PID THE WORLD BANK GROUP AWorldFroioPoverty 4 U - _,i--.*,--*- _, - _ ________________-- ----------- lnfoShop Report No AB7 Updated Project Information Document (PID) Project Name DJIBOUTI-HIIV/AIDS, Malaria and Tuberculosis Control Project Region Middle East and North Africa Region Sector Other social services (60%); Health (30%), Central government administration (1 0%) Project ID P073603 Supplemental Project Borrower(s) REPUBLIC OF DJIBOUTI Implementing Agency COMMUNICABLE DISEASES CONTROL INTERMINISTERIAL Address COMMITTEE Address Cabinet du Ministre, Ministere de la Sante Publique, Djibouti-Ville, Djibouti Contact Person Mr All Sillaye Abdallah, Directeur des Projets sante Tel 253 35 32 82 Fax 253 35 21 38 Email sillay_fr@yahoo fr Environment Category B Date PID Prepared March 31, 2003 Auth Appr/Negs Date March 25, 2003 Bank Approval Date May 29, 2003 1. Country and Sector Background Despite its relatively high nominal per capita income of US$780 (compared to an average of $510 for Sub-Saharan Africa, US$320 for Yemenl, and US$110 for Ethiopia), Djibouti has one of the poorest sets of social indicators in the world. Gross primary school enrollmenit is less than half the average for Africa (39 percent of school age population, compared to 78 percent for Sub-Salharani Africa) Health indicators are below regional standards. Approximately 33 percent of the population lacks access to potable water, and sanitary conditionis, and, many are very poor. The incidence of infectious diseases suchi as malaria, tuberculosis and HIV/AIDS is high and rising. Nation-wide HIV/AIDS sero-prevalence rate is estimated at 3.0 % for the whole population (3 1% for womeni and 2.9% for men), wlhichi is lower thani expected However, analysis of the data by age groups slhow a prevalence superior to 5% among persons aged 20 to 35 years of age, which indicates that HIV infects early the economilically productive and sexually active persons. Malaria has been a problem in Djibouti only since the late 1980's. Before 1973, whenl there was little urbanization, no irrigation and an active attempt at contr-ollinig the vector during the rainy season, more than 80% of the notified cases were coming from neighborilig couLntries From 1973 to 1987, more Djiboutian cases appeared along the maini transport axes linking Djiboutl to the neighlboring counltries and later in the ulbani areas It is during this period that thousanids of refugees came to Djibouti. Since 1988, malaria is steadily increasing and reaching areas where it was unkinown until then, SuChi as the northeril districts of Tajourah and Obock. Uncontrolled urbanization with inappropriate water supply, non-existent used wvater evacuation system, the sedentarizationi of the nomliad population in rural areas 2 PID whiich caused the increase of irrigated areas, and frequent inunidationis contributed to the endemization of malaria Pro-active interventionls are needed to prevent malaria from becoming more prevalent. With 588 cases of TB per 100,000 ihiiabitanits, Djibouti has the second highest rate of TB in the world, after Swaziland. However, about 40% of the cases are cominig from neighbor-ing coulitries, in particular from Ethiopia Foreigners come to Djibouti because it offers more and better quality services (and free of charge), which inflates the rate. Nevertheless, these TB patients are present in Djibouti and can infect people around them. As in other counitries the link between HIV and TB is apparent. Although the sero-prevalence rate in the general populationi is 3.0%, among TB patients it Is 23% In the last few years, two main factors contributed to the weakening of the nationial program Although it remains one of the best in the region with 72% therapeutic success (treatment completed and patients cured) in 2000, an acute lack of personnel and the departure of the French Cooperation which ceased all assistance (financial and technical) in June 2002 makes it difficult to keep it as performing as in the past Drugs are presently supplied through the Global Fund Facility for the next three years WHO, and to a lesser extent, the Government of Djibouti (10% of the US$150 000 which are budgeted) provide some finiancial assistance, but the program remains in increasing need of finanicial assistance. Infant mortality is 106 per thousand live births, compared to an average of 92 for Sub-Saharan Africa, 45 for the Middle East and North Africa, and 82 for Yemen. High maternal mortality (740 per 1 00,000 live births) can be largely attributed to high fertility rates, anemia caused by malnutrition, and the poor health care facilities which are saturated by patients coming from neighiboring Ethiopia and Somalia Free health care contributes to the influx of patient-refugees seeking treatment in DjiboutI, in particular for tuberculosis. Althoughi the country spends about 7 percent of GDP on health, well above the regional average of 5%, service delivery is very poor External assistance, notably from France, Italy and Spaiin, accounts for 30 percent of expenditires on health care, but assistance has declined, putting additional pressure on an overtaxed and inefficienit system. Indicators Djiboutl (in %) Subsaharan Africa Life expectancy at birth 50 50 HIV/AIDS infection among adiilts 3.9 8 Infant mortality (per 1,000 live births) 106 92 Unemiiploymenlt 45% Gross primary enrollmenit 39% 78% Male 44% 85% Female 32% Mortality at delivery (per 100,000) 740 - 810 HIV/AIDS The first AIDS cases were notified in Djibouti in 1986. Since then the situation has been steadily worsening: At the end of 2000, 2,179 AIDS cases were registered. Between 1994 and 2000 several surveys including among pregnanit women and blood donors, showed that prevalence was particularly hiigih in some groups (as soon as 1994, it was 55% among Commercial Sex Workers (CSWs), 24% among women working in bars, and 22.2% among STI patients), but the informationl was discordant for the general population, varying from 4% or 6% in 1995 to 1.9% in 2000 Hlowever, nonle were as high as the 1999 UNAIDS estimate among Djiboutian adults aged 15-49 (11 9%). As the strategy was not to be the same if the rate was inferior or superior to 5%, it was decided to carry out a sero-prevalence survey durinig the preparation of the project. As mentioned above, the rate was found to be 2 9% following the 3 PID results of the survey, and is still low. However, it should be underlined tihat the rate is more thani 5% among persons aged 20-35, whvich confirms that the rate is on the increase, and that the critical threshold of 5%, when the infectioni reaches the exponenitial growth rate, aggressively affects the most sexually active and economically productive age group. This situation is cause for concern and calls for a multi-sectoral response along witlh the full recognitioni of HIV/AIDS as a developmental issue The analysis