Page  1
Document 
of 
The 
World 
Bank 
Report 
No: 
25 
109-PAK 
PROJECT 
APPRAISAL DOCUMENT 
ON 
A 
PROPOSED 
CREDIT 
IN 
THE 
AMOUNT 
OF 
SDR20.2 
MILLION 
(US$27.83 
MILLION 
EQUIVALENT) 
AND 
GRANT 
IN 
THE 
AMOUNT 
OF 
SDR6.7 
MILLION 
(US$9.28 
MILLION 
EQUIVALENT) 
TO 
THE 
GOVERNMENT 
OF 
PAKISTAN 
FOR 
THE 
HIV/AIDS 
PREVENTION 
PROJECT 
May 
13,2003 
Human 
Development 
Unit 
South 
Asia 
Regional 
Office 
Page  2
CURRENCY 
EQUIVALENTS 
(Exchange Rate 
Effective 
) 
Currency 
Unit 
= 
Rupee 
(Rs.) 
Rs. 
58.6 
= 
US$l.OO 
US$l.OO 
= 
Rs. 
58.6 
AJK 
ARCS 
BCC 
BOD 
BTAs 
CAS 
CGA 
CIDA 
DFID 
DPT3 
EMP 
EPI 
FIS 
FMC 
FSWs 
GPN 
GOP 
ICB 
IDA 
IDUS 
IPC 
I-PRSP 
LHW 
MSM 
NACP 
NCB 
NGOs 
NPV 
NSC 
NWFP 
OED 
PAD 
PAS 
FISCAL 
YEAR 
July 1 
-- 
June 
30 
ABBREVIATIONS 
AND 
ACRONYMS 
Azad, 
Jammu and 
Kashmir 
Audit 
Reports 
Compliance 
System 
Behavior 
Change 
Communication 
Burden 
of 
Disease 
Blood 
Transfusion 
Authorities 
Country 
Assistance Strategy 
Controller 
General 
of 
Accounts 
Canadian 
International Development Agency 
Department 
for 
International 
Development 
Third 
Dose 
of 
Diphtheria, 
Pertusis, 
& 
Tetanus 
Vaccine 
Environmental 
Management 
Plan 
Expanded Program 
on 
Immunization 
Financial 
Information 
System 
Financial 
Management 
Consultant 
Female 
Sex 
Workers 
General 
Procurement 
Notice 
Government 
of 
Pakistan 
International Competitive 
Bidding 
International Development Association 
Injecting 
Drug 
Users 
Inter-personal Communications 
Interim 
Poverty Reduction 
Strategy 
Lady Health 
Worker 
Males 
Who 
Have 
Sex 
with 
Males 
National 
AIDS 
Control 
Program 
National 
Competitive 
Bidding 
Non-Government 
Organizations 
Net 
Present 
Value 
National 
Steering 
Committee 
North-West 
Frontier Province 
Operations 
Evaluation 
Department 
Project Appraisal Document 
Procurement 
Accredited 
Staff 
Page  3
PDHS 
PDS 
PIHS 
PIPS 
PLWHA 
PPPS 
SAP 
STIs 
TACA 
TB 
TFR 
UN 
UNAID 
S 
UNDB 
UNDCP 
UNICEF 
VCT 
WHO 
Pakistan Demographic 
and 
Health 
Survey 
Project 
Document 
System 
Pakistan Integrated 
Household 
Survey 
Project 
Implementation 
Plans 
People 
Living 
with 
HIV/AIDS 
Public-Private 
Partnerships 
Social 
Action 
Program 
Sexually Transmitted 
Infections 
Technical 
Advisory 
Committee 
on 
AIDS 
Tuberculosis 
Total 
Fertility 
Rate 
United 
Nations 
United 
Nations 
AIDS 
Program 
United 
Nations 
Development 
Business 
United 
Nations 
Fund 
for 
Population 
Activities 
United 
Nations 
Children’s 
Fund 
Voluntary 
Counseling and Testing 
World 
Health 
Organization 
Vice 
President: 
Mieko 
Nishimizu 
Country ManageriDirector: 
John 
Wall 
Sector 
ManagedDirector: 
Anabela 
Abreu 
Task 
Team 
Leader/Task Manager: 
Benjamin 
Loevinsohn 
Page  4
Page  5
PAKISTAN 
HIV/AIDS 
PREVENTION 
PROJECT 
CONTENTS 
A. 
Project Development 
Objective 
1. 
Project 
development 
objective 
2. 
Key 
performance 
indicators 
B. 
Strategic 
Context 
1. 
Sector-related 
Country 
Assistance Strategy 
(CAS) goal 
supported 
by 
the 
project 
2. 
Main 
sector 
issues 
and 
Government strategy 
3. 
Sector 
issues 
to 
be 
addressed 
by 
the 
project 
and strategic choices 
C. 
Project 
Description 
Summary 
1. 
Project 
components 
2. 
Key 
policy 
and 
institutional 
reforms 
supported 
by 
the 
project 
3. 
Benefits 
and target 
population 
4. 
Institutional 
and 
implementation 
arrangements 
D. 
Project Rationale 
1. 
Project 
alternatives considered 
and 
reasons 
for rejection 
2. 
Major 
related projects financed 
by 
the 
Bank 
andor 
other development 
agencies 
3. 
Lessons learned 
and 
reflected 
in 
the 
project 
design 
4. 
Indications 
of 
borrower 
commitment and ownership 
5. 
Value 
added 
of 
Bank 
support 
in 
this 
project 
E. 
Summary 
Project 
Analysis 
1. 
Economic 
2. 
Financial 
3. 
Technical 
4. 
Institutional 
5. 
Environmental 
6. 
Social 
7. 
Safeguard 
Policies 
F. 
Sustainability 
and 
Risks 
1. 
Sustainability 
2. 
Critical 
risks 
Page 
2 
2 
2 
3 
9 
11 
16 
16 
17 
19 
20 
20 
21 
22 
22 
24 
24 
24 
25 
26 
28 
28 
29 
Page  6
3. 
Possible 
controversial 
aspects 
30 
G. 
Main 
Conditions 
1. 
Effectiveness 
Condition 
2. 
Other 
H. 
Readiness 
for 
Implementation 
I. 
Compliance 
with 
Bank 
Policies 
Annexes 
Annex 
1: 
Project Design 
Summary 
Annex 
2: 
Detailed 
Project 
Description 
Annex 
3: 
Estimated Project 
Costs 
Annex 
4: 
Cost 
Benefit Analysis 
Summary, 
or 
Cost-Effectiveness 
Analysis 
Summary 
Annex 
5: 
Financial 
Summary 
for 
Revenue-Earning 
Project Entities, 
or 
Financial 
Summary 
Annex 
6: 
(A) 
Procurement 
Arrangements 
(B) 
Financial 
Management 
and 
Disbursement 
Arrangements 
Annex 
7: 
Project 
Processing 
Schedule 
Annex 
8: 
Documents 
in 
the 
Project 
File 
Annex 
9: 
Statement 
of 
Loans 
and Credits 
Annex 
10: 
Country 
at 
a 
Glance 
30 
30 
32 
33 
Page  7
PAKISTAN 
HN/AIDS 
Prevention 
Project 
Project 
Appraisal 
Document 
South 
Asia 
Regional 
Office 
SASHD 
Date: 
April 
14,2003 
Sector 
ManagedDirector: 
Anabela 
Abreu 
Country ManagedDirector: 
John 
W. 
Wall 
Project 
ID: 
PO74856 
Lending Instrument: 
Specific Investment 
Loan 
(SIL) 
Team 
Leader: 
Benjamin 
Loevinsohn 
Sector(s): 
Health 
(100%) 
Theme(s): 
Fighting 
communicable 
diseases 
(P) 
IDA 
CANADA: 
CANADIAN 
INTERNATIONAL. DEVELOPMENT 
AGENCY 
(CIDA) 
UK: 
BRITISH 
DEPARTMENT 
FOR 
INTERNATIONAL 
DEVELOPMENT 
(DFID) 
IDA 
GRANT 
FOR 
HIVIAIDS 
[ 
] 
Loan 
[XI 
Credit 
[ 
] 
Grant 
[ 
] 
Guarantee 
[ ] 
Other: 
Total: 
For LoanslCreditslOthers: 
Amount (US$m): 
$37.11 
36.80 
I 
10.97 
I 
47.77 
6.16 
22.82 
2.00 
0.56 
5.26 
0.00 
5.01 
1 
.oo 
0.94 
4.02 
6.16 
27.83 
3 
.OO 
1.50 
9.28 
Page  8
A. 
Project Development Objective 
1. 
Project 
development objective: 
(see 
Annex 
1) 
With 
a systematic and 
immediate 
response, 
Pakistan 
has 
an 
opportunity 
to 
prevent 
a 
widespread 
HIV/AIDS 
epidemic. Hence, 
the 
objective 
of 
the 
proposed 
project 
is 
to 
prevent 
HIV 
from 
becoming 
established 
in 
vulnerable populations and 
preventing 
its 
spread 
to 
the 
general 
adult population, 
while 
avoiding 
further 
stigmatization 
of 
the 
vulnerable populations. 
The 
vulnerable 
populations include 
female 
sex 
workers 
(FSWs), 
injecting 
drug 
users 
(IDUs), 
men 
who 
have 
sex 
with 
men 
(MSM), 
prisoners, and 
migrant 
workers 
particularly 
long-distance 
truck 
dnvers. 
2. 
Key 
performance 
indicators: 
(see 
Annex 
1) 
Maintaining 
HIV 
prevalence 
below 
5% 
among 
the 
vulnerable populations 
as 
measured 
by 
annual 
sero-prevalence 
surveillance 
surveys 
would 
be 
the 
key 
impact 
measure. 
Similarly, 
HIV 
prevalence 
among 
women 
attending 
antenatal 
care 
would 
be 
used 
as 
an 
indicator 
of 
spread 
of 
the 
disease 
to 
the 
general 
population. 
While 
these 
indicators 
would 
reflect 
the 
outcome 
of 
interest, 
they 
may not 
be 
sensitive 
enough 
to 
define 
success 
of 
the 
proposed project. 
This 
is 
because 
they 
would 
not 
be 
expected 
to 
change 
much 
during 
the 
life 
of 
the 
project 
and 
there 
is 
no 
obvious counter-factual. 
Thus, 
these 
two 
impact indicators 
need 
to 
be 
supplemented 
by 
other 
indicators 
such 
as 
the 
prevalence 
of 
sexually transmitted 
infection 
(STIs), 
particularly 
syphilis, 
among the 
vulnerable 
populations 
which 
would 
be 
expected 
to 
decrease 
as 
condom 
use 
and 
STI 
treatment 
improve. 
In 
order 
to 
be 
considered 
successful, 
the 
proposed 
project should 
also 
be 
able 
to 
document a 
significant 
increase 
in 
condom 
use 
and 
the 
use 
of 
clean, 
unshared 
needles 
among 
IDUs. 
The 
extent 
to 
which 
vulnerable populations 
are 
stigmatized 
will 
be 
assessed 
through attitudes 
expressed 
during 
surveys 
of 
the 
general 
population. 
It 
may 
be 
possible 
to 
supplement 
this 
data 
with 
qualitative 
information 
obtained 
from 
focus 
group 
discussions 
and 
key 
informant interviews 
with 
members 
of 
the 
vulnerable populations. 
The 
details 
on 
the 
principal 
indicators 
for 
judging 
the 
achievement 
of 
the 
development objectives, 
including 
baseline 
data, 
means 
of 
verification, 
and 
availability 
of 
a 
counter-factual 
or 
comparison 
is 
described 
in 
Table 
2 
of 
Annex 
1. 
Table 
3 
of 
Annex 
1 
describes 
the 
details 
of 
data 
collection including 
responsibility, 
timing, 
and 
budget. 
B. 
Strategic 
Context 
1. 
Sector-related 
Country 
Assistance 
Strategy (CAS)  goal supported 
by 
the project: 
(see 
Annex 
1) 
Document number: 
241 14-PAK 
Date 
of 
latest 
CAS 
discussion: 
June 
11, 
2002 
General 
CAS 
Goals 
and 
Health 
Sector 
Objectives: 
The 
goal 
of 
the 
CAS 
is 
to 
support 
reforms outlined 
by 
the 
Government 
of 
Pakistan 
(GOP) 
in 
its 
Interim 
Poverty Reduction 
Strategy (I-PRSP). 
The 
strategy 
is 
based 
on 
achieving 
measurable outcomes 
linked 
to 
the 
millennium 
development 
goals 
and 
aims 
to 
assist 
Pakistan 
in 
three 
critical 
areas: 
(i) 
strengthening 
macroeconomic 
stability 
and 
government 
effectiveness; 
(ii) 
improving 
the 
business 
environment 
to 
facilitate 
economic growth; and 
(iii) 
improving 
equity 
through 
support 
for 
policies 
that 
are 
pro-poor and 
improve 
the 
status 
of 
women. 
In 
the 
social 
sectors, 
the 
CAS 
envisages 
support 
to 
the 
core objective 
of 
the 
I-PRSP, 
which 
are 
to empower people 
by 
creating 
opportunities 
for 
increasing 
incomes, 
promoting 
education, 
improving 
access 
to 
health 
services, 
and 
implementing 
safety 
nets 
programs. 
The broad 
determinants 
of 
health 
would 
be 
addressed 
by 
mainstreaming 
gender, 
supporting 
community 
based 
infrastructure 
interventions 
including improving 
availability 
of 
water 
and sanitation 
services, 
and 
expansion 
of 
micro-credit. 
To 
improve 
health 
services, 
the 
aim 
is 
to 
support 
the 
key 
programmatic interventions 
such 
as 
immunization, 
communicable 
disease 
control 
including 
tuberculosis 
(TB) 
and 
HIv/AIDS, 
and 
maternal 
and 
child 
health 
including family 
planning 
programs. 
Improved 
governance 
and 
increased 
efficiency 
of 
public 
expenditures 
would 
be 
-2- 
Page  9
achieved 
through devolution 
of 
powers 
to local 
governments, 
strengthening 
of 
district 
health 
systems, 
improving monitoring 
of 
health 
indicators, and development 
of 
partnerships 
with 
the 
private 
sector, 
including 
NGOs. 
Relationship 
of 
the 
Project 
to 
the 
CAS: 
The 
project 
is 
fully 
consonant 
with 
the 
CAS 
and 
I-PRSP 
health 
sector 
goals 
as 
it 
would: 
(i) 
systematically 
strengthen 
the 
Government’s 
program 
for 
preventing 
an 
HIV 
epidemic; 
(ii) 
help 
establish 
and 
evaluate a coherent 
mechanism 
for 
the 
Government 
to 
work 
with 
non-government and 
private 
sector organizations; and 
(iii) 
improve 
governance 
in 
the 
sector 
by 
introducing 
a systematic approach 
to 
quality 
assurance, 
monitoring, 
supervision, 
and 
evaluation. 
2. 
Main 
sector 
issues 
and Government strategy: 
Current 
Health 
Status: 
Palustan 
has 
long 
lagged 
its 
neighbors 
and 
many 
other 
low-income 
countries 
in 
terms 
of 
health 
and 
fertility 
outcomes 
although 
both 
contraceptive prevalence 
and 
infant 
mortality 
rates 
have 
improved 
during 
the 
1990s. 
The 
infant 
mortality 
rate 
was 
85/1000 
live 
births 
in 
2000/01 
(Palustan 
Reproductive 
Health 
and 
Family 
Planning 
Survey 2000-01) 
as 
compared 
to 
101/1000 
in 
1991-1993 
(PIHS 1995/96). 
The 
total 
fertility 
rate 
(TFR) 
is 
currently 
4.8 
(Pakistan 
Reproductive 
Health 
and 
Family 
Planning 
Survey 2000-01) 
as 
compared 
to 
5.4 
at 
the 
beginning 
of 
the 
1990s 
(PDHS 
1990/91). 
In 
spite 
of 
the 
gains, 
progress 
has 
been 
much 
slower 
than 
in 
neighboring 
countries and 
appears 
to 
be 
leveling 
off. 
An 
analysis 
of 
the 
burden 
of 
disease 
(BOD) 
conducted 
in 
1996 (Pakistan: 
Towards 
Health 
Sector 
Strategy, 
World 
Bank) 
indicated 
that 
almost 
40 
percent 
of 
the 
total 
BOD 
was 
related 
to 
communicable 
diseases, 
and 12 
percent 
to 
reproductive 
health 
problems. 
Nutritional 
deficiencies 
accounted 
for 
a 
further 
6 percent 
of 
the 
total 
BOD. 
Thus, 
Pakistan 
appears 
to 
be 
in 
an 
early 
stage 
of 
the 
epidemiological 
transition, 
with 
basically 
preventable 
or 
readily 
treatable 
diseases 
primarily 
affecting 
young children 
and 
women accounting 
for 
a 
dominant 
share 
of 
morbidity 
and 
premature 
mortality. 
Determinants 
of 
Health: 
Further 
progress 
in 
health 
outcomes 
will 
partly 
depend 
on 
factors outside 
the 
health 
sector, 
such 
as 
advances 
in 
primary 
education, 
particularly 
of 
girls, 
and 
improvements 
in 
the 
social 
status 
and 
power 
of 
women. 
However, 
there 
is 
also 
much 
scope 
to 
improve health 
outcomes 
through 
improvements 
in 
health 
services. 
For 
example, 
routine immunization 
coverage 
nationwide 
remains 
low 
with 
only 
56% 
of 
infants 
receiving 
DPT3. 
Government expenditure 
on 
health 
services 
is 
very 
low, 
and 
the 
public 
obtains 
poor 
value 
from 
what expenditure there 
is. 
Public 
sector 
health 
services 
suffer 
from 
weak 
management, 
frequent 
transfers, 
lack 
of 
accountability, 
and 
imbalances 
in 
the 
object composition 
of 
expenditure 
(too 
many 
staff 
relative 
to workload 
coexisting 
with 
insufficient 
budgets 
for 
key 
non-salary 
inputs). 
The 
quality 
of 
care 
is 
often 
low 
in 
the 
public 
sector 
and 
quality 
assurance 
mechanisms 
are 
barely 
operative. 
There 
are 
also 
quality 
problems 
and widespread consumer 
abuse 
in 
the 
largely 
unregulated 
private 
sector, 
which 
accounts 
for 
about 
four-fifths 
of 
outpatient 
contacts. 
Initiatives 
to protect and 
educate 
consumers 
of 
health 
services have 
been 
very 
limited 
and 
most 
households 
lack 
access 
to 
risk 
pooling 
mechanisms 
for 
catastrophic 
diseases 
or 
accidents. 
The 
Social 
Action 
Program: 
Beginning 
in 
1993, 
the 
Government 
tried 
to 
address 
a 
number 
of 
the 
above 
weaknesses 
through 
its 
Social 
Action 
Program 
(SAP), 
focusing 
on 
programmatic 
and 
management 
reforms 
with 
a clear 
thrust 
toward 
communicable 
disease 
control 
and 
maternal and 
child 
health. 
However, progress 
was 
limited, 
especially 
in 
improving immunization 
coverage 
and 
the 
nutrition 
of 
mothers 
and 
children. Management 
and 
organizational reforms 
either 
were 
not 
implemented 
or 
implemented halfheartedly 
with 
little 
effect 
on 
the 
quality 
of 
health 
care. 
In 
addition, 
issues 
related 
to 
governance 
including staff 
absenteeism, 
lack 
of 
adequate measures 
to monitor 
outputs 
and 
outcomes and 
lack 
of 
supervision 
significantly 
hindered 
progress. 
-3- 
Page  10
The Government’s 
Current Health 
Policy: 
The 
GOP’s 
devolution initiative, 
while 
broader than 
just 
health, 
is 
aimed 
at 
addressing 
some 
of 
the 
important 
issues 
facing 
the 
sector 
by 
enhancing the 
accountability 
of 
staff, 
improving 
the 
efficiency 
and 
quality 
of 
services, 
and 
improving 
coordination 
with 
the 
private 
sector. 
Besides 
the 
devolution initiative, 
a 
medium-term 
strategy 
for 
human 
development 
has 
been 
outlined 
in 
the 
I-PRSP 
and 
the 
GOP’s 
2001 
Health 
Policy, 
which 
focuses 
on: 
(i) 
strengthening 
preventive health 
services 
including 
immunization, communicable 
diseases 
such 
as 
malaria, 
TB, 
and 
HIV/AIDS, 
maternal 
and 
child 
health, 
and 
family 
planning; 
(ii) 
improving 
the 
quality 
of 
health 
care at 
the 
tehsil 
and 
district 
headquarter hospitals; and 
(iii) 
strengthening management 
capacity 
at 
the 
district 
level. 
pregnancy 
% 
of 
currently married women 
using 
any 
method 
of 
contraception 
% 
of 
currentlv married 
women 
usine 
modern method 
of 
contraceDtion 
Lessons 
Learned 
in 
the 
Government 
Health 
Sector: 
While 
overall 
there 
has 
been 
only 
limited 
progress 
during 
the 
last 
decade 
in 
improving 
the 
delivery 
of 
publicly 
funded 
health 
services, 
there 
are 
some 
areas 
where 
good 
results 
have 
been 
achieved. 
For 
example, 
the 
number 
of 
community-based 
female 
health 
workers, 
including 
female physicians and paramedics 
has 
improved 
significantly 
in 
all 
provinces, 
resulting 
in 
improved 
availability 
of 
maternal 
and 
child 
health 
and 
family 
planning 
services. 
Similarly, 
through the 
lady health worker 
(LHW) 
program, 
access 
to primary 
health 
care 
and 
family 
planning 
services 
in 
the 
periphery 
has 
improved. 
The 
recent 
third 
party 
evaluation 
of 
the 
program 
indicates 
that 
those 
areas 
with 
LHWs 
have better 
access 
to 
services 
compared 
to 
areas 
without 
LHWs 
(see 
table 
1). 
Given 
the 
increasing 
number 
of 
LHWs, 
they 
could 
become an 
important conduit 
for 
health 
education 
related 
to 
HIV 
and other 
diseases. 
The 
experience 
of 
these 
successes 
and 
a 
few 
others 
suggests 
that 
for 
the 
Government to 
achieve 
results 
on 
the 
ground 
requires: 
(i) 
a clear 
and 
coherent strategy; 
(ii) 
bold 
thinking 
and 
a 
willingness 
to 
innovate; 
(iii) 
rigorous 
evaluation 
of 
programs; 
(iv) 
consistent 
financing; 
and 
(v) 
strong 
and dedicated 
management. 
32 
23 
22 
15 
Table 
1: 
Household 
Survey 
Results 
Related 
to 
Service 
Delivery 
in 
Rural 
Areas 
With 
and 
Without 
Lady 
Health 
Workers, 
Percent 
I 
% 
of 
children 
under 
3 
years 
ever 
weighed 
by 
health 
worker 
I 
33 
19 
I 
32 
I 
15 
% 
of 
children 
with 
diarrhea 
given 
more 
liquids 
to 
drink 
o/n 
of 
children 
12-35 
months 
fullv 
vaccinated 
I 
47 
I 
45 
I 
Source: 
External 
Evaluation 
of 
the 
National 
Program 
for 
Family 
Planning 
and 
Primary 
Health 
Care, 
Oxford Policy 
Management, 
May 
200 
1 
Public-Private 
Partnerships (PPPs): 
In 
the 
past 
the 
GOP 
was 
reluctant 
to work 
with 
the 
private 
sector 
in 
provision 
of 
health 
services. 
For 
example, under 
the 
SAP, 
the 
GOP 
planned 
to 
work 
with 
NGOs 
and 
community 
based 
organizations through 
the 
Participatory 
Development 
Program 
and 
provincial 
education and health foundations. 
The implementation 
of 
these 
efforts 
was 
unenthusiastic 
and 
both 
their 
scope 
and 
success 
were modest. 
More 
recently 
there have 
been 
some 
successful examples 
of 
PPPs 
including: 
the 
partnership 
of 
Government 
and 
NGOs 
under 
the 
Northern Health 
Project, 
during 
which 
publicly 
financed tuberculosis 
management 
and 
family 
planning 
services 
were 
provided 
by 
NGOs, 
with 
impressive 
positive 
results; 
and 
provision 
of 
micro-credit 
and 
community 
infrastructure 
through 
the 
Pakistan 
Poverty 
Alleviation 
Fund. 
A 
recent 
Bank-financed 
study 
of 
ten previous 
and 
ongoing 
PPPs 
-4- 
Page  11
(Analysis 
of 
the 
Experience 
of 
Government Partnerships 
with 
Non-Government 
Organizations-2002) 
indicated 
that 
the 
major 
lessons learned 
from 
these 
experiences 
included: 
Those partnerships 
where 
the 
government 
defined 
the 
services 
to 
be 
delivered 
(the 
“contracting” 
model) 
were 
generally 
successful 
in 
achieving 
their 
goals. 
In 
those partnerships 
where 
grants 
were 
given 
to 
NGOs for 
activities 
that 
they 
themselves 
defined 
(the 
“grant”  model), 
success 
was 
less 
likely 
although 
still 
possible 
where 
activities 
were 
clearly 
focused. 
Systematic 
monitoring 
and 
reporting 
of 
activities 
has 
not 
always been 
done, 
but 
has 
been 
key 
to 
successful partnerships. 
Careful 
attention 
to 
financial reporting and auditing 
has 
been 
critical for 
monitoring 
the 
performance 
of 
partner NGOs. 
A 
funding 
mechanism 
that 
allows 
for 
smooth 
transfer 
of 
funds 
to 
the 
NGOs 
has 
been 
critical for 
a 
successful partnership. 
e 
Transparency 
and good 
governance 
in 
the 
NGO 
selection process 
were 
also 
important 
factors 
in 
the 
success 
of 
the partnerships. 
HIV/AIDS 
Pakistan 
is 
a 
low 
prevalence 
but 
high-risk 
country 
for 
HIV/AIDS. 
While 
the current 
reported 
number 
of 
HIV 
cases 
is 
low, 
experience 
in 
the 
regions and 
in 
other, 
previously 
low 
prevalence, 
countries strongly 
indicates 
that 
this 
could 
change 
quickly. 
The 
presence 
of 
high 
risk 
behaviors 
such 
as 
high-volume, 
unprotected commercial 
sex, 
injecting 
drug 
use, 
and 
male 
to 
male 
sex, 
points out 
the 
precarious 
situation 
Pakistan 
faces. 
An 
HIV/AIDS 
epidemic 
would 
threaten 
the 
improvements 
in 
health 
status 
that 
have 
been 
achieved over 
the 
last 
40 
years. 
The 
evidence 
from Africa 
indicates that a generalized epidemic 
can 
reverse improvements 
in 
health 
outcomes 
with 
disastrous 
consequences 
for 
economic 
and 
social 
development. 
HIV 
Prevalence 
and 
Means 
of 
Transmission: 
Up 
until 
the 
end 
of 
September 2002, 
1,741 
HIV 
cases 
and 
23 
1 
AIDS 
cases 
were reported 
to 
the 
National 
AIDS 
Control 
Program 
(NACP). 
The 
number 
of 
actual 
cases 
is 
believed 
to 
be 
higher 
due 
to 
under-reporting. 
Based 
on 
limited 
surveillance 
data 
and 
computer 
modeling, 
LJNAIDS 
has 
estimated that there about 
70,000 
to 
80,000 
persons 
with 
HIV, 
or 
about 
0.1 
percent 
of 
the 
adult 
population. 
Among 
reported 
cases 
of 
HIV, 
the 
most 
common forms 
of 
transmission 
are 
heterosexual 
sex 
(41%) 
and contaminated 
blood 
or 
blood 
products 
(17%), 
followed 
by 
homosexual 
or 
bisexual 
sex 
(4%), 
injecting 
drug 
use 
(3%), 
and 
mother 
to 
child 
transmission 
(1%). 
However, 
in 
34% 
of 
cases 
no 
means 
of 
transmission 
could 
be 
identified. The male 
to 
female 
ratio 
of 
HIV 
cases 
is 
almost 
7: 
1. 
Vulnerable 
Populations: 
The 
vulnerable populations 
in 
Pakistan 
whose 
behaviors 
put 
them 
at 
especially 
high 
risk 
of 
HIV 
infection 
are 
primarily 
female 
sex 
workers 
(FSWs), 
injecting 
drug 
users 
(IDUs), 
males 
who 
have 
sex 
with 
males 
(MSMs), 
long-distance 
truck 
drivers, 
and prisoners. 
FSWs: 
Although 
illegal, 
commercial 
sex 
is 
common 
in 
major 
cities 
and 
a recent 
mapping 
exercise 
concluded 
that 
there 
are 
a 
total 
of 
about 
100,000 
FSWs 
in 
Lahore, 
Multan, 
and 
Karachi. 
While 
FSWs 
previously 
operated 
primarily 
out 
of 
brothels 
and 
entertainment establishments 
(where 
they 
are 
identified 
as 
singing 
and dancing 
girls), 
now 
most 
are 
found 
on 
the 
street, 
in 
residential 
houses 
(“kothis”),  and 
hotels. Hence, 
the 
efforts 
in 
the 
1980’s 
to 
close 
down or 
reduce 
the 
size 
of 
red-light 
areas 
has 
resulted 
in 
a 
less 
organized and 
more 
widespread 
form 
of 
commercial 
sex 
in 
which 
it 
is 
harder 
to 
find 
the 
FSWs 
and 
provide 
them 
services. 
It 
is 
estimated 
that 
NGO 
programs 
are 
reaching 
only 
5% 
of 
the 
FSWs 
and 
few 
of 
-5- 
Page  12
the 
FSWs 
interviewed 
for 
the 
social 
assessment 
were aware 
of 
existing 
programs. 
The 
median 
age 
of 
the 
FSWs 
is 
less 
than 
20 and about 
20% 
are 
under 
15 
years 
of 
age. 
Low 
levels 
of 
literacy 
and 
high 
mobility 
further 
complicate 
efforts 
to 
provide 
essential 
information 
to 
FSWs. 
FSWs 
engage 
an 
average 
of 
3-5 
clients 
per 
day and 
their 
customers 
are 
primarily 
businessmen, 
laborers, 
and 
students. 
Condom 
use 
remains 
very 
low 
and 
FSWs 
report 
that 
they 
find 
it 
hard 
to 
negotiate 
condom 
use 
out 
of 
fear 
of 
losing 
clients. 
Injecting 
Drug 
Users: 
There 
are 
about 
500,000 
hard-core 
heroin 
addicts 
in 
Pakistan, 
of 
which 
60,000 
(12%) 
are 
IDUs 
(UNDCP 
2001). 
UNAIDS 
and 
UNDCP 
carried out a 
study 
in 
Lahore 
in 
1999 and 
found 
that 
89% 
of 
IDUs 
studied 
tested 
positive 
for 
Hepatitis 
C. 
This 
finding 
is 
very 
womsome 
because 
it 
demonstrates 
that 
needle 
sharing 
is 
very 
common 
and 
has 
already 
lead 
to 
the widespread transmission 
of 
another 
blood-borne 
disease. 
The 
same 
study 
found 
that 
64% 
of 
IDUs 
reported 
sharing 
needles 
in 
the 
last 
week alone. Hence, 
the 
introduction 
of 
HIV 
into 
this 
population 
could 
lead, 
as 
it 
has 
elsewhere, 
to 
an 
explosive 
increase 
in 
prevalence. 
In 
addition 
to 
heroin, 
the 
study 
also 
discovered increasing 
use 
of 
legally 
procured injectable 
medicines. 
Males who 
have 
Sex 
with 
Males: 
A 
mapping 
and 
behavioral 
assessment 
of 
MSM 
was 
recently 
carried 
out 
in 
Lahore 
(Naz 
Foundation International 
- 
2002) 
which 
estimated 
that 
there 
are 
approximately 
38,000 
MSM 
in 
the 
city. 
The 
MSM 
community 
is 
quite 
heterogeneous 
and includes 
Hijras 
(biological 
males 
who 
are 
usually 
fdly 
castrated), Zenanas 
(the 
term 
used 
by 
males 
who 
perceive 
themselves 
as 
“a 
woman 
in 
a 
man’s 
body” 
and 
who usually 
dress 
as 
women), 
and 
masseurs. 
Many 
sell 
sex 
and 
have 
multiple 
sexual 
partners. 
Of 
the 
200 
study 
respondents, 
75% 
had more 
than 
7 
partners 
in 
the 
previous 
month 
and 
15% 
had 
more 
than 
21 
partners. 
Condom 
use 
is 
low 
with 
only 
17% 
of 
anal intercourse 
acts 
in 
the previous 
month 
covered 
by 
a 
condom. 
Impediments 
to 
condom 
use 
included 
a 
perception 
that 
they 
and 
their 
partners 
were 
not 
sick 
(67%), 
that condoms 
interfered 
with 
pleasure 
(79%), 
not 
carrying 
condoms 
at 
the 
time 
of 
sexual contact 
(85%), 
and 
not being 
able 
to 
put 
on 
a 
condom 
properly 
(80%). 
Many 
respondents 
also 
reported 
symptoms suggestive 
of 
STIs. 
In 
terms 
of 
harassment, 
the 
study 
concluded that 
it 
is 
casual, 
opportunistic, 
localized, 
but 
frequent. 
The 
police 
are 
often involved, 
partly 
to 
show 
that they 
are 
“doing 
something”, 
but 
it 
is 
also 
carried out 
by 
criminals, 
clients, 
and 
other sexual partners. 
Long-Distance 
Truck 
Drivers: 
Previous 
reports 
suggested 
that 
there 
were 
128,000 
licensed 
trucks 
in 
Pakistan 
and 
about 
one 
million 
long-distance 
truck 
drivers. 
