses; (ii) increasing access to treatment, care and impact mitigation services using VCT and social mobilization activities financed with dedicated funds to identify seropositive cases of adults and children, coordinating their referral to health centers for effective treatment and follow up, and increasing support to PLWHA and to orphans and vulnerable children; (iii) supporting the response to HIV/AIDS by the Ministry of Health (MOH) and by selected non-health sector line ministries; and (iv) increasing coordination of the NAHSP, to ensure transparent procurement procedures, fiduciary management of IDA funds and effective programmatic monitoring and evaluation of the NHASP. 3. Preliminary description Potential Project components with indicative Costs. The proposed project would have four components to achieve the project development objectives presented above. A. Component 1: Demand-driven Grants for Subprojects to Communities . This component would finance social mobilization activities at the community level, using local response subprojects in support of the National Program’s three-pronged balanced strategy of prevention, access to treatment, and support and care for PLWHAs and OVC. About US$18 million would be allocated for local grants at the commune level and would be awarded on a competitive basis to initiatives contributing to the indicators of the national program. Implementation modalities and relations with Health District Committees (COSA) will be defined during project preparation. The implementation manual would direct resources with an emphasis on girls, boys, women and specific high risk groups, identified by recent DHS and seroprevalence studies. Results of these studies were disaggregated by commune level and are available in all 365 communes. The Implementation Manual would strengthen the use of participatory M&E tools such as report cards that are already used in 6,000 communities. B. Component 2: Coordinating the Local Response with the Health Sector . This component would also be executed at the local commune level and would support coordination by regional and local authorities, including streamlining Local Response activities with health services such as the referral of seropositive cases of adults and children for effective treatment and follow up, at an indicative cost of US$2 million. Specific activities with the health sector are detailed in the next component. C. Component 3: Scaling up the National Response . This component would enhance the capacity of the Ministry of Health to provide technical guidance on the national response to HIV/AIDS and would strengthen HIV/AIDS related services for prevention, treatment, and care delivered through the health care system. The content of this component will be defined during project preparation. As much as possible, this component would not Page 5 duplicate activities funded in the health Sector program (SWAp) and would focus on supplies to facilitate universal access to health services in relation with HIV-AIDS. This could include for example subsidizing access to tests and treatment in a coherent framework defined by the National Program. This could also include specific equipment in relation with HIV-AIDS and safe disposal of medical waste in relation with HIV- AIDS. This component would also support the response to HIV/AIDS by selected non-health sector line ministries. There are basic cross-cutting HIV/AIDS activities which all participating ministries are expected to implement under their respective sectoral HIV/AIDS programs. These include: development and implementation of workplace HIV/AIDS policies; IEC/BCC for HIV/AIDS and STDs; condom distribution and promotion; advocacy to reduce HIV/AIDS stigmatization and discrimination, particularly in the work place; and establishment of a support group for HIV/AIDS patients and their families (either as a single ministry or in collaboration with other ministries). A maximum of five key non-health line ministries would be selected during project preparation, such as for example, those responsible for education, transportation, armed forces, police, and prison inmates. Some HIV/AIDS related interventions are specific to a particular ministry and each ministry will identify its own HIV/AIDS program needs to be supported by this component. For example, populations potentially at risk within the sphere of influence of the Ministry territorial administration are prisoners, delinquent youth, juvenile delinquents and police officers. For the Ministry of Education it will be school age children, unattached youth, and out of school youth. Truck drivers are a high risk group for the Ministry of Transportation . Ministries will appoint their respective HIV/AIDS focal points (person or unit) to coordinate the ministry’s HIV/AIDS planning, implementation, monitoring and evaluation. The indicative cost of this component would be US$11 million allocated as follows: US$6 million for the Ministry of Health, US$4 million for four non-health line ministries, and an additional US$1 million to the MOH dedicated to safe biomedical waste disposal. D. Component 4: Strengthening Institutional Capacity For Program Management, Monitoring and Evaluation . Under this component the proposed project would allocate US$2 million for ensuring transparent financial management and procurement procedures of IDA funds, and US$2 million to support the unified M&E system and to help finance the next DHS. US$3 million would remain unallocated. 4. Safeguard policies that might apply [Guideline: Refer to section 5 of the PCN. Which safeguard policies might apply to the project and in what ways? What actions might be needed during project preparation to assess safeguard issues and prepare to mitigate them?] The proposed alternative assumes that all health activities would be financed under a separate Health Sector Strengthening Program. The Medical Waste Mitigation plan would therefore be included under this Health program. The proposed project would be rated C. Page 6 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 2 INTERNATIONAL DEVELOPMENT ASSOCIATION 40 Total 42 6. Contact point Contact: Jean J. Delion Title: Senior Social Development Specialist Tel: (202) 473-5010 Fax: Email: Jdelion@worldbank.org