of the AIDS cases notified in 1998 and 1999 indicates that. * the transmission is mostly heterosexual (95.6% of declared cases amonig women and 91 6% among men); * persons aged 15-29 represent 47.4% of registered AIDS cases, which shows that people are infected at an early age, and confirimied by studies carried out In 2002; and * women are infected at a younger age than meni: womiieni aged 15-29 represent 54 3% of declared cases, while men of the same age group represent only 42.7%. Risk factor specific to Djibouti Trade: Djiboiiti is a higilly urbanized state (more than 80% of population live in urban areas) with economic activity centered arouLid the port whiich serves the Horn of Africa and services the French military bases. In addition, about a thousand transport trucks enter in and out of Djibouti's port on a daily basis to supply Ethiopia's needs (a counltry about 100 timies larger in population according to the World Developmenit Social Indicators Database). The prevalence rate of HIV/AIDS in the adult population of Ethiopia is 11% (end 1999). Djibouti is therefore highly susceptible to the spread of HIV/AIDS through the transport sector, and the disease is likely to spread to the whole sub-region along the truck routes In addition, taking into accounlt that the city of Djibouti is a gravitational center for trade and the location of French military bases, prostitution is higlhly prevalent. STIs, another factor contributing to the spread of the epidemic, are frequent, the number of infections being estimated at 25,000 per year. The population is young and the age for first sexual contact is precocious Finally, condoms are not readily available and are expensive. Migration: The situation is further complicated by the large influx of refugees and displaced persons. Cooperation with neighbors, such as Ethiopia, Somalia and Eritrea, in assessing prevalence rates, providing for voluntary testing and counselinig, formulating consistenit behavioral change communlication messages and treatment of TB, are a strategic option which Djibouti and its neighbors need to explore to mutual benefit This could be done througlh the Horn of Africa Regional HIV/AIDS project wlhichi is being developed in the context of the MAP2, possibly in partinershiip with the Intergoverinmenital Authority on Development (IGAD), a regional development organization includinlg seven countries (Djibouti, Ethiopia, Kenya, Somalia, Sudani and Uganda) based in Djibouti Such discussions could also be carried out through NGOs whiclh function inter-regionally such as "Save the Childreni", a US-NGO financed by USAID-Ethiopia, whicih has carried out a Knowledge, Attitudes, Belief and Practices (KABP) survey on the Djibouti/Addis Ababa corridor. Gender Inequality: Women are the most vulnerable segment of the Djiboutian society Economically, women have a low participation rate, and low levels of education (between the 20-29 age range, 60% of womeni, compared to 30% of meni, have never attended school) Healthwise, materinal mortality is 740 per 100,000 births (according to estimiations made by the Safe Motherhood project finanlced by UNFPA), one of the highest rates in the world This is due to high fertility rates, anemia caused by i-nahlutritioni, and the widespread practice of female genital cutting (FGC). About 99% of women have been subjected to FGC (mostly infibulationi, i.e , the most extreme type of female genital cutting), which tends to lead to other health problems. A law prohibiting the practice was adopted in 1995, but it not enforceable because of the private nature of the procedure. UNICEF, the Ministry of Health, CARITAS (a Catholic 4 PID charity NGO) and UNFPA in 1999 jointly initiated a project to reduce FGC. A multi-institutional professional team conducted awareness meetings with a number of decision-makers In addition, sensitization meetings were conducted witlh religious leaders to address the problem of FGC and to identify ways to limit and/or eradicate it. The project approach, which emplhasizes gender as a key issue, is consistent with one of the key levers of IDA's regional strategy. Government response to HIV/AIDS In the early 1990s, some HIV/AIDS preventioni activities -- mostly IEC activities -- took place when financing from the Global Program for AIDS (GPA) was available. However, since the end of the GPA, the National AIDS Control Programii (NACP) has been dormant In 2001, the Governmiienet of Djibouti carried out a health sector study which was used to develop the Government's health sector reform program, as well as a mediumi-termii plan for the development of the sector. In the context of this reforn program, and in order to respond more equitably to the needs of the population, it was decided to redynamize the NACP and STIs treatment. In October 2001, the President of the Republic himself endorsed the fight against HIV/AIDS when he inaugurated the new NACP and treatment of STIs facility, which dynamized the fight against HIV/AIDS About a year ago, the HIV/AIDS program was re-organized: a new director was nominiated, the program moved to newly renovated offices (with the assistance of the Frenich Cooperation), and certain staff were trained in counseling Some timid awareness campaigns were conducted. Outreach programs remained very limiited and involved mostly some newly created NGOs in scattered activities, which were, for the most part, conducted in the context of Internationlal AIDS day in December 2001 and 2002 The Ministry of Social Affairs and Promotion of Women is carrying out some -LIV/AIDS IEC activities and the Ministry of Defense also distributes some condoms. Durinig the appraisal of the Health Sector Development Project (HSDP), in May 2002, HIV/AIDS was identified as an emergency situationl and the Government, through the President and the Minister of Health, who are strongly and publicly backing the fight against HIIV/AIDS, subsequently requested IDA's assistance to address the problem. It theni ilitiated, using a participative approach, a National HIV/AIDS Strategic Plan which is now completed and whichi was approved at a consensus seminar in December 2002. As required in its National HIV/AIDS Strategic Plan, the Governmiienet has recently created an Interministerial Committee against HIV/AIDS, malaria and tuberculosis (IC), which will have a policy role (see section C4 on institutionial arrangemlenits for more details) and a Technical Interminiisterial Committee (TIC), which will be the technilcal arn of the IC, to manage the response to HIV/AIDS. These two entities are to be assisted by an Executive Secretariat (ES) The Ministry of Health hired a consulting firn to assist with the preparation of the National HIV/AIDS Strategic Plan The prevalence surveys carried out during project preparation provide baseline data for the general population and STI patients, military