However, a recent 
mapping 
exercise 
found 
less 
than 
12,000 
in 
Karachi, 
the 
largest 
truck 
center 
in 
the 
country. 
Hence, 
it 
is 
believed 
that 
the 
number 
of 
truck 
drivers 
nationwide 
is 
significantly 
less 
than 
originally 
thought. 
A 
recent 
study 
of 
300 
trucker’s 
reports that one 
third 
of 
truckers report unprotected 
sex 
with 
FSWs 
or 
Hijras 
and 
nearly 
50% 
reported 
having 
sex 
with 
another 
man. 
Condom 
use 
was 
found 
to 
be 
very 
low, varying 
from 
3 
to 
6%. 
Prisoners: 
While 
the 
incarceration 
rate 
in 
Pakistan 
is 
not particularly 
high, 
prisoners 
appear 
to 
be 
involved 
in 
many 
high 
risk 
behaviors 
both 
during 
and 
prior 
to 
their 
confinement. 
A 
study 
of 
more 
than 
3,400 
male 
prisoners 
in 
Sindh 
found 
that 
4% 
were 
injecting 
drug 
users, 
23% 
had 
sold 
their 
blood, 
and 
27% 
admitted 
to having 
sex 
with 
other 
men. 
Of 
the 
latter, 
more 
than 
80% 
indicated 
male 
to 
male 
sexual 
contact began 
prior 
to 
their 
current incarceration. 
Knowledge, Attitudes, 
and 
Behaviors 
in 
the General 
Population: 
There 
has 
been 
an 
increase 
in 
the 
general 
population’s 
knowledge 
of 
HIV 
prevention 
over 
the 
last 
few 
years, 
however knowledge 
is 
still 
inadequate 
and actual behaviors 
remain 
disquieting. 
A 
household 
survey 
conducted 
in 
2001 
(Dataline 
Services) 
provided 
results 
that 
could 
be compared to a 
survey 
done 
in 
1996, 
before 
the 
GOP 
had 
undertaken 
an 
awareness 
campaign 
using 
mass 
media. 
As 
table 2 
indicates, 
there 
was 
a 
significant 
improvement 
in 
people’s 
knowledge 
of 
HIV 
transmission 
and 
how 
to 
prevent 
it. 
However, 
only 
1% 
-6- 
Page  13
spontaneously 
mentioned 
condoms 
as 
a 
method 
for 
preventing 
HIV. 
Similarly, 
of 
136 respondents 
who 
admitted 
to having 
pre-marital 
or 
extra-marital 
sex 
only 
15% 
reported that 
they 
always 
used 
a 
condom 
and 
of 
192 respondents 
who had 
recently received 
blood 
transfusions, 
only 
67% 
were 
sure 
that 
the 
blood 
had 
been 
screened. 
Attitudes 
towards people 
living 
with 
AIDS 
were 
mixed. 
Among 
respondents 
who 
knew 
about 
AIDS, 
65% 
expressed a 
positive 
attitude 
towards 
meeting 
an 
AIDS 
patient 
in 
their 
community. However, 
only 
12% 
indicated 
that 
an 
AIDS 
patient should 
have 
the 
right 
to 
keep 
their 
illness 
secret. 
Table 
2: 
Knowledge 
of 
the General Population 
about 
HIV 
Transmission 
and 
Prevention, 
1996 
and 
2001 
~ 
Source: 
Dataline 
Services 
- 
2001 
Safety 
of 
Blood 
Transfusion 
Services: 
About 
1.2 
million 
units 
of 
blood 
are 
transfused 
annually 
in 
Pakistan 
and 
a recent 
extemal 
review 
by 
WHO 
and the Swiss 
Red 
Cross 
found 
that 
at 
least 
20% 
of 
blood 
used 
is 
inadequately 
tested 
for 
HIV 
and 
Hepatitis 
B. 
The 
actual 
figure 
may 
be 
higher 
because 
in 
many 
instances 
good 
records 
are 
not 
being 
kept, 
despite 
the 
existence 
of 
national 
guidelines 
for 
blood 
transfusion 
services. 
Three 
of 
the 
four 
provinces 
of 
Pakistan 
have 
passed 
legislation 
establishing 
blood 
transfusion authorities 
(BTAs). 
These 
BTAs 
have 
now 
been 
formally 
constituted 
but 
they 
have 
just 
begun 
working 
and 
so 
both 
the 
public 
and 
private 
sector 
blood 
banks 
are 
not 
well 
regulated. 
While 
there 
is 
clearly 
much work 
to 
do, 
the 
successful experience 
in 
Punjab 
is 
encouraging. 
Punjab 
has 
been 
able 
to 
establish 
quality 
transfusion 
services 
in 
the 
public 
sector 
and 
had 
been 
able 
to 
finance 
the 
introduction 
of 
Hepatitis 
C 
screening 
using 
its 
own 
resources. 
The 
Government’s 
AIDS 
Control Program: 
In 
recognition 
of 
the 
threat 
of 
HIV, 
the 
GOP 
established a 
National 
AIDS 
Control 
Program 
(NACP), 
in 
the 
late 
1980’s. 
The 
program 
made 
slow 
progress 
in 
the 
early 
1990’s 
due 
to: 
(i) 
a 
failure 
to 
recognize 
the 
seriousness 
of 
the 
HIV 
threat, 
resulting 
in 
low 
allocations and 
expenditures; 
(ii) 
a 
vague 
strategy 
that 
mainly 
concentrated 
on 
blood 
screening 
and 
did 
not 
address 
the 
vulnerable populations; 
(iii) 
weak surveillance and operational 
research 
which 
resulted 
in 
GOP 
officials not having 
credible 
data 
on 
which 
to 
base 
decisions; 
and 
(iv) 
slow 
mobilization 
of 
staff 
and 
other resources. 
Towards the 
mid-1990s there 
was 
a 
gradual improvement 
in 
the 
level 
of 
GOP 
commitment 
to 
the 
program 
which 
resulted 
in 
its 
inclusion 
in 
the 
Social 
Action 
Program Project 
financed 
by 
the 
World 
Bank 
and other 
donors. 
This 
enhanced 
commitment 
was 
reflected 
in 
slowly 
increasing 
expenditures, 
increases 
in 
staffing 
levels, 
and 
establishment 
of 
provincial 
AIDS 
control 
programs. 
However, 
the 
overall 
strategy 
remained 
unchanged 
with 
the 
exception 
of 
an 
increased focus 
on 
health 
promotion 
and 
HIV 
education aimed 
at 
the 
general 
public. 
In 
2000, 
the 
GOP, 
through 
a 
broad 
consultative 
process, 
developed 
a 
National 
Strategic 
Framework 
for 
HIV/AIDS 
that 
set 
out 
the 
broad 
strategies 
and 
priorities 
for 
effective 
control 
of 
the epidemic. 
While 
the 
framework 
was 
very 
comprehensive, 
it 
did 
provide 
for 
increased focus 
on working 
with 
the 
vulnerable populations. 
The 
framework 
has 
been 
formally 
adopted 
by 
the 
GOP 
and 
its 
development 
partners and 
provides 
a 
useful 
-7- 
Page  14
general approach 
for 
HIV 
prevention. 
The 
program 
is 
currently 
spending 
about 
US$2.5 
million 
per 
year 
from 
all 
sources. 
Institutional 
Analysis: 
An 
external 
review 
of 
the 
federal 
and 
provincial 
AIDS 
control 
programs 
was 
carried out 
in 
200 
1 
and 
indicated 
some 
progress 
since 
the 
previous 
program 
review 
in 
1993. 
However, 
it 
identified 
a 
number 
of 
key 
issues, 
including: 
(i) 
there were 
strong 
program 
units 
at 
the 
federal 
level 
and 
in 
Sindh province 
but 
the 
other 
provinces 
needed 
to 
have 
their 
management 
strengthened 
and 
their 
staffing 
increased 
significantly; 
(ii) 
there 
was a 
need 
to 
enhance 
the GOP’s 
reliance 
on 
NGOs for 
working 
with 
vulnerable 
populations; 
(iii) 
the surveillance and research components 
of 
the 
program 
were 
found 
to 
be 
weak and needed 
to 
be 
brought 
into 
line 
with 
global 
best 
practices; and 
(iv) 
there 
was 
an 
urgent 
need 
to 
expedite release 
of 
funds 
and 
provide 
the 
provincial 
programs 
with 
greater 
autonomy 
in 
using 
available 
resources. 
NGO 
Interest 
in 
HIV/AIDS 
Activities: 
During 
preparation 
of 
the 
project, 
considerable 
attention 
was 
given 
to 
consulting 
with 
NGOs 
and 
assessing 
their 
capacity 
to 
implement 
HIVIAIDS 
prevention 
activities. 
In 
large 
meetings 
and 
also 
during 
visits 
to 
their 
offices, 
a 
wide 
variety 
of 
NGOs 
expressed 
great 
interest 
in 
being 
involved 
in 
expanded 
efforts 
to 
prevent 
HIV. 
NGOs 
who 
are 
currently 
involved 
in 
other 
aspects 
of 
health 
care 
delivery, 
including 
some 
very 
large 
ones, 
also 
voiced 
a desire 
to 
take 
on 
HIV 
prevention 
activities. 
All 
the 
NGOs 
already 
involved 
in 
HN 
prevention 
felt 
constrained 
by 
the 
severe 
lack 
of 
resources and the 
fact 
that 
funding 
was 
only 
available 
on 
a year-by-year basis, 
which, 
they 
felt, 
significantly 
interfered 
with 
program 
development 
and 
expansion. 
Much 
of 
the 
support 
currently 
being 
provided 
by 
donors 
does 
not 
allow for 
overhead 
costs, 
including 
the 
costs 
of 
management. 
The 
concern 
most 
frequently 
expressed 
by 
all 
the 
NGOs 
consulted 
was 
about 
the 
Government’s 
ability 
and 
willingness 
to 
pay 
them 
on 
time 
for 
work 
they 
carried 
out. 
For 
example, one 
NGO 
involved 
in 
family 
planning 
recently had 
bills 
for 
Rs. 
5 
million 
outstanding 
with 
the 
Government 
for 
more than 
five 
months. 
Because 
they 
have 
limited 
capital, 
the 
NGOs 
realize that 
failure 
to 
receive 
timely 
payments 
could 
seriously 
interfere 
with 
their 
work. 
NGO 
Capacity: 
In 
terms 
of 
the 
financial 
and management 
systems 
required, 
it 
appears 
that 
there 
are 
a 
reasonably 
large 
number 
of 
NGOs 
in 
Pakistan 
who 
have 
at 
least 
the 
management 
capacity 
to 
carry out 
extensive 
HIV 
prevention 
activities. 
For 
example, a 
recent 
study 
of 
27 
NGOs from 
all 
over 
Pakistan 
currently 
involved, 
or 
interested, 
in 
HN 
work 
found 
that 
85% 
of 
the 
NGOs 
surveyed 
had 
annual 
audits 
carried 
out 
by 
certified 
accountants, 
89% 
had 
computerized accounting 
systems, 
and 
52% 
had 
substantial 
experience 
with 
procurement. 
In-depth 
visits 
were made 
to 
the 
offices 
and 
field 
sites 
of 
more 
than 
15 
NGOs 
during 
project 
preparation 
and 
corroborated 
the 
findings 
of 
the 
above 
study. 
The 
visits 
also 
found 
that the 
NGOs 
were 
impressive 
in 
terms 
of 
their 
commitment, 
dedication, 
and 
innovativeness. 
While 
the 
NGOs 
visited 
were 
not 
necessarily a representative 
sample, 
they 
can 
be classified 
into 
roughly 
four 
groups: 
0 
Small 
HIV 
NGOs 
of 
Limited 
Capacity: 
These 
NGOs, 
mostly comprising 
volunteers, have 
limited 
funds 
(often 
less 
than 
US$l,OOO 
per 
year) 
and 
carry 
out 
HIV 
prevention activities 
on 
a 
very 
small 
scale. 
Their 
knowledge 
of 
HIV 
prevention 
is 
not 
very 
deep 
and 
they 
have 
neither 
the 
managerial 
capacity 
nor 
the 
systems 
to 
be 
able 
to 
expand 
their activities 
rapidly. 
An 
example 
of 
such 
an 
NGO 
is 
an 
organization 
in 
Balochistan that 
provides 
HIV 
counseling 
to 
teenagers 
and 
truck-drivers 
out 
of 
a 
small 
office 
using 
volunteers. 
They 
see 
about 
20 
clients 
per 
week 
and 
their 
knowledge 
of 
unlinked, 
anonymous 
testing and counseling 
more 
generally, 
is 
very 
limited. 
These 
kinds 
of 
NGOs 
could 
not 
take 
on 
significant 
HIV 
prevention activities 
for 
a 
long 
time 
although 
some 
of 
them 
may grow 
into 
effective 
NGOs 
with 
training 
and 
support. 
Unfortunately, 
this 
would 
be 
the 
largest group 
of 
NGOs, 
by 
number, 
currently 
working 
on 
HIV. 
-8- 
Page  15
0 
Small 
to 
Medium-Sized 
HIV 
NGOs 
of 
Uncertain 
Capacity: 
These 
NGOs 
are 
more 
sophisticated, have 
a 
deeper 
knowledge 
and 
understanding 
of 
HIV 
prevention, and 
have 
often 
been 
in 
existence 
for 
more than 
five 
years. 
They 
often 
have reasonable accounting, 
information, 
and 
management 
systems 
and 
their 
management 
is 
often 
charismatic 
and 
strong. 
Their 
capacity 
to 
expand 
their 
activities 
is 
uncertain 
because 
they 
have 
always 
faced 
limited 
budgets. 
An 
example 
of 
such 
an 
NGO, 
is 
an 
organization 
in 
Punjab that 
has 
worked 
with 
long-distance 
truck 
drivers 
for 
eight 
years, 
survives 
on 
about US$5,000 
per 
year, 
and 
has 
not 
had 
the 
resources 
to 
expanded 
their 
activities. 
The 
quality 
of 
their 
work 
is 
highly 
regarded 
and 
their 
director 
is 
a 
successful businessman 
who 
is 
very 
committed. 
Unfortunately, 
he 
is 
only 
able 
to 
work 
part-time 
because 
their 
grant 
does 
not 
allow for 
managerial 
or 
administrative 
overhead. 
This 
kind 
of 
NGO 
might 
be 
able 
to 
significantly 
expand 
its 
HIV 
activities 
if 
provided 
sufficient 
resources, 
technical 
guidance, and management support. 
As 
an estimate 
there 
are 
probably 
10-15 
NGOs 
that 
fit 
this 
description. 
0 
Medium 
to 
Large 
HIV 
NGOs 
of 
Demonstrated 
Capacity: 
These 
NGOs 
are 
working 
with 
particular 
vulnerable populations 
on 
a 
reasonable scale 
and have 
a detailed understanding 
of 
HTV 
prevention activities 
acquired 
through 
experience 
on 
the 
ground. 
They 
are 
better 
funded 
than 
the 
smaller 
NGOs 
and 
have 
strong 
management 
systems. 
They 
are 
well 
managed 
and 
have dynamic 
leadership 
that 
is 
willing 
to 
innovate and 
take 
on 
new 
challenges. 
An 
example 
of 
such an 
NGO 
is 
an 
organization that 
is 
working 
very 
successfully 
with 
IDUs. 
They 
run 
an 
increasing 
number 
of 
drop-in 
centers, 
have 
pioneered 
needle 
exchange 
programs, and 
have developed a 
very 
impressive 
management 
information 
system. 
The 
IDUs 
appear 
to 
genuinely 
trust 
the 
staff, 
some 
of 
whom 
are 
themselves 
ex-IDUs. 
This 
kind 
of 
NGO 
could significantly 
expand 
its 
operations 
if 
provided 
sufficient 
resources. 
There 
are 
about 
4-7 
NGOs 
that 
fit 
this 
description. 
0 
Medium 
to 
Large 
Health 
NGOs: 
These 
NGOs 
have 
long 
and 
successful 
track record 
of 
delivering 
health, 
nutrition, 
and 
family 
planning 
services 
in 
various 
parts 
of 
the 
country. 
They 
have 
fairly 
secure 
financing 
for 
their 
health 
service 
delivery 
and 
are 
interested 
in 
becoming 
involved 
in 
HW 
prevention 
as 
a 
natural 
extension 
of 
their ongoing activities. They 
have 
well 
developed 
management 
systems 
and 
very 
experienced managers 
but 
their 
knowledge 
of 
HIV 
prevention, 
particularly working 
with 
vulnerable 
populations, 
is 
pretty 
limited. 
An 
example 
of 
such 
an 
NGO 
is 
an 
organization that 
operates 
a 
very 
large 
number 
of 
reproductive health clinics 
throughout 
Pakistan. 
Their clinics 
provide 
high 
quality 
services 
and 
are 
heavily 
used. 
Their 
management 
systems 
are 
sophisticated and 
their 
management 
is 
very 
professional. 
While 
expressing 
a 
keen 
interest 
in 
HIV 
prevention 
they 
would 
require additional 
resources 
to 
take 
it 
on. 
They 
frankly 
admit 
their 
need 
to 
learn 
more 
about 
working 
with 
vulnerable populations 
and 
the 
details 
of 
HIV 
prevention. There 
are 
about 5-10 
NGOs 
that 
fit 
this 
description. 
3. 
Sector 
issues to 
be 
addressed by 
the 
project 
and 
strategic 
choices: 
The threat 
of 
HIV/AIDS 
competes 
with 
a 
number 
of 
other challenges 
confronting 
the 
health 
sector 
in 
Pakistan 
and 
the 
proposed 
project 
cannot 
address 
all, 
or 
even 
many, 
of 
them. 
For 
example, 
it 
cannot 
address 
issues 
of 
under-funding 
or 
the 
composition 
of 
current 
expenditure, 
nor 
can 
it 
tackle 
many 
of 
the 
managerial, 
motivational, 
and 
governance 
issues 
facing 
publicly 
provided 
health 
services. 
The 
proposed 
project 
can also 
make 
only 
a 
marginal 
contribution 
to 
the Government’s 
devolution 
initiative 
although 
its 
design 
will 
fully 
reflect the delegation 
of 
financial 
and 
managerial 
responsibilities 
to 
local 
governments. 
-9- 
Page  16
What 
the 
proposed 
project 
can do 
is 
help 
address 
some 
of 
the 
important 
sector 
issues 
described 
above 
by: 
0 
0 
0 
0 
controlling 
the 
spread 
of 
HIVIAIDS 
so 
that 
it 
does 
not 
become a 
large 
drain 
on 
scarce 
health 
sector 
resources; 
providing 
an example 
of 
successfully and 
rapidly 
scaling 
up 
important 
communicable 
disease 
control 
activities; 
helping 
to 
introduce 
a systematic approach 
to 
quality 
assurance, 
including monitoring 
and 
supervision; 
and 
helping 
establish 
an 
effective 
mechanism 
for 
the 
Government 
to 
work 
with 
NGOs 
and private 
sector 
firms 
in 
a concerted manner and 
on 
a 
large 
scale. 
Based 
on 
discussions 
with 
the client, 
the 
following 
strategic choices have 
been 
made: 
0 
0 
0 
Most 
of 
the 
services 
provided 
to 
vulnerable 
populations 
and 
some 
other 
activities 
would 
be 
implemented 
by 
the 
private 
sector 
rather 
than 
the 
government; 
The 
Government's partnership 
with 
NGOs 
and 
private 
firms 
would 
use 
a systematic approach 
rather 
than 
the 
current 
piecemeal 
approach; 
and 
There 
would 
be 
a 
focused, 
phased approach 
to 
implementation 
rather than 
trying 
to 
do 
everything 
at 
once. 
Delivew 
of 
services 
by 
NGOs 
andor 
private 
sector 
firms 
(vs. 
delivery 
by 
Government 
agencies) 
The 
experience 
in 
Pakistan and 
elsewhere demonstrates 
that 
NGOs 
andor 
private 
firms 
(for 
convenience 
the 
term 
"NGOs" 
in 
the discussion 
below 
will 
be 
used 
to 
include private 
sector 
firms, 
academic 
institutions, 
and consultants) 
are 
able 
to 
provide 
HIV 
prevention 
services 
to 
vulnerable populations 
more 
effectively 
and 
efficiently 
by 
than 
the 
Government. 
This 
is 
because: 
(i) 
the 
Government 
is 
reluctant 
to 
work directly 
with 
groups that 
may 
be 
involved 
in 
activities 
of 
questionable 
legality; 
(ii) 
NGOs, 
unlike 
the 
Government, have experience 
in 
doing 
the 
kind 
of 
community-based 
work 
needed 
to 
effectively 
reach 
the 
vulnerable populations; 
(iii) 
despite serious 
obstacles, 
such 
as 
short contracts and 
limited 
funding, 
some 
NGOs 
have demonstrated 
success 
in 
working directly 
with 
the 
vulnerable populations; 
(iv) 
the 
Government 
would 
likely 
have 
to 
hire 
new staff 
which 
would 
entail long-term 
financial liabilities 
and 
delays 
due 
to 
the 
time 
required 
for 
staff 
recruitment; and 
(v) 
NGOs 
have demonstrated 
more innovation 
and 
better 
motivation 
than 
the 
Government, 
partly 
because 
they 
are 
not 
constrained 
by 
civil 
service 
rules 
and 
regulations. 
There 
are 
other 
aspects 
of 
the 
proposed 
project 
where 
it 
will 
be 
preferable 
for 
the 
private 
sector 
to 
carry 
out 
activities 
because 
of 
greater expertise 
or 
experience. 
This 
would 
include 
the 
production 
of 
behavior 
change 
communication materials and advertising 
spots. 
For 
some 
other 
activities, 
such 
as 
providing 
health education 
to 
in-school 
youth, 
it 
is 
unclear whether 
the 
private 
sector 
has 
an 
advantage 
over 
the 
Government 
and 
it 
would 
be 
useful 
to 
test 
both 
approaches. 
Clearly 
there 
are 
functions 
which 
only 
the 
Government can undertake, such 
as 
regulation 
of 
blood 
banks, 
setting 
policy 
and 
technical 
standards, 
planning, and 
financing 
of 
services 
which 
are 
public 
goods. 
A 
systematic approach 
to working 
with 
NGOs 
(vs. 
expansion 
of 
the 
piecemeal 
approach) 
In 
the 
past, 
the 
mechanisms 
employed 
for 
public-private 
partnerships 
have 
relied 
mostly 
on 
a 
piecemeal 
approach 
in 
which 
NGOs 
applied 
for 
grants 
to 
carry 
out activities 
that 
the 
NGOs 
themselves 
defined. 
In 
the 
more 
systematic approach, 
the 
Government 
would 
define 
the 
outputs 
and 
the 
scope 
of 
services 
to 
be 
provided, 
delineate 
the 
size 
of 
the 
contract 
package 
by 
stipulating 
the 
geographical 
area 
to 
be 
covered, 
select 
NGOs 
through 
a 
competitive 
process, 
and 
standardize 
the 
way 
in 
which 
contracts 
would 
be 
-10- 
Page  17
monitored, evaluated, 
and 
audited. 
The decision 
to utilize 
the 
systematic approach 
is 
based 
on: 
(i) 
the 
lack 
of 
success 
of 
the 
piecemeal 
approach; 
(ii) 
the 
Government’s widespread 
and, 
generally, successful 
use 
of 
systematically contracting 
with 
private 
firms 
in 
other 
sectors, 
such 
as 
construction 
services; 
(iii) 
the 
better 
coordination 
of 
activities 
that 
would 
result 
from 
the 
systematic approach; 
(iv) 
larger 
scale 
and 
more 
focused 
activities 
that 
the 
systematic approach 
would 
lead 
to; 
(v) 
the 
reduced 
number 
of 
contracts that 
would 
need 
to 
be 
managed 
which 
would 
result 
in 
more 
timely 
payment and 
more 
effective 
monitoring, 
evaluation, 
and auditing; 
and 
(vi) 
the 
Government’s reluctance 
to 
use 
the 
piecemeal approach 
because 
of 
concems about 
obtaining 
value 
for 
money. 
A 
focused. 
phased approach 
(vs. 
a broader strategy 
implemented 
all 
at 
once) 
During 
the discussions that 
lead 
to 
the 
development 
of 
the 
National 
Strategic 
Framework 
for 
HIV/AIDS 
Control 
a 
consensus 
emerged that a 
focused, 
phased approach 
to 
implementing 
HIV 
activities 
would 
be 
more 
appropriate 
than 
trying 
to 
implement 
them 
all 
at 
the 
same 
time. 
The rationale 
for 
a 
focused, 
phased 
approach 
includes: 
(i) 
the experience 
of 
the 
NACP 
and 
previous 
Bank 
projects 
in 
Pakistan strongly 
suggests 
that 
only 
a 
few 
interventions 
can 
be 
implemented 
successfully 
at 
the 
same 
time 
and that 
attempting to 
do 
too 
much 
imperils 
the 
success 
of 
all 
activities; 
(ii) 
not 
all 
of 
the 
interventions 
are 
of 
equal 
priority 
and 
the 
highest and most immediate 
priority 
is 
to 
scale 
up 
the 
provision 
of 
HIV 
prevention 
services 
to 
FSWs, 
IDUs 
and 
other vulnerable 
populations; 
(iii) 
there 
are 
geographical 
priorities 
as 
well, 
such 
as 
Karachi 
where 
there 
is 
a 
dense 
concentration 
of 
high 
risk 
behaviors. 
Scaling 
up 
HIV 
prevention 
services 
among 
vulnerable populations 
in 
the 
large 
cities 
is 
likely 
to 
have 
the 
largest 
impact 
in 
preventing 
the 
epidemic. 
C. 
Project Description 
Summary 
1. 
Project 
components 
(see 
Annex 
2 
for 
a 
detailed 
description 
and 
Annex 
3 
for 
a 
detailed 
cost 
breakdown): 
The 
National 
Strategic 
Framework 
for 
the 
control 
of 
HIV/AIDS, 
adopted 
by 
the Government and 
its 
development partners 
in 
2000, 
provides 
the 
basis 
for 
a 
detailed 
design. 
Building 
on 
the 
framework, 
the 
project 
would 
comprise 
4 
components: 
Expansion 
of 
Interventions 
Among 
Vulnerable 
Populations 
(a) 
Service 
Delivery 
Contracts 
with 
NGOs: 
This 
component 
would 
support 
the 
rapid 
expansion 
of 
HIV 
prevention 
services 
to 
vulnerable populations 
at 
the 
greatest 
risk 
of 
HIV, 
including: 
(i) 
FSWs; 
(ii) 
IDUs; 
(iii) 
MSM; 
(iv) 
migrant 
workers, 
particularly truck 
drivers; 
and 
(v) 
prisoners. 
Preventing 
the 
spread 
of 
HIV 
among 
these 
populations, 
particularly 
those 
living 
in 
large 
cities, 
will 
be 
critical 
and 
will 
be 
the 
project’s 
highest 
priority. 
The Government 
would 
contract 
with 
NGOs 
to 
measurably change 
behaviors 
through 
the 
provision 
of 
services 
in 
geographically 
defined 
areas 
to 
a 
particular 
vulnerable population. 
The 
service package 
would 
include: 
(i) 
behavior 
change 
communication aimed 
at 
improving 
the 
vulnerable population’s  knowledge, 
attitudes, 
and 
behaviors 
related 
to 
HIV; 
(ii) 
promotion 
of 
effective condom 
use; 
(iii) 
voluntary 
counseling and 
HIV 
testing; 
(iv) 
proper 
management 
of 
STIs; 
(v) 
needle 
exchange 
and 
promotion 
of 
safe 
injection 
practices 
(among 
IDUs); 
and 
(vi) 
empowering activities 
that 
allow 
members 
of 
the 
vulnerable 
populations 
to 
assert 
greater 
control 
of 
their 
lives. 
-11 
- 
Page  18
The 
Government 
would 
select 
NGOs 
through 
an 
open 
and 
competitive 
process. 
The 
contracts 
would 
have 
specific 
measurable goals 
that 
the 
NGOs 
would 
be 
responsible 
for 
achieving 
in 
their 
geographical 
area. 
NGOs 
would 
be 
short-listed 
mainly 
on 
the 
basis 
of 
their 
relevant 
experience 
and 
be 
eligible 
to 
bid 
if 
they 
met 
certain 
minimum 
criteria 
including: 
(i) 
being 
a 
legal 
entity 
with 
named 
officers, 
(ii) 
having 
audited 
financial 
statements 
for 
the last 
three 
years, 
and 
(iii) 
having 
experience 
delivering 
social 
services 
in 
Pakistan. 
Evaluation 
of 
the 
submitted 
proposals 
would 
be 
based 
both 
on 
price 
and technical 
merit 
including: 
(i) 
experience 
of 
the 
NGO 
in 
successfully 
delivering 
health 
and 
other 
social 
services; 
(ii) 
the 
competence 
of 
key 
personnel; and 
(iii) 
the 
adequacy 
of 
the 
methodology 
and 
work plan for 
delivering 
the 
services. 
Bid 
evaluation 
would 
be 
carried 
out 
by 
multi-disciplinary 
teams 
including 
representatives 
of 
the 
local 
and national 
governments, 
the 
NGO 
community, 
United 
Nations 
technical 
agencies, 
and 
academic 
institutions, 
while 
ensuring that 
there 
are 
no 
conflicts 
of 
interest. 
Monitoring 
of 
NGO 
performance 
would 
be 
carried 
out 
by 
the 
local 
and 
provincial 
governments 
on 
a regular 
basis 
and 
would 
be 
supplemented 
by 
visits 
to 
project 
areas 
carried 
out 
by 
a 
third 
party. 
Annual 
evaluations 
of 
performance 
on 
key 
indicators 
would 
also 
be 
carried 
out 
by 
the 
third 
party 
based 
on 
interviews 
with 
members 
of 
the 
vulnerable 
population. 
The 
key 
indicators 
would 
be 
spelled 
out 
in 
the 
contracts 
and 
would 
include 
reduction 
in 
syphilis 
prevalence, increase 
in 
reported condom 
use, 
and 
increased 
use 
of 
STI 
treatment services. 
Five 
service 
delivery 
contracts 
will 
be 
signed 
by 
the 
concerned 
AIDS 
control 
program 
with 
the 
selected 
NGOs 
shortly after 
effectiveness 
of 
the 
financing 
as 
part 
of 
advanced 
procurement 
actions. 
Further 
service 
delivery 
contracts 
will 
be 
signed 
during 
the 
subsequent 
year 
and documents 
could 
be 
changed 
to 
reflect 
lessons 
learned 
from 
the 
first 
batch 
of 
contracts. 
The 
package 
for 
IDUs 
will 
be 
financed 
for 
three 
years 
by 
the 
Department 
for 
International 
Development 
(DFID). 
(b) 
Small 
Grants: 
As 
part 
of 
the 
project 
a 
small 
grants system 
will 
be 
established 
to: 
(i) 
help 
develop 
the 
capacity 
of 
NGOs 
and 
other 
institutions 
to 
carry out 
work 
on 
HIV/AIDS; 
(ii) 
allow 
small NGOs, 
and 
NGOs 
who 
have 
not 
previously 
worked 
in 
HIV, 
to 
develop a 
track 
record 
so 
they 
can 
eventually 
take 
on 
a 
greater 
role 
in 
HIV 
prevention; 
and 
(iii) 
create 
opportunities 
for 
testing 
and 
rigorously 
evaluating 
innovative 
approaches 
and 
carrying 
out 
needed 
operational 
research. 
NGOs, 
universities, 
and 
other 
organizations 
will 
submit 
project 
proposals 
using 
a 
standard 
format 
which 
will 
be 
evaluated 
by 
peer 
reviewers 
and 
a 
grant 
committee. 
Draft 
guidelines 
for 
this 
program 
have 
already 
been 
developed 
by 
the 
NACP. 
This 
component 
has 
been 
kept 
deliberately small 
(US$0.62 
million) 
to 
avoid 
excessive 
demands 
on 
managers 
time 
and 
on 
the 
financial 
management 
system. 
Improved 
HIV 
Prevention 
bv 
the 
General 
Population 
This 
component 
would 
comprise 
four 
sets 
of 
activities: 
(a) 
Behavior 
change 
communication 
(BCC) 
aimed 
at 
the 
general 
adult 
population: 
The 
NACP 
in 
coordination 
with 
provincial 
programs 
will 
undertake 
BCC 
with 
the 
following 
-12- 
Page  19
behavioral 
objectives: 
(i) 
use 
of 
condoms 
with 
non-regular sexual partners; 
(ii) 
use 
of 
STI 
treatment services 
when 
they 
have symptoms 
of 
STI 
and 
knowledge 
of 
the 
link 
between 
STIs 
and 
HIV; 
(iii) 
use 
of 
sterile 
syringes 
for 
all 
injections; 
(iv) 
reduction 
in 
the 
number 
of 
injections 
received; 
(v) 
voluntary 
blood 
donation (particularly 
among the 
age 
group 
18-30); 
(vi) 
use 
of 
blood for 
transfusion 
only 
if 
it 
has 
been 
screened 
for 
HIV; 
and 
(vii) 
displaying 
tolerant and 
caring 
behaviors towards 
people 
living 
with 
HTV/AIDS 
and 
members 
of 
vulnerable populations. 
These 
objectives 
would 
be 
achieved 
by 
a 
series 
of 
activities 
that 
would 
include 
mass-media 
campaigns 
and 
inter-personal 
communications 
(IPC) 
by 
lady 
health 
workers 
(LHWs). 
For 
the 
mass 
media 
campaigns, 
the 
NACP’s 
new 
strategy 
calls 
for: 
(i) 
recruitment 
on 
a 
competitive 
basis 
of 
an 
advertising 
firm 
to 
carry out 
the 
entire 
campaign; 
(ii) 
explicit 
market 
segmentation 
so 
that advertisements 
and 
activities 
are 
specifically 
tailored to 
important 
sub-populations; 
(iii) 
formative 
research among 
the 
important 
sub-populations; 
(iv) 
testing 
the 
messages 
and 
advertisements 
on 
members 
of 
the 
target audience; 
(v) 
a 
more 
extensive 
use 
of 
mass 
media, 
including 
print 
and 
radio 
spots 
in 
local 
languages; 
and 
(vi) 
follow-up 
surveys 
to 
judge 
the effectiveness 
of 
the 
mass 
media 
campaign. 
The 
IPC 
to 
be 
carried 
out 
by 
the 
LHWs 
will 
use 
specially 
designed 
materials aimed 
at 
informing 
women 
in 
the 
community 
and 
reinforcing 
the 
BCC 
messages 
that 
are 
being 
broadcast. 
(b) 
Advocacy: 
In 
order 
to 
raise 
awareness 
of 
decision 
makers 
and 
opinion 
leaders about 
HrV/AIDS, 
the 
project 
will 
support 
activities 
aimed 
at 
having 
these 
groups: 
(i) 
appreciate 
the 
threat 
of 
HIV 
to 
Pakistan; 
(ii) 
better 
understand 
the 
actions 
that 
can 
prevent 
a 
full-blown 
HIV 
epidemic; 
(iii) 
become 
effective 
sources 
of 
information 
for 
the 
rest 
of 
the 
community; 
(iv) 
take actions themselves 
to 
assist 
their 
communities 
to 
avoid 
HIV; 
(v) 
provide 
continuous 
support 
for 
the 
AIDS 
control 
program; and 
(vi) 
help 
avoid 
stigmatization 
or 
harassment 
of 
vulnerable populations. 
To 
accomplish 
these 
objectives, 
priority 
will 
be 
given 
to 
the 
large 
cities, 
formative 
research 
will 
be 
undertaken, 
specific 
messages 
will 
be 
developed 
and 
tested 
for 
this 
group, 
and 
the 
messages 
will 
be 
employed 
in 
a 
number 
of 
innovative 
ways, 
including 
personal 
visits 
by 
influential 
personalities. 
To 
be better able to 
deal 
with 
public 
relations 
“crises,” 
the 
NACP 
will 
develop a 
clear 
protocol 
for 
constituting 
an emergency 
response 
committee and contracted 
NGOs 
will 
be 
provided 
with 
training 
in 
how 
to 
deal 
with 
such emergencies. 
(c) 
Targeted 
interventions for 
youth, 
the 
police, 
and 
formal 
sector 
workers: Pakistani 
external 
migrant 
workers 
will 
be reached 
through 
the 
Bureau 
of 
Immigration 
offices 
at 
Karachi, Lahore 
and 
Rawalpindi, 
using 
specially 
designed 
BCC 
materials. 
Similarly, 
employees 
of 
parastatal organizations 
will 
also 
receive 
BCC 
through 
existing facilities 
of 
the 
Ministry 
of 
Labor. 
Health 
workers 
of 
the 
Employees 
Social Institutions 
will 
be 
provided training 
on 
STIs 
using 
the 
syndromic 
approach. 
The 
activities 
with 
formal 
sector 
workers 
will 
be 
implemented 
through 
the 
Ministry 
of 
Labor 
with 
some 
financial 
and 
technical 
support 
coming 
from 
the 
International 
Labor 
Office 
and 
other 
UN 
agencies. 
In 
addition 
to 
the 
mass-media 
BCC 
that 
will 
be 
targeted 
at 
youth, 
IPC 
techniques 
will 
be 
used 
to 
reach 
a 
particularly 
high 
risk 
group, 
Le., 
in-school 
youth 
in 
grades 
9 
and 
10 
in 
the 
large 
cities. 
NACP, 
in 
collaboration 
with 
the 
Ministry 
of 
Education, 
will 
carry 
out 
an 
assessment 
of 
the 
behavior 
of 
youth 
during 
the 
first 
year 
of 
the 
project 
and 
identify 
mechanisms 
for 
successfully reaching 
those 
most 
at 
risk. 
Project 
funds 
will 
be 
made 
available 
to 
implement 
the 
approaches 
developed 
by 
the 
assessment 
study. 
The 
interventions 
will 
be 
developed 
and 
implemented 
in 
cooperation 
with 
UNFPA 
and 
UNICEF. 
Among 
uniformed 
personnel, 
-13- 
Page  20
the 
NACP 
and 
provincial 
AIDS 
control 
programs 
will 
strengthen advocacy 
activities 
for 
city 
police 
to 
create 
an 
enabling 
environment 
for 
the 
NGOs 
working 
with 
vulnerable 
populations. 
To 
reach 
new 
police 
recruits, advocacy 
sessions 
will 
be 
held 
at 
police 
academies. 
The 
NACP 
will 
also establish 
a 
liaison 
with 
the 
management 
of 
Pakistan 
Armed 
Forces 
Medical 
Crops 
to 
address 
HIV 
prevention 
issues. 
(d) 
Improved 
and 
expanded management 
of 
STI 
cases: 
The project 
will 
support 
the 
improvement and 
expansion 
of 
STI 
case 
management based 
on 
a 
protocol 
developed 
by 
WHO 
and 
the 
Government 
that 
uses 
a 
“syndromic”  approach. 
In 
the 
public 
sector 
diagnosis, treatment, 
and 
contact 
tracing 
will 
be 
expanded 
to 
all 
health facilities 
down to 
at 
least 
the 
district 
hospital 
level. 
Prevention 
of 
HIV/STI 
Transmission 
Through 
Blood 
Transfusion 
In 
order 
to 
prevent 
the 
transmission 
of 
HIV 
and other 
STIs through 
blood 
transfusions, 
the 
project 
will 
support 
the 
following 
four 
sets 
of 
activities: 
(a) 
Establishing 
and 
building 
the 
capacity 
of 
provincial 
blood 
transfusion 
authorities: 
Building 
on 
the 
successful experience 
in 
the 
Punjab, 
the 
project 
would 
help 
establish 
effective 
provincial 
blood 
transfusions services 
and 
BTAs 
and 
build 
the 
latter’s capacity 
to 
regulate 
private 
and 
public 
sector 
blood 
banks. 
(b) 
Implementation 
of 
a 
quality 
assurance system: 
The 
project 
would 
support 
the 
operationalization 
of 
a 
robust 
and 
practical quality 
assurance 
system 
that 
would 
likely 
include laboratory 
proficiency 
testing, 
monitoring 
and 
supervision, 
improved 
record 
keeping, 
end 
use 
audits 
for 
test 
kits, 
and 
re-testing 
of 
screened 
blood 
by 
reference 
laboratories. 
The 
development 
of 
the 
monitoring 
and 
quality 
assurance 
systems 
will 
be 
carried 
out 
during 
the 
first 
year 
of 
the 
project. 
(c) 
Screening 
of 
blood 
for 
HIV 
and 
other 
STIs: 
The 
project 
would 
help 
provide 
the 
necessary 
materials and 
reagents 
for 
testing 
all 
blood 
in 
the 
public 
sector 
for 
HJY 
and 
hepatitis 
B. 
The 
introduction 
of 
hepatitis C 
outside Punjab, 
would 
be 
dependent 
on 
the 
successful 
implementation 
of 
the 
quality 
assurance 
system 
as 
judged 
by 
third 
party 
evaluation 
and 
a 
functioning provincial 
BTA. 
(d) 
Waste 
management: 
In 
order 
to 
begin 
implementing 
the 
environmental 
management 
plan 
(EMP),  the 
Ministry 
of 
Health 
would 
develop 
guidelines 
for 
proper 
handling 
of 
wastes 
in 
blood 
banks 
and 
needle exchange programs. 
Staff 
of 
health 
facilities 
with 
blood 
banks 
and 
NGOs 
involved 
in 
needle exchange 
would 
be 
provided 
with 
training 
in 
these 
guidelines 
and the 
materials 
for 
properly 
handling 
bio-hazardous 
wastes. 
Cauacitv 
Building 
and 
Proaam 
Management 
In 
order 
to 
strengthen 
the capacity 
of 
the 
National 
and 
Provincial 
AIDS 
Control 
Programs 
and 
their 
NGO 
partners 
to 
undertake 
significantly 
expanded 
HIV 
prevention 
activities, the 
Project 
would 
support 
the 
following 
four 
sets 
of 
activities. 
(a) 
Strengthening 
of 
federal 
and 
provincial 
AIDS 
Control 
Programs: 
The project 
would 
support the 
strengthening 
of 
the 
national 
and 
provincial 
AIDS 
control 
programs 
through: 
-14- 
Page  21
(i) 
recruitment 
of 
a 
firm 
to 
help 
build 
the 
capacity 
of 
the 
federal and 
provincial 
staff 
to 
manage 
contracts and 
carry out 
procurement; 
(ii) 
recruitment 
of 
more 
full 
time 
staff 
to 
work 
in 
the 
federal 
and 
provincial 
AIDS 
control 
programs; 
(iii) 
office 
support 
including 
furniture, 
equipment, 
vehicles, and 
access 
to 
the 
world 
wide 
web; 
(iv) 
an 
annual 
conference that 
would 
bring 
together 
staff 
from 
government, 
NGOs, and 
research 
institutions 
to 
discuss lessons 
learned and 
latest 
findings; 
(v) 
short 
term 
attachments 
of 
technical 
staff to 
other 
AIDS 
control 
programs 
in 
the 
region 
to 
learn 
first 
hand 
about 
the 
successes 
and 
difficulties 
encountered. 
(b) 
NGO 
capacity 
development: 
Technical 
assistance 
and 
training 
on 
applicable 
procurement 
procedures 
would 
be 
provided 
to 
the 
NGOs. 
The 
project 
management 
and 
procurement 
firm 
would 
provide 
the 
winning 
bidders 
with 
assistance 
in 
general management procedures 
and 
project 
implementation 
techniques. 
Staff 
from 
the 
winning 
NGOs 
would 
also 
be 
given 
the 
opportunity 
to visit 
other 
NGOs 
in 
the 
region 
who 
have 
been 
successful 
in 
working 
with 
vulnerable 
populations, 
for 
example, 
the 
work 
of 
Sonorgachi 
in 
Kolkota 
with 
FSWs. 
Technical 
support 
for 
the 
NGOs 
would 
be 
provided 
by 
other partners, 
particularly 
UNAIDS 
and 
UNICEF. 
(c) 
Second 
generation 
HIV 
surveillance 
and 
evaluation: 
Systematic 
behavioral 
surveillance 
and 
HIV 
sero-prevalence 
surveillance 
would 
be 
undertaken 
among 
the 
vulnerable populations 
on 
a 
regular 
basis 
using 
consistent 
methodologies. 
The 
surveillance 
activities 
will 
be 
undertaken 
by 
a 
cell 
in 
the 
NACP 
which 
would 
also have 
staff 
based 
in 
each 
province. Technical 
and 
financial 
support 
for 
surveillance 
activities 
will 
be provided 
by 
the 
Canadian 
International 
Development 
Agency 
(CIDA). The project 
will 
support 
the 
recruitment 
of 
an independent 
findorganization 
to 
carry 
out 
evaluations 
of 
the 
project's 
components, 
including: 
(i) 
interviews 
with 
members 
of 
the 
vulnerable populations 
in 
the 
areas 
covered 
by 
service 
delivery 
contracts; 
(ii) 
quality 
of 
care 
provided 
in 
public 
STI 
clinics; 
(iii) 
implementation 
of 
the 
quality 
assurance 
systems 
in 
blood 
banks; 
and 
(iv) 
household 
surveys 
to 
examine 
the 
effectiveness 
of 
the 
mass 
media 
campaigns. 
(d) 
Care 
for 
people 
living 
with 
AIDS: 
The 
project 
will 
support the 
care 
of 
people 
living 
with 
HIV/AIDS 
(PLWHA) 
through 
the 
establishment 
or 
strengthening 
of 
five 
units 
for 
HIV/AIDS 
management 
which 
would 
provide 
the 
following 
services: 
(i) 
counseling 
for 
patients 
and 
their 
families; 
(ii) 
treatment 
of 
opportunistic infections; 
(iii) 
palliative 
care; 
(iv) 
supportive 
care 
for 
the 
patient 
and 
their 
families; 
(v) 
linkages 
with 
other programs and 
services 
such 
as 
the 
Tuberculosis 
Control 
Program; and 
(vi) 
prevention 
of 
mother 
to 
child 
transmission 
of 
HI" 
in 
cases 
of 
HIV 
positive 
mothers 
who 
are 
referred. Such 
units 
would 
comprise 
staff 
with 
various 
skills 
and backgrounds 
who 
will 
receive 
training 
under 
the 
project. 
The 
project 
will 
also 
provide 
the 
medicines 
needed 
for 
these 
units. 
WHO will 
provide technical 
assistance 
to 
plan for 
the 
medium 
to 
long-term 
needs 
of 
a 
program 
of 
care 
for 
PLWHA. 
Within 
two 
years 
of 
the 
start 
of 
the 
project, 
an 
economic 
and 
policy 
analysis 
will 
be 
carried 
to 
analyze the 
Government's options 
in 
regard 
to 
the 
management 
of 
AIDS 
patients 
with 
anti-retroviral 
therapy. 
The 
total 
cost 
of 
the 
project 
over 
the 
five-year 
period 
is 
estimated 
at 
US$47.77 
million. 
IDA 
will 
provide 
US$37.11 
million, 
25% 
(US$9.28 
million) 
of 
which 
will 
be 
grant. 
The 
Department 
for 
International 
Development 
nad 
the 
Canadian 
International 
Development 
Agency 
will 
provide 
a 
total 
of 
US$4.50 
million 
in 
parallel 
co-financing. 
A 
summary 
of 
costs 
by 
component 
is 
given 
below. Retroactive financing 
up 
to 
an 
amount 
of 
US$1.7 
million 
would 
cover 
eligible 
expenditure 
for 
implementation activities 
after 
-15- 
Page  22
March 
3 
1,2002. Retroactive 
financing 
would 
support 
training 
workshops, 
research, 
behavior 
change 
communications, 
and 
operating 
expenses 
including 
salaries 
of 
new 
staff. 
Table 
3: 
Project 
Cost 
by 
Component 
II. 
Improved 
HIV 
Prevention 
by 
General 
Population 
111. 
Prevention 
of 
HIV/STI 
transmission 
through 
blood 
transfusion 
apacity 
Building 
& 
Program 
Management 
2. 
Key 
policy 
and 
institutional 
reforms 
supported 
by 
the 
project: 
As 
indicated 
above 
(section 
B.3) 
the 
key policy 
reforms 
sought 
relate 
to 
the 
delivery 
of 
services 
by 
NGOs 
and 
the 
private 
sector. 
The 
other 
policy 
reforms 
sought 
include: 
(i) 
establishment 
of 
provincial 
blood 
transfusion authorities 
to 
implement 
existing 
legislation, 
without 
which 
improvements 
in 
the 
blood 
safety 
may not 
be 
sustainable; 
(ii) 
development 
and 
implementation 
of 
guidelines 
related 
to 
bio-medical 
waste management; 
and 
(iii) 
development 
of 
clear 
technical 
guidelines 
by 
NACP 
on 
key 
issues 
such 
as 
bio-ethical 
review 
of 
proposed 
studies 
and 
content 
of 
pre- 
and 
post-HIV 
test 
counseling. 
3. 
Benefits 
and 
target 
population: 
The 
major 
benefit 
of 
the 
proposed 
project 
is 
preventing an 
HIV 
epidemic 
from 
raging out 
of 
control 
in 
Pakistan and 
avoiding 
the 
resultant suffering, 
premature 
death, 
family 
devastation, 
and 
economic 
losses. 
If 
Pakistan 
were 
to 
experience an 
epidemic 
similar 
to 
India’s, 
in 
10 years 
it 
would 
have about 
500,000 
cases 
of 
HIV 
and 
could 
expect 
more 
than 
70,000 
new 
cases 
of 
full-blown 
AIDS 
each 
year. 
Annex 
4 
describes 
the 
cost-benefit analysis 
of 
the 
project 
if 
it 
could 
prevent 
an 
Indian-style 
HIV 
epidemic. 
While 
the 
largest 
group 
of 
beneficiaries 
of 
the 
project 
are 
the 
general 
population 
of 
adults, 
many 
of 
the 
project’s activities 
would 
be 
focused 
on 
serving 
the 
vulnerable populations 
such 
as 
FSWs, 
IDUs, 
MSM, 
and prisoners. 
If 
camed 
out 
well, 
the services 
provided 
by 
NGOs 
to 
these 
vulnerable 
groups 
could 
have 
benefits 
beyond 
simply 
preventing 
HIV. 
The 
project’s 
activities 
would 
also 
build 
the 
self-esteem 
of 
these 
marginalized 
people 
and 
reduce 
their 
stigmatization and 
harassment 
by 
other parts 
of 
society. 
The 
project 
would 
also 
bring 
long-term 
institutional 
benefits 
including: 
(i) 
the 
experience 
acquired 
by, 
and 
mechanisms 
developed 
for, 
contracting 
with 
NGOs 
could 
have 
broader 
application 
in 
the 
future 
for 
other 
services 
in 
the 
health 
sector 
and 
in 
other 
sectors; 
(ii) 
strengthening 
the 
capacity 
of 
the 
NACP 
and 
the 
provincial 
AIDS 
control 
programs 
to 
manage an 
effective 
and 
large 
communicable 
disease 
control 
program; 
and 
(iii) 
the 
attention 
paid 
in 
the 
project 
to 
monitoring 
and 
evaluation 
could 
demonstrate 
to 
the 
Government the value 
of 
doing 
this 
well 
and dedicating 
the resources 
to 
this 
public 
function. 
-16- 
Page  23
4. 
Institutional 
and 
implementation 
arrangements: 
Timing 
of 
Implementation: 
The 
proposed 
project 
would 
use 
a 
focused, 
phased approach 
to 
implementation. 
During 
the 
first 
phase, 
which would 
correspond 
to 
the 
first 
year 
of 
the 
project, 
only 
the 
highest 
priority 
activities 
would 
be 
implemented 
and 
disbursements 
would 
be 
modest. 
The 
focus 
would 
be 
on 
HIV 
prevention activities 
among 
vulnerable 
populations, 
particularly 
FSWs, 
IDUs, 
and 
MSMs 
concentrated 
in 
the largest cities, 
and 
the establishment 
of 
a 
second 
generation 
HIV 
surveillance 
system. 
Some 
other 
activities 
that have 
high 
political 
profile, 
such 
as 
mass 
media 
campaigns 
and 
initial 
advocacy 
work would 
also 
begin 
implementation 
during 
the 
first 
phase. 
The 
lessons 
learned 
from 
the 
initial 
experience 
would 
be 
applied 
to 
the 
second 
phase 
during 
which 
HIV 
prevention activities 
would 
expand 
to 
other 
vulnerable populations 
and other parts 
of 
the 
country. 
Blood 
safety 
activities, 
and 
improved 
management 
of 
STIs 
for 
the 
general 
adult 
population 
would 
also 
gear 
up 
during 
the 
second 
phase 
which 
corresponds 
to 
the 
second 
and 
third 
years 
of 
implementation. 
The 
third 
phase 
of 
the 
project 
would 
allow 
for 
the 
consolidation 
of 
these 
activities, 
for 
example, 
the 
accomplishment 
of 
100% 
of 
blood 
in 
the 
public 
sector 
being 
properly 
screened 
for 
HIV 
and 
other STIs. 
The 
proposed 
project 
would 
last 
five 
years. 
Roles 
and Responsibilities: 
The 
NACP 
has 
had 
overall responsibility 
for 
the 
program 
and 
would 
oversee 
implementation 
of 
the proposed 
project. 
However, a 
strong 
multi-sectoral 
and decentralized 
approach 
lies 
at 
the 
heart 
of 
project 
design 
and implementation. 
Provincial 
AIDS 
control 
program 
managers 
would 
oversee 
the 
implementation 
of 
most activities, 
including 
signing 
contracts 
with, 
and 
monitoring 
the 
performance 
of, 
NGOs 
who 
are 
providing 
HIV 
prevention 
services 
to 
vulnerable 
populations and 
targeted 
interventions 
for 
youth 
and 
migrant 
labor. 
The 
provincial 
programs 
would 
also 
have 
responsibility 
for: 
(i) 
administering 
the 
small 
grants program; 
(ii) 
helping 
to 
carry 
out 
BCC 
and 
advocacy 
work 
in 
local 
languages; 
(iii) 
working 
with 
districts 
to 
improve 
STI 
management; 
(iv) 
helping 
to 
coordinate 
HIV 
surveillance and operational 
research; 
and 
(v) 
ensuring 
the 
development 
of 
units 
to 
care 
for 
people 
living 
with 
HIV/AIDS. 
District 
governments 
will 
be 
responsible 
for 
implementation 
of 
the 
STI 
management 
and 
blood 
screening 
activities 
that occur 
in 
district health facilities. 
Activities 
to 
be 
carried out 
by 
the 
Ministries 
of 
Labor 
and 
Education 
with 
migrant 
labor and in-school 
youth 
will 
also 
be 
coordinated through 
the 
NACP 
and the 
provincial 
AIDS 
control 
programs. 
Both 
ministries 
will 
second 
people 
to 
work 
full 
time 
with 
NACP 
on 
implementation 
of 
their 
activities. 
The 
NACP 
will 
focus on: 
(i) 
formulating 
policy 
and 
guidelines; 
(ii) 
directing 
behavioral 
and 
sero-surveillance 
as 
well 
as 
monitoring 
and 
evaluation; 
(iii) 
implementing 
the 
BCC 
campaign 
on 
national 
mass 
media; 
(iv) 
carrying out 
advocacy 
work 
at 
national 
level 
for 
decision 
makers 
and 
opinion 
leaders; 
(v) 
procuring 
HIV, 
Hepatitis 
B, 
and 
Hepatitis 
C 
test 
kits; 
(vi) 
coordinating activities 
with 
international 
partners; 
and 
(vii) 
overseeing 
the 
work 
of 
an 
NGO 
contracted 
to 
work 
with 
long-distance 
truck-drivers 
nationwide. 
A 
detailed 
description 
of 
the 
roles 
and 
responsibilities 
of 
the 
various 
actors 
is 
included 
in 
the 
project implementation 
plans 
(PIPS) 
and 
the PC-I. 
Project 
Coordination 
and 
Oversight: 
A 
multi-sectoral 
National 
Steering 
Committee 
(NSC) 
, 
comprising 
high 
level 
Government 
officials 
from 
the 
Ministries 
of 
Finance, 
Education, 
and Interior, 
and 
chaired 
by 
the 
Minister 
of 
Health, 
has 
been 
recently 
established and 
will 
meet 
twice 
a 
year 
to 
formulate 
the 
Government’s 
policy 
on 
HIV. 
In 
order 
to 
support 
and coordinate 
AIDS 
control 
activities 
at 
the 
working level 
a 
Technical 
Advisory 
Committee 
on 
AIDS 
(TACA) 
has 
been 
established 
which 
comprises 
representatives 
of 
government, 
civil 
society, academic 
institutions, 
UN 
agencies, 
and 
donors. 
The 
committee 
would 
be 
similar 
to 
the 
Interagency 
Coordinating 
Committee that 
has 
been 
established 
for 
immunization 
which 
has 
been 
quite 
successful. 
A 
TACA 
has 
also 
been 
established 
in 
each 
province. 
The 
NACP 
has 
begun 
organizing 
quarterly meetings 
of 
all 
the 
provincial 
AIDS 
control program 
managers 
to 
exchange 
information 
and coordinate activities. 
The 
project 
will 
support 
annual 
conferences 
which 
would 
bring 
together 
people 
and 
organizations 
involved 
in 
HIV 
prevention. 
-17- 
Page  24
Monitoring 
and 
Evaluation: 
The 
indicators 
for 
tracking 
the 
project’s 
development 
objectives 
and 
implementation 
success 
are 
described 
in 
Annex 
1 
(including 
the 
details 
in 
Tables 
2 
and 
3) 
and 
for 
judging 
the 
performance 
of 
NGOs 
in 
Annex 
2. 
Many 
of 
the 
activities aimed 
at 
preventing 
the spread 
of 
HTV 
are 
difficult 
to 
effectively 
monitor 
simply 
through 
tracking 
of 
inputs, 
like 
the 
number 
of 
workshops 
held 
or 
the 
number 
of 
HIV 
test 
kits 
procured. 
Instead, 
there 
is 
a 
need 
to 
regularly 
evaluate progress 
by 
measuring 
changes 
in 
outcomes, 
outputs such 
as 
knowledge, attitudes, 
and 
behaviors, 
as 
well 
as 
process 
indicators 
like 
the 
quality 
of 
STI 
management and 
blood 
transfusion 
services. 
In 
order 
to 
collect 
information 
on 
outputs 
and 
outcomes, 
the 
project 
will 
support 
behavioral 
and 
sero-surveillance 
aimed 
at 
tracking 
behaviors 
and 
sero-prevalence 
of 
HIV 
and 
syphilis 
among 
vulnerable populations. 
An 
important 
way 
of 
judging 
the 
success 
of 
the 
project 
will 
be 
to 
determine 
rates 
of 
condom 
use 
and 
syphilis 
infection 
among 
vulnerable populations 
in 
cities covered 
from 
the 
beginning 
of 
the 
project 
with 
cities 
scheduled 
for 
inclusion 
in 
the 
project 
in 
years 
two 
and 
three 
of 
implementation. 
A 
firm 
will 
also 
be 
hired 
to 
provide 
third 
party 
assessments 
of: 
(i) 
individual 
service 
delivery 
contracts 
with 
NGOs; 
(ii) 
BCC 
and 
advocacy 
activities; 
(iii) 
targeted 
interventions 
aimed 
at 
youth, 
migrant 
labor, 
and the police; 
(iv) 
LHW 
inter-personal 
communications; 
(v) 
STI 
services; 
and 
(vi) 
blood 
transfusion 
services. 
These 
types 
of 
evaluation 
should 
be 
carried 
out 
independently 
to 
avoid distraction 
of 
managers 
and 
staff 
from 
the 
work 
of 
actually preventing 
HIV 
and 
to 
ensure 
an 
unbiased 
evaluation. The 
terms 
of 
reference 
for 
the 
third 
party evaluation 
firm 
have already been 
developed 
and 
approved 
and 
the 
recruitment 
process 
has 
already 
begun 
as 
part 
of 
advanced 
procurement activities. 
Procurement: 
Goods 
under 
the 
Project 
will 
be 
procured 
in 
accordance 
with 
the 
Bank’s 
Procurement 
Guidelines, 
and 
Consultants’ 
services 
in 
accordance 
with 
the 
Consultants’ 
Guidelines. 
Details 
on 
the 
applicable procurement 
procedures 
are 
provided 
in 
Annex-6. 
An 
assessment 
of 
the 
procurement capacity 
of 
the 
implementing 
agencies 
was 
carried out 
and 
it 
was 
determined 
that 
the 
NACP 
has 
had 
limited 
experience 
with 
procurement, 
particularly 
under 
Bank 
financed projects, 
and 
the 
provincial 
AIDS 
control 
programs have 
had 
even 
less. 
Given 
the 
amount 
of 
service contracts and goods 
that 
will 
need 
to 
be 
procured 
under 
the 
proposed 
project, 
the 
capacity 
of 
NACP 
and 
the 
provincial 
AIDS 
control 
program 
will 
need 
to 
be 
strengthened 
through 
the 
engagement 
of 
consultants 
and 
training 
to 
effectively 
and 
efficiently 
carry out 
procurement, manage 
and monitor 
the 
contracts. 
NACP 
will 
engage 
a 
qualified 
individual 
procurement consultant 
for 
one year 
who 
will 
serve 
as 
the 
focal 
point 
for 
all 
procurement 
matters 
under 
the 
project. The 
consultant 
will 
provide 
comprehensive 
procurement 
assistance 
and 
guidance, 
including 
procurement 
planning 
and 
monitoring, 
preparation 
of 
bidding 
documents, 
evaluation 
of 
bids 
and 
contracts, 
to 
the 
national 
as 
well 
as 
the 
provincial 
ADS 
programs 
in 
complying 
with 
agreed 
procurement 
procedures. 
The 
procurement consultant 
will 
be 
engaged 
through 
DFID 
financing 
and 
in 
the 
meantime 
Family 
Health 
International 
has 
provided 
procurement support 
to 
NACP. 
After 
effectiveness, 
procurement 
support 
and 
assistance 
will 
be 
provided 
as 
part 
of 
the 
contract 
with 
a 
Management 
Consulting 
firm 
that 
is 
to 
be 
engaged 
through 
a 
competitive 
process 
under 
the 
project. The 
contract 
for 
such a 
firm 
will 
contain 
performance 
clauses 
related 
to 
timely 
procurement 
and implementation. 
IDA 
has 
already conducted the 
first 
of 
a 
series 
of 
procurement 
training 
workshops 
for 
key 
procurement 
staff 
of 
the 
implementing 
agencies 
that 
will 
take 
place before 
and 
during 
implementation 
of 
the 
project. 
The 
aim 
of 
these 
workshops 
is 
to 
improve 
key 
government 
officials’ 
knowledge 
of 
IDA’S 
procurement 
procedures. 
Advanced 
Action 
on 
Procurement: 
Requests 
for 
expression 
of 
interest have 
been 
issued 
for 
key 
consulting 
services 
needed 
during 
the 
first 
year 
of 
the 
Project, 
particularly 
five 
service 
delivery 
contracts, 
-18- 
Page  25
the 
management 
and 
procurement contract, and 
the 
evaluation 
and 
monitoring 
contract. 
Also, 
bidding 
documents 
for 
key 
goods needed 
during 
the 
first 
year 
of 
the 
Project, 
particularly 
blood 
screening 
kits 
(HIV, 
Hepatitis 
B) 
have already 
been 
drafted. 
Financial 
Management: 
Effective financial 
management 
and expeditious 
funds 
flow 
are 
crucial 
to 
project 
success, 
particularly 
as 
key 
activities 
will 
be 
undertaken 
by 
NGOs 
or 
private 
firms 
under 
contract. 
The 
funds 
flow 
arrangements 
have 
been 
agreed 
to 
by 
all 
stakeholders 
and 
will 
involve 
the 
use 
of 
special 
accounts managed 
by 
the 
program 
managers. 
A 
financial 
information 
system (FIS) 
and a corresponding 
financial 
procedures 
manual 
have 
been 
developed 
and 
accepted 
by 
the 
various Government 
departments 
involved 
in 
the 
management 
and 
oversight 
of 
the 
project’s 
finances. 
Each 
of 
the 
AIDS 
control 
programs 
(at 
federal and 
provincial 
level) 
will 
recruit 
a 
finance 
officer 
and 
a finance 
manager 
has 
already 
been 
recruited 
with 
funds 
from 
DFID 
to 
work 
with 
the 
NACP 
to 
help 
implement 
the 
FIS 
and 
the 
financial 
procedures manual. 
The 
GOP 
has 
already: 
(i) 
recruited 
finance 
officers 
as 
part 
of 
proper staffing 
of 
the 
AIDS 
control 
programs; 
(ii) 
finalized 
the 
FIS 
and 
financial 
procedures manual; 
(iii) 
resolved 
outstanding 
audit objections 
on 
the 
HTV/AIDS 
program; and 
(iv) 
provided 
written 
confirmation 
from 
the 
provincial 
finance 
departments 
that 
there 
are 
adequate 
counterpart 
funds 
available 
(at least 
50% 
of 
annual 
requirements) 
to 
meet 
project 
needs.When the 
conditions 
for 
negotiations 
have 
been 
met, 
an 
adequate 
financial 
management 
system 
will 
be 
in 
place. 
D. 
Project Rationale 
1. 
Project 
alternatives 
considered 
and 
reasons 
for 
rejection: 
Develop 
a 
short 
project 
with 
a 
uossible 
follow-on 
lending 
operation. 
The 
idea 
here 
would 
be 
to 
design 
a 
short 
project 
of 
say, 
three 
years 
and 
begin 
the 
design 
of 
a 
subsequent 
lending 
operation after 
18 
months 
of 
implementation, 
incorporating 
the 
lessons 
learned. 
There 
are 
aspects 
of 
this 
approach 
that 
are 
attractive, however: 
(i) 
global 
best-practice 
indicates that 
service 
contracts 
with 
NGOs 
should 
be 
at 
least 
four or 
five 
years 
in 
duration, 
partly 
to 
allow 
enough 
time 
for 
innovation 
and 
partly to 
allow 
NGOs to 
develop 
and 
maintain 
close 
relationships 
with 
the 
vulnerable 
populations 
they 
work 
with. 
A 
Bank 
analysis 
of 
management 
services 
contracts 
(Bureaucrats 
in 
Business 
: 
The Economics 
and 
Politics 
of 
Government Ownership, 
1995) 
concluded that 
the 
length 
of 
a contract 
was 
an important 
positive 
predictor 
of 
success; 
(ii) 
this 
approach 
would 
make 
it 
difficult to 
phase 
in 
other 
aspects 
of 
AIDS 
control 
such 
as 
improving blood 
safety. 
In 
order 
to 
be 
able 
to 
incorporate 
lessons 
learned 
in 
the 
follow-on 
project, 
all 
components 
of 
the 
initial 
project 
would 
have 
to 
be implemented 
right 
from 
the 
start; 
and 
(iii) 
a 
short 
duration project 
might 
present 
a 
reputational 
risk 
because 
it 
could 
be 
interpreted 
by 
people 
in 
the 
Government, 
civil 
society, 
and 
the 
media 
as 
an 
indication 
that 
the 
Bank 
is 
not 
seriously 
committed 
to 
combating 
AIDS. 