personnel and CSWs and made it possible to identify the Priority Vulnierable Groups (PVG). Also during project preparation, KABP studies were carried out among the general population, school children, military personnel, and dockers in addition to the survey being donriwy Mhe Children" mentioned above. UNICEF is in the process of setting up a Mother to Child Transmission (MTCT) pilot program, wlhichi should start at the end of March 2003 The UNAIDS Thematic Group has also been redynamized It has prepared a workplan which made it possible to coordinate activities while the National Strategic Plan was being developed and the coordinatiig bodies being created so as to avoid duplication. During the identification mission, it was decided that all documents and min1utes produced by the Thematic group would be sent to IDA wlhich is to be considered a "virtual" member of the Thematic group (note: there is no Country Office in Djibouti). In addition, the Thematic group is informed of all visits planned by the Counltry Director or the Sector Manager who will also be informed of the planned dates for the Thematic Group meetings so that they participate in the meetings wheniever possible in order to raise the level of attention among donors and UN agencies In addition, the Thematic 5 PID Group organizes meetings every time the IDA ImlissioIl comes to Djibouti and there is regular communication between the President of the Tlhematic Group (the UNICEF Resident Representative) and the Team Recently, In the light of the setting up the institutional structure for the fight against HIV/AIDS, Malaria and Tuberculosis, the mandate of the National Program for AIDS Control (NPAC) has been chaniged. The Program for AIDS Control (PLS) of the Ministry of Health will lIilit its coordinating and planning role to the Ministry of Health. A new Director has been nominated and a new organigram for the PLS has been developed The mandate of the Center Younis Toussainit has also been redefined. It will be a reference center for ambulatory treatment of STIs and of opportunistic diseases, and later, whien the ARV pilot program Is put In place, as a Ambulatory Treatmenit Center for the Ministry of Health. New job descriptions are being prepared and the MOH has promised to provide the necessary personiel, during the next 8 months The Center will be completely functional when the project becomes effective. 2. Objectives In accordance with the main goal of MAP2, the overall objectives of the project are to assist the Government of Djiboutl in settilg up and implementing the response agaaist HIV/AIDS, sexually transmitted infections (STIs), malaria and tuberculosis (TB), whicih are important risk cofactors. Djibouti meets the criteria for MAP2 eligibility and only key features are highiligited below which are relevant to the HIV/AIDS epidemic in DjiboIiti and the Djibouti HIV/AIDS, Malaria and Tuberculosis Control Project The proposed project will be to support the National Strategic Plans to respectively fight against HIV/AIDS, malaria and tuberculoII1ai( stral2giqite national de prevention dc/ VIHJ/SIDA, PlansStratu;gtqzte de Lzutte contre le Paludiav?ePlan strategique national cle Lutte conlre la Tuberc2/lose) for the period 2003-2008. The objective of the Project is to contribute to the chanige in behavior of the Djiboiitian popuilation in order to contain or reduce the spread of the HIV/AIDS epidemic and to mitigate its impact on infected and affected persons and to contribute to the control of malaria and tuberculosis. It will do so through a multi-sector approach by. (i) preventinig the spread of HIV/AIDS by reducing transmission, in particular among high risk groups, (ii) expandinig access to treatment of opportunistic illnesses and malaria, and to care, support and treatment to People Living withi HIV/AIDS (PLWHA) in Djibouti; and (iii) supporting multi-sectoral, civil society and community initiatives for HIV/AIDS preventioni and care and malaria preventioni In the context of the above mentioned strategic plans, the project will support and promote civil society and comimiuniity ilitiatives, for prevention and care of HIV/AIDS, malaria and tuberculosis put forward by beneficiary groups selected on the basis of the technical quality, cost-effectiveness and likely impact of their proposals 6 PID 3. Rationale for Bank's Involvement The Multi-country HIV/AIDS Program for the Africa Region places HIV/AIDS at the center of the development agenda for work in the region. The curtailment of the spread of the HIV virus is pivotal if htiman development and overall development goals are to be achieved in Djibouti and in neighboring countries In addition, IDA's comparative advantage is its past and present involvemenit in the sector, and its flexibility to work across sectors, whiicih will facilitate the proposed multi-sectoral approach being considered here Furthermore, there are clear liiks with other IDA-funded projects, such as the Social Fun1d and Public Works Project, the School Access Improvemenit Project and the proposed Health Sector Development Project, and the possibility of using these entry points to disseminate the message on HIV/AIDS. Given the potential macroeconomic impact of HIV/AIDS in Djibouti, IDA's involvement with structural adjustimenit, public sector reform and close working partnership with the IMF will help reduce expenditures on noni-priority areas, thereby freeing up resources for the health and education sectors primarily. IDA's involvemenlt will also be key in: (i) ensurinlg better coordination among key stakeholders, (ii) preventinig duplication of efforts; and (iii) exploiting the complementary aspects of the different projects currently being finaniced by IDA. As IDA is a key partner in the global STOP TB Initiative in collaboration with UNAIDS, the ability to play a facilitating role in identifying expertise and possible partners is also an asset 4. Description The project will support the implementation of Djibouti's HIV/AIDS National Strategic Plan, the Malaria Strategic Plan, and the National Tuberculosis Strategic Plan through a wide variety of public sector agencies, private and non-governmental organizations, and communlity-based organizations. The project WIill include four major componenits as follows: 1) capacity building and policy development; 2) public healthi-sector responses to HIV/AIDS, the managemiienit of TB and STIs, includinig prevention, treatmelit and care and malaria prevention; 3) multi-sector responses to HIV/AIDS prevention and care, and 4) support to community-based initiatives for the three diseases These activities will take into account the existing conditions and Djibouti's capacity level both at the central and the district levels, recognizing that at present capacity is weak at both levels. Presented below are the main sub-components of each component