Suuuort 
the 
AIDS 
Control 
Programs 
through 
a 
promammatic 
lending 
operation 
This 
was 
tried 
during 
the 
Social 
Action 
Program 
and 
while 
SAP 
may 
have 
helped 
the 
development 
of 
the 
program, progress was 
too slow 
and 
insubstantial 
to 
meet 
Pakistan’s 
needs. 
The 
AIDS 
control 
program 
needs 
sustained support 
and 
the 
kinds 
of 
innovations 
and 
pilot 
testing 
that 
would 
be 
difficult to 
achieve 
through programmatic-type 
lending. 
Focus 
narrowlv 
on 
interventions 
targeted 
only 
at 
vulnerable populations. 
Global 
experience 
and 
computer 
simulations 
suggest 
that 
programs 
targeted 
only 
at vulnerable 
-19- 
Page  26
populations 
would 
slow 
the 
spread 
of 
the 
HIVIAIDS 
epidemic 
but 
would 
not 
avert 
transmission 
on 
an 
epidemiologically important 
scale. 
Preventing a 
generalized epidemic 
would 
also 
require 
systematically 
and deliberately 
addressing other groups 
at 
risk 
of 
contacting 
and spreading 
the 
infection, 
such 
as 
adolescents, 
the 
police, 
and 
soldiers. 
In 
addition, other 
activities 
such 
as 
ensuring a 
safe 
blood 
supply 
and 
implementing 
mass 
media 
campaigns can 
help 
maintain program 
visibility 
and 
political 
support 
for 
HIV/AIDS 
control 
and 
avoid 
the 
stigmatization 
of 
vulnerable 
populations. 
2. 
Major 
related 
projects financed 
by 
the 
Bank 
and/or 
other development 
agencies 
(completed, 
ongoing 
and 
planned). 
Sector Issue 
Project 
Bank-financed 
3ther 
development agencies 
ADB 
UNICEF 
UNAIDS 
SAPP-11, 
completed 
Northern 
Health, completed 
Population 
Welfare, completed 
Family Health 
I, 
completed 
Family Health 
11, 
completed 
Women's 
Health 
Various, 
support 
of 
NGOs 
Support 
of 
NGOs 
Latest SI 
(PW 
(Bank-finance 
Implementation 
Progress 
(IP) 
S 
S 
S 
S 
S 
Highly Unsatisf; 
ervision 
ntings 
projects 
only) 
Development 
Objective (DO) 
U 
S 
S 
S 
S 
ory) 
3. 
Lessons 
learned 
and 
reflected 
in 
the project 
design: 
The 
design 
of 
the 
proposed 
project reflects global 
state 
of 
the 
art 
information 
on 
HIV/AIDS 
control. The 
key 
lessons 
from 
field 
experience 
and 
scientific 
studies 
are: 
(i) 
a 
strategy 
of 
early 
and 
aggressive 
prevention 
is 
the 
most 
effective 
approach 
in 
low 
prevalence countries; 
(ii) 
interventions 
targeted 
at 
specific 
vulnerable 
populations 
is 
the 
most 
effective 
way 
of 
combating 
HIV 
during 
the 
early 
stages 
of 
the 
epidemic; 
(iii) 
these 
targeted 
interventions 
need 
to 
be 
coupled 
with 
broader 
awareness 
and 
advocacy 
efforts 
to 
ensure 
political 
support 
and 
prevent stigmatization 
of 
vulnerable 
groups; 
and 
(iv) 
close 
coordination 
and 
partnering 
among concerned 
sectors 
is 
an 
important 
aspect 
of 
success. 
There 
have 
not 
been 
many 
completed Bank-financed 
HIV 
projects 
in 
countries that 
are 
at a 
similar 
level 
of 
development 
as 
Pakistan, 
although 
OED 
has 
begun a 
study 
that 
is 
in 
its 
initial 
stages. 
The 
anecdotal 
experience 
from 
Asia 
and 
Africa 
seems 
to point 
out that most 
implementation 
difficulties 
have centered 
around 
weak 
management 
capacity 
and 
inadequate 
staffing 
of 
AIDS 
programs, 
lack 
of 
coordination 
among 
the 
various stakeholders, 
slow 
financial 
disbursements, 
and 
delayed procurement 
of 
goods 
and 
services. 
The 
first 
HIV 
project 
in 
India, 
while 
generally 
successful 
in 
developing 
the 
Government's 
AIDS 
control 
program, also 
suffered 
from 
implementation 
difficulties 
that 
arose 
from: 
(i) 
unfamiliarity 
with 
guidelines 
and 
project 
processing 
requirements; 
(ii) 
delays 
in 
funds 
release 
and 
poor financial 
management; 
(iii) 
staffing 
vacancies 
and 
frequent transfers; and 
(iv) 
insufficient 
ownership 
at 
state 
level 
of 
what 
was 
perceived 
as 
a 
centrally 
driven 
scheme. 
The 
experience 
in 
India 
and 
elsewhere 
has 
also 
pointed 
out 
how difficult 
it 
is 
to effectively 
reach 
the 
vulnerable populations 
on 
a 
significant 
scale, 
although 
experience 
in 
Thailand 
and 
Cambodia 
does 
- 
20 
- 
Page  27
indicate that 
it 
is 
possible 
to 
influence 
condom 
use 
among 
FSWs 
and 
their 
clients. 
The 
Cambodia 
experience indicates that, 
even 
in 
a 
very 
poor 
country, 
it 
is 
possible 
to 
dramatically 
increase 
the 
use 
of 
condoms 
in 
commercial 
sex 
and that 
this 
can 
significantly 
reduce 
HIV 
prevalence 
. 
Between 
1997 
and 
2000 
condom 
use 
among 
FSWs 
increased 
from 
42% 
to 
more 
than 
78% 
while 
HIV 
prevalence 
decreased 
by 
28%. 
A 
Bank-financed 
HIV/AIDS 
prevention 
project 
in 
Bangladesh became 
effective 
in 
February, 
2001 
and 
has 
experienced delays 
in 
implementation. 
The 
initial 
implementation 
experience 
suggests 
that: 
(i) 
avoiding 
initial 
implementation 
delays requires advanced 
action 
on 
procurement, 
particularly 
when 
NGOs 
are 
to 
be 
recruited; 
(ii) 
additional 
staff 
positions 
in 
the 
AIDS 
control 
programs 
need 
to 
be 
filled 
prior 
to 
effectiveness; 
and 
(iii) 
early recruitment 
of 
technical 
assistance 
for 
capacity 
development 
should 
also 
be 
a subject 
of 
advanced action. 
These 
findings 
are 
consistent 
with 
the 
lessons 
learned 
from 
previous 
health 
sector 
projects 
in 
Pakistan 
which 
also experienced 
significant 
procurement delays 
due 
to 
lack 
of 
advance 
preparation. 
The 
experience 
of 
the 
Northem 
Health 
Project 
and 
SAPP 
ll 
suggests 
that 
public-private 
partnerships 
will 
work 
best 
when: 
(i) 
the 
services 
provided 
by 
the 
NGO 
are 
clearly 
defined; 
(ii) 
the 
Government 
is 
directly 
involved 
and 
can 
maintain 
oversight; 
and 
(iii) 
the 
Government 
has 
confidence 
in 
the 
NGO 
and 
there 
is 
a 
strong 
working 
relationship. 
An 
OED 
evaluation 
of 
the Bank’s 
experience 
in 
working 
with 
NGOs 
(NGOs 
in 
Bank 
Supported Projects 
- 
September, 
1998) 
suggests 
that 
there 
has 
been 
a 
gap 
between promise 
and 
performance. Based 
on 
a 
study 
of 
37 
operations, 
obtaining 
successful 
NGO 
outcomes 
appears 
to 
require: 
(i) 
shared 
goals, 
clear 
roles, 
and 
aligned 
procedures rather 
than 
an 
ad 
hoc approach; 
(ii) 
a 
supportive environment 
with 
strong 
government-NGO relationships 
and 
NGO 
involvement 
in 
project 
design; 
and 
(iii) 
adequate 
and 
balanced 
capacities among 
the 
partners. 
These 
lessons 
have been 
reflected 
in 
the design 
of 
the 
proposed 
project. 
4. 
Indications 
of 
borrower 
commitment 
and ownership: 
The 
NACP 
has 
been 
in 
operation 
since the 
late 
1980s, 
jointly 
implemented 
by 
the 
Ministry 
of 
Health 
and 
provincial 
Departments 
of 
Health. 
In 
the 
past several 
years 
there 
has 
been 
an 
increasing 
recognition 
in 
public 
health 
circles that 
the 
program 
needs 
to 
be 
scaled 
up. 
Indications 
of 
borrower 
commitment 
and 
ownership include: 
0 
In 
2000, 
the 
Govemment, 
using 
a 
broad participatory 
approach 
involving 
NGOs, 
academic 
institutions, 
PLWHA 
and 
donors, 
including 
the 
Bank, 
formulated 
a 
National 
Strategic 
Framework 
to 
serve 
as 
the 
basis 
for 
a stronger 
response 
to 
the 
threat 
of 
an 
HIV/AJDS 
epidemic. 
0 
The 
Government 
made a 
request 
to 
the 
Bank 
to 
send 
a 
technical 
assistance 
mission to 
advise 
on 
next 
steps. 
As 
a 
consequence 
of 
discussions 
with 
this 
mission 
in 
April 
2001, 
the 
Ministry 
of 
Finance 
asked 
the 
Bank 
to 
help 
in 
the 
design and 
financing 
of 
an enhanced 
HIV/AIDS 
control 
program. 
0 
Commitment 
among the 
provinces 
varies, 
but 
all 
provinces have 
recently 
begun 
to 
allocate 
some 
of 
their 
own 
resources 
to 
the 
program 
(which 
was 
previously entirely 
financed 
by 
the 
Federal Government and 
U.N. 
agencies). 
0 
The 
Government 
has 
used 
its 
own 
funds 
to 
carry 
out 
some 
of 
the 
studies 
that 
were 
required 
to 
prepare 
the project. 
-21 
- 
Page  28
The 
Government 
has 
carried out 
advanced procurement 
activities 
such 
as 
issuance 
of 
requests 
for 
expressions 
of 
interest 
and 
drafting 
of 
bid 
documents 
for 
five 
service 
delivery 
contracts and 
two 
consulting 
services 
contracts. 
0 
The 
Government 
has 
strengthened 
the 
management 
and 
staffing 
of 
the 
NACP 
and 
the 
provincial 
AIDS 
control 
programs 
in 
Balochistan, 
NWFP, 
and 
Punjab. 
0 
The 
project 
has 
received exceptionally 
rapid 
approval 
by 
the 
Planning 
Commission. 
5. 
Value 
added 
of 
Bank 
support 
in 
this 
project: 
0 
The 
Bank 
has 
by 
now 
extensive experience 
across 
a 
variety 
of 
countries 
concerning 
HIV 
prevention 
programs. 
It 
can 
thus 
play 
an 
important 
role 
in 
ensuring that 
the 
lessons 
learnt 
elsewhere 
are 
incorporated 
in 
the 
design 
and 
implementation 
of 
the 
enhanced 
program. 
0 
The 
Bank 
can 
help 
provide 
a 
broad 
perspective that 
takes 
account 
of 
the context 
into which 
the 
investment 
will 
fit, 
thereby assisting 
in 
building 
capacity 
and 
sustainability. 
0 
The 
Bank 
can 
help 
ensure 
a 
proper 
mix 
of 
different 
interventions 
in 
the 
program. 
This 
is 
important 
because 
the 
internal 
political 
dynamics 
could 
otherwise 
result 
in 
some 
interventions 
being 
given 
an 
undue 
weight 
while 
other 
key 
interventions 
are 
downplayed 
(e.g., 
support 
for blood 
safety 
interventions 
is 
generally strong 
among senior government 
officials 
and 
the 
public, 
but 
there 
is 
much 
less 
awareness 
of 
the 
importance 
of 
interventions 
that focus 
on 
behavioral 
change 
among 
FSWs 
and 
their 
clients). 
0 
The 
Bank, 
through 
its 
knowledge 
and experience 
of 
helping 
governments 
to work 
with 
NGOs 
on 
delivery 
of 
social 
services, 
can also 
contribute 
to 
the 
development 
of 
a successful 
public-private 
partnership. 
E. 
Summary 
Project 
Analysis 
(Detailed 
assessments 
are 
in 
the 
project 
file, 
see 
Annex 
8) 
1. 
Economic 
(see 
Annex 
4): 
0 
Cost 
benefit 
NPV=USS647 
million; 
ERR 
= 
% 
(see 
Annex 
4) 
- 
Cost 
effectiveness 
Other 
(specify) 
r 
There 
are 
four 
main 
issues 
in 
the 
economic analysis: 
(i) 
whether 
the 
HIV/AIDS 
program 
as 
presented 
in 
the 
PAD 
would 
be 
a 
worthwhile 
investment 
compared 
to 
other investments 
generally available 
in 
the 
economy, 
as 
shown 
by 
a 
positive 
Net 
Present 
Value 
(and 
the 
related 
question 
of 
whether 
this 
particular 
program 
is 
the 
one 
with 
the 
highest 
NPV 
of 
all 
the 
mutually 
exclusive alternative 
designs one 
could 
consider); 
(ii) 
what 
the 
Net 
Fiscal Impact 
of 
the 
program 
would 
be; 
(iii) 
the 
economic 
justification 
for 
government 
financing 
of 
the 
program; 
and 
(iv) 
poverty 
aspects. 
0 
The 
NPV 
of 
the 
program 
(discounted 
benefits 
less 
discounted 
costs) 
is 
estimated 
to 
be 
positive 
(US$647 
million) 
in 
the 
base 
case 
using 
a 
10% 
annual 
discount 
rate. 
In 
the 
base 
case 
it 
is 
assumed 
that 
the 
HIV 
epidemic 
in 
Pakistan 
will 
emulate 
that 
in 
India 
in 
which 
HTV 
prevalence 
in 
the 
adult 
population 
grew 
to 
about 0.4% 
in 
10 
years. 
Assuming 
that 
the 
program 
will 
slow 
the 
increase 
in 
new 
cases 
from 
50% 
per 
year 
to 
40% 
per 
year, 
the 
base 
case 
would 
translate 
into 
the 
prevention 
of 
about 
two 
million 
infections over 
a 15-year 
period 
(equivalent 
to 
about 47% 
of 
the 
number 
of 
infections 
that 
would 
occur 
in 
the 
- 
22 
- 
Page  29
without-program 
situation). 
Economic 
benefits 
would 
be 
in 
the 
form 
of 
medical 
costs 
avoided 
and 
lost 
earnings 
avoided --both 
during 
the 
stage 
of 
full-blown 
AIDS. 
Further 
details 
are 
given 
in 
Annex 
4. 
The 
most uncertain 
(and 
critical) 
variable 
in 
the 
above 
calculation 
of 
NPV 
is 
the 
estimate 
of 
the 
number 
of 
HIV 
infections 
averted 
by 
the 
program. 
Alternative 
scenarios were 
examined 
in 
this 
regard. 
The 
number 
of 
infections 
averted 
is 
higher: 
(i) 
the 
higher 
the 
assumed 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new infections 
in 
the 
without-program 
situation; and 
(ii) 
the 
greater 
the 
difference between 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program situation 
as 
compared 
with 
the 
with-project 
situation. 
The 
base 
case assumes 
that 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program 
situation 
would 
grow 
at 
a 
constant 
50%, 
while 
in 
the 
with-project situation 
the 
rate 
of 
increase 
would 
decline gradually to 
40% 
and 
remain 
at 
that 
level 
thereafter. 
But 
even 
if 
the 
annual 
rate 
of 
increase 
of 
infections declined 
to only 
45% 
in 
the 
with-project 
situation, 
the 
NPV 
of 
the 
program 
would 
still 
be 
positive 
(US$371 
million). 
Alternatively, 
with 
a rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
of 
only 
30% 
(instead 
of 
50%) 
in 
the 
without-program 
situation, 
the 
NPV 
of 
the 
program 
is 
still 
positive 
(at 
US$42 
million) 
if 
the difference between 
the 
two 
scenarios 
is 
again 
only 
5 
percentage 
points 
starting 
in 
Year 
4. 
The 
NPV 
is 
about zero 
if 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
is 
assumed 
to 
be 
20% 
in 
the 
without-program situation 
and 
five 
percentage 
points 
less 
(15%) 
in 
the 
with-program 
situation. 
Based 
on 
these 
calculations 
it 
is 
likely 
that 
the 
NPV 
of 
the 
program 
as 
outlined 
in 
this 
PAD 
would 
be 
positive. 
It 
is 
possible 
that 
while 
the 
HN/AIDS 
program outlined 
in 
the 
PAD 
would 
have a 
positive 
NPV, 
there 
is 
some 
other 
program 
design 
or 
mix 
of 
interventions 
to 
combat 
HIVIAIDS 
that 
would 
have 
a 
higher 
NPV, 
and 
on 
economic 
efficiency 
grounds 
would 
thus 
be 
preferable. 
Moreover, 
if 
a constraint 
were 
imposed that 
all 
of 
the 
alternative 
(mutually 
exclusive) 
programs considered 
should 
have 
the 
same 
total 
cost 
in 
present 
value, 
then 
the 
one 
with 
the 
highest 
NPV 
is 
likely 
also 
to 
be 
the 
one 
with 
the 
lowest 
unit 
cost 
per 
infection 
averted, 
but 
this 
outcome 
is 
not 
necessary 
since 
the 
distribution 
in 
time 
of 
the 
infections 
averted 
under 
the 
various 
alternatives 
would 
also 
be 
a 
factor. 
The 
issue 
of 
"cost-effectiveness" 
is 
addressed 
in 
more 
detail 
in 
Annex 
4. 
0 
The 
estimated 
netfiscal 
impact 
of 
the 
program 
is 
positive 
in 
the 
base 
case 
at 
US$154 
million. 
Details 
of 
the 
calculation 
and 
assumptions 
are 
given 
in 
Annex 
4. 
The 
economic 
justification for 
government 
financing 
of 
the 
HIV/AIDS 
program 
hinges 
on 
whether 
the 
activities 
in 
the 
program 
would 
be 
financed 
by 
the 
private 
sector 
in 
the 
absence 
of 
government 
financing. 
At 
a 
more 
advanced 
stage 
of 
the 
epidemics, 
it 
is 
possible that 
some 
private financing 
would 
be 
available 
for 
prevention-- 
e.g. 
from 
firms 
concerned 
about 
protecting 
their 
employees against 
HIV 
infection. 
However, at 
the 
current 
stage 
of 
the 
HIV 
epidemics 
in 
Pakistan 
there 
is 
no 
substitute 
for 
government leadership 
and financing. 
0 
Whle 
there 
is 
no 
evidence 
to 
suggest 
that 
HIV/AIDS 
infection 
rates 
in 
Pakistan 
are 
disproportionately 
higher 
for 
the 
poor, 
clearly poor 
households 
are 
least 
able 
to 
bear 
the 
costs 
of 
treatment 
for 
opportunistic 
infections 
or 
the 
loss 
of 
income 
resulting 
from 
sickness 
and 
death. 
- 
23 
- 
Page  30
2, 
Financial 
(see 
Annex 
4 
and 
Annex 
5): 
NPV=US$ 
647 
million; 
FRR 
= 
% 
(see 
Annex 
4) 
Given 
that 
the 
project 
supports a 
variety 
of 
activities 
that 
are 
either 
pure 
public 
goods 
or 
have 
significant 
positive 
externalities, 
Government 
financing 
of 
the 
activities 
in 
the 
long-term 
will 
be required 
and the 
analysis above 
clearly points 
out 
that 
this 
is 
an 
efficient 
use 
of 
public 
resources. 
Using 
external 
resources 
to 
prevent 
an 
HIV 
epidemic 
is 
a 
sensible 
strategy. 
The 
only 
issue 
with 
such 
external 
sources 
relate 
to 
coordination 
of 
activities. 
For 
example, 
DFID 
co-financing 
is 
only for 
three 
years 
which 
could 
pose 
a 
problem 
in 
terms 
of 
ensuring 
seamless 
continuation 
of 
the 
activities 
with 
IDUs. 
Issues 
related 
to financial 
management 
constitute 
a serious 
risk 
to 
the successful 
implementation 
of 
the 
project 
and 
will 
be 
addressed 
through 
development 
of 
a 
financial information 
system 
and 
the 
recruitment 
of 
financial 
management specialists 
by 
the 
NACP 
and 
the 
provincial 
AIDS 
control 
programs 
Fiscal 
Impact: 
See 
above. 
3. 
Technical: 
The 
design 
of 
the 
proposed 
project 
appears 
to 
be 
appropriate 
for 
Pakistan at 
the 
current 
stage 
of 
its 
HIV 
epidemic and 
is 
consistent 
with 
the 
approaches 
recommended 
in 
the 
Bank’s 
policy 
research report, 
Confronting 
AIDS: 
Public 
Priorities 
in 
a 
Global 
Epidemic 
(1997) and 
subsequent 
work 
on 
the 
subject. 
Remaining 
technical 
issues 
that 
will 
need 
to 
be 
resolved 
include: 
(i) 
the 
size 
of 
the 
vulnerable 
populations 
outside 
the 
large cities 
and 
whether 
it 
is 
an 
epidemiological 
priority 
to 
cover 
them; 
and 
(ii) 
there 
is 
little 
information 
on 
the 
cost 
of 
providing 
services 
to 
the 
vulnerable populations and 
so 
cost 
estimates 
for 
component 
1 
are 
approximate. 
4. 
Institutional: 
4.1 
Executing 
agencies: 
National 
AIDS 
Control 
Program, 
Provincial 
AIDS 
Control 
Programs, 
Ministry 
of 
Labor, 
Ministry 
of 
Education 
4.2 
Project 
management: 
The 
NACP 
currently 
has 
strong 
management and 
is 
addressing 
its 
staffing 
needs. 
However, 
its 
ability 
to 
manage 
contracts and 
oversee 
a 
significantly 
expanded 
program 
requires strengthening. Hence, 
procurement and management consultants 
will 
be 
recruited 
to 
help 
build 
the capacity 
of 
NACP 
and 
help 
ensure 
implementation 
is 
carried 
out expeditiously. 
The 
contract 
for 
the 
procurement and 
management 
consultants 
will 
include 
performance 
bonuses 
related 
to 
timely 
procurement 
and 
implementation. 
With 
the 
exception 
of 
Sindh, 
the 
provincial 
AIDS 
control 
programs 
are 
very 
weak 
and 
have 
an 
unimpressive 
track 
record 
of 
implementing 
HIV 
prevention 
activities. 
Their 
capacity 
to 
implement 
an 
expanded 
effort 
against 
HIV 
is 
questionable and 
they 
will 
require 
significant 
amounts 
of 
technical 
assistance 
from 
the 
procurement 
and 
management 
consultants 
who 
will 
maintain 
offices 
in 
each 
province. 
All 
the 
provinces 
now 
have enough 
staff 
in 
their 
AIDS 
control 
programs 
to 
implement 
the 
project effectively 
and 
efficiently. 
4.3 
Procurement 
issues: 
The 
procurement and contract 
management 
capacity 
of 
the 
national 
and 
provincial 
AIDS 
Control 
- 
24 
- 
Page  31
Programs 
requires 
strengthening 
for which 
consultants 
will 
be 
engaged 
and 
procurement 
training 
will 
be 
provided 
by 
IDA. 
4.4 
Financial 
management issues: 
The 
GOP 
has 
systematically 
addressed 
the 
serious 
financial 
management 
issues 
it 
faces 
by 
carrying 
out 
the 
following: 
(i) 
development 
of 
an 
efficient 
and 
effective 
finds 
flow 
mechanism; 
(ii) 
design 
of 
an 
appropriate 
financial 
management 
system 
and corresponding 
financial 
management manual; 
(iii) 
recruitment 
of 
relevant 
staff 
in 
the 
national 
and 
provincial 
AIDS 
control 
programs; 
and 
(iv) 
ensuring 
sufficient 
counterpart 
funds 
are 
available 
in 
a 
timely 
fashion. 
5. 
Environmental: 
5.1 
Summarize 
the 
steps 
undertaken 
for 
environmental 
assessment 
and 
EMP 
preparation 
(including 
consultation and 
disclosure) and 
the 
significant 
issues 
and 
their 
treatment 
emerging 
from 
this 
analysis. 
The 
formulation 
of 
the 
EMP 
was 
undertaken 
by 
the 
NACP 
with 
the 
assistance 
of 
an 
experienced 
consulting 
firm. 
The 
EMP 
was 
developed 
using 
the 
following 
methodology: 
(i) 
the 
principal 
environmental 
issues 
of 
the 
proposed 
project 
were 
broadly 
identified; 
(ii) 
a 
review 
of 
the 
global 
literature 
and 
Pakistani 
experience 
was 
carried 
out; 
(iii) 
initial 
discussions were 
held 
with 
key 
stakeholders; 
(iv) 
existing 
practices 
in 
the 
generation 
of 
environmentally 
noxious 
materials 
(needles 
and 
other 
sharps, 
syringes, and 
blood 
bank 
waste materials) were mapped out; 
(v) 
environmental 
aspects 
of 
these 
activities 
were 
listed 
and a 
risk 
analysis 
was 
carried 
out; 
(vi) 
mitigation 
measures 
were 
identified; 
and 
(vii) 
institutional 
requirements 
for 
successful 
implementation 
of 
the 
plan 
were 
identified. 
Environmental 
Category: 
B 
(Partial 
Assessment) 
The proposed 
project 
will 
NOT 
add 
to 
the amount 
of 
bio-medical 
wastes 
generated 
by 
the 
health 
care 
system 
in 
Pakistan, 
nor would 
it 
increase 
the 
hazard 
posed 
by 
such waste 
as 
is 
currently 
being 
produced. 
However, 
it 
makes 
sense 
for 
the 
project 
to 
help 
prevent 
HIV 
infection 
through 
contaminated 
waste 
and 
demonstrate 
how 
such 
materials 
can 
realistically be handled 
and 
disposed 
of 
safely. Hence, the 
project 
will 
help 
mitigate existing 
hazards 
such 
as: 
(i) 
the 
disposable 
equipment 
used 
in 
blood 
transfusions 
including 
blood 
bags 
and 
bottles, 
silastic 
tubing, 
and 
catheters 
and 
needles; 
(ii) 
the 
needles 
and 
syringes 
used 
in 
needle 
exchange programs 
(although 
a 
needle 
exchange 
program 
is 
a 
critically 
important 
component 
of 
bio-hazard 
containment 
because 
it 
deals 
with 
the 
highest 
risk 
of 
spread 
of 
HIV 
associated 
with 
medical 
devices) 
and 
in 
HN 
testing; 
and 
(iii) 
the 
relatively 
small 
amount 
of 
materials 
associated 
with 
testing 
blood 
for 
HIV 
including 
used 
HIV 
test 
kits, 
small 
aliquots 
of 
blood 
used 
for 
quality 
assurance, 
and 
blood 
found to 
be 
HIV 
positive. 
The 
risk 
of 
HIV 
infection 
resulting 
from 
improper 
handling 
of 
medical 
waste 
must 
be 
seen 
in 
perspective. 
Medical 
waste 
poses 
much 
less 
of 
a 
risk 
to 
the 
community 
than 
improperly 
screened 
blood, 
high 
risk 
sexual 
activity, 
or 
sharing 
of 
syringes 
and 
needles 
among 
IDUs. 
5.2 
What 
are 
the 
main 
features 
of 
the 
EMP 
and 
are 
they 
adequate? 
The 
main 
features 
of 
the 
EMP 
are 
to 
safely 
handle, 
store, 
and 
dispose 
of 
syringes, 
needles 
and 
sharps, 
and 
blood 
bags. 
For 
syringes and needles 
two 
strategies 
are 
envisaged 
for initial 
handling 
and 
storage: 
(i) 
the 
safe 
destruction 
of 
the 
syringe 
and 
needle 
shortly after 
patient 
use 
through 
the 
use 
of 
needle 
cutters 
in 
a 
specially 
designed, 
puncture 
proof box 
and 
treatment 
of 
the 
waste 
with 
disinfectant 
; 
and 
(ii) 
auto-disabled syringes 
that 
prevent 
re-use 
through 
a 
locking 
mechanism 
in 
the 
barrel 
of 
the syringe and 
are 
then 
put 
into 
a 
specially 
designed safety 
box. 
The 
second approach 
has 
been 
introduced 
in 
Pakistan 
through 
the 
expanded 
program 
on 
immunization 
(EPI). 
Under 
no 
circumstances 
would 
needles ever 
be 
recapped 
or 
syringes 
re-used. 
Blood 
bags 
and 
related, non-sharp 
equipment 
would 
be 
segregated 
into 
specially 
marked, non-permeable, 
plastic 
bags. 
The 
storage 
and disposal 
of 
syringes, needles, 
and 
blood 
transfusion 
equipment 
would 
depend 
on 
the 
volume 
of 
waste generated 
at 
the 
health 
facility. 
In 
health 
centers 
or 
hospitals 
with 
small 
volumes 
of 
- 
25 
- 
Page  32
bio-hazardous 
waste, 
deep 
burial 
in 
appropriate 
locations 
which 
are 
not 
accessible 
to 
the 
public, 
would 
be 
the 
preferred 
option. 
In 
facilities 
with 
large 
amounts 
of 
bio-hazardous 
waste, 
incineration 
in 
high 
temperature 
fumaceslincinerators 
with 
burial 
of 
the 
resulting 
ash 
is 
the 
preferred 
option. 
These 
waste 
materials 
would 
not 
be 
stored 
for 
more 
than 
24 hours. 
EA 
start-up 
date: 
Date 
of 
first 
EA 
draft: 
Date 
of 
final 
draft: 
In 
order 
to 
begin 
implementing 
the 
EMP, 
the 
Ministry 
of 
Health 
will 
develop 
guidelines 
for 
proper 
handling 
of 
wastes 
in 
blood 
banks. 
Staff 
of 
health 
facilities 
with 
blood 
banks 
will 
be 
provided 
with 
training 
in 
these 
guidelines 
and 
the 
materials 
for 
properly handling 
bio-hazardous 
wastes. 
A 
systematic 
checklist 
that 
provides a 
score 
of 
compliance 
with 
the 
guidelines 
would 
be 
developed and 
used 
by 
third 
party 
auditors 
to monitor 
compliance. 
The 
above 
procedures 
would 
provide 
a 
sensible 
means 
for 
reducing 
the 
bio-hazard 
posed 
by 
syringes, 
needles, 
and 
blood 
transfusion 
equipment, 
and 
would 
provide 
a 
useful 
beginning 
to 
a longer-term 
effort to 
properly 
deal 
with 
all 
medical 
waste. 
5.3 
For 
Category 
A 
and 
B 
projects, 
timeline 
and 
status 
of 
EA: 
Date 
of 
receipt 
of 
final 
draft: 
June 
30, 
2002 
March 
30,2002 
June 
8,2002 
June 
30,2002 
5.4 
How 
have stakeholders 
been 
consulted 
at 
the 
stage 
of 
(a) 
environmental 
screening 
and 
(b) 
draft 
EA 
report 
on 
the 
environmental 
impacts and proposed 
environment 
management 
plan? 
Describe 
mechanisms 
of 
consultation 
that were used and 
which 
groups 
were 
consulted? 
The 
key 
stakeholders 
regarding environmental 
issues 
include: 
(i) 
laboratory 
staff 
and 
other 
health 
workers, 
(ii) 
Government regulators, 
(iii) 
NGOs 
involved 
in 
trying 
to 
make 
injection 
practices 
safer; 
(iv) 
blood 
transfusion 
patients, 
(v) 
NGOs 
who 
are 
involved 
in 
needle 
exchange programs, 
and 
(vi) 
the 
communities affected 
by 
improper 
bio-medical 
waste disposal practices. 
Extensive 
consultations 
were 
carried 
out 
with 
Government regulators, 
health 
workers 
and 
laboratory 
staff, 
and 
NGOs 
involved 
in 
needle 
exchange 
and 
harm 
reduction. 
These 
consultations 
involved 
meetings and 
interviews 
with 
key 
informants. 
Initial 
discussions 
were 
held 
with 
some 
of 
the 
other stakeholders 
during 
preparation 
and 
need 
to 
be 
followed 
up 
during 
appraisal. 
The 
EMP 
will 
be 
put 
on 
the 
NACP 
web-site 
and 
other web-sites 
that 
are 
deemed appropriate. Copies 
have been 
provided 
to 
NGOs 
who 
have expressed 
interest 
in 
this 
or 
related 
issues. 
5.5 
What 
mechanisms have 
been 
established 
to monitor 
and 
evaluate 
the 
impact 
of 
the 
project 
on 
the 
environment? 
Do 
the 
indicators 
reflect 
the 
objectives and 
results 
of 
the 
EMP? 
The 
firm 
recruited 
to 
carry out 
third 
party 
evaluation 
of 
project activities 
will, 
as 
part 
of 
its 
audit 
of 
blood 
banks’ 
adherence 
with 
quality 
assurance standards 
for blood 
screening also examine 
the 
blood 
bank’s 
compliance 
with 
guidelines developed 
for 
waste 
management. 
The 
checklist 
developed 
for 
supervisors 
will 
be 
used 
to 
assign 
a 
score 
to 
sampled 
facilities 
and 
scores 
would 
be 
tracked 
over 
time. 
6. 
Social: 
6.1 
Summarize 
key 
social 
issues 
relevant 
to 
the 
project 
objectives, 
and 
specify 
the 
project’s social 
development 
outcomes. 