For inore details, see Annex 2. Component 1. Capacity Building and Policy Development (US$ 4.5 million) This component would aimi at strengthening Djibouti's capacity to cope with the spread of HIV/AIDS, of malaria and tubercuilosis by supportling: (i) the work of the Initeriniilisterial Committee, the Technical Interministerial Committee and the Executive Secretariat (ES), including project coordination and facilitation, (ii) the up-dating of the National Strategic Plans (for each of the three diseases) and annual Action Plans; and (iii) strengthening of public, private and nongoverinmenital institutions in preparing and implementing prevention, care and treatmenit interventions. Human resources are very liited both in number and in quality. The acute shortage of human resources remains the most important constraint to the success of the project For instance in the MOH the number of qualified persons is limited and most of these persons are already engaged in the launchinig of the HSDP and/or in implementinig the ministry's programs. In order to address this problem, it has been agreed with the Government that (a) some tasks would be contracted out (monitorinig and evaluationi); (b) some Djiboutian experts will be recruited on the basis of a competitive process and hired withi one-year contracts renewable on the basis of performiance; (c) training wvill be organized, in particular for specialized tasks and for NGOs and ABC before they are awarded finanicinig to implement a project, and (d) twvo long term international technical assistants (a procurement/implemenitationi specialist and a social communicationi expert) and some short termi experts for specialized tasks (for example, trailing in counseling or development of a condomli distribution strategy) will be recruited All the terms of 7 PID reference of the technical assistants specify that one of their task is to transfer competences. Each TA will have an official counterpart named or recruited by the Djiboutiall authorities. This componenit will also include training activities, Linder contract wvith local institLtiolIs, for the NGOs and governmental institutions which will have the responsibility to supervise and train other entities and for the minlistries' units and local NGOs and associations which will be implementinig activities. Some study tours may be included as part of this training as well as for selected members of the IC, the TIC and ES Finally, the buIlding of a laboratory and the rehabilitation of the builiding next to the offices of the Aids Control Program of the MOH and the Center Younis Toussaint, will be included in this component The laboratory equipment is being financed under the HSDP, but the laboratory building itself is presently located in unsafe or temporary buildings which need to be replaced as soon as possible. The rehabilitation work being envisaged will provide space for expandinig the role of Younis Toussaint Center to counseling, voluntary testing and care aiid treatment of sero-positive persons It will also provide space whiere informationl will be available and where NGO and associations can meet This will be one of the centers included in the AIDS treatment pilot project included in the Public health component (see next section and Aniex 2 for more details). Component 2. Public Health Sector Response to HIV/AIDS, TB and STI Management (US$2.3 million) The Ministry of Health (MOH) and more broadly the health community, have special responsibilities for malaria, STIs, HIV/AIDS, and opportunistic infections (including tuberculosis) preventioni and management. This sector therefore warranits a separate componenit, making provision for prevention, care and treatment from a health sector perspective. This component will ain at expandinig access to preventive measures such as condoms, to treatment of STIs, opportLIistic illnesses (includilig tuberculosis and malaria, and to care, support and treat People Living withi HIV/AIDS (PLWHA) in Djibouti. In addition, a subcomponent would have as an objective to increase clinical safety and ameliorate the treatment of solid medical waste Under this component, the project will include: a) development of Volulitary Counselinig and Testing (VCT) protocols as well as a significant role in training counselors and in carrying out VCT activities and follow-up; b) implemiientationi of syndromic algorithims for diagnostic and case managemenit of sexually transmitted infections; c) the strengtheniniig of the health system for the treatment of malaria, HIV/AIDS, STIs, and opportillistic infectionls in particular TB; d) the setting LIp of measures to prevent the transilmission of the HIV in clinical settings; e) the procuremenit of condoms, and a significant role in the distribution of condoms; f) the scaling up of activities geared to vulnerable/potentially highi transmitter groups in collaboration with other sector partners (in particular, the project could finance technical assistance for the IEC Uiiit of the MOH); g) the support to the decentralizationi program for TB screening and treatmenit, Ih) the strengtheninig of the detection, preventionl and response to malaria, and 1) the finanicinig of drugs, test kits, and medical consumables, which will be bought from the Central Drug Procurement Agency once it is set up. The possibility of a partnership with WHO for the supervision of some of the above activities is being explored, but needs to be discussed in detail with the MOH, the ES and the Government The Bankli has also been working closely with its UNAIDS partners, drug companiies, and developing-country governmeits on access to ARV therapy. This is an evolving situation which progressively allows for low cost choices and alternative options. The project intenids to support the 8 PID development of guidelines and the strengtheniing of health infrastructure to allow ARV therapy drug,s to be used in a safe, effective, and sustainable manier. It will assist the MOH, in collaboration with other partners (e g., the French Cooperation, WHO and UNICEF) in putting in place a one-year pilot project including the treatment with ARV of sero-positive persons in the three public healthi systems of the couLitry (Ministry of Health, Ministry of Defense and Ministry of Emp6Wnriuntimon de Protection Sociale [OPS]) This pilot project will be used to assess the feasibility and cost of extendiig the treatment program to the whole country The drugs for the pilot project are being included in the first purchase being procured under the HSDP. The Government of Djibouti is now eligible to apply to the Global Fund and is preparing a proposal for the next round. It is hoped that in future, at least part of the drugs for the program can be bought with Global Fund financing The prevention of mother to child transmission of the HIV (PMTCT) is not included in the project because UNICEF is presently setting up a PMTCT program in two centers in Djibouti (one in a public maternity center and the other in the MCH Center of SPO). The project, however, may contribute to the training of counselors, as the pilot program may be scaled up, and to providing artificial milk for mothers who decide not to breastfeed. Finally, withi regard to condoms, a consultant may be recruited either under the PPF or early during project launch, to develop a condom distribution strategy. Condoms will be provided on a no-cost basis to STI patients, but condoms must also be made available outside of the health system as needed (based on the strategy developed). Component 3. Multi-sector Responses for HIV/AIDS Prevention and Care (US$ 3.1 mi llion) As has been demonstrated in other countries, and in order for the fight against HIV/AIDS to be efficient, it is necessary to have a multi-sectoral approach in order to better target Priority Vulilerable Groups Although the multi-sectoral response is presently very weak, the ministries of Social Affairs and Women Promotion, and Defense, already carry out some IEC and condom distribution activities. The project will reinforce on-going activities and provide support to the following key ministries outside of the MOH the miniistries of (a) Economy, Fiianices and Planninig, (b) Youth and Sport, (c) National Educationl, Women Promotion, (d) Social Affairs and Family Welfare, (e) Defense (army), (f) Employment and National Solidarity, (g) Communlication, Telecommunication and Culture, (h) Justice, Penitentiary and Religious Affairs, (i) Ministry of Wakfs and Islamic Affairs, (j) Interior and Decentralizationi (police), and (k) Equipment and Transport This component will provide these ministries with resources and training to improve their capacity to respond to the HIV/AIDS epidemic, emphasizinig prevention and care Most of the above mentioned ministries are finalizinig their action plans whichi include performance indicators and define monitoring systems and budgets. The action plans are targeted to staff of Iine iniiiistries and focus on training peer educators on issues of HIV/AIDS and STIs, the importance of condoms in the fight against these diseases, including other support mechanisms to encourage a chanlge in behavior. These plans will be integrated into the ministries' ongoing operations. At this point it is not planied that the project assists the Ministry of Transport becau!ive the Childreq finanlced by USAID/Ethiopia, is providing support to that Ministry, which could in addition, receive additional support througil the Regional Project for the Horn of Africa being developed by ActAfrica in the context of the MAP2. The Ministry of Communilcation will have a special role to play at the beginninig of the project, it will assist the international specialist in communiicationl and its Djiboutian counterpart, in developing a nationial communicationi strategy for the fight against HIV/AIDS, Malaria and Tuberculosis Durinlg this process, its role in the strategy will be defined At a later stage, it is expected that it will disseminate audio-visual and written materials prepared in the context of the communlication strategy The preparationi of these materials will be contracted out 9 PID Activities in the Ministries will be financed on the basis of an annual workplan and budget The Ministry will receive a first trancile which it will have to justify in order to receive the second tranche The Administrative and Financial Manager of each Ministry xvho will manage these funds will receive training if necessary. Component 4. Support to community-based initiatives (US$ 2.1 million) In order to enlist communities in the fight against HIV/AIDS and to provide them with the means to mitigate the impact of the epidemic, it is necessary to provide them the resources at the local level The objectives of this componlenit are to. (a) strengtheni communities and Djiboutian associations and NGOs, so that can implement some essential activities for the reduction of the vulnerability to HIV/AIDS, malaria and tuberculosis; and (b) strengthien institutionial capacities of Djiboutian NGOs and associations so that they can deliver essential services needed to the most vulnierable groups. Project support will be provided in such a way as to ensure that community interventions are complementary and in synergy with interventionis carried out by governmental services and other potential partners In order to ensure that this component takes into account Djiboutian realities, a pilot project will be developed, with the assistance of an NGO, to provide nutritionial support to PLWHA in Djibouti-Ville and the Hospital Paul Faure (TB Hospital) This will done during the preparation phase of the project so as to fine tune the mechanisms of intervention and define an acceptable and reasonably priced social package (which could also include assistance for disabled HIlV/AIDS persons). Essential activities identified for community intervenltions can be classified in three categories.(i) prevention of HIV, TB and malaria transmission; (ii) reduction of the impact of HIV/AIDS (includinig psycho-medico-social support and care to PLWHA and their- families, social/economic support, includinig food, to PLWIIA and their families, and income generating activities for the families of PLWHA), and (iii) legal support (see Annex 2 for more details on activities) In order to implement the above activities, it will be necessary for the project to finanice support activities to strengtlhen the institutionial capacities of the Djiboutian NGOs In order to do so, NGO personiel will be trained in the following areas: (a) management and development of social projects; (b) basic informationi on HIV/AIDS, tuberculosis and malaria; (c) analysis of vulnerability and identification of appropriate solutions; (d) quality control for activities being financed at community level, (e) mobilization and promotion of commullity participation, and (f) supervision and evaluationl of services This training could either be contracted out to local institutiolIs, or if the Goverinmenit agreed, by the UNDP in the context of their 2003-2006 program, (througIl cost-shar-ing or other arrangements) The need for training and supervision of local NGOs and associations was assessed durinig the development of the HIV/AIDS National Strategic Plan. Support to local NGOs and associations will be provided by governmenital and non-governmienital institutions whicil will be responsible for training and supervision (called "Technical Assistance (TA) Institutions" or "TA NGOs"). The preparation team is conscious of the fact that even the capacities of these TA Institutions will need to be strengthenied. At the end of the training, an exam will identify the best 5 to 9 institutions to serve as TA institutiolIs, taking into account the