Key 
social 
issues 
related 
to 
project 
objectives: 
During 
project preparation 
a 
series 
of 
studies 
and 
social 
assessments 
were 
undertaken, 
including 
a 
review 
of 
previous 
and 
ongoing 
partnerships 
between 
the 
Government 
and 
NGOs, a 
general 
social 
assessment, 
and 
separate 
mapping 
and 
social 
assessments 
of 
FSWs, 
truck 
drivers, 
and 
MSMs. 
Some 
of 
the 
major 
findings 
from 
these 
studies 
are 
described 
in 
section 
- 
26 
- 
Page  33
B2 
above. 
The 
key 
issues 
identified 
include: 
(i) 
partnerships 
between 
the GOP and 
NGOs 
have generally 
not 
been successful 
and 
require 
particular 
attention; 
(ii) 
vulnerable 
populations 
have 
limited 
access 
to 
appropriate 
HW 
prevention 
services; 
(iii) 
they 
lack 
the 
knowledge and 
skills 
to 
reduce 
their 
risk 
of 
getting 
infected 
with 
HTV; 
(iv) 
the 
vulnerable 
populations 
also 
suffer 
from 
significant 
social 
stigmatization 
and 
exclusion; 
and 
(v) 
individual 
members 
of 
the 
vulnerable 
groups 
suffer 
from 
very 
low 
self-esteem and 
a 
sense 
of 
disempowerment. 
Indigenous 
peoples 
will 
not 
be 
directly 
benefited 
by 
the 
project 
because 
most 
of 
the 
focus 
will 
be 
on 
the 
large 
cities 
where 
the 
threat 
of 
HTV 
is 
the 
greatest. 
Social 
development 
outcomes: 
The 
key 
social 
development outcomes 
of 
the 
proposed 
project 
would 
be: 
(i) 
development and successful 
implementation 
of 
a mechanism 
for 
the 
Government 
to 
work 
with 
the 
NGO 
sector 
in 
a 
mutually 
beneficial 
way; 
(ii) 
significantly 
increased 
access 
of 
the 
vulnerable 
groups 
to 
HW 
prevention 
services and increased prevalence 
of 
safe 
sexual 
and 
injecting 
practices; 
and 
(iii) 
improved 
social 
inclusion 
and 
empowerment among 
the 
vulnerable populations 
The 
project 
would 
try 
to 
minimize 
stigmatization 
of 
the 
vulnerable populations through 
advocacy 
activities, 
its 
BCC 
campaign, 
and 
specific 
work 
with 
the 
police. 
Activities 
aimed 
at 
empowerment 
would 
be 
undertaken 
by 
the 
NGOs 
as 
part 
of 
their 
contracts. 
6.2 
Participatory 
Approach: 
How 
are 
key 
stakeholders 
participating 
in 
the 
project? 
The 
development 
of 
the 
National 
Strategic 
Framework 
used 
a 
highly 
participatory 
approach, 
including 
extensive consultations 
with 
FSWs, 
truckers, 
etc. 
Detailed 
and 
extensive consultations 
with 
the 
vulnerable populations 
have also 
taken place 
during 
the 
design 
of 
the 
project 
through 
the 
social 
assessment 
and 
mapping 
exercises. These 
relied 
on key 
informant 
interviews, 
focus 
group 
discussions, 
and 
informal 
conversations. Consultations 
with 
the 
vulnerable 
populations 
would 
continue 
periodically 
during 
project implementation 
as 
part 
of 
the 
evaluation 
and 
monitoring 
process. 
As 
peer-educators, 
members 
of 
the 
vulnerable populations 
would 
also 
be 
directly 
involved 
in 
implementing 
the 
project. 
Peer 
educators 
would 
also 
participate 
in 
evaluating 
NGO 
performance and 
in 
carrying 
out 
behavioral 
and 
sero-prevalence surveillance. 
The 
general 
adult 
population 
has 
been 
surveyed 
to 
obtain 
their 
reaction 
to 
mass 
media 
efforts. They 
would 
be 
involved 
during 
the 
formative 
research 
for 
future 
BCC 
activities 
and 
would 
also 
be 
surveyed 
periodically to 
obtain 
their 
feedback. 
6.3 
How 
does 
the 
project 
involve 
consultations 
or 
collaboration 
with 
NGOs 
or 
other 
civil 
society 
organizations? 
Many 
of 
the 
project’s 
activities 
will 
be carried 
out 
by 
NGOs 
in 
partnership 
with 
the 
GOP. 
NGOs 
have 
been 
heavily involved 
in 
the 
design 
of 
the 
project through 
formal 
and 
informal 
consultations. 
They 
have 
also 
had 
a 
chance 
to review 
the 
draft 
generic 
tender 
documents and 
a 
representative 
of 
the 
NGO 
community 
will 
have 
the 
opportunity 
to 
be 
involved 
in 
bid 
evaluation. 
(This 
representative and 
herlhis 
NGO 
would 
not 
be 
allowed 
to 
bid 
on 
any 
of 
the 
contracts.) 
6.4 
What institutional 
arrangements have 
been 
provided 
to 
ensure 
the 
project 
achieves 
its 
social 
development outcomes? 
The 
contracts 
with 
the 
NGOs 
will 
explicitly 
list 
the 
social 
development outcomes 
and 
indicators 
that 
they 
will 
be 
responsible 
for 
including 
reaching more 
members 
of 
the 
vulnerable populations, 
improving 
the 
knowledge and attitudes 
towards 
HTV 
prevention, 
and 
helping 
to 
empower 
them. 
6.5 
How 
will 
the 
project 
monitor 
performance 
in 
terms 
of 
social development 
outcomes? 
The 
timeliness 
of 
contract 
payments 
to 
NGO 
will 
be 
tracked 
and 
regular 
discussions 
will 
be 
held 
with 
NGOs 
and 
Government 
officials 
about 
how 
the 
partnerships 
are 
proceeding. 
Behavioral 
surveillance and 
evaluation 
of 
specific 
service 
delivery 
contracts 
will 
provide information 
on 
the 
knowledge 
and 
skills 
of 
the 
vulnerable populations. 
Periodic 
household 
surveys 
among 
the general 
adult 
population 
will 
be 
used 
- 
27 
- 
Page  34
to 
assess 
the 
extent 
to which 
vulnerable 
populations 
have 
been 
stigmatized. 
Follow-up 
focus 
group 
discussions 
and 
in-depth 
interviews 
among 
members 
of 
the 
vulnerable 
populations 
will 
be 
used 
to 
assess 
progress 
on 
empowerment and 
reduction 
in 
stigmatization 
and 
discrimination. 
7. 
Safeguard 
Policies: 
7.2 
Describe 
provisions 
made 
by 
the 
project 
to 
ensure 
compliance 
with 
applicable 
safeguard 
policies. 
OP 
4.01 
Environmental 
Assessment. 
The 
NACP 
has 
developed 
an 
environmental 
management 
plan 
which 
has 
been 
disclosed 
on 
its 
website 
and 
provided 
to 
interested 
members 
of 
civil 
society 
such 
as 
SIGN-Pakistan, an 
NGO 
working 
in 
the 
field 
of 
promoting 
safe 
injection 
practices. 
Clear 
implementation 
arrangements 
to 
ensure 
safe 
disposal 
of 
substances 
will 
be 
developed 
as 
part 
of 
the 
project 
and 
will 
be 
monitored 
as 
part 
of 
systematic 
auditing 
of 
government 
and 
NGO 
performance. 
OP 
7.60 
Disputed 
Areas. 
A 
part 
of 
the 
proposed 
project 
will 
be 
carried out 
in 
AJK, 
an 
area 
over 
which 
India 
and 
Pakistan 
have been 
in 
dispute 
since 
1947. 
By 
financing 
the 
Credit 
and 
Grant, 
IDA 
does 
not 
intend 
to 
make any 
judgment 
as 
to 
the 
legal 
or 
other 
status 
of 
the 
disputed 
territory 
or 
to 
prejudice 
the 
final 
determination 
of 
the 
parties’ 
claim. 
The 
Project 
will 
not involve 
any 
new 
construction. Since the 
primary 
focus 
of 
the 
project 
are 
the 
larger 
cities, indigenous peoples 
will 
not 
be 
directly 
effected 
or 
benfitted 
by 
the 
project. 
The 
project, therefore 
does 
not 
trigger 
OP 
4.20 
although 
the 
project 
will 
support 
communications 
activities 
in 
local 
languages 
directed 
to 
the 
public 
at 
large. 
F. 
Sustainability 
and 
Risks 
1. 
Sustainability: 
Technical sustainability 
of 
the 
project 
would 
be 
sought 
through 
focusing 
on 
relatively 
low-cost 
preventive 
activities 
that 
will 
reduce 
the 
number 
of 
future 
cases 
of 
HIV. 
Through 
extensive training, 
technical 
assistance 
and operational 
research the 
capacity 
of 
NGOs 
to 
delivery 
effective 
HIV 
prevention 
services 
would 
be 
strengthened. 
In 
addition, 
the 
small 
grant 
program 
would 
help 
build 
the 
technical 
capacity 
of 
smaller 
NGOs or NGOs 
without 
experience 
in 
HIV 
prevention. 
Political 
sustainability 
of 
the 
project 
would 
be 
achieved 
by 
increasing 
awareness 
among the 
general 
adult 
population 
and 
intensive 
advocacy 
efforts 
among 
decision 
makers 
and 
opinion 
leaders. 
There 
would 
be 
a 
focus 
on 
leaders 
who could 
be 
instrumental 
to 
the 
project 
including 
religious 
leaders, 
politicians 
and 
- 
28 
- 
Page  35
local 
officials, 
and 
journalists. 
I 
Managerial 
sustainability 
of 
the 
project 
would 
be 
accomplished 
through 
enhancing 
the 
capacity 
of 
the 
national 
and 
provincial 
AIDS 
control program 
managers 
and 
their 
staffs. 
By 
working 
closely 
with 
management professionals 
from 
the 
management 
and procurement 
firm, 
they 
would 
develop 
new 
skills 
in 
project 
and 
contract 
management, 
procurement, 
financial 
management, 
and 
monitoring 
and 
evaluation. 
The 
managerial capacity 
of 
the 
NGOs 
would 
also 
be 
strengthened. 
The 
management 
and 
procurement 
firm 
would 
receive incentives 
for 
performance 
based 
on 
their 
ability 
to 
ensure 
timely 
disbursement 
of 
project 
funds. 
Financial 
sustainability 
would 
be 
almost 
completely 
a question 
of 
the 
GOP’s 
willingness 
to 
finance 
the 
project’s 
recurrent 
costs 
in 
the 
long 
run. 
Almost 
all 
the 
activities 
financed 
under 
the 
project 
are 
pure 
public 
goods 
with 
few 
opportunities 
for 
cost-recovery. 
2. 
Critical 
Risks 
(reflecting 
the 
failure 
of 
critical 
assumptions 
found 
in 
the 
fourth column 
of 
Annex 
1): 
Risk 
From 
Outputs 
to 
Objective 
Current 
understanding 
of 
HIV 
epidemiology 
in 
low 
prevalence 
countrie: 
is 
wrong 
and 
interventions 
are 
not 
properly 
targeted. 
Repressive 
measures 
are 
taken against 
vulnerable populations. 
The 
political 
commitment 
to 
HIV/AIDS 
control 
is 
sustained 
so 
that 
behavior 
changes 
are 
maintained. 
From 
Components 
to 
Outputs 
There 
are 
not 
enough capable 
NGOs 
willing 
to 
bid 
on 
contracts. 
Bid 
prices 
for 
service 
delivery 
contracts 
are 
significantly higher 
than 
estimated. 
Government 
becomes 
more reluctant 
to 
partner 
with 
NGOs. 
NGOs 
are 
unable 
to 
maintain good 
relations 
with 
vulnerable populations. 
There 
is 
a backlash 
from 
higher 
profile 
Risk Rating 
I 
Risk Mitigation Measure 
N 
S 
M 
M 
M 
S 
The 
Government and 
NGOs 
will 
stay abreast 
of 
new 
knowledge 
through 
the 
internet, 
technical 
advice 
from 
UNAIDS 
& 
WHO, 
and 
annual 
conferences. 
Annual 
behavior 
and 
sero-surveillance 
will 
provide 
needed 
data. 
Advocacy 
and 
awareness 
campaigns 
prevent 
stigmatization. 
Crisis 
management strategy 
developed beforehand 
to 
deal 
with 
this 
scenario. 
Government complies 
with 
UN 
International 
Guidelines 
on 
IW/AIDS 
& 
Human 
kghts. 
Advocacy 
and 
awareness 
campaigns increase 
understanding among 
policy 
makers 
of 
HIV/AIDS 
issues. 
There 
will 
be 
extensive 
advertising 
of 
tenders. 
Procurement 
training 
workshops 
will 
be 
held. 
Tender 
documents 
will 
not 
have excessive 
barriers 
to 
entry. 
Ensure 
adequate 
competition 
(see 
above) 
and 
ensure 
bidders understand 
how 
important price 
is. 
Re-bid 
contracts 
possibly 
adjusting 
scope. 
Careful monitoring 
of 
NGO 
performance 
convinces Government 
of 
the 
utility 
of 
working 
with 
NGOs. 
Quick 
success 
overcomes 
reluctance. 
Monitoring 
by 
Government and 
3rd 
party 
can 
provide 
feedback 
from 
vulnerable 
groups. 
Poorly performing 
NGOs 
can 
be 
warned 
and 
ultimately 
fired. 
Crisis 
management strategy 
would 
be 
- 
29 
- 
Page  36
BCC 
activities. 
The 
GOP 
and 
its 
censors 
do 
not 
allow 
mentioning 
of 
condoms 
in 
mass 
media. 
No 
political 
support 
for 
effective 
enforcement 
of 
legislation on 
blood 
safety. 
Skilled 
staff 
are 
not 
retained 
or 
are 
unnecessarily 
transferred 
Overall 
Risk 
Rating 
?isk Rating 
- 
H 
(High 
Risk), 
S 
(Substantial Risl 
S 
S 
M 
S 
), 
M 
(Modest Risk), 
developed beforehand and 
advocacy 
activities 
will 
prevent 
or 
reduce 
effects 
of 
backlash. 
Ongoing 
dialogue 
between 
MOH, 
censors, 
high 
level 
govemment 
officials, 
and 
advertising 
agency 
on 
acceptable 
spots 
and 
images. 
Gradual 
introduction 
of 
condom 
message. 
Effective 
enforcement 
of 
existing 
legislation 
would 
be 
a 
condition 
for 
procurement 
of 
hepatitis 
C 
screening 
kits. 
Professional 
development 
opportunities 
provided 
to 
staff 
will 
encourage retention. 
Staff 
turnover 
to 
be 
monitored 
during 
supervision. 
GOP 
agrees 
to maintain 
NACP 
and PACPs 
staffing 
at levels 
agreed 
to 
during 
appraisal. 
Vegligible 
or 
Low 
Risk) 
3. 
Possible 
Controversial 
Aspects: 
As 
a 
result 
of 
intensified 
BCC 
activities, 
there 
may 
be 
a backlash 
from 
some 
parts 
of 
the 
community 
that 
advertising 
is 
too 
explicit. 
Particularly 
as 
there 
is 
more 
discussion 
of 
condom 
use 
or 
needle 
exchange 
as 
means 
of 
preventing 
the 
spread 
of 
STIs, 
including 
HIV, 
members 
of 
the 
general 
public 
may 
feel 
that such 
advertising 
encourages 
illicit 
behavior. 
(The 
international literature 
on 
this 
issue 
points 
strongly 
in 
the 
opposite 
direction. 
Talking 
to youth 
about 
HIV, 
sex, 
and 
condoms 
tends 
to 
decrease 
teen 
pregnancy, 
delay 
age 
at 
first 
intercourse, 
and 
decrease 
pre-marital 
sex.) 
Another 
possible controversy 
may 
result 
from 
the 
contracts 
with 
NGOs. 
Some 
civil 
servants 
may 
be 
opposed 
to 
public 
funds 
being 
used 
to 
finance 
NGOs, 
particularly 
ones 
that 
are 
working 
with 
groups 
engaged 
in 
illegal 
activities. 
Conversely, 
NGOs 
may 
become 
vocal 
if 
they 
are 
not paid 
on 
time 
for 
services 
they 
have 
provided. 
G. 
Main Loan Conditions 
1. 
Effectiveness Conditions 
The 
GOP 
will 
submit 
to 
the 
Bank 
a 
legal 
opinion 
from 
the 
Ministry 
of 
Justice 
regarding 
whether 
the 
development 
finance 
agreement 
conforms 
to 
Pakistan 
laws 
and 
regulations. 
2. 
Other 
[classify according 
to 
covenant 
types 
used 
in 
the 
Legal 
Agreements.] 
Financial 
Covenants: 
The 
GOP 
will 
maintain 
a 
financial 
management system, 
including 
records 
and 
accounts, 
and 
prepare 
financial 
statements 
in 
a 
format 
acceptable 
to 
the 
Bank, 
adequate 
to 
reflect 
its 
operations, resources and 
expenditures 
related 
to 
the 
Project. 
The 
GOP 
will 
have the records, accounts and 
financial 
statements 
and 
accounts 
for 
the 
Special 
Accounts 
for 
each 
fiscal 
year audited, 
in 
accordance 
with 
auditing 
standards 
acceptable 
to 
the 
Bank, 
consistently 
applied, 
by 
independent auditors acceptable 
to 
the 
Bank. 
The 
GOP 
will 
provide 
the 
Bank, 
not 
later 
than 
six 
months after the end 
of 
each 
year, 
copies 
of 
the 
financial 
statements 
and 
an 
opinion 
on 
these 
such 
statements, 
records and 
accounts 
by 
the 
independent 
auditors. 
- 
30 
- 
Page  37
For 
all 
expenditures made 
on 
the 
basis 
of 
statements 
of 
expenditure, 
the 
GOP 
will: 
(i) 
maintain 
separate 
accounts 
reflecting 
such expenditures; 
(ii) 
retain, 
until 
at 
least 
one year 
after 
the 
Bank 
has 
received 
the 
au&t 
report 
for 
the 
fiscal 
year 
in 
which 
the last 
withdrawal 
from 
the 
Financing 
Accounts 
was 
made, 
all 
records 
for 
the 
expenditures; 
(iii) 
enable 
the 
Bank’s 
representatives 
to 
examine 
the 
records; 
and 
(iv) 
ensure 
that 
such records and accounts 
are 
included 
in 
the 
annual audit. 
I 
Province 
j 
AJK 
The 
GOP 
will 
prepare 
and 
hish 
to 
the 
Bank 
a 
Financial 
Monitoring 
Report, 
in 
a 
format 
satisfactory 
to 
the 
Bank, 
not 
later than 
45 
days 
after 
the 
end 
of 
the 
each quarter. 
Proposed 
full 
strength 
Minimally 
Acceptable 
Staffing 
4 
2 
Implementation 
Covenants: 
~ 
~~ 
Balochistan 
NWFP 
Ensure 
that 
monitoring 
and evaluation 
is 
carried 
out 
a 
on 
ongoing 
basis 
to 
allow 
assessment 
of 
progress 
towards achievement 
of 
the 
objectives 
of 
the 
project. 
7 
2 
7 
4 
Carry 
out 
a 
detailed 
mid-term 
review 
of 
the 
project 
by 
October 
3 
1,2006. 
Punj 
ab 
Sindh 
NACP 
The 
GOP 
and 
provincial 
governments 
will 
maintain staffing 
levels 
in 
their 
AIDS 
Control 
Programs 
at 
least 
as 
high 
as 
agreed 
to 
during 
project 
preparation. 
The 
minimally 
acceptable 
level 
of 
full 
time 
officer 
level 
staff 
for 
each 
program 
is 
indicated 
in 
table 
4 
as 
is 
the 
staffing 
levels 
targeted 
by 
the 
programs. 
9 
5 
11 
5 
10 
7 
Table 
4: 
Minimally 
Acceptable and 
Future 
Full-Time 
Staffing 
(Officer 
Level) 
of the 
National 
and 
Provincial 
AIDS 
Control 
Programs 
Through 
out 
the 
period 
of 
project implementation 
the 
GOP 
will 
ensure 
that 
National 
Steering Committee 
continues 
to 
fulfill 
its 
role 
to 
provide 
oversight 
of 
project 
implementation. 
The 
GOP and 
the 
provinces 
will 
ensure 
that 
the 
Technical 
Advisory 
Committees 
on 
AIDS 
continue to 
function 
effectively 
during 
implementation 
of 
the 
project. 
Within 
one year 
of 
the 
date 
of 
effectiveness, 
the 
Ministry 
of 
Health 
will 
formulate,  approve, 
and 
begin 
implementation 
of 
technical 
guidelines 
on 
the 
following 
topics: 
0 
The 
proper 
handling, 
storage, 
and 
disposal 
of 
sharps 
and 
needles, 
syringes, 
and 
disposable 
blood 
transfusion equipment 
such 
as 
blood 
bags 
and 
tubing. 
0 
Best 
practices 
in 
carrying out voluntary 
counseling and 
testing 
(VCT) 
for 
HIV, 
that 
respects 
the 
patient’s 
dignity 
and 
civil 
rights 
including 
confidentiality. 
-31 
- 
Page  38
e 
The 
conduct 
of 
research 
related to 
HIVIAIDS 
including 
bio-ethical review, 
informed 
consent 
by 
subjects, 
and 
respect 
for 
subject's 
dignity 
and 
civil 
rights, 
including 
confidentiality. 
H. 
Readiness 
for 
Implementation 
I- 
1. 
a) 
The 
engineering 
design documents 
for 
the 
first 
year's 
activities 
are 
complete 
and 
ready 
for 
the 
- 
start 
of 
project 
implementation. 
i 
1. 
b) 
Not 
applicable. 
7 
A 
2. 
The 
procurement documents 
for 
the 
first 
year's 
activities 
are 
complete and 
ready 
for 
the 
start 
of 
project 
implementation. 
quality. 
3. 
The 
Project 
Implementation 
Plan 
has 
been 
appraised 
and 
found 
to 
be 
realistic and 
of 
satisfactory 
3 
4. 
The 
following 
items 
are 
lacking 
and 
are 
discussed 
under 
loan 
conditions 
(Section 
G): 
- 
32 
- 
Page  39
1. 
Compliance with 
Bank 
Policies 
E 
2. 
The 
following 
exceptions 
to Bank 
policies 
are 
recommended 
for 
approval. 
The project 
complies 
1. 
This 
project 
complies 
with all 
applicable 
Bank 
policies. 
with all 
other 
applicable 
Bank 
policies. 
// 
,5.,c 
/ 
Ben& 
BL 
Loevinsohn 
sbreu 
Te{m,4!eader 
/ 
i, 
Actor 
ManagerlDirector 
b.dtry 
ManagerlDirector 
- 
33 
- 
Page  40
Hierarchy 
of 
Objectives 
Sector-related 
CAS 
Goal: 
To 
impr0i.e 
human 
dei,elopment 
ivith 
specific 
reference 
to 
improving 
the 
health 
status 
of 
the 
people 
of 
Project Development 
Objective: 
To 
prevent 
HIV 
from 
becoming 
established 
in 
vulnerable populations 
and 
spreading 
to 
the general 
adult 
population, 
while avoiding 
stigmatization 
of 
the 
Annex 
1 
: 
Project Design 
Summary 
PAKISTAN: 
HlVlAlDS Prevention Project 
Sector 
Indicators: 
0 
Infant 
mortality 
rate 
Malnutrition 
in 
children 
0 
Total Fertility 
Rate 
htcome 
I 
Impact 
ndicators: 
Prevalence 
of 
HIV 
Infection 
remains 
below 
5% 
in 
vulnerable 
populations 
0 
Sexually transmitted 
infection (STI) 
Prevalence 
in 
vulnerable 
populations 
is 
reduced 
from 
baseline 
levels 
0 
HIV 
prevalence 
among 
pregnant 
women 
remains 
at 
or 
below 
baseline 
levels 
0 
Positive attitude 
among 
the general 
population 
towards 
people 
living 
with 
HIV 
and vulnerable 
population 
as 
measured 
by 
responses 
to 
survey 
questions 
Sector1 
country reports: 
0 
Pakistan 
Integrated 
Household 
Survey 
0 
National 
Nutrition 
Survey 
'roject reports: 
0 
National 
sero-prevalence 
surveillance system 
0 
Occasional 
surveys 
among 
women 
attending 
antenatal 
clinics 
Behavior 
Change 
Communication (BCC) 
campaign 
and 
similar 
follow-up 
surveys 
0 
Impact 
Assessment 
of 
from Goal to Bank Mission) 
0 
Other 
key 
aspects 
of 
human 
development 
(e.g. 
increased 
access 
to 
education) 
are 
in 
place 
0 
Macro-economic 
stability 
is 
maintained and 
economic 
growth 
accelerates 
from Objective 
to 
Goal) 
0 
Other factors 
that 
influence the 
health 
status 
of 
the 
population 
(including 
education, 
water 
and 
sanitation, 
status 
of 
women, 
other 
communicable 
disease 
control, 
etc.) 
improve 
significantly 
district 
level 
does 
not 
have negative 
impact 
on 
quality and 
access 
to 
preventive programs 
0 
Decentralization 
to 
- 
34 
- 
Page  41
Iutput 
from each 
:omponent: 
. 
Increased 
prevalence 
of 
safe 
)ehaviors 
and improved 
.vailability 
of 
STI 
services 
.mong 
vulnerable populations. 
:. 
Improved 
knowledge and 
iractice 
of 
HIV 
preventive 
neasures, 
including 
use 
of 
iigh 
quality 
STI 
services, 
by 
:enera1 
adult population. 
Output Indicators: 
1.1 
more 
than 
60% 
of 
sex 
workers used 
condom with 
the 
last client 
1.2 
% 
of 
injecting drug 
users 
(IDUs) 
who 
did 
not 
share 
#. 
Reduced 
transmission 
of 
IIV/STI 
through 
blood 
ransfusion. 
1 
-- 
lrograms 
in 
public 
and private 
ector. 
.. 
Strengthened 
capacity 
to 
serological 
and 
behavioral 
surveillance 
report published 
on 
schedule. 
4.2 
Proportion 
of 
vulnerable 
populations covered 
by 
contracted 
NGOs 
4.3.90% 
of 
NGOs 
paid 
on 
schedule 
as 
stipulated 
in 
needles 
in 
the 
last 
week 
1.3 
increased 
% 
of 
sex 
workers 
with 
symptoms 
of 
STI 
who 
went 
for 
STI 
treatment 
during 
the 
last week 
1.4 
80% 
of 
STI 
clinics 
working 
with 
vulnerable 
populations 
score above 
minimum 
acceptable 
score 
2.1 increased 
% 
of 
people 
who 
admit 
to 
extra- 
or 
pre-marital 
sex 
who 
use 
a 
condom 
2.2 
increased 
% 
of 
men, 
women, 
youth 
who 
know 
condoms can 
protect them 
from 
STI 
2.3 
increased 
% 
of 
menlwomedyouth 
who 
report 
use 
of 
new 
disposable 
syringe 
when receiving 
the 
last 
injection 
2.4 
increased 
% 
of 
adults 
who 
are 
willing to 
work 
with 
an 
HIV 
positive person 
2.5 
% 
of 
health 
facilities 
with 
appropriate 
drugs, 
recording, 
and skilled 
staff 
for 
STI 
management 
3.1 100% 
ofblood 
transfused 
in 
the 
public 
sector 
effectively 
screened 
for 
HIV 
and 
hepatitis 
B 
3.2 
Quality 
Assurance system 
institutionalized 
in 
the 
public 
sector 
4.1 
High 
quality and 
'roject reports: 
National 
Behavioral 
Surveillance System 
0 
Third 
Party 
Annual 
Assessment 
of 
sample 
health facilities 
Impact 
assessment 
of 
BCC 
campaign 
and 
follow-up 
surveys 
0 
Third 
Party 
Annual 
Assessment 
of 
sample 
health facilities 
0 
Blood 
Bank 
Information 
System 
0 
Annual 
Third 
Party 
Assessment 
0 
Copies 
of 
published 
reports 
fumished 
to 
stakeholders 
0 
Government 
and 
NGO 
records 
0 
Monitoring 
reports 
:Tom 
Outputs to Objective) 
0 
Current 
understanding 
of 
HIV 
epidemiology 
in 
low 
prevalence countries 
is 
correct. 
0 
There 
are 
no 
repressive 
measures 
taken 
against 
vulnerable populations 
0 
The 
political 
commitment 
to 
HIViAIDS 
control 
is 
sustained 
so 
that 
behavior 
changes 
are 
maintained 
- 
35 
- 
Page  42
Project Components 
I 
Sub-components: 
I. 
Expansion of 
Interventions for 
Vulnerable 
Populations 
1.1 
Recruit 
NGOs 
and 
other 
sectors 
to 
increase 
provision 
of 
an 
agreed package 
of 
services 
to: 
sex 
workers, 
IDUs, 
Men 
who 
have 
sex 
with 
men 
(MSM),  migrant 
workers 
including truck 
drivers, 
and 
prisoners 
1.2 
Pilot 
testing 
of 
innovative 
approaches 
(such 
as 
100% 
condom 
use 
policy). 
11. 
Improved 
HIV 
Prevention 
by 
General 
Population 
2.1 
BCC 
Activities aimed 
at 
general 
population 
2.2 
Advocacy 
2.3 
Targeted interventions 
for 
Youth, Police, 
Defense, 
Labor 
2.4 
Improved 
and expanded 
Management 
of 
STI 
cases 
111. 
Prevention 
of 
HIV/STI 
transmission 
through 
blood 
transfusion 
3.1 
Establish 
Provincial 
Blood 
Transfusion 
Authorities 
3.2 
Quality 
Assurance 
System 
3.3 
Screening 
of 
blood for 
HIV 
and 
other 
STIs 
3.4 Waste 
management 
IV. 
Capacity 
Building 
& 
Program 
Management 
4.1 
Strengthening 
of 
FederaliProvincial 
lother 
sector 
program 
Units 
4.2 
NGO 
capacity 
development 
ontract 
.4 
90% 
of 
NGO 
programs 
ipervised 
by 
Government 
uring 
the last quarter 
iputs: 
(budget 
for 
each 
omponent) 
9.2 
million 
;9.7 
million 
i7.7 
million 
j6.0 
million 
National and Provincial 
Annual 
Program 
Reports 
0 
Quarterly 
Provincial 
Program 
Reports 
'roject reports: 
0 
Annual 
Third 
Party 
Assessment 
Government 
and 
NGO 
records 
National 
and Provincial 
Annual 
Program 
Reports 
0 
Quarterly 
Provincial 
Program 
Reports 
0 
Financial 
Management 
Reports 
0 
Supervision Reports 
rom Components 
to 
Nutputs) 
0 
There 
are 
enough 
capable 
NGOs 
willing 
to 
bid 
on 
contracts. 
0 
Government maintains 
its 
willingness 
to 
partner 
with NGOs 
0 
NGOs 
able 
to maintain 
good 
relations 
with 
vulnerable populations 
0 
There 
is 
no 
backlash 
from 
higher 
profile 
behavior 
change 
communications 
(BCC) 
activities. 
0 
The GOP 
and 
its 
censors 
allow 
mentioning 
of 
condoms 
in 
mass 
media. 
0 
Political 
support 
for 
effective enforcement 
of 
legislation 
on 
blood 
safet) 
0 
Skilled staff 
are 
retained 
and 
unnecessary 
staff 
transfers 
avoided. 
- 
36 
- 
Page  43
4.3 
Second 
Generation 
HIV 
Surveillance and Operational 
Research 
4.4 
Care 
for 
people 
living with 
AIDS 
Remains 
4 
% 
6O-8OYO 
8 
0% 
Table 
2: 
Principal Indicators 
for 
Judging Achievement 
of 
Development 
Objectives 
Other 
low 
prevalence 
countries. 
Vulnerable 
population 
in 
Karach 
etc. 
vs. 
Year 
2 
and 
Year 
3 
locations. 
IDUs 
in 
Karachi 
etc. 
vs. 
subsequent 
exaansion locations 
among vulnerable 
populations 
2. 
STI 
(syphilis) 
prevalence 
among 
vulnerable 
populations, 
100% 
in 
year 
5 
3. 
HIV 
prevalence 
among women 
coming for 
ANC 
Variations among 
provinces, 
and 
improvements 
over 
time. 
4. 
Condom 
use 
during 
last 
sex act 
among 
vulnerable 
populations 
85% 
5. 
Use 
of 
clean 
needles 
during 
last 
week 
by 
IDUs 
Change 
over 
time 
from 
baseline 
survey 
in 
2001 
6. 
Percent 
of 
blood 
transfusions 
in 
public 
sector 
screened 
for 
HIV 
in 
labs 
meeting 
QA 
standards. 
7. 
Percent 
of 
general 
population 
expressing 
“positive” 
attitude 
towards 
AIDS 
patient 
8. 
Among 
general 
adult 
population 
admitting 
to 
sex 
with 
non-regular 
partner, 
proportion 
using 
a 
condom. 
Sero-prevalence 
surveillance 
Sero-prevalence 
surveillance 
Periodic 
surveys 
in 
selected 
health facilities 
Behavioral 
surveillance 
Behavioral 
surveillance 
Third 
party 
assessment 
of 
blood 
banks 
in 
public 
sector 
Household 
survey 
to 
assess 
public 
knowledge 
& 
attitudes 
Household 
survey 
to 
assess 
public 
knowledge 
& 
attitudes 
Schedule 
(year 
of 
project) 
123 
45 
xxxxx 
xxxxx 
X 
X 
xxxxx 
xxxxx 
xxx 
x 
xx 
xx 
June 
2004 
June 
2004 
June 
2004 
June 
2004 
June 
2004 
June 
2004 
65% 
15% 
/comparison 
Xemains 
<5% 
Other low-prevalence 
countries 
I 
I 
40% 
by 
year 
5 
Other 
low 
prevalencf 
countries. 
Change 
over 
time 
from 
baseline survey 
in 
I 
2001 
- 
37 
- 
Page  44
Table 
3: 
Details 
of 
Data 
Collection 
for 
Means 
of 
Verification 
(MOV) 
Behavioral 
Annual 
surveillance 
among 
vulnerable 
uouulations 
Sero-surveillance 
Annual 
among vulnerable 
population 
HIV 
survey 
Year 
5 
among women 
coming 
for 
antenatal 
care 
Household 
survey Years 
3 
and 
5 
to 
assess 
public 
knowledge 
& 
attitudes 
3rd 
party 
Years 1,2,3 
evaluation 
of 
and 
5 
blood 
transfusion 
services 
3rd 
party 
evaluations 
of 
STI 
services 
3rd 
party 
evaluation 
of 
advocacy 
& 
IPC 
among youth 
Years 
2 
and 
4 
Years 
1,2 
and 
3 
lesponsi- 
How 
MOV 
will 
be 
Nility 
implemented 
Technical 
assistance 
will 
be 
provided to 
NACP 
by 
CIDA. 
Data collection 
by 
a 
fir"GO/research 
institution 
under contract 
provided 
to 
NACP 
by 
CIDA. 
Data 
collection 
by 
a 
fir"G0Iresearch 
institution 
under contract 
firm 
/organization 
will 
be 
recruited 
to 
carry out this and 
other surveys 
on 
contract 
Part 
of 
the evaluation 
and 
monitoring 
firm's 
contract. 
NACP 
Technical 
assistance 
will 
be 
NACP 
Evaluation and 
monitoring 
NACP 
NACP 
Part 
of 
the 
evaluation 
and 
monitoring 
firm's 
contract. 
NACP 
Part 
of 
the 
evaluation 
and 
monitoring 
firm's 
contract. 
NACP 
Part 
of 
the 
evaluation 
and 
monitoring 
firm's 
contract. 
($450,000 
Yes 
per year) 
$2,000,000 
Yes 
($400,000 
per year) 
Yes, 
but 
episodically 
$60,000 
$100,000 
Yes, 
but 
less 
($50,000 
per 
frequently 
survey) 
$60,0000 
No, 
could 
be 
($15,000 
per 
done 
by 
Year) 
provincial 
blood 
transfusion 
authorities 
$30,000 
No. 
could 
be 
($15,000 
per 
done 
by 
round) 
provincial 
$30,000 
Partly, once 
($10,000 
per 
shown 
to 
be 
effective 
could 
be 
done 
less 
frequently 
supervisors 
- 
38 
- 
Page  45
Annex 
2: 
Detailed Project Description 
PAKISTAN: HlVlAlDS Prevention Project 
The 
project 
will 
total an 
estimated 
US$47.64 
million 
and 
will 
be 
financed 
by 
the 
Government 
of 
Palustan, 
IDA, 
the Department 
for 
International Development 
(UK), 
and 
the Canadian International 
Development Agency. 
The 
project 
comprises 
four 
components: 
three 
directly 
related 
to 
providing 
services 
and 
one 
for 
capacity 
building 
and 
program 
management. 
By 
Component: 
Project 
Component 
1 
- 
US$9.23 
million 
1. 
Expansion 
of 
Interventions 
Among 
Vulnerable 
Populations 
Service 
Delivery 
Contracts 
with 
NGOs: 
This 
component 
would 
support 
the 
rapid 
and 
systematic 
expansion 
of 
programs 
aimed 
at 
providing 
vulnerable 
populations 
with 
the 
services 
they need 
to 
prevent 
HIV. 
From 
available 
evidence, the 
populations 
that 
are 
at the 
greatest 
risk 
of 
HIV 
are: 
(i) 
female 
sex 
workers 
FSWs; 
(ii) 
IDUs; 
(iii) 
MSM; 
(iv) 
migrant 
workers, 
particularly 
truck 
drivers; 
and 
(v) 
prisoners. 
Preventing the 
spread 
of 
HIV 
among 
these 
populations, 
particularly 
those 
living 
in 
large 
cities, 
will 
be 
the 
single 
most important 
means 
for 
preventing 
a 
widespread epidemic 
and 
will 
be the project’s highest 
priority. 
Based 
on 
the best 
available scientific 
and 
programmatic 
evidence, 
and 
reflecting 
global 
best practice, the 
Government 
has 
selected 
a package 
of 
services 
that 
should 
be 
provided 
to 
these 
vulnerable populations. 
The 
Government 
would 
contract 
with 
NGOs 
to 
measurably 
change 
behaviors 
through 
the 
provision 
of 
services 
in 
geographically 
defined 
areas 
to 
a 
particular vulnerable 
population. The 
service 
package 
would 
include: 
(i) 
behavior 
change 
communication 
aimed 
at 
increasing the vulnerable population’s 
practical 
knowledge 
of 
HIV, 
improving 
their 
attitude 
towards 
prevention and their 
own 
risk 
of 
HIV, 
and 
changing 
their 
high 
risk 
behaviors; 
(ii) 
promotion 
of 
effective 
condom 
use 
including 
increasing 
their 
skills 
related 
to 
condom 
use 
and 
negotiating condom 
use 
with 
their 
sexual 
partners; 
(iii) 
voluntary 
counseling and 
HIV 
testing; 
(iv) 
proper 
management 
of 
STIs; 
(v) 
needle exchange 
and 
promotion 
of 
safe 
injection 
practices 
(among 
drug 
users); 
and 
(vi) 
empowering 
activities 
that 
allow 
members 
of 
the vulnerable populations 
to 
feel 
they 
have 
greater 
control 
of 
their 
lives. 
These 
activities 
would 
be 
defined 
by 
the beneficiaries 
themselves 
but 
could include 
literacy 
training, 
formation 
of 
associations, 
and instruction 
in 
self-defense. 
The 
contracts 
would 
specify 
measurable targets 
to be 
achieved. 
For 
example, 
in 
the 
case 
of 
FSWs, the 
following 
indicators 
and 
targets 
would 
be 
specified 
for 
achievement 
by 
the 
end 
of 
the 
project period 
in 
the 
project 
area: 
Behaviors: 
(i) 
70% 
have 
used 
a 
condom 
in 
their 
most recent 
commercial 
sex act 
(ii) 
70% 
carry 
a 
condom 
when working 
(and 
can show 
it 
to 
a researcher) 
(iii) 
60% 
have 
sought treatment 
within 
7 
days 
of 
having 
STI 
symptoms 
(iv) 
HIV 
prevalence remains 
below 
3% 
among 
FSWs 
in 
the 
project 
area 
(assessed 
through 
HIV 
sero-surveillance) 
(v) 
STI 
(syphilis) 
prevalence 
is 
reduced 
by 
half 
of 
the baseline levels 
(which 
will 
be 
assessed 
through 
the 
HIV 
sero-surveillance 
system) 
- 
39 
- 
Page  46
Skills 
- 
70% 
of 
FSWs 
can: 
(i) 
(ii) 
Demonstrate 
the 
correct 
use 
of 
a condom 
Explain 
at 
least 
two 
proven 
strategies 
for 
convincing 
clients 
to 
use 
a 
condom 
Attitudes 
- 
70% 
of 
FS 
Ws 
express 
positive 
attitudes towards: 
(i) 
personalized 
risk 
of 
HIV 
infection 
(“it 
can happen 
to 
me”) 
(ii) 
risk 
of 
HIV 
and 
STI 
through 
commercial 
sex 
(iii) 
their 
own 
use 
of 
condoms 
in 
commercial 
sex 
(“I 
can 
insist 
that clients 
use 
condoms”) 
(iv) 
the 
use 
of 
condoms 
by 
other 
FSWs 
(“I 
know 
of 
other 
women who 
use 
condoms 
with 
clients”) 
(v) 
getting 
prompt 
treatment 
for STD 
symptoms 
(“I 
try 
to 
see 
the 
doctor 
as 
soon 
as 
possible”) 
(vi) 
avoid 
having 
sex 
with 
IDU 
(“I 
avoid having 
sex 
with 
anyone 
I 
know 
to 
be 
an 
IDU”) 
(vii) 
FSWs 
getting 
tested 
for 
HlV 
Knowledge 
- 
80% 
of 
FSWs 
can correctly 
identijjx 
(i) 
two 
ways 
that 
HIV 
is 
transmitted 
(ii) 
three 
ways 
to 
prevent 
HIV 
transmission, 
including 
condom 
use 
(iii) 
that 
STI 
infection 
can 
lead 
to 
infertility 
(iv) 
the symptoms 
of 
STI 
(v) 
the increased 
risk 
of 
HIV 
transmission 
through 
sex 
with 
IDU 
(vi) 
that condoms can 
prevent 
other 
STI 
infections 
(vii) 
at 
least 
3 
sites 
for 
obtaining 
condoms 
(viii) 
a 
local clinic 
or 
private 
doctor 
that 
provides quality 
STI 
treatment 
(ix) 
the 
location 
of 
a 
local 
center 
for 
VCT 
and the 
rationale 
for 
testing. 
The 
Government 
would 
select 
NGOs 
through 
an open 
and 
competitive 
process. 
Based 
on 
regional 
and 
global 
experience 
of 
contracting 
with 
NGOs, 
tender 
documents have 
been drafted 
and 
discussed 
with 
the 
various stakeholders. 
The 
contracts 
would 
have 
specific 
measurable goals 
that 
the 
NGOs 
would 
be 
responsible 
for 
achieving 
in 
their 
geographical 
area. 
NGOs would 
be 
eligible to 
bid 
if 
they 
met 
certain 
minimum 
criteria 
including: 
(i) 
being 
a 
legal 
entity 
with 
named 
officers, 
(ii) 
having 
audited 
financial 
statements 
for 
the 
last 
three 
years, 
and 
(iii) 
having 
experience 
delivering 
social 
services 
in 
Pakistan; 
(iv) 
minimum 
annual 
budget 
amount 
(USS20,OOO 
per 
year), 
from 
whole 
consortium; and 
(v) 
no 
prior 
convictions 
for 
financial 
crimes 
and 
no 
consistent 
history 
of 
civil 
litigation 
findings 
against 
the 
organization 
or 
key 
staff. 
Evaluation 
of 
the 
submitted 
proposals 
would 
be 
based 
both on 
price 
and 
technical 
merit 
including: 
(i) 
experience 
of 
the 
NGO 
in 
successfully 
delivering 
health 
or 
other 
social 
services; 
(ii) 
the 
quality 
of 
key 
personnel (project 
manager, 
deputy 
manager, and 
field 
manager); 
and 
(iii) 
the 
quality 
of 
the 
plan 
of 
actiodstrategy 
for 
delivering 
the services 
and accomplishing 
the 
outputs 
specified 
in 
the 
contracts. 
Bid 
evaluation 
would be 
carried 
out 
by 
multi-disciplinary 
teams 
including 
representatives 
of 
the 
local 
and 
national 
governments, 
the 
NGO 
community (obviously 
not 
anyone whose 
organization 
was 
involved 
in 
the 
bidding 
process), 
United 
Nations 
technical 
agencies, 
and 
academic 
institutions. 
Monitoring 
of 
NGO 
performance 
would 
be 
carried out 
by 
the 
local 
and 
provincial 
governments 
on 
a 
regular 
basis and 
would 
be 
supplemented 
by 
visits 
to 
project 
areas 
carried out 
by 
third 
parties. 
Annual 
evaluations 
of 
performance 
on 
key 
indicators 
would be 
carried out 
by 
third 
parties 
based 
on 
interviews 
- 
40 
- 
Page  47
with 
members 
of 
the 
vulnerable 
population. 
The 
key 
indicators 
would 
be 
spelled out 
in 
the 
contracts 
and 
would 
include: 
(i) 
reduction 
in 
syphilis 
prevalence; 
(ii) 
increase 
in 
reported condom 
use 
and 
the 
proportion 
of 
beneficiaries 
carrying 
a 
condom 
at 
the 
time 
of 
interview; 
and 
(iii) 
increased 
use 
of 
STI 
treatment 
services 
when 
suffering 
from 
symptoms 
of 
STIs. 
The 
contracts 
for 
service 
delivery 
would 
be 
for 
four 
or 
five 
years 
and 
continuation 
of 
the 
NGOs 
would 
be 
dependent 
on 
acceptable 
progress 
on 
key 
indicators. 
Failure 
to 
make 
improvements 
in 
key 
indicators 
such 
as 
condom 
use 
and 
syphilis 
prevalence 
could 
lead 
to 
termination 
of 
the 
contract 
by 
the 
Government. 
The 
contracts 
would 
also have 
the 
following 
stipulations: 
(i) 
contractors 
would 
be 
expected 
to 
work 
closely 
with 
community 
groups, 
police, 
religious 
leaders, etc. 
to 
ensure 
smooth implementation; 
(ii) 
contractors 
would 
be 
expected 
to 
work 
closely 
with 
the 
researchers 
carrying 
out 
behavioral and 
sero-surveillance; 
(iii) 
contractors 
will 
have 
to 
respect 
clients 
humadcivil 
rights 
e.g. 
confidentiality. 
Exploitation 
(sexual 
or 
otherwise) 
of 
clients 
would 
be 
grounds 
for 
contract 
termination; 
(iv) 
NGOs 
will 
have 
to 
keep 
separate 
accounts 
so 
that 
actual 
expenditures can 
be 
determined 
for 
subsequent 
activities and 
cost-effectiveness 
analysis; and 
(v) 
performance 
bonuses 
could 
be 
paid 
for 
particularly 
meritorious work. 
Five 
service 
delivery 
contracts 
will 
be 
signed 
by 
the 
local 
governments 
with 
the 
selected 
NGOs 
shortly 
after 
effectiveness 
of 
the 
financing 
following 
advanced procurement 
activities. 
These contracts 
include: 
(i) 
FSWs, 
one 
contract 
in 
Karachi 
and 
one 
in 
Lahore;; 
(ii) 
MSM, 
one 
contract 
in 
Lahore; 
(iii) 
long-distance 
truck 
drivers, 
one 
contract 
nationwide 
with 
initial 
implementation 
in 
Karachi 
and Lahore; 
(iv) 
prisoners, 
one 
contract 
in 
Sindh; 
and 
(v) 
IDUs, 
one 
contract 
nationwide. 
This 
last 
package 
will 
be 
financed 
for 
three 
years 
by 
the 
Department 
for 
International 
Development 
(DFID) 
of 
the 
United 
Kingdom. 
A 
further 
seven 
service 
delivery 
contracts 
will 
be 
signed 
during 
the 
subsequent 
year 
and 
documents 
could be 
changed 
to reflect 
lessons 
learned 
from 
the 
first 
batch 
of 
contracts. 
These 
packages 
will 
include 
contracts 
for 
fishermen 
in 
Sindh, and ship-breakers and 
miners 
in 
Balochistan. 
Small Grants: 
As 
part 
of 
the 
project 
a 
small 
grants 
system 
will 
be 
established 
to: 
(i) 
help 
develop 
the 
capacity 
of 
NGOs 
and 
other 
institutions 
to 
carry 
out 
work on HIV/AIDS; 
(ii) 
allow 
small 
NGOs, and 
NGOs 
who 
have 
not 
previously 
worked 
in 
HIV, 
to develop a 
track record 
so 
they 
can eventually 
take 
on 
a 
greater 
role 
in 
HIV 
prevention; 
and 
(iii) 
create 
opportunities 
for 
testing 
and 
rigorously 
evaluating 
innovative 
approaches 
and carrying out 
needed 
operational 
research. 
NGOs, universities, and 
other 
organizations 
will 
submit 
project 
proposals 
using 
a 
standard 
format 
which 
will 
be 
evaluated 
by 
peer 
reviewers 
and 
a 
grant 
committee. 
Draft 
guidelines 
for 
this 
program 
have already 
been developed 
by 
the 
NACP. 
Project 
Component 
2 
- 
US$9.74 
million 
2. 
Improved 
HIV 
Prevention 
by 
the 
General 
Population 
This 
component 
would 
comprise 
four 
sets 
of 
activities: 
(a) 
Behavior 
change 
communication 
(BCC) 
aimed at 
the 
general adult 
popu1ation:The 
NACP 
has 
been 
conducting 
mass-media campaigns 
aimed 
at 
raising 
awareness 
of 
HN 
for 
more 
than 
seven 
years. 
While 
a 
recent 
evaluation 
demonstrated increased 
awareness 
of 
HN, 
there 
has 
actual 
preventive 
behaviors 
are 
still 
worrying. 
The 
Government 
has 
recently 
developed a 
communications 
strategy 
that 
addresses 
the 
need 
to 
improve 
HN 
prevention 
behaviors 
among 
the 
general 
adult 
population 
and 
the 
project 
would 
support 
the 
implementation 
of 
the 
new 
strategy. 
The behavioral 
objectives 
of 
these 
activities 
would 
be: 
(i) 
the 
use 
of 
condoms 
with 
non-regular sexual partners; 
(ii) 
use 
of 
STI 
treatment services 
when 
they 
have 
symptoms 
of 
STI 
and 
knowledge 
of 
the 
link 
between STIs 
and 
HIV; 
(iii) 
use 
of 
sterile 
syringes 
for 
all 
injections; 
-41 
- 
Page  48
(iv) 
reduction 
in 
the 
number 
of 
injections 
received; 
(v) 
voluntary 
blood 
donation (particularly 
among 
the 
age 
group 
18-30); 
(vi) 
use 
of 
only 
blood 
screened 
for 
HN; 
and 
(vii) 
displaying 
tolerant 
and 
caring 
behaviors towards people 
living 
with 
HIVIAIDS 
and 
members 
of 
vulnerable populations. 
These 
objectives 
would 
be 
achieved 
by 
a 
series 
of 
activities 
that 
would 
include 
mass-media campaigns 
and 
inter-personal 
communications (IPC) 
by 
lady health 
workers 
(LHWs). 
For 
the 
mass 
media 
campaigns, 
the 
NACP’s new 
strategy 
calls 
for: 
(i) 
recruitment 
on 
a 
competitive 
basis 
of 
an 
advertising 
firm 
to 
carry out 
the 
entire 
campaign 
using 
the 
same 
methods 
as 
private 
sector advertisers; 
(ii) 
explicit 
market 
segmentation 
so 
that advertisements and 
activities 
are 
specifically tailored 
to 
important 
sub-populations, 
especially young 
men 
and 
women, 
opinion 
leaders, 
and 
urban 
employed 
males; 
(iii) 
the 
conduct 
of 
formative 
research among 
the 
important 
sub-populations 
to 
better 
understand 
their 
knowledge, 
attitudes, 
and 
behaviors towards 
HIV; 
their 
viewing, 
reading, and 
listening 
habits; 
finding 
out 
what 
images 
and 
information 
would 
be 
convincing 
to 
them; 
all 
as 
a 
means 
for 
designing 
effective 
messages 
and advertisements; 
(iv) 
testing 
the 
messages 
and advertisements 
on 
members 
of 
the target audience 
to 
judge 
its 
likely 
effectiveness and 
provide 
feedback 
to 
the 
creative team 
of 
the 
advertising 
firm; 
(v) 
a 
much 
more 
extensive 
use 
of 
mass 
media, 
including 
print 
and 
radio 
spots 
in 
local 
languages; 
and 
(vi) 
follow-up 
surveys 
to judge 
the effectiveness 
of 
the 
mass 
media 
campaign. 
The 
IPC 
to 
be 
carried 
out 
by 
the 
LHWs 
will 
use 
specially 
designed materials 
aimed 
at 
informing 
women 
in 
the 
community 
and 
reinforcing 
the 
BCC 
messages 
that 
are 
being 
broadcast. 
(b) 
Advocacy: 
In 
the 
past, 
the 
Government 
has 
relied 
almost 
exclusively 
on 
workshops 
and 
seminars 
to 
raise 
awareness 
of 
decision 
makers 
and 
opinion 
leaders about 
HIVIAIDS. 
While 
the 
awareness 
of 
these 
groups 
may 
have increased, 
it 
is 
clear 
that 
future 
efforts 
must 
be 
more 
focused 
on 
changing 
behaviors 
and 
using 
other 
means 
to 
reach the 
opinion 
leaders. 
The 
NACP’s new 
communications 
strategy aims 
to 
have 
these 
groups: 
(i) 
appreciate 
the 
threat 
of 
HN 
to 
Pakistan; 
(ii) 
better 
understand 
the actions 
that 
can 
prevent a 
full-blown 
HIV 
epidemic; 
(iii) 
become 
effective 
sources 
of 
information 
for 
the 
rest 
of 
the 
community; 
(iv) 
take 
actions 
themselves 
to 
assist 
their 
communities 
to avoid 
HN; 
(v) 
provide 
continuous 
support 
for 
the 
AIDS 
control 
program; and 
(vi) 
help 
avoid 
stigmatization 
or 
harassment 
of 
vulnerable 
populations. 
To 
accomplish 
these 
objectives, 
priority 
will 
be 
given 
to 
the 
large 
cities, 
formative 
research 
will 
be 
undertaken, 
specific 
messages 
will 
be 
developed 
and 
tested 
for 
this 
group, and 
the 
messages 
will 
be 
employed 
in 
a 
number 
of 
innovative 
ways, 
including 
personal 
visits 
by 
influential 
personalities. 
(c) 
Targeted 
interventions 
for 
youth, 
the 
police, 
and 
formal 
sector 
workers: 
Pakistani external 
migrant 
workers 
will 
be 
reached 
through 
the 
Bureau 
of 
Immigration 
offices 
at 
Karachi, Lahore 
and 
Rawalpindi, 
using 
specially 
designed 
BCC 
materials. 
Similarly, 
employees 
of 
parastatal 
organizations 
will 
also 
receive 
BCC 
through 
existing 
facilities 
of 
the 
Ministry 
of 
Labor. 
Health 
workers 
of 
the Employees Social 
Institutions 
will 
be 
provided training 
on 
STIs 
using 
the 
syndromic 
approach. 
The activities 
with 
formal 
sector 
workers 
will 
be 
implemented 
through 
the 
Ministry 
of 
Labor 
with 
some 
financial 
and 
technical 
support 
coming 
from 
the 
International 
Labor 
Office 
and 
other 
UN 
agencies. 
In 
addition 
to 
the 
mass-media 
BCC 
that 
will 
be 
targeted 
at 
youth, 
IPC 
techniques 
will 
be 
used 
to 
reach 
a 
particularly 
high 
risk 
group, 
i.e., 
in-school 
youth 
in 
grades 
9 
and 
10 
in 
the 
large 
cities. 
NACP 
will 
carry out an 
assessment 
of 
the 
behavior 
of 
youth 
during 
the 
first 
year 
of 
the 
project 
and 
identify 
mechanisms 
for 
successfully 
reaching 
those 
most at 
risk. 
Project 
funds 
will 
be 
made 
available 
to 
implement 
the 
approaches 
developed 
by 
the 
assessment 
study 
in 
cooperation 
with UNFPA 
and 
UNICEF. 
Among 
uniformed 
personnel, 
the 
NACP 
and 
provincial 
AIDS 
control 
programs 
will 
strengthen advocacy 
- 
42 
- 
Page  49
activities 
for city 
police 
to 
create 
an 
enabling environment 
for 
the 
NGOs 
working 
with 
vulnerable populations. 
To 
reach 
new police 
recruits, 
advocacy 
sessions 
will 
be 
held 
at 
police 
academies. 
The 
NACP 
will 
also establish 
a 
liaison 
with 
the 
management 
of 
Pakistan 
Armed 
Forces 
Medical 
Crops 
to 
address 
HTV 
prevention 
issues. 
(d) 
Improved 
and 
expanded management 
of sexually 
transmitted 
infection 
(STI) 
cases: 
The 
project 
will 
support 
the 
improvement and 
expansion 
of 
STI 
case 
management based 
on 
a 
protocol 
developed 
by 
WHO 
and 
the 
Government 
that 
uses 
a “syndromic” 
approach. 
In 
the 
public 
sector diagnosis, treatment, 
and 
contact 
tracing 
will 
be 
expanded 
to 
all 
health facilities 
down to 
at 
least 
the 
district hospital 
level. 
In 
Sindh, where 
all 
district 
hospitals 
already have 
functioning 
STI 
clinics, 
there 
will 
be 
expansion 
down 
to 
the 
tehsil 
level. 
An 
ongoing 
experiment 
in 
Karachi 
of 
training 
private 
practitioners 
in 
the 
syndromic 
approach 
would 
be 
carefully 
evaluated and 
if 
successful, 
such 
training 
will 
be 
expanded 
to 
other 
large 
cities. 
The 
project 
will 
also support: 
(i) 
testing 
the 
feasibility 
of 
procuring 
STI 
drugs 
in 
blister 
packs 
and 
packaging 
them 
with 
condoms; 
(ii) 
recording 
and 
reporting forms 
developed 
by 
the 
Sindh 
ACP 
would 
be 
reviewed 
for 
adaptation 
by 
all 
the provinces; 
(iii) 
development 
of 
a 
check 
list 
for 
supervision 
of 
facilities 
providing 
STI 
services; 
and 
(iv) 
a 
review 
of 
the 
syndromic 
management 
protocols. 
Project Component 
3 
- 
US$7.68 
million 
3. 
Prevention 
of 
HIV/STI 
Transmission 
Through 
Blood 
Transfusion 
About 
1.2 
million 
units 
of 
blood 
are 
transfused 
annually 
in 
Pakistan and 
at 
least 
20% 
of 
blood 
used 
is 
inadequately 
tested 
for 
HIV 
and 
Hepatitis 
B. 
The 
actual 
figure 
may 
be 
higher 
because 
in 
many 
instances 
good 
records 
are 
not 
being 
kept, 
despite the existence 
of 
national 
guidelines. 
NWFP, 
the 
Punjab, 
and 
Sindh 
have 
passed 
legislation 
establishing 
blood transhsion 
authorities 
(BTAs). 
Unfortunately, 
none 
of 
these 
BTAs 
has 
been 
formally 
notified 
and 
so 
both 
the 
public 
and 
private 
sector 
blood 
banks 
are 
unregulated. 
In 
order 
to 
prevent 
the transmission 
of 
HTV 
and 
other 
STIs 
through 
blood 
transfusions, 
the 
project 
will 
support 
the 
following 
three 
sets 
of 
activities: 
Establishing 
and 
building 
the capacity 
of 
provincial 
blood transfusion 
authorities: 
Building 
on 
the 
successful experience 
in 
the Punjab, 
the 
project 
would 
help 
establish 
effective 
provincial 
BTAs 
and 
build 
their 
capacity 
to 
regulate 
private 
and 
public 
sector 
blood 
banks. 
The 
project 
would 
help 
by 
providing 
training, 
office 
equipment, 
and 
transport. 
Implementation 
of 
a 
quality 
assurance system: 
The 
project 
would 
support 
the 
operationalization 
of 
a robust and 
practical 
quality 
assurance 
system 
that 
would likely 
include 
laboratory 
proficiency 
testing, 
monitoring 
and 
supervision, 
improved record 
keeping, 
end 
use 
audits 
for 
test 
kits, 
and 
re-testing 
of 
screened 
blood 
by 
reference laboratories. 
Screening 
of 
blood 
for 
HIV 
and other 
STIs: 
The 
project 
would 
help 
provide 
the necessary 
materials 
and 
reagents 
for 
testing 
all 
blood 
in 
the 
public 
sector 
for 
HTV 
and 
hepatitis 
B. 
The 
introduction 
of 
hepatitis C 
outside Punjab, 
would 
be 
dependent 
on: 
(i) 
successful 
implementation 
of 
a 
quality 
assurance 
system 
that 
meets 
criteria 
to 
be 
established 
by 
the 
federal 
government 
(with 
technical 
assistance) 
as 
judged 
by 
a 
third 
party 
assessment; 
and 
(ii) 
the 
existence 
of 
records, reports, 
and 
a 
monitoring 
system 
that 
facilitate 
end-use 
audits 
and 
ensures 
reporting 
to 
the 
provincial 
and 
federal 
governments. 
-43- 
Page  50
(d) 
Waste 
management: 
In 
order 
to 
begin 
implementing 
the 
EMP, 
the 
Ministry 
of 
Health would 
develop 
guidelines 
for 
proper 
handling 
of 
wastes 
in 
blood 
banks 
and 
needle 
exchange 
programs. 
Staff 
of 
health 
facilities 
with 
blood 
banks and 
NGOs involved 
in 
needle 
exchange 
would 
be 
provided 
with 
training 
in 
these 
guidelines 
and 
the 
materials 
for 
properly 
handling 
bio-hazardous 
wastes. 
A 
systematic 
checklist 
that 
provides a 
score 
of 
compliance 
with 
the 
guidelines 
would 
be 
developed 
and 
used 
by 
third 
party 
auditors 
to monitor 
compliance. 
Project Component 
4 
- 
US$5.96 
million 
4. 
Capacity 
Building 
and 
Program 
Management 
An 
external 
review 
of 
the 
federal 
and 
provincial 
AIDS 
Control 
Programs 
in 
Pakistan 
has 
pointed 
out 
a 
number 
of 
institutional 
issues 
that 
need 
to 
be 
addressed 
if 
HIV 
prevention activities 
are 
to 
be 
successfully 
scaled 
up. 
Some 
of 
the 
issues 
identified 
included 
shortage 
of 
staff, 
particularly 
in 
the 
provincial 
AIDS 
Programs 
and 
the 
lack 
of 
managerial capacity 
of 
the government and 
NGOs 
to 
implement 
a 
much 
larger 
program. 
It 
is 
also 
clear 
that 
there 
is 
a dearth 
of 
high 
quality 
information 
about the 
epidemic and 
the 
success 
of 
prevention activities 
on 
the 
ground. 
In 
order 
to 
address 
these 
issues, 
the 
project 
would 
comprise 
four 
sets 
of 
activities. 
(a) 
Strengthening 
of 
federal and 
provincial 
AIDS 
Control 
Programs: 
The 
project 
would 
support 
the 
strengthening 
of 
the 
national 
and 
provincial 
AIDS 
control 
programs 
through: 
(i) 
recruitment 
of 
a 
firm 
to 
help 
build 
the 
capacity 
of 
the 
federal 
and 
provincial staff 
to 
manage 
contracts 
and 
carry 
out 
procurement; 
(ii) 
recruitment 
of 
more 
full 
time staff 
to work 
in 
the 
federal 
and 
provincial 
AIDS 
control 
programs; 
(iii) 
office 
support 
including 
furniture, 
equipment, vehicles, and 
access 
to 
the 
world 
wide 
web; 
(iv) 
an 
annual 
conference 
that 
would 
bring 
together 
staff 
from 
government, 
NGOs, 
and 
research 
institutions 
as 
well 
as 
international 
and 
local 
experts 
to 
discuss 
lessons learned, 
research 
findings 
in 
Pakistan, 
results 
of 
behavioral 
and sero-surveillance, 
and 
cutting 
edge 
research 
from 
other countries; 
(v) 
short 
term 
attachments 
of 
technical 
staff 
to 
other 
AIDS 
control 
programs 
in 
the 
region to 
learn 
first 
hand 
about 
the 
successes 
and 
difficulties 
encountered 
in 
areas 
such 
as 
workmg 
with 
NGOs, 
surveillance, 
and 
BCC. 
These 
attachments 
could 
take 
place 
in 
Bangladesh, 
Nepal, 
Thailand, 
or 
Cambodia. 
(b) 
NGO 
capacity development: 
Technical 
assistance 
and 
training 
would 
be 
provided to NGOs 
in 
bid 
preparation 
and 
proposal 
writing 
for 
the 
small 
grants. 
The 
project 
management 
and 
procurement 
firm 
would 
provide 
the 
winning 
bidders 
with 
assistance 
in 
general management 
procedures 
and project implementation 
techniques, 
including 
development 
of 
management 
information 
systems, 
report 
preparation, procurement, 
and 
monitoring 
and 
supervision. 
Staff 
from 
the 
winning 
NGOs 
would 
also 
be 
given 
the 
opportunity 
to 
visit 
other 
NGOs 
in 
the 
region 
who 
have 
been 
successful 
in 
working 
with 
vulnerable populations, 
for 
example, 
the 
work 
of 
Sonorgachi 
in 
Kolkota 
with 
FSWs. 
Technical 
support 
for 
the 
NGOs would 
be 
provided 
by 
other partners, 
particularly 
UNAIDS 
and 
UNICEF. 
(c) 
Second 
generation 
HIV 
surveillance and evaluation: 
Systematic 
behavioral 
surveillance 
and 
HW 
sero-prevalence 
surveillance 
would 
be 
undertaken among the 
vulnerable 
populations 
on 
an 
annual basis 
using 
consistent methodologies. 
The 
surveillance 
activities 
will 
be 
undertaken 
by 
a 
cell 
in 
the 
NACP 
which 
would 
also have 
staff 
based 
in 
each 
province. Technical 
and 
financial 
support 
for 
the surveillance 
activities 
will 
be 
provided 
by 
CIDA, 
although 
the 
project 
will 
provide additional 
funds 
to 
support 
these 
activities. 
The 
project 
will 
support 
the 
recruitment 
of 
an 
independent 
fidorganization 
to 
carry out evaluations 
of 
the 
different 
components, 
including: 
(i) 
interviews 
with 
members 
of 
the vulnerable 
populations 
in 
the 
areas 
- 
44 
- 
Page  51
covered 
by 
service 
delivery 
contracts; 
(ii) 
quality 
of 
care 
provided 
in 
public 
STI 
clinics; 
(iii) 
implementation 
of 
the 
quality 
assurance 
systems 
in 
blood 
banks; 
and 
(iv) 
household 
surveys 
to 
examine 
the 
effectiveness 
of 
the 
mass 
media 
campaigns. 