criteria defined durinlg a consensus workshop on traillilig and supervision. The ES is currently preparing the Procedure Manual for Communilty Interventionis This Manual should be finalized prior to effectiveness, throughi a consensus workshop organized in collaboration with the UN Agencies and whichl would be attended by all the ministries concerned withi the fight againist HIV/AIDS, civil society and other partners. The consultant being recruited under the HSDP to prepare the project Procedure Manual will be requested to prepare the Procedure Manual for Community Intervenitionis as 10 PID well as the Project Operations Manual (POM) on the basis of the model elaborated by the ActAfrica team. With regard to the identification of local projects for community interventionis for the first year of the project, it will be done in a realistic maniner whichi will prioritize learning and the development of capacities of the personilel involved as well as quality control. Coverage will be gradually increased. On the basis of the response analysis carried out in 2002, it has been agreed upon that about 30 communiity projects will be developed for 2004 These projects will be implemilented by 25 to 30 local NGOs and associations assisted by 5-9 TA mistitutions, and the ministry dealing with the same vulnerable group and the Community Intervention SuppoI-t Unit (CISU) of the ES The preparation and selection process of community projects to be financed by the project will be an annual process whicil will be carried out in each district (or neighborhood) ulider the responsibility of the regional HIV/AIDS Councils. The project xvill be identified and selected taking into account the essential activities necessary to reduce the vulnerability of priority groups in each district of the country and neighborhood of Djibouti-Vilie and governmental interventions identified in the sectoral plans. The implementation of these projects will be monitor and supervised, at the central level, by the Community Interventioni Support Unit (CISU) in close collaboration with the person responsible for sectoral response in the ES and at the regional level, with the TA institutions, the HIV/AIDS regional committees and the consultanit to which monitorinig and evaluation will be contracted out. The modalities of these arrangements will be defined in the Monitoring and Evaluation Plan The financilig of community projects and of contracts with TA institutions will be carried out by the CISU in agreemilent with the Community Intervention Procedure Manual which will need to be finalized before the project becomes effective. The mechaniisms to chaninel funds from the CISU to communities was agreed upon during the February 2003 mission The selection process of the projects will be carried out by an independent Committee Government, civil society and donor representatives. The selection iriodalities will be stipulated in the Procedure Manual for Comminuity Interventions Capacity Building and Policy Development Public Hlealth Sector Response to HIV/AIDS, TB and STI Managemlient Multi-sector Responses for HiV/AIDS Prevention and Care Support to community-based initiatives 5. Financing Total (US$m) BORROWER/RECIPIENT $1.52 I BRD IDA IDA GRANT FOR HIV/AIDS $1200 FRANCE MINISTRY OF FOREIGN AFFAIRS (MOFA) $1.00 UN CHILDREN'S FUND $0.10 UN DEVELOPMENT PROGRAMME $0.30 UN FUND FOR POPULATION ACTIVITIES $0.10 Total Project Cost $15 02 11 PID 6. Implementation The implementation arrangements of the project will follow general MAP guidelines, with the establishment of an Interministerial Committee under the auspices of the Prime Minister, and a Technical Interminisrerial Committee to be assisted by an Executive Secretariat. This was deemed as the most appropriate mechanism for implementing the project given the multi-sectoral nature of the activities being proposed, and the coordination efforts needed to ensure efficient use of funids, and impact of project activities. The Interministerial Committee (IC), is chaired by the Prime Minister, with the vice-presidency held by the Minister of Health The IC serves as the policy focal point, and will be made up of representatives from sectoral ministries. The IC will have responsibility for coordinating the implementation of the National Strategic Plans (HIV/AIDS, Malaria, and Tuberculosis), increasinig awareness and mobilizing civil society in the promotion of prevention measures regarding HIV infection, malaria and TB, and providing guidance to the project. The IC will meet at least twice a year. The Technical Interimiinisterial Committee against transmittable diseases (TIC), is the technical arm of the IC whiicih will oversee the preparation of annual action plans and budgets and the implementation of the program and project activities related to HIV/AIDS, malaria and TB The TIC will have responsibility for ensuring that the integrationi of activities (HIV/AIDS, Malaria and TB) are executed in the public, para-public, and private sectors to promote the multi-sectoral impact of the actions being carried out, and will validate and supervise the execution of the multi-sectoral action plans and associated budgets through Its executilig arm, the Executive Secretariat (ES). The TIC will meet at least four timles a year, and will have represenitatives from the mniistries concerined, civil society, international organizationis, and bilateral donors who are financing HIV/AIDS, tuberculosis, and malaria interventionis The TIC will need to closely coordinate its efforts witil the UNAIDS Thematic Group. Project funds will be budgeted in the Prime Minister's office whichi will delegate them to the Executive Secretariat (ES) of the IC and the TIC, whicih will be responsible for day-to-day implementation of the three National Strategic Plans (HIV/AIDS, Malaria, and Tuberculosis) To do so, the ES will be comprised of about ten full time professionals (including t-wo interinational technical assistants as specified below in this paragraph), it will include an Administrative and Finalcial Unit (AFU), a Planninig, Monitorinig and Evaluation Unit (PMEU), a Multisectoral Unit, a Community Intervenltioni Support Unit (CISU) and a Social Communication Unit (SCU) The technical assistants will be a specialist in procurement and project implemenitation for five years and social communication specialist who will be hired to transfer their competences to the staff of the ES. The ES will be responsible for project execution, coordination, follow-Lip and moniitoring of project interventions, inCLidilig the finalization of the M&E operations manual The ES will coordinate the activities of the proposed action plans presented by the Ministry of Health (through the Epidemiology and Public Hygiene Department), ministerial focal polints, and the communities. The ES will also need to closely liaise with the Ministry of