(d) 
Care 
for 
people 
living 
with 
AIDS: 
The 
project 
will 
support 
the 
care 
of 
people 
living 
with 
W/AIDS 
(PLWHA) 
through 
the 
establishment 
or 
strengthening 
of 
five 
units 
for 
HIVIAIDS 
management 
which would 
provide 
the 
following 
services: 
(i) 
counseling 
for 
patients 
and 
their 
families; 
(ii) 
treatment 
of 
opportunistic infections; 
(iii) 
palliative 
care; 
(iv) 
supportive 
care 
for 
the patient and 
their 
families; 
(v) 
linkages 
with 
other 
programs 
and 
services such 
as 
the 
Tuberculosis 
Control 
Program; 
and 
(vi) 
prevention 
of 
mother 
to 
child 
transmission 
of 
HIV 
in 
cases 
of 
W 
positive 
mothers 
who 
are 
referred. Such 
units 
would 
comprise 
staff 
with 
various 
skills 
and 
backgrounds 
who 
will 
receive 
training 
under 
the 
project. 
The 
project 
will 
also 
provide 
the 
medicines 
needed 
for 
these 
units. 
WHO 
will 
be 
requested 
to 
provide 
technical 
assistance 
to 
plan 
for 
the 
medium 
to 
long-term 
needs 
of 
a 
program 
of 
care 
for 
PLWHA. 
-45- 
Page  52
Annex 
3: 
Estimated 
Project 
Costs 
PAKISTAN: 
HIWAIDS 
Prevention 
Project 
Total Financing Required 
Improved 
HIV 
Prevention 
by 
the 
General 
Population 
Prevention 
of 
HIV/STI 
Transmission through 
Blood 
Transfusion 
Capacity 
Building 
and 
Program 
Management 
Total Baseline Cost 
Physical 
Contingencies 
Price 
Contingencies 
Total Proiect Costs’ 
36.80 
10.97 
I 
47.77 
11.81 
2.69 
7.30 
32.33 
1.61 
2.86 
36.80 
1 
Goods 
Civil Works 
Services 
Salaries and Operational Costs 
ITraining 
and 
Research 
1 
Total Project Costs 
Total Financing Required 
0.00 
6.52 
2.22 
8.98 
11.20 
0.00 
0.00 
0.00 
27.74 
1.76 
29.50 
4.37 
0.00 
4.37 
2.47 
0.23 
2.70 
36.80 
10.97 
47.77 
36.80 
10.97 
47.77 
3.25 
9.77 
0.49 
0.71 
10.97 
11.81 
9.21 
10.55 
42.10 
2.10 
3.57 
47.77 
3 
I 
Identifiable 
taxes 
and duties arc 
0 
(US%m) 
and the 
total 
project 
cost, 
net 
of 
taxes, 
is 
47.77 
(US$m). 
Therefore, 
the 
project 
cost 
sharing 
ratio 
is 
58.26% 
of 
total 
project 
cost net 
of 
taxes. 
-46- 
Page  53
Annex 
4: 
Cost 
Benefit Analysis 
Summary 
PAKISTAN: HlVlAlDS 
Prevention Project 
[For 
projects 
with 
benefits 
that 
are measured 
in 
monetary 
terms] 
Medical costs 
avoided (US$M) 
Lost earnings 
avoided (US$M) 
Total Benefits 
(US$M) 
265 
428 
694 
costs: 
HlVlAlDS 
Program 
Net 
Benefits: 
Present value 
of 
net 
I 
Not 
applicable 
47.1 
(132.5) 
25.2 
47.1 
(107.3) 
1 
benefits fUS$M) 
I 
I 
I 
I 
RR 
Not 
applicable 
1 
If 
the difference between 
the present 
value 
of 
financial and 
economic 
flows 
is 
large 
and 
cannot 
be 
explained 
by 
taxes 
and 
subsidies, a 
brief 
explanation 
of 
the difference 
is 
warranted, 
e.g. 
"The 
value 
of 
financial 
benefits 
is 
less 
than 
that 
of 
economic benefits 
because 
of 
controls 
on 
electricity 
tariffs." 
Summary 
of 
Benefits and 
Costs: 
In 
order 
to 
arrive 
at 
an 
estimate 
of 
the 
costs 
and 
benefits 
of 
theprogram, 
it 
should 
first 
be noted 
that 
there 
are 
three 
main 
types 
of 
benefits 
arising 
from 
an 
HIV/AIDS 
prevention 
program 
such 
as 
the 
one 
discussed 
in 
this 
PAD: 
(i) 
medical 
costs 
avoided 
on 
account 
of 
treatment 
of 
opportunistic infections 
and 
other secondary 
illnesses 
associated 
with 
full-blown 
AIDS; 
(ii) 
AIDS 
patients' 
lost 
earnings avoided; 
and 
(iii) 
the 
value 
of 
years 
of 
life 
lost 
avoided. 
In 
the 
present cost-benefit calculations, 
only 
(i) 
and 
(ii) 
have 
been 
included. 
All 
three 
types 
of 
benefits 
arise 
from 
the 
stream 
of 
new 
HN 
infections avoided 
as 
a 
consequence 
of 
the 
program. 
In 
addition 
to 
the 
main 
types 
of 
program 
benefits 
listed 
above, 
promoting 
safer sexual 
practices should 
have 
an 
effect 
not 
only 
in 
reducing 
the spread 
of 
HIV/AIDS 
but 
also 
of 
other sexually 
transmitted 
diseases 
such 
as 
syphilis 
and 
gonorrhea. 
Reducing 
the 
spread 
of 
HIV/AIDS 
is 
also 
likely 
to 
reduce 
the 
spread 
of 
pulmonary 
tuberculosis. 
As 
with 
HIV/AIDS, 
the 
economic 
benefits 
in 
all 
of 
these 
cases 
would 
consist 
of 
a 
combination 
of 
medical 
costs 
avoided and 
earnings 
lost avoided 
(plus 
value 
of 
years 
of 
life 
lost 
in 
the 
case 
of 
tuberculosis). 
These 
benefits 
have 
not 
been 
included 
in 
the 
cost-benefit calculations. 
Costs 
included 
in 
the 
calculations 
are 
the 
estimated 
costs 
for 
the 
entire 
program, regardless 
of 
source 
of 
financing. 
-47 
- 
Page  54
Costs 
pertain 
to 
the 
period 
2003-17, 
while 
benefits 
would 
start 
in 
201 
1 
and continue 
until 
2023 
(because 
of 
the 
lags 
involved, benefits 
from 
the 
program 
would 
be 
forthcoming 
for 
another 
six 
years 
after 
discontinuation 
of 
the 
program, 
falling to 
zero 
thereafter). 
The 
program 
in 
its 
present 
form 
is 
assumed 
to 
be 
discontinued 
after 
2017 
(with 
the 
strategy 
shifting 
at 
that 
time 
to 
universal 
vaccination 
against 
HIV). 
As 
indicated 
in 
the 
table 
above, 
the 
calculations 
in 
the 
base 
case 
yield 
apositive 
netpresent value 
for 
the 
program 
of 
US$647 
million 
(using 
a 
10% 
annual discount rate). 
About 
60% 
of 
the 
benefits 
are 
in 
the 
form 
of 
foregone earnings 
avoided 
during 
the 
stage 
of 
full-blown 
AIDS 
and 
the 
remaining 
40% 
in 
the 
form 
of 
medical 
treatment 
costs 
avoided 
during 
the 
same 
stage. 
The table also 
presents 
an estimate 
of 
theJiscal impact 
of 
the 
program 
in 
the 
2003-23 
period. 
The 
net 
estimated 
fiscal 
impact 
(Le., 
incremental 
fiscal 
gains 
in 
the 
form 
of 
additional tax 
revenues 
or 
expenditure 
savings, 
less 
incremental 
government outlays) 
is 
positive 
in 
the 
base 
case, 
at 
US$154.4 
million. 
This 
is 
obtained 
by 
adding 
the value 
of 
incremental 
tax 
revenues 
that 
would 
accrue 
to 
the 
Government 
on 
account 
of 
taxation 
on 
lost 
eamings 
avoided 
(US$47.1 
million, 
assuming 
an 
average 
rate 
of 
taxation 
of 
11% 
as 
estimated 
from 
studies 
in 
Pakistan) 
to 
the 
fiscal 
savings 
in 
the 
form 
of 
medical 
costs 
avoided that 
would 
have been 
incurred 
by 
government 
health facilities 
(assumed 
to 
be 
one-half 
of 
total medical 
costs, 
or 
US$132.5 
million), 
and 
then 
subtracting 
the 
present 
value 
of 
incremental 
government 
outlays 
(US$25.2 
million, 
which 
is 
equal 
to 
the 
sum 
of 
the 
present 
value 
of 
the 
government's 
share 
of 
project 
cost 
financing 
plus 
the 
present value 
of 
the 
repayments 
of 
the 
IDA 
credit). 
Cost-effectiveness 
Analysis 
It 
is 
possible 
that 
while 
the 
HIV/AIDS 
program 
presented 
in 
the 
PAD 
would 
have a 
positive 
NPV, 
there 
is 
some 
other 
program 
design 
or 
mix 
of 
interventions to combat 
HIViAIDS 
that 
would 
have a 
higher 
NPV, 
and 
on 
economic 
efficiency 
grounds 
would 
thus 
be 
preferable. 
Moreover, 
if 
a 
constraint 
were 
imposed 
that 
all 
of 
the 
alternative 
(mutually 
exclusive) 
programs considered 
should 
have the 
same 
total 
cost 
in 
present 
value, 
then 
the 
one 
with 
the 
highest 
NPV 
is 
likely 
also 
to 
be 
the one 
with 
the 
lowest 
unit 
cost 
per 
infection 
averted, 
but 
this 
outcome 
is 
not 
necessary 
since 
the 
distribution 
in 
time 
of 
the 
infections 
averted 
under 
the 
various alternatives 
would 
also 
be 
a factor. 
The 
program 
in 
this 
PAD 
basically 
seeks 
to 
scale 
up 
three 
types 
of 
interventions 
for 
the 
prevention 
of 
HIV/AIDS: 
Expansion 
of 
interventions 
for 
vulnerable populations 
- 
female 
sex 
workers, intravenous 
drug 
users, 
males 
who 
have 
sex 
with 
males, 
long-distance 
truck 
drivers 
and 
prisoners 
(28% 
of 
total 
program 
cost). 
This 
component 
would 
include 
behavior 
change 
communication, 
promotion 
of 
effective condom 
use, 
voluntary 
counseling 
and 
testing, 
proper 
management 
of 
STIs 
in 
the 
vulnerable 
groups, 
needle 
exchange 
for 
drug 
users. 
Improved 
HIVprevention 
by 
the 
general 
population 
(30%). 
This 
component 
would 
include 
behavior 
change 
communication 
aimed 
at 
the general 
adult population; 
advocacy; targeted 
interventions 
for 
youth, 
the 
police 
and 
formal 
sector workers; 
and 
improved 
and 
expanded 
management 
of 
sexually 
transmitted 
infection 
cases. 
- 
48 
- 
Page  55
(c) 
Prevention 
of 
HIV/STI 
transmission 
through 
blood 
transfusions 
(24%). 
This 
component 
would 
include 
screening 
of 
blood 
for 
HIV, 
major 
STIs, 
Hepatitis 
B, 
and 
possibly Hepatitis 
C 
(if 
the 
blood 
transfusion 
authorities 
are 
able 
to 
implement a 
quality 
assurance 
system 
in 
public 
blood 
banks). 
The 
remaining 
18% 
of 
total 
program 
cost 
is 
for 
capacity 
building 
and 
program 
management 
which would 
be 
required 
for 
the 
implementation 
of 
(i) 
to 
(iii) 
above. 
A 
recent 
report 
from 
UNAIDS 
entitled 
"Effective 
Prevention 
Strategies 
in 
Low 
HIV 
Prevalence Settings" 
attempts 
to 
summarize 
what 
has 
been 
leamt 
so 
far 
about 
prevention 
at 
the 
early 
stage 
of 
the 
epidemics. 
The 
report 
makes 
the 
point 
that 
extensive 
epidemiological 
evidence 
and 
modeling 
work both 
clearly 
show 
that 
the most 
efficient 
means 
for 
reducing 
epidemic spread 
is 
to 
reduce 
HIV 
transmission 
among 
those 
with 
higher 
rates 
of 
partner 
change 
--either sexual 
of 
needle-sharing. 
Transmission 
must 
be 
interrupted 
early 
among those sub-groups 
at 
higher 
risk. 
While 
no 
formal 
calculations 
of 
"cost-effectiveness" have 
been 
carried out 
for 
this 
project, 
it 
is 
likely 
that 
if 
the 
program 
only 
had 
resources 
equal 
to 
28% 
of 
what 
it 
is 
assumed 
to 
have 
in 
this 
PAD, 
all 
of 
the 
program's 
resources 
should 
be 
spent 
on 
intervention 
category 
(i) 
above, 
if 
cost-effectiveness were 
the 
only 
criterion 
used 
to 
select 
interventions 
for 
inclusion. 
As 
the 
resource envelope 
of 
the 
program 
expands, 
however 
(and 
assuming 
that capacity 
constraints 
or 
sharply 
rising 
marginal 
costs 
make greater 
spending 
on 
intervention 
(i) 
impossible 
or 
undesirable), 
it 
is 
less 
clear what 
the 
ranking 
of 
the 
remaining 
interventions 
would 
be. 
A 
recent 
optimization 
exercise 
in 
Honduras, 
for 
example, 
found 
that 
blood 
safety 
interventions 
only 
become 
part 
of 
the 
optimal 
package 
for 
HIV 
prevention 
at 
high 
levels 
of 
the 
resource envelope, 
but 
it 
should 
be 
taken 
into 
account that 
the 
investments 
that 
would 
be 
made 
on 
blood 
safety 
in 
the 
proposed 
program 
would 
have 
benefits 
beyond 
€€IV 
prevention 
(Le., 
there 
would 
also 
be 
benefits 
in 
terms 
of 
prevention 
of 
STIs and hepatitis 
B 
and 
C). 
The 
Honduras 
exercise also 
resulted 
in 
very 
low 
priority 
for 
workplace interventions 
and 
IEC 
(Information, 
Education 
and 
Communication) 
for 
pregnant women. 
Of 
course, 
the 
conditions 
in 
Honduras 
are 
different 
from 
those 
in 
Pakistan 
(HIV 
prevalence 
is 
much 
higher 
in 
the 
former), 
and 
moreover 
the 
list 
of 
interventions 
are 
not 
exactly 
the 
same, 
so 
the 
results 
for 
Honduras 
are 
not 
directly 
applicable. 
Main 
Assumptions: 
In 
the 
base 
case, 
it 
is 
assumed 
that 
in 
the 
absence 
of 
the 
program 
the 
HIV 
epidemic 
will 
resemble that 
in 
India, 
i.e. 
HIV 
prevalence 
in 
the 
general 
population 
increases 
to 
about 
0.4% 
in 
10 years. 
This 
means 
that 
the annual 
number 
of 
new 
HIV 
infections 
would 
increase 
by 
50% 
per 
year 
throughout 
the 
projection 
period. 
The 
program 
is 
assumed 
to 
be 
modestly effective 
and 
the 
annual 
rate 
of 
increase 
in 
new 
infections 
is 
assumed 
to 
slow down to 
45% 
in 
Year 
4, 
to 
40% 
in 
Year 
5, 
remaining 
at 
that 
level 
thereafter. 
The 
number 
of 
new 
infections 
in 
Year 
1 
of 
the 
projection 
(2003) 
is 
assumed 
to 
be 
5,000. 
With 
these 
assumptions, 
the 
number 
of 
new 
HIV 
infections 
that 
would 
be 
prevented 
in 
the 
2003-17 
period 
would 
be 
about 2.1 
million, which 
would 
be 
equivalent 
to 
about 47% 
of 
the 
total 
number 
of 
cases 
in 
the 
without-program situation 
--in 
other words, 
the 
program 
would 
permit 
to 
avert almost 
one-half 
of 
all 
cases. 
It 
is 
assumed 
that 
after 
15 years 
from 
the 
start 
of 
the 
program 
an 
effective 
vaccine 
would 
be 
available, 
which 
would 
prompt adoption 
of 
a 
different 
design 
of 
the 
HIV 
prevention 
program. 
- 
49 
- 
Page  56
Other assumptions 
for 
the 
cost-benefit 
calculation 
are: 
0 
0 
0 
Average 
number 
of 
years 
between 
infection 
and the onset 
of 
full-blown 
AIDS: 
5. 
Average 
number 
of 
years 
between the 
onset 
of 
full-blown 
AIDS 
and 
death: 2. 
Average annual cost 
per 
patient 
of 
medical 
treatment 
of 
opportunistic 
infections 
and 
other 
related 
illnesses 
during 
the 
full-blown 
AIDS 
stage 
(including 
both 
costs 
borne 
by 
the 
Government and 
by 
the patient): 
US$350. 
This 
estimate 
does 
not 
include 
the 
cost 
of 
anti-retroviral 
therapy. 
Average annual 
number 
of 
days 
of 
work 
lost 
per 
patient 
during 
the 
full-blown 
AIDS 
stage: 
130. 
Average earnings 
per 
worker 
(patient) 
per 
day: 
US$2.50 
in 
2002 
and increasing 
by 
3% 
per 
year 
in 
real 
terms 
thereafter. 
[The US$2.50 
number 
was 
obtained 
by 
using 
the 
formula 
{ 
[ 
(US$500 
x 
0.80) 
/ 
260 
days 
3 
I 
0.43 
} 
x 
0.70}, 
where 
US$500 
is 
the 
per 
capita 
income 
in 
2002; 
0.80 
is 
the 
percentage 
of 
national 
income 
paid 
out 
to 
labor; 
0.43 
is 
the 
proportion 
of 
the 
population 
in 
the 
labor 
force; and 
0.70 
is 
the 
proportion 
of 
those 
whose 
HN 
infections 
would 
be 
averted 
who 
would 
actually 
be 
employed]. 
Discount 
rate: 
10% 
per 
year. 
0 
0 
0 
In 
addition 
to 
the 
above, 
assumptions 
for 
the 
estimate 
offiscal 
impact 
are: 
0 
0 
About 
one-half 
of 
the 
costs 
of 
medical 
treatment 
of 
opportunistic 
infections 
and 
other 
HTV-related illnesses 
are 
borne 
by 
the 
Government. 
The 
tax 
rate 
on 
foregone earnings 
avoided 
is 
11% 
(mostly 
consisting 
of 
indirect 
taxes). 
The 
most 
uncertain 
(and 
critical) 
variable 
in 
the 
above estimate 
of 
Net 
Present 
Value 
is 
the 
estimate 
of 
the 
number 
of 
HN 
infections 
averted 
by 
the 
program. 
Alternative 
scenarios 
were examined 
in 
this 
regard. 
The 
number 
of 
infections 
averted 
is 
higher: 
(i) 
the 
higher 
the 
assumed 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new infections 
in 
the 
without-program 
situation; 
and 
(ii) 
the 
greater 
the 
difference 
between 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program situation 
as 
compared 
with 
the 
with-project 
situation. 
As 
noted 
above, 
the 
base 
case assumes 
that 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program 
situation 
would 
grow 
at 
a 
constant 
50%, 
while 
in 
the 
with-project situation 
the rate 
of 
increase 
would 
decline 
gradually 
to 
40% 
and 
remain 
at 
that 
level 
thereafter. 
But 
even 
if 
the 
annual 
rate 
of 
increase 
of 
infections 
declined 
to 
only 
45% 
in 
the 
with-project 
situation, 
the 
NPV 
of 
the 
program 
would 
still 
be 
positive 
(US$371 
million). 
Alternatively, 
with 
a rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
of 
only 
30% 
(instead 
of 
50%) 
in 
the 
without-program 
situation, 
the 
NPV 
of 
the 
program 
is 
still 
positive 
(at 
US$42 
million) 
if 
the 
difference between 
the 
two 
scenarios 
is 
again 
only 
5 
percentage 
points 
starting 
in 
Year 
4. 
The 
NPV 
is 
about zero 
if 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
is 
assumed 
to 
be 
20% 
in 
the 
without-program situation and 
five 
percentage 
points 
less 
(1 
5%) 
in 
the 
with-program 
situation. 
Based 
on 
these 
calculations 
it 
is 
likely 
that 
the 
NPV 
of 
the 
program 
would 
be 
positive. 
Sensitivity analysis 
I 
Switching 
values 
of 
critical 
items: 
The 
most uncertain 
(and 
critical) 
variable 
in 
the 
above estimate 
of 
Net 
Present 
Value 
is 
the estimate 
of 
the 
number 
of 
HN 
infections 
averted 
by 
the 
program. 
Alternative 
scenarios 
were 
examined 
in 
this 
regard. 
The 
number 
of 
infections 
averted 
is 
higher: 
(i) 
the 
higher 
the 
assumed 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program 
situation; 
and 
(ii) 
the greater 
the 
difference 
between 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program situation 
as 
- 
50 
- 
Page  57
compared 
with 
the 
with-project 
situation. 
As 
noted 
above, 
the 
base 
case assumes 
that 
the 
annual 
number 
of 
new 
infections 
in 
the 
without-program 
situation 
would 
grow 
at 
a constant 
50%, 
while 
in 
the 
with-project situation 
the 
rate 
of 
increase 
would 
decline 
gradually 
to 
40% 
and 
remain 
at 
that 
level 
thereafter. 
But 
even 
if 
the 
annual 
rate 
of 
increase 
of 
infections declined 
to 
only 
45% 
in 
the 
with-project 
situation, 
the 
NPV 
of 
the 
program 
would 
still 
be 
positive 
(US$371 
million). 
Alternatively, 
with 
a 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
of 
only 
30% 
(instead 
of 
50%) 
in 
the 
without-program 
situation, 
the 
NPV 
of 
the 
program 
is 
still 
positive 
(at 
US$42 
million) 
if 
the 
difference between 
the 
two 
scenarios 
is 
again 
only 
5 percentage 
points starting 
in 
Year 
4. 
The 
NPV 
is 
about zero 
if 
the 
rate 
of 
increase 
in 
the 
annual 
number 
of 
new 
infections 
is 
assumed 
to 
be 
20% 
in 
the 
without-program situation 
and 
five 
percentage 
points 
less 
(15%) 
in 
the 
with-program 
situation. 
Based 
on 
these 
calculations 
it 
is 
likely 
that 
the 
NPV 
of 
the 
program 
would 
be 
positive. 
-51 
- 
Page  58
Annex 
5: 
Financial Summary 
PAKISTAN: 
HIVIAIDS Prevention Project 
Years Ending 
I 
Year1 
I 
year2 
I 
Year3 
I 
year4 
1 
Year5 
I 
Year6 
I 
Year 
7 
Total Financing Required 
Project 
Costs 
Investment 
Costs 
2.9 
1.9 
1.9 
1.7 
1.6 
Recurrent Costs 
4.8 
6.4 
8.6 
8.2 
9.8 
Total Project Costs 
7.7 
8.3 
10.5 
9.9 
11.4 
0.0 
0.0 
Total 
Financing 
7.7 
8.3 
10.5 
9.9 
11.4 
0.0 
0.0 
I 
Financing 
IBRDllDA 
Government 
Central 
Provincial 
Co-financiers 
User 
FeeslBeneficiaries 
Other 
Total Project Financing 
5.5 
6.0 
1.1 
6.4 
0.0 
0.0 
0.0 
0.0 
1.1 
1.1 
0.0 
0.0 
0.0 
0.0 
7.7 
13.5 
7.4 
1.2 
0.0 
0.0 
1.9 
0.0 
0.0 
10.5 
8.6 
1.3 
0.6 
0.7 
0.0 
0.0 
0.0 
9.9 
9.6 
1.8 
0.0 
0.0 
0.0 
0.0 
0.0 
11.4 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
0.0 
Main 
assumptions: 
- 
52 
- 
Page  59
Annex 6(A):  Procurement  Arrangements 
PAKISTAN 
: 
H IVlAl 
DS 
Prevention Project 
Procurement 
Procurement 
Capacity 
1. 
Procurement 
Accredited 
Staff 
(PAS). 
The 
main 
findings 
are 
as 
follows: 
A 
procurement capacity 
assessment 
of 
the 
Implementing 
Agencies’ was 
carried 
out 
by 
a 
Organization 
2. 
The 
existing 
procurement capacity 
of 
the 
implementing 
agencies 
i.e. 
the 
National and 
Provincial/AJK 
AIDS 
Control 
Programs, 
requires strengthening 
to 
be 
able 
to 
effectively carry out 
the 
expected 
project 
procurement 
in 
accordance 
with 
agreed procedures. 
The 
existing staff 
have 
little 
knowledge and 
experience 
of 
IDA’s 
procurement 
procedures. 
While 
some 
staff 
have 
been 
involved 
in 
the 
Government’s 
own 
procurement 
of 
goods, 
they 
have 
not had 
any 
exposure 
to 
procurement under 
IDA 
financed 
projects, 
particularly 
of 
consultants’ 
services. 
3. 
The 
procurement capacity 
of 
the 
implementing 
agencies 
will 
be 
strengthened 
through 
engagement 
of 
consultants 
and training 
to 
enable 
the 
implementing 
agency 
to 
effectively carry out 
procurement 
under the project. 
The 
National 
AIDS 
Control 
Program 
(NACP)  at 
the 
federal 
level 
will 
engage 
through 
DFID 
financing 
a 
qualified individual 
procurement consultant 
to work 
full 
time 
during 
the 
first 
year 
of 
the 
project. 
A 
part-time 
consultant 
is 
already 
working 
on 
procurement 
issues. 
Shortly 
after 
effectiveness,  a 
Procurement 
and 
Management 
Consulting 
firm 
will 
be 
recruited. 
The 
firm 
and 
the 
individual 
procurement 
consultant 
will 
serve 
as 
the 
focal 
point for 
all 
procurement matters under 
the 
project, 
will 
provide 
comprehensive 
procurement 
assistance 
and 
guidance, 
including 
procurement 
planning 
and 
monitoring, preparation 
of 
bidding 
documents, 
and 
evaluation 
of 
bids 
and 
contracts 
to 
NACP 
and the 
provincial 
AIDS 
control 
programs. 
4. 
procurement 
staff 
of 
the 
implementing 
agencies, 
before the 
start 
and 
during 
implementation 
of 
the 
project, 
in 
order 
to improve their knowledge 
of 
IDA’s 
procurement 
procedures. 
The 
first 
of 
these 
workshops 
has 
already 
been 
conducted. 
IDA 
will 
assist 
in 
capacity 
building 
by 
conducting 
procurement 
training 
workshops 
for 
key 
Procurement Procedures 
5. 
The 
procurement 
procedures 
of 
the 
implementing 
agencies 
were reviewed. Procurement 
procedures were 
found 
to 
be 
broadly 
based 
on 
competitive 
methods 
of 
selection. 
There 
is 
also 
a 
system 
for 
internal 
reviewlclearances 
through 
established purchase committees. 
It 
was 
however 
noted 
that 
there 
are some 
differences 
between 
the 
procurement 
procedures 
of 
the 
implementing 
agencies 
and 
IDA, 
such 
as 
preferences 
to 
registered 
firms 
in 
terms 
of 
lower 
performance 
security 
requirements 
than 
unregistered 
firms; 
the practice 
of 
price 
negotiations, 
etc. 
which 
are 
unacceptable 
under 
IDA 
procedures. 
Such 
differences 
will 
be 
removed through application 
of 
IDA’s 
Procurement 
Guidelines 
which 
will 
govern 
all 
procurement 
of 
Goods 
financed 
under the Project. 
Consultants’ 
services 
will 
be 
procured 
in 
accordance 
with 
IDA’s 
Consultant Guidelines. 
The 
specific procurement 
arrangements 
described 
below 
are 
designed 
to 
ensure 
conformity 
with 
the 
Bank’s 
procurement 
procedures. 
6. 
Procurement 
under 
IBRD 
Loans and 
IDA 
Credits, January 
1995, 
revised 
January 
1999. 
Consultants 
Goods 
to 
be 
financed 
under the 
project 
shall 
be 
procured 
in 
accordance 
with 
the 
Guidelines 
for 
- 
53 
- 
Page  60
Services 
financed 
under 
the 
project 
shall 
be 
procured 
in 
accordance 
with 
the 
Guidelines 
for 
Selection 
and 
Employment 
of 
Consultants 
by 
World 
Bank 
Borrowers, 
January 
1997, 
revised 
January 
1999, 
and 
May 
2002. 
In 
case 
of 
conflict 
between 
IDA’S 
procurement procedures 
and 
any 
national 
rules 
and regulations, 
IDA’S 
procurement 
procedures 
would 
take 
precedence. 
7. 
The 
Bank’s 
Standard 
Bidding 
Documents and 
bid 
evaluation forms 
for 
procurement under 
International Competitive 
Bidding 
(ICB) 
and 
sample 
bidding 
documents 
and 
bid 
evaluation 
forms 
for 
procurement 
under 
National 
Competitive 
Bidding 
(NCB) 
which 
are 
already 
in 
use 
on 
other 
IDA 
financed 
projects 
in 
Pakistan, 
will 
be 
used 
for 
procurement 
of 
Goods. 
IDA’s 
Standard 
Request 
for 
Proposal 
document 
and evaluation 
form 
will 
be 
used 
in 
the 
selection 
of 
Consulting 
firms. 
8. 
General Procurement 
Notice 
(GPN) 
that 
is 
published 
in 
the 
United 
Nations; Development 
Business 
(UNDB). 
A 
consolidated 
GPN 
for 
the 
whole project 
has 
already been 
published 
in 
UNDB 
on 
February 
16, 
2002, 
and 
will 
be 
updated 
annually. 
All 
expected 
procurement 
of 
goods, 
works 
and 
consultants’  services 
will 
be 
listed 
in 
the 
project’s 
Goods 
9. 
Goods 
under 
the 
Project 
would 
generally 
include: 
(i) 
Diagnostic/Screening 
Kits 
(ii) 
Laboratory 
equipment 
and 
supplies 
(iii) 
Pharmaceuticals 
(iv) 
Non-Drug itemdmedical 
goods 
(v) 
Vehicles 
(vi) 
Office 
equipment 
and 
supplies 
(vii) 
Printing 
10. 
estimated 
to 
cost 
more 
than 
US$200,000 
equivalent. Diagnostic/Screening 
Kits, 
which 
constitute 
approximately 
70% 
of 
the 
total 
value 
of 
goods 
under 
the 
project, 
will 
be 
procured 
mainly 
through 
the 
World 
Health 
Organization 
(WHO). 
Preference 
will 
be 
allowed 
for 
domestically 
manufactured 
goods 
under 
ICB 
contracts. 
International Competitive 
Bidding 
(ICB) 
procedures 
will 
be 
followed 
for 
each 
contract 
for 
goods 
11. 
contract 
up 
to 
an 
aggregate 
amount 
not to 
exceed US$1.63 
million 
are 
expected 
to 
be 
procured 
through 
National 
Competitive 
Bidding 
(NCB) 
procedures acceptable 
to 
IDA. 
Small 
value 
off-the-shelf 
goods 
estimated 
to 
cost US$30,000 
equivalent 
or 
less 
per 
contract 
and 
up 
to 
an aggregate 
ceiling not 
to 
exceed 
US$1.59 
million 
are 
expected 
to 
be 
procured 
following 
National 
Shopping 
procedures 
in 
accordance 
with 
the Procurement 
Guidelines. 
Contracts 
for 
goods estimated 
to 
cost 
between 
US$30,000 
equivalent and 
US$200,000 
per 
Improvement 
of 
Bidding 
Procedures 
under 
National 
Competitive 
Bidding 
12. 
Works 
under 
National 
Competitive 
Bidding, 
in 
order 
to 
ensure 
economy, 
efficiency, 
transparency and 
broad 
consistency 
with 
the 
provisions 
of 
Section 
1 
of 
the 
Guidelines: 
The 
following 
improvements 
in 
bidding 
procedures 
will 
apply 
to 
all 
procurement 
of 
Goods and 
Invitation 
to 
bid 
shall 
be 
advertised 
in 
at 
least one 
national 
newspaper 
with 
a 
wide 
circulation, at 
least 
30 
days 
prior 
to 
the 
deadline 
for 
the 
submission 
of 
bids; 
bid 
documents 
shall 
be 
made available, 
by 
mail 
or 
in 
person, 
to 
all 
who 
are 
willing 
to 
pay 
the 
. 
- 
54 
- 
Page  61
required 
fee; 
foreign 
bidders 
shall 
not 
be 
precluded 
from 
bidding 
and 
no 
preference 
of 
any 
kind 
shall 
be 
given to 
national 
bidders 
in 
the 
bidding 
process; 
bidding 
shall 
not 
be 
restricted 
to 
pre-registered 
firms; 
qualification 
criteria 
shall 
be 
stated 
in 
the 
bidding 
documents; 
bids 
shall 
be 
opened 
in 
public, immediately 
after 
the 
deadline 
for 
submission 
of 
bids; 
bids 
shall 
not 
be 
rejected 
merely 
on 
the 
basis 
of 
a comparison 
with 
an 
official 
estimate 
without 
the 
prior 
concurrence 
of 
the Association; 
before rejecting 
all 
bids 
and 
soliciting new 
bids, 
the 
Association’s 
prior 
concurrence 
shall 
be 
obtained; 
bids 
shall 
be 
solicited 
and contracts 
shall 
be 
awarded 
on 
the 
basis 
of 
unit 
prices and 
not 
on 
the 
basis 
of 
a 
composite 
schedule 
of 
rates; 
contracts 
shall 
not 
be 
awarded 
on 
the 
basis 
of 
nationally 
negotiated 
rates; 
contracts 
shall 
be 
awarded 
to 
the lowest 
evaluated 
and 
qualified 
bidder; 
and 
post-bidding 
negotiations shall 
not 
be 
allowed 
with 
the 
lowest 
evaluated 
or 
any 
other 
bidders. 