Health's Planning Unit, the Direction of Primary Health Care, as well as other national techniical experts, who may be called upoIn to provide assistance, either as TA or as specialist trainers The ES will also need to collaborate with the Regional Coulisels, whio should be in place once the deconcentrationi efforts take place early in 2003. The ES will prepare all documentationi for the TIC (meeting documents, minutes, progress reports on the national program, inter-miniisterial project activities, and community interventionis) and the IC. It is expected that the relationship between the new structure (IC, TIC and ES) and the MOH will be satisfactory for the following reasons. (a) the MOH has been the architect of the new structure and has defended it so that it could be ratified; (b) the Ministry of Health is the Vice-president of the IC, (c) the president of the TIC is the General Secretary of the MOH, and (d) the Executive Secretary has been selected among the key health civil servants The organizationi still give an important role to the MOH 12 PID which is intimately involved in the new structure. The different stakeholders will need to prepare aninual action plans with associated estimated buidgets These actions plans will be submitted to the ES who will need to ascertain whether the plans match the actions to be undertakell under the National Strategic Plans T he CIU will play a particular role within the ES to ensure that the activities submitted by the communities respond to the targeted populations, and fall withinl the predefined criteria established in the Project Operational Manual The selection of community sub-projects will be handled out by a tripartite committee (Governmelt, Donors, and Civil Society) Given the shortage of existing capacity in the country, and the complexity of the project that requires in-depth follow-up, the responsibilities under the PMEU (Planninig and M&E) for M&E will be sub-contracted out, and part of the civil works activities may be sub-contracted out to the Agence Djiboutienne d'Execution de Travaux d'lnteret Public (ADETIP) In addition, as mentioned above, two long-tern technical advisors will be hired to assist with procuremenit and social conimunication. Finally, some partnerships are envisaged withi some UN Agencies whicih, being presenit in the field, might be able to assist with supervision activities Until such time as the above arrangements are runninig and functional, the Credit Adminiistration Unit (CAU) of the MOH will be responsible for project activities in the "transition" phase, and withi oversight and executive responsibility for the project's Project Preparation Facility (PPF) The financial managemenit and procurement capacities of the CAU were partially evaluated during the February 2003 mission and wvere foulid to be satisfactory. Partnership Project preparation has been carried out in close collaboration wvith UN Agencies, il particular those represented in the UNAIDS Thematic Group, the bilateral donors and the NGOs. Interventions to be financed by the project have been selected after discussion of the National Strategic Plans with the various partners. As mentioned above in the section on institutional arrangements, it will be thie role the TIC and the ES to coordinate donor interventions and ensure that they are in agreement with the objectives of the strategic plans as wvell as complementary. In addition, PPF funds were used to contribute to the financinig of the POPFAM study, whichi will provide baseline data needed for the monitoring and evaluation of the HIV/AIDS activities, being carried out by the FNUAP. During project implementation, it is envisaged to continue this close collaboration In particular, the possibility of partnerships with UN agencies and the Frencih Cooperation have been explored with the donor agencies. These partnerships would make it possible for them to participate in specific areas, and allow the Bank to delegate certain aspects of program supervision thereby freeing up supervision funds. However, these partnerships still need to be discussed in detail with the Executive Secretariat (ES) and the Minist-y of Health. This could be undertakeni at the tine of the Donor's conferenice that the Djiboutianl autilorities will organize In mid-May 2003. If the Global FuLid proposal results in additional resources for Djibouti, it may free up some project funds which could be reallocated to other needs and whiich could not be micluded at the time of preparation. If the funds were to be allocated to HIV/AIDS, they could contribute to increasing the number of persons treated withi ARV after the end of the pilot project. 7. Sustainability The sustainability of the project wvill depend on the degree to whicil the strategy and activities become fully owvned by the various partners at nationial, district, and local levels. It will hinige on improved capacity at all levels to develop and implemenit action plans and proposals that are effective in changiig behaviors and providing care and support to affected groups 13 PID 8. Lessons learned from past operations in the country/sector Lessons learned fronflIV/AIDS program development and implementation in other countries shows that preventive measures suchi as IEC/BCC interventionis designed to bring about behavior chanige, condom use, treatimenit of sexually transmitted infectionis and opportullistic infectionls such as tuberculosis, voluntary couLiselinlg and testing, the improvement in blood supply, and preventing mother-to-child transmission, have all proven highly effective in reducing HIV transmission Community-based programs have been especially effective in enilanicinig prevention, care, support, and treatment for those infected and affected by HIV/AIDS. Lessons learned during the implemenitationi of effective HI V/AIDS programs in various countries will be integrated into the project as appropriate. Specific lessons taken into account, and learned fi-om internationial experience with HIV/AIDS programs (MAP1) include: Ismportance of political leadership and comli7itmient Experience shows that strong commiiitmeit from the top political and religious leadership in the country is important for the success of HIV/AIDS efforts In recent months the President of the Republic of Djibouti, includinig several Ministers, have demonstrated strong support for the program Need for a inulti-sectoral approach Experience in many countries in Africa has shown that HIV/AIDS control activities start in the health sector, but need to be expanded to other sectors. However, past experience has demonstrated difficulties in implementing projects across multiple ministries. Obviously a multi-sectoral HIV/AIDS project must engage a number of line miniistries and other governmiellt/public sector mechanisms. The risks iniherent in this arrangemenlt will be mitigated by the fact that the project is to be "coordinated" by the Interministerial Committee which will be placed in the Office of the Prime Minister Stakeholder Conssultation Key stakeholders, particularly those with an important role in implementation, should be involved as early-on in the process as possible. Project identification has been done in consultation withi Inie miniistries, includinig that of Religious Affairs, NGOs (includinig the NGO 'Oini a? la vie"which include PLWHA), UNAIDS and UN Agencies, other IDA projects, OPS and donor agencies. Several workshops have taken place in the five districts and in Djibouti-Ville to contribute to the finalization of the HIV/AIDS National Strategic Plan and to discuss the KABP studies The HIV/AIDS National Strategic Plan was approved durinig a consensus seminar which included all the partners consulted for project identificationi Additional regional workshops will be held aniually to set priorities and plan activities for the year at the level of the communiities and the districts. It should be noted that PLWHA have been very active and involved durinig project preparation and in the design and implementation of the ethnological studies of the impact of AIDS on families and individuals. Need for community participation Local comimlunities have a key role to play in the prevention of HIV/AIDS, the care of infected people and the support to affected groups. They also have a role to play in sanitationl and controlling malaria. The spread of infectious diseases, anid of HIV/AIDS In particular, results in a heavy burdeni to local communities They need support to cope and to be able to express their needs. Appropriate mechanisms must be put in place to facilitate the provision of support and resources to communities (such as education of comimiunities to better engage themil in the process, and so that adequate controls on finanicinig mechanisimis are put In place) It is recognized that experience with NGOs have been difficult in Djibouti. An NGO institutional analysis carried oLut during preparation indicated that NGOs were very weak, lack expertise, professionalism and know how. These finding suggests that in-depth systematic institutional capacity building is ilecessary. Consequently it was decided to have capacity building activities up front before launching community interventions (see annex 2 section 4, for further details) In addition, the project intenids to select 8 to 10 NGOs, or other institutiolns with recognized capacities, to train them, arid, on the basis of a competition, select 5 of them as "TA institutions" These will have the responsibility of 14 PID training local NGOs and associations, assist them with project preparation, and supervise and control the quality of their activities This two-tiers system should ensuL-e close supervision. Finally, a pilot project to provide support to sero-positive persons and their families is being carried out during project preparation. At the end of this project, mechianisms to better work with NGOs and local associations and means to avoid some of the past constraints will be identified. This pilot project will also assist in defining the social package to be provided to infected and affected persons MAP projects tended to lose momentum after Board approvd PPF has been requested by Government to sensitize representatives of public sector and civil society organizationis, to establish program coordinationi and implemenitation mechianisms, to start pilot operations as soon as possible and to carry KABP studies. Funds available under a PHRD grant were used to provide techilical assistance to assist in the development of a strategic plan and the carrying out of a sero-prevalence survey, disseminationi workshops, and establish a monitoring and evaluation system. Importance of monitoring and evalutation The design of the monitoring and evaluation system should focus on who will use the indicators and how they will influence the decision-miiakinig process Baseline data are essential for proper monitoring and have been collected during the preparation phase (see the above point). The Monitoring and Evaluationi Manual was prepared and this task will be subcontracted out to ensure that it is carried out by qualified experts Capacity buildling and transfer of competences will be a big part of the contractor's TIOR. Overall implementation experience in the education sector has showil that by havinig the project implemented by a unit within the Ministry of Education, there is better coordination among the different partners (government, civil society, stakeholders) withiin the framework of a sectoral committee established at that level, as well as better coordinationi between the donors. The Implemilentationi Unit has a better grasp of the reform process, and hiow the different interventions fit in. There are now regular meetings between the donors and the Ministry of Educationi, which has led to better synergy in impact interventions 9. Environment Aspects (including any public consultation) Issues : The program is not expected to have major environmenital impact. The handling and disposal of clinical and in particular of HlV/AIDS-infected materials is the most significant issue. Although an environmenltal plan was prepared for the Health Sector Development Project, a more substantive assessment on medical solid waste was prepared and submitted to the Infosihop on February 27, 2003. The plan Includes jilprovemenits to the legal text oni sanitary waste management, training oii how to safely dispose of contamilinated blood and other materials, wider dissemination of information to the general population, health supplies suchi as gloves, waste disposal canisters, incinierators, etc., and monitoring aiid evaluation. Health facilities benefiting from proceeds to the credit will be required to demonstrate that they have safe methods of waste disposal and that the training provided to their staff includes precautions ii handling sensitive materials 10. List of factual technical documents: CREDES Report. Tome 1: Analyse de la situationi et de la reponse nationale Tome 2 Cadre strategique 2003-2007 T'ome 3: Plan operationnel 2003-2005 Tome 4 . Manuel de suivi et evaluatioln Environmenital Managemilenit Plan on Waste Managemelit 15 PID 11. Contact Point: Task Manager Michele L. Lioy The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone 202-473-4810 Fax: 202-473-8216 12 For information on other project related documents contact The InfoShop The World Bank 1818 H Street, NW Washington, D C 20433 Telephone (202) 458-5454 Fax (202) 522-1500 Web http /1 www worldbank org/linfoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. Tables, Charts, Graphs: Processed by the InfoShop week ending 03/31/2003 For a list of World Bank news releases on projects and reports, click here SEARC - - FEc2flAC - SEU ACAp F StI-LAt E