. 
* 
. 
‘ 
* 
. 
. 
. 
Consultants’  Services 
13. 
more 
than 
USS100,OOO 
per 
contract 
will 
be procured 
in 
accordance 
with 
Quality 
and Cost 
Based 
Selection 
procedures. 
Contracts estimated 
to 
cost 
less 
than 
US$lOO,OOO 
per 
contract 
may be 
procured 
through 
the 
method 
of 
Selection 
Based 
on 
Consultants’ 
Qualifications. 
Contracts 
with 
individual 
consultants 
will 
be 
procured 
in 
accordance 
with 
the 
provisions 
of 
Section 
V 
of 
the 
Consultants 
Guidelines. 
Contracts 
with 
consulting 
firms/NGOs, 
including 
the 
service 
delivery 
contracts, estimated 
to 
cost 
Procurement 
Planning 
14. 
case 
of 
consultants’ 
services, 
each 
implementing 
agency 
will 
prepare 
and 
provide 
for 
IDA’s 
review, 
updated annual procurement 
plans 
for 
Goods 
and 
Consultants’  Services. 
Preliminary 
procurement 
plans 
for 
goods 
and 
consultants’ services expected 
to 
be procured 
during 
the 
first 
year 
of 
the 
Project 
have 
been 
provided 
to 
IDA 
and 
are 
available 
in 
IDA’s 
files. 
Procurement  under 
the 
project 
will 
be 
carried out 
in 
accordance 
with 
the 
agreed procurement 
plan. 
Procurement 
plans 
will 
be 
closely 
monitored 
and updated 
on 
a 
quarterly 
basis. 
Prior to 
issuing 
the 
first 
invitation 
for 
bids 
in 
the 
case 
of 
goods 
and 
request 
for 
proposals 
in 
the 
Review 
of 
Procurement 
by 
the 
Bank 
(Table 
B) 
15. 
Prior 
Review: 
The 
following 
contracts 
will 
be 
subject 
to 
IDA’s 
prior 
review: 
0 
0 
The 
first 
NCB 
contract 
for 
Goods, 
irrespective 
of 
value, 
by 
each 
implementing 
agency 
and 
thereafter each contract 
for 
Goods estimated 
to 
cost 
USSlO0,OOO 
equivalent 
or 
more. 
The 
first 
Consultants’  Services 
contract 
with 
consulting 
firms, 
irrespective 
of 
value, 
by 
each 
implementing 
agency 
and 
thereafter 
each 
contract 
with 
firms 
estimated 
to 
cost 
USS50,OOO 
or 
more. 
The 
first 
consulting 
services 
contract 
with 
individual 
consultants, 
irrespective 
of 
value, 
by 
each 
implementing 
agency 
and 
thereafter each 
contract 
with 
individuals 
estimated 
to 
cost 
US$25,000 
equivalent 
or 
more. 
e 
- 
55 
- 
Page  62
16. 
All 
other contracts 
will 
be 
subject 
to 
Post-Review 
by 
IDA. 
The 
National 
AIDS 
Control 
Program 
will 
send 
to 
the 
Bank 
on 
a 
quarterly 
basis, 
a 
list 
of 
all 
contracts 
under 
the 
project 
subject 
to 
post-review. 
Procurement 
Information 
and 
documentation 
17. 
Procurement 
information 
will 
be 
recorded 
and 
reported 
as 
follows: 
Complete 
procurement 
documentation 
for 
each 
contract, 
including 
bidding 
documents, 
advertisements, 
bids 
received, 
bid 
evaluations, 
letters 
of 
acceptance, 
contract 
agreements, 
securities, 
related 
correspondence 
etc., 
will 
be 
maintained 
by 
each 
implementing 
agency 
in 
an orderly 
manner 
so 
as 
to 
be 
readily 
available 
for 
audit. 
Contract 
award 
information 
will 
be 
promptly 
recorded 
and 
contract 
rosters, 
in 
IDA’S 
sample 
format, 
maintained 
by 
each 
implementing 
agency. 
Comprehensive 
quarterly reports 
by 
each 
implementing 
agency 
indicating: 
(i) 
(ii) 
revised 
cost 
estimates, 
where applicable, 
for 
each contract; 
status 
of 
on-going 
procurement, 
including 
a 
comparison 
of 
originally 
planned 
and 
actual 
dates 
of 
the 
procurement 
actions, 
including 
preparation 
of 
bidding 
documents, 
advertising, 
bidding, 
evaluation, contract 
award 
and 
completion 
time 
for 
each 
contract; 
and 
(iii) 
updated procurement 
plans, 
including 
revised 
dates, 
where 
applicable, 
for 
the 
procurement actions. 
- 
56 
- 
Page  63
Table A: 
Project 
Costs 
by 
Procurement 
Arrangements 
(USS 
million 
equivalent) 
I 
Total 
Project 
Cost 
Procurement methods (Table 
A) 
0.65 
1.63 
40.42 
5.06 
47.77 
(0.55) 
(1.39) 
(29.50) 
(0.00) 
(37.11) 
Figures 
in 
parenthesis 
are 
the 
amounts 
to 
be 
financed 
by 
the 
IDA 
Financing. 
Includes 
goods 
to 
be 
procured 
through 
WHO, 
national 
shopping, consultants' 
services, 
and training. 
I 
2 
- 
57 
- 
Page  64
Table 
AI 
: 
Consultant Selection Arrangements (optional) 
(US$ 
million 
equivalent) 
Including 
contingencies 
Note: QCBS 
= 
Quality- 
and 
Cost-Based 
Selection 
QBS 
= 
Quality-based 
Selection 
SFB 
= 
Selection 
under 
a Fixed 
Budget 
LCS 
= 
Least-Cost 
Selection 
CQ 
= 
Selection 
Based 
on 
Consultants' Qualifications 
Other 
= 
Selection 
of 
individual consultants (per Section 
V 
of Consultants Guidelines), Commercial 
Practices, etc. 
N.B.F. 
= 
Not Bank-financed 
Figures in parentheses 
are 
the amounts 
to 
be financed 
by 
the 
Bank Credit. 
- 
58 
- 
Page  65
Prior review thresholds 
(Table 
B) 
1. 
Works 
2. 
Goods 
Table 
B: 
Thresholds for Procurement Methods and Prior Review 
(US$7) 
>200,000 
ICB 
All 
100,000-200,000 
NCB 
All 
30,000-1 
00,000 
NCB 
First 
contract 
<30,000 
NS 
None 
13. 
Services 
Firms 
Individuals 
>100,000 
50,000-1 
00,000 
<50,000 
>25,000 
<25.000 
QCBS 
SBCQ 
SBCQ 
Section 
V 
- 
CG 
Section 
V 
- 
CG 
(USSl9) 
All 
All 
First 
contract 
All 
First 
contract 
4. 
Miscellaneous 
5. 
Miscellaneous 
6. 
Miscellaneous 
Total value of contracts subject to prior review: 
Frequency 
of 
procurement 
supervision 
missions 
proposed: 
US$26 
million 
One 
every 
6 
months 
(includes 
special 
procurement 
supervision 
for post-reviewlaudits) 
Overall Procurement Risk Assessment: 
High 
- 
59 
- 
Page  66
Annex 
6(B): 
Financial Management and Disbursement Arrangements 
PAKISTAN: 
HIVIAIDS Prevention Project 
Financial Management 
1. 
Summary 
of 
the 
Financial 
Management 
Assessment 
After 
lengthy 
consultations 
with 
stakeholders, 
the 
Ministry 
of 
Finance 
has 
indicated 
that projects 
financed 
by 
the 
multilateral 
development banks 
will 
use 
special accounts 
and personal ledger 
accounts 
to 
disburse 
funds. 
In 
order 
to 
ensure 
that 
these 
accounts 
work 
effectively 
and 
efficiently, 
a 
comprehensive 
Financial 
Information 
System 
(FIS) 
has 
been developed 
for 
the 
project 
by 
a 
Financial 
Management 
Consultant 
(FMC). 
The 
FIS 
has 
been 
structured 
to 
meet 
the 
accounting, 
financial 
reporting, 
auditing 
and 
internal 
control 
requirements 
of 
the 
Bank 
and 
the 
Government 
of 
Pakistan. 
The 
personal leger 
accounts 
will 
only 
be 
replenished 
on 
the 
basis 
of 
reimbursed 
claims 
for 
elgible 
expenditures.The 
funds 
flow 
arrangements 
and 
the 
financial 
management 
system 
have 
been 
described 
in 
a manual 
of 
financial 
procedures 
that 
has 
been 
approved 
by 
the 
GOP. 
In 
the 
absence 
of 
qualified 
accounting 
staff 
at 
the federal 
level 
a Finance 
Manager 
has 
been 
recruited 
to 
assist 
the 
National 
Aids 
Control 
Program 
(NACP) 
Coordinator 
in 
designing 
and 
implementing 
an 
adequate 
financial 
management 
system 
and 
head 
the 
finance 
function 
of 
the 
project. The 
provincial 
AIDS 
programs have 
recruited 
full 
time 
staff to 
work on 
the 
financial 
management 
aspects 
of 
the 
program. 
The 
HIV/AIDS 
prevention project 
will 
be 
implemented 
by 
the 
Ministry 
of 
Health 
at 
the 
Federal, 
Provincial 
and selectively at 
the 
District 
levels. 
There 
will 
be 
Federal and 
Provincial 
Project 
Managers 
and 
District 
Coordinators 
who 
will 
be 
responsible 
for 
the 
implementation 
of 
the 
project 
at 
the 
various 
levels. 
Other Government 
departments 
like 
Labor, 
Education, 
Police 
etc 
will 
also 
implement 
parts 
of 
the 
project. 
NGO's 
will 
be 
contracted 
to 
deliver 
services 
on 
a 
competitive 
basis 
at the Federal and 
Provincial 
levels. 
2. 
Audit 
Arrangements 
The 
accounts 
and 
financial 
statements 
of 
the 
Program 
for 
the 
fiscal 
years 
ending 
June 
30 
will 
be 
audited 
by 
the 
Auditor 
General 
of 
Pakistan 
under 
the 
usual 
TOR 
acceptable 
to 
the 
Bank. 
The 
auditors 
shall 
commence 
the 
audit 
by 
September 
30, 
and 
submit 
the 
audited 
accounts 
and 
their 
report 
thereon 
by 
December 
3 
1 
each year. 
Funds 
provided to 
other 
Government departments 
or 
ministries 
will 
flow 
through 
the 
respective 
National or Provincial 
AIDS 
Control 
Program and 
will 
be 
accounted 
for 
in 
the 
latter's 
financial 
statements, SOEs 
and special 
accounts. 
The 
following 
six 
audit 
reports 
(one 
for 
the 
NACP 
and 
one 
each 
for 
each 
of 
the 
provincial 
AIDS 
Control 
Programs, 
including 
AJK) 
will 
be 
monitored 
in 
Audit 
Reports 
Compliance 
System (ARCS): 
- 
60 
- 
Page  67
Implementing 
Agency 
[Audit 
I 
Auditors 
Provincial 
and 
AJK 
AIDS 
Control 
IPLA, 
special account, 
financial 
/Auditor 
General 
of 
Pakistan 
Programs 
National 
AIDS 
Control 
Program 
statement 
(ie., 
the 
Sources 
and 
Uses 
of 
Funds 
Statement and 
SOE) 
PLA, 
special 
account, 
financial 
statement 
(Le., 
the 
Sources 
and 
Uses 
of 
Funds 
Statement 
and 
SOE’I 
Auditor 
General 
of 
Pakistan 
3. 
Disbursement Arrangements 
The 
IDA 
Credit 
of 
SDR 
__ 
million 
(US$27.74 
million 
equivalent) 
and the 
IDA 
Grant 
of 
SDR 
__ 
million 
(US$9.24 
million) 
would 
be 
disbursed 
over 
a 
period 
of 
five 
years. 
Disbursement 
from 
the 
IDA 
credit 
and 
grant 
would 
be 
made 
in 
the 
traditional 
system 
(replenishment 
and 
reimbursement 
with 
full 
documentation 
and 
against statement 
of 
expenditures). 
The 
final 
disbursement 
is 
anticipated to 
made 
by 
September 
30,2008. 
Allocation 
of 
Credit 
and 
Grant 
proceeds 
under 
the 
proposed 
project 
will 
be 
made 
as 
indicated 
in 
Table 
C. 
-61 
- 
Page  68
Allocation 
of 
credit proceeds (Table 
C) 
0.17 
Table C: 
Allocation of 
Credit Proceeds 
procured 
locally 
100% 
of 
foreign 
<quipment/Fumiture/Vehicles 
4.6 
1.76 
)rugs 
and Supplies 
expenditures; 
100% 
of 
local 
expenditures (ex 
factory 
cost); 
and 
80% 
of 
local 
expenditures 
for 
other 
items 
procured 
locally. 
95% 
of 
expenditures 
until 
June 
30,2004; 
90% 
of 
expenditures 
until 
June 
30,2005; 
85% 
of 
expenditures 
until 
June 
30,2006; 
80% 
of 
expenditures 
until 
June 
30,2007; 
and 
70% 
of 
expenditures 
until 
June 
30,2008. 
95% 
of 
expenditures 
until 
June 
30,2005; 
90% 
of 
expenditures 
until 
June 
30,2006; 
80% 
of 
expenditures 
until 
June 
30,2007; 
and 
70% 
of 
expenditures 
until 
June 
30.2008. 
rest 
Kits 
for 
KIV, 
Hepatitis 
B 
21.71 
’est 
Kits 
for 
Hepatitis 
C 
90% 
of 
expenditures 
for foreign 
firms 
or 
individuals, and 98% 
of 
expenditures 
for 
local 
firms 
or 
individuals, 
and 
100% 
of 
expenditures 
for 
training: 
:onsultant’s services 
and 
training 
factory 
cost); 
and 
80% 
of 
local 
expenditures 
I 
- 
62 
- 
Page  69
Incremental 
staff 
and 
operating 
costs 
Small 
grants 
80% 
of 
expenditures 
til 
June 
30,2005, 
til 
June 
30,2007, 
of 
expenditures 
and 
40% 
of 
expenditures 
until 
2.17 
June 
30,2008 
disbursed 
0.62 
100% 
of 
amounts 
Total 
Project 
Costs 
Total 
IUnallocated 
I 
4.70 
I 
37.11 
47.77 
Use 
of 
statements 
of 
expenditures 
(SOEs): 
Disbursement 
will 
be 
on 
the 
basis 
of 
the 
statement 
of 
expenditures 
for 
(a) 
goods 
(equipment 
) 
for 
contracts 
not 
exceeding 
US$lOO,OOO; 
(b) 
consultant 
firms 
contracts 
not 
exceeding 
US$50,000 
and 
individuals 
not 
exceeding US$25,000; and 
(c) 
training, workshop 
and 
study 
tours; 
and 
(d) 
incremental 
operating 
and maintenance costs. 
Special 
account: 
Six 
Special 
Accounts 
with 
a 
total 
of 
USS3.0 
million 
will 
be 
established 
at 
the 
National 
Bank 
of 
Pakistan 
to 
meet 
anticipated 
expenditures 
of 
about 
four 
months. 
The 
six 
special accounts 
will 
be 
for 
NACP 
(US$700,000), 
Punjab 
(US$700,000), 
Sindh 
(USS700,000), 
NWFP 
(US$400,000), 
Balochistan 
(USS300,000), 
and 
AJK 
(US$200,000). 
Eligible 
payments greater 
that 
one 
fifth 
of 
the 
Special Accounts' 
amount 
may 
be 
paid 
by 
the 
bank 
directly 
to 
suppliers 
at 
a 
specific 
request 
of 
the Government. 
The 
Special 
Accounts 
will 
be 
replenished 
on 
the 
basis 
of 
reimbursed 
claims 
for 
eligible 
expenditures 
received 
by 
IDA 
on 
a 
monthly 
basis 
or 
whenever 
20 percent 
of 
the 
account 
has 
been 
utilized. 
Retroactive Financing: 
Retroactive 
financing 
up 
to 
an 
amount 
of 
US$1.7 
million 
would 
cover 
eligible 
expenditure 
for 
implementation 
activities 
after 
March 
3 
1,2002. Retroactive 
financing 
would 
support 
training 
workshops, 
research, 
behavior 
change 
communications, 
and operating 
expenses 
including 
salaries 
of 
new 
staff. 
Some 
of 
these 
funds 
have already been 
spent 
on 
eligible 
expenditures. 
- 
63 
- 
Page  70
Annex 
7: 
Project Processing Schedule 
PAKISTAN: HlVlAlDS Prevention Project 
/Project 
Schedule 
Planned 
Actual 
/Time 
taken to prepare 
the 
project (months) 
I 
I 
12 
I 
Negotiations 
Planned Date 
of 
Effectiveness 
/First 
Bank mission (identification) 
I 
0711 
4/200 
1 
I 
0711 
4/2001 
I 
12/15/2002 
02/25/2003 
0311 
112002 
071 
1412003 
IAppraisal mission departure 
I 
12/10/2001 
I 
06/24/2002 
I 
Bank 
staff 
who 
worked 
on 
the 
project 
Name 
Benjamin 
Loevinsohn 
Inaam 
Haq 
Hugo 
Diaz-Etchevehere 
Muhammad 
Bashirul 
Haq 
Nancy 
Fee 
Salim 
Habayeb 
Maj-Lis 
Voss 
Mohammad 
Khalid 
Khan 
Javed 
Karimullah 
Ahsan 
Ali 
Arif 
Yaqub 
Qazi 
hat 
Isa 
Silvia 
Albert 
Akhtar 
Hamid 
Nawaf 
Al-Mahamel 
included: 
Sr. 
Public Health 
Specialist 
Sr. 
Health 
Specialist 
Lead 
Operations 
Officer 
Sr. 
Health 
Specialist 
AIDS 
Specialist, 
UNAIDS 
Secondee 
Lead Public Health 
Specialist 
Operations 
Officer 
Program 
Assistant 
Team 
Assistant 
Sr. 
Procurement 
Specialist 
Sr. 
Financial 
Management Specialist 
Sr. 
Community 
Development Specialist 
Program 
Assistant 
Lead 
Counsel 
Counsel 
Speciality 
Prepared by: 
National 
AIDS 
Control 
Program, 
Ministry 
of 
Health, 
Government 
of 
Pakistan. 
Preparation assistance: 
UNICEF, 
UNAIDS, 
CIDA, 
DFID, 
FHI 
(USAID), 
- 
64 
- 
Page  71
Annex 
8: 
Documents 
in 
the Project File* 
PAKISTAN 
: 
HlVlAl 
DS 
Prevention Project 
A. 
Project Implementation Plan 
NACP 
(NATIONAL 
AIDS 
Control 
Program), 
[??is 
there 
a later version?] 
January 
26, 
2002,  “Pakistan: 
Expanded 
Response 
to 
HIVIAIDS”, 
PakistanBalochistan 
HIV/AIDS 
Program Implementation 
Plan, 
Institute 
of 
Public Health 
Quetta 
Enhanced 
HIV/AIDS 
Control 
Program, 
Program Implementation 
Plan, 
Punj 
ab, 
Provincial 
AIDS 
Control 
Unit, 
Department 
of 
Health, Government 
of 
Punjab 
SINDH, 
Expanded 
€€&‘/AIDS 
Program 
Project Implementation 
Plan, 
SWDH 
AIDS 
Control 
Program 
NWFP 
AIDS 
Control 
Program, 
Department 
of 
Health: 
NWFP, 
Expanded 
Program Project 
Implementation 
Plan 
AJK 
AIDS 
Control 
Program: 
AJK 
Expanded 
Program Project Implementation 
Plan. 
PC-I 
B. 
Bank 
Staff Assessments 
IDA, 
HIV/AIDS 
Prevention Project Surveillance Mission, Report 
on 
WIAIDS?? 
do 
we 
have 
this 
yet? 
IDA, 
HIV/AIDS 
Prevention Project:  Project 
Information 
Document 
IDA, 
HIV/AIDS 
Prevention Project: Integrated 
Safeguards 
Data 
Sheet, 
October 
10,2001 
Do 
we 
include 
preparation, 
pre-appraisal, 
and 
appraisal 
mission 
aide-memoires? 
C. 
Other 
Pakistan 
Enhanced 
HIV/AIDS 
Program:  Social 
Assessment 
and 
Mapping 
of 
Men 
who 
have 
Sex 
with 
Men 
(MSM) 
in 
Lahore, Pakistan, 
Naz Foundation International, 
April 
21, 
2002 
Pakistan Enhanced 
HIV/AIDS 
Program:  Social 
Assessment 
and 
Mapping 
of 
Men 
who 
have 
Sex 
with 
Men 
(MSM) 
in 
Lahore 
(Short 
Report), Pakistan, 
Naz 
Foundation International, 
April 
2 
1, 
2002 
Study 
of 
Assess 
the 
KAB 
of 
the People 
in 
Response 
to the 
AIDS 
Awareness 
Campaign, 
Section 
1 
(Household Survey), Section 
2 
Focus 
Group 
Discussions, 
Dataline 
Services 
(Private) 
Limited, 
January 
2002 
- 
65 
- 
Page  72
Analysis 
of 
the Experience 
of 
Government 
Partnerships 
with 
Non-Government 
Organizations, 
Multi-Donor 
Support 
Unit 
for 
SAPiWorld Bank 
Enhanced 
HIV/AIDS 
Program, January 2002 
Pakistan 
Expanded 
Response 
to 
HIV/AIDS 
Enhanced 
HIV/AIDS 
Control 
Program, 
Consultants 
Report 
Developing 
the 
Behavioural 
Change 
Communications 
Components, 
Richard Pollard 
and 
Qamar-ul-Islam Siddiqui, 
April 
2002 
External 
Review/Impact 
Assessment 
of 
National 
Aids 
Control 
Programme, 
Conducted 
for 
the 
Ministry 
of 
Health 
by 
International 
Health 
Development 
Chapter, Qaiser 
Siraj 
Memorial 
Trust, 
Islamabad, Pakistan, 
October 
17, 
2001 
@raft 
Report) 
Social 
Assessment 
of 
Vulnerable 
Groups, 
Dr. 
J. 
Anwar, 
Dr. 
Saman, 
Yazdani 
Khan 
and 
Dr. 
Akhtar 
Ali, 
Centre 
for 
Health 
and 
Population 
Studies, 
Lahore, 
April 
2002 
(Draft 
Report) 
Project Proposal for 
the 
Rehabilitation 
of 
Blood 
Transfusion Services 
(BTSs) 
in 
Pakistan, 
WHO/EMRO 
(Dr. 
Nabila 
E. 
Metwalli 
and 
BTS/Swiss 
Red 
Cross 
(SRC) 
(Dr. 
Guy 
Levey) 
Mapping 
of 
HIV 
Risk 
Behavior 
among 
Truckers 
in 
Pakistan: 
Social 
Marketing 
Pakistan, 
August 
2002 
A 
Behavioral 
Mapping 
Study, Female 
Commercial 
Sex 
Workers 
in 
Lahore, 
Karachi, 
and 
Multan, 
Technical 
Alliance 
for 
Change, September 
2002. 
Environmental 
Assessment 
of 
Sharps, 
Syringes, 
& 
Blood 
Bank 
Material. 
Hagler 
Bailey, 
September 
2002. 
Study 
on 
Prevalence 
of 
STI 
in 
Women 
Attending 
ANC, National 
AIDS 
Control 
Program 
?? 
2002. 
*Including electronic files 
- 
66 
- 
Page  73
Annex 
9: 
Statement 
of 
Loans 
and Credits 
PAKISTAN: HIV/AIDS Prevention Project 
04-NOV-2002 
Oriainai Amount 
in 
US$ Millions 
Difference between expected 
and actual 
disbursements' 
Project 
ID 
FY 
Purpose 
IBRD 
IDA 
GEF 
Cancel. 
Undisb. 
Orig 
Frm Rev'd 
PO74797 
2003  Banking Sector Technical Assistance 
0.00 
26.50 
0.00 
0.00 
27.24 
-0.75 
0.00 
PO71454 
2003  AJK 
Comnunity Infrastructure 
& 
Services 
0.00 
20.00 
0.00 
0.00 
20.41 
-0.75 
0.00 
PO55292 
PO35823 
PO56213 
PO71092 
PO49791 
PO37834 
PO10500 
PO36015 
PO10478 
PO39281 
PO34101 
2002  BSRPP 
2001  GEF-Protected 
Areas 
Managemnt 
Project 
2001 TRADE 
8 
TRANSPORT 
2001  NWFP ON-FARM 
WATER 
MANAGEMNT 
PROJECT 
1999 POVERTY 
ALLEVIATION FUND 
1998 
NORTHERN EDUCATION 
1998 NATIONAL 
DRAINAGE PR 
1997 IMPR FIN 
REP 
&AUDIT 
1996 NWFP 
COMMUNITY INFRA 
1996 GHAZl BAROTHA HYDROP 
1996 
PK-TELECOM 
REG 
& 
PRIVAT 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
350.00 
35.00 
300.00 
0.00 
3.00 
21.35 
90.00 
22.80 
285.00 
28.80 
21.50 
0.00 
0.00 
0.00 
0.00 
118.56 
-193.12 
0.00 
10.08 
0.00 
10.34 
0.00 
0.00 
0.00 
0.00 
1.45 
0.22 
0.00 
0.00 
0.00 
21.54 
-0.58 
0.00 
0.00 
0.00 
44.62 
-10.57 
0.00 
0.00 
0.09 
12.48 
13.83 
0.00 
0.00 
0.24 
113.29 
87.57 
0.00 
0.00 
0.00 
18.44 
20.47 
1.01 
0.00 
0.00 
5.59 
8.81 
7.42 
0.00 
0.00 
37.73 
37.73 
24.04 
0.00 
13.15 
4.44 
17.59 
7.59 
Total: 
385.00 
818.95 
10.08 
13.48 
436.13 
-19.55 
40.05 
- 
67 
- 
Page  74
PAKISTAN 
STATEMENT 
OF 
IFC's 
Held 
and 
Disbursed 
Portfolio 
In 
Millions 
US 
Dollars 
Ju~ 
30 
- 
2002 
Committed 
Disbursed 
1995 
1991 
1994 
1995 
1996 
1995 
1996 
1995 
1996 
1994 
0 
1991194195 
1995 
1993 
1993197101 
1996 
0194195196 
1998 
1991195197 
1996 
1990191196 
1993102 
1995 
1994196 
1995 
1996 
1988 
199 
1/95 
1992196 
1995 
2001 
0194195197 
2002 
0193 
1984194 
1994 
1994 
1994 
1994 
199 
1194195 
IFC 
IFC 
FY 
Approval 
Company 
Loan 
Equity 
Quasi 
Partic 
Loan 
Equity 
Quasi 
Partic 
Pakistan 
Unit 
Tr 
0.00 
1.48 
0.00 
0.00 
0.00 
1.48 
0.00 
0.00 
Prudential 
Regent 
Knitwear 
Rupafab 
Uch 
Power 
AES 
La1 
Pir 
AES 
Pak 
Gen 
Abamco 
Mgmt 
Atlas 
Inv 
Bank 
Atlas 
Lease 
BRRIL 
BRRIM 
BSJS 
Fund 
CDCPL 
Crescent 
Greenwd 
Crescent 
IBank 
D.G. 
Khan 
Engro Asahi 
Engro Chemical 
Engro Vopak 
FIIB 
Fauji 
Cement 
First 
Crescent 
First 
Leasing 
First 
UDL 
Gul 
Ahmed 
Hala 
Spinning 
IHFL 
JSCL 
Kohinoor 
Lasmo Pakistan 
Maple Leaf 
Micro 
Bank 
Muslim 
Comm 
Bank 
NDLC 
Orix 
Finance 
Orix 
Leasing 
PACRA 
PI&CL 
PILCO 
0.00 
0.40 
6.80 
0.00 
2.75 
0.00 
38.05 
0.00 
30.82 
9.50 
15.58 
9.50 
0.00 
0.29 
2.50 
0.00 
1.80 
0.36 
0.00 
0.24 
0.00 
0.00 
0.00 
0.50 
0.00 
0.16 
2.50 
0.00 
6.00 
0.00 
0.00 
0.07 
6.86 
0.00 
5.14 
0.00 
6.76 
0.00 
1.35 
0.00 
0.00 
3.72 
0.00 
0.00 
0.00 
0.69 
0.00 
0.00 
18.90 
4.10 
3.62 
0.00 
0.00 
0.40 
0.00 
0.27 
16.25 
6.30 
30.00 
0.00 
0.00 
0.52 
0.00 
2.66 
0.94 
0.00 
2.11 
1.25 
0.00 
0.58 
2.11 
1.25 
0.00 
0.10 
1.25 
0.00 
0.00 
0.54 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
5.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
5.00 
0.00 
10.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.40 
0.00 
2.80 
6.80 
0.00 
0.00 
0.00 
2.75 
0.00 
0.00 
71.24 
33.09 
0.00 
0.00 
0.00 
30.82 
9.50 
0.00 
26.83 
15.58 
9.50 
0.00 
0.00 
0.00 
0.29 
0.00 
0.00 
2.50 
0.00 
0.00 
0.00 
1.80 
0.36 
0.00 
0.00 
0.00 
0.24 
0.00 
0.00 
0.00 
0.00 
5.00 
0.00 
0.00 
0.50 
0.00 
0.00 
0.00 
0.16 
0.00 
1.50 
2.40 
0.00 
0.00 
0.00 
6.00 
0.00 
0.00 
0.00 
0.00 
0.07 
0.00 
0.00 
6.86 
0.00 
0.00 
3.75 
5.14 
0.00 
0.00 
2.82 
6.76 
0.00 
0.00 
0.00 
1.35 
0.00 
0.00 
0.00 
0.00 
3.72 
0.00 
0.00 
0.00 
0.00 
5.00 
0.00 
0.00 
0.69 
0.00 
0.00 
0.00 
0.00 
10.00 
20.61 
18.90 
4.10 
0.00 
0.00 
3.62 
0.00 
0.00 
0.00 
0.00 
0.40 
0.00 
0.00 
0.00 
0.27 
0.00 
18.30 
16.25 
6.30 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.52 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.94 
0.00 
0.00 
0.00 
2.11 
1.25 
0.00 
0.00 
0.00 
0.58 
0.00 
0.00 
2.11 
1.25 
0.00 
0.00 
0.00 
0.10 
0.00 
0.00 
1.25 
0.00 
0.00 
0.00 
0.00 
0.54 
0.00 
0.00 
2.80 
0.00 
56.20 
0.00 
26.83 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
1.50 
0.00 
0.00 
0.00 
3.75 
2.82 
0.00 
0.00 
0.00 
0.00 
0.00 
20.61 
0.00 
0.00 
0.00 
18.30 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
0.00 
1983184194102 
PPL 
0.00 
6.63 
0.00 
0.00 
0.00 
6.63 
0.00 
0.00 
1965180182187l9119419 
2.25 
2.50 
0.00 
0.00 
2.25 
2.50 
0.00 
0.00 
5 
Pakistan Service 
1.00 
3.00 
0.00 
0.00 
1.00 
3.00 
0.00 
0.00 
1993 
Total 
Portfolio: 
205.34 
57.01 
20.00 
147.85 
170.28 
54.35 
20.00 
132.81 
- 
68 
- 
Page  75
Auurovals 
Pendine Commitment 
FY 
Approval 
Company 
Loan 
Equity 
Quasi 
Partic 
2002 
Network 
Leasing 
2.00 
0.00 
0.00 
0.00 
Total 
Pending 
Commitment: 
2.00 
0.00 
0.00 
0.00 
- 
69 
- 
Page  76
Annex 
10: 
Country at 
a 
Glance 
PAKISTAN: HlVlAlDS Prevention Project 
POVERTY and SOCIAL 
Pakistan 
2001 
Population, mid-year 
(millions) 
GNI 
per capita 
(Atlas method, 
US$) 
GNI 
(At/as 
method, 
US$ 
billions) 
Average annual growth, 
1995-01 
Population 
(%) 
Labor 
force 
('A) 
Most recent estimate (latest 
year 
available, 
1995-01) 
Poverty 
(% 
of 
population below national poverty 
line) 
Urban population 
(% 
of 
total population) 
Life expectancy 
at 
birth 
(years) 
infant mortality 
(per 
1,000 
live 
births) 
Child malnutrition 
(% 
of 
children 
under5) 
Access 
to 
an improved 
water 
source 
(% 
ofpopulation) 
lliiteracy 
(% 
ofpopulation 
age 
75+) 
Gross 
primary enroliment 
(% 
of 
school-age population) 
Male 
Female 
KEY ECONOMIC RATIOS and LONG-TERM TRENDS 
1981 
GDP 
(US$ 
billions) 
Gross domestic 
investmenVGDP 
Exports 
of 
goods and 
services/GDP 
Gross 
domestic savingslGDP 
Gross 
national savingslGDP 
Current 
account balancelGDP 
interest paymentsiGDP 
Total 
debVGDP 
Total debt service/exports 
Present 
value of 
debffGDP 
Present value 
of debVexports 
28.1 
18.8 
12.3 
8.1 
15.1 
-3.6 
0.7 
37.7 
1981-91 
1991.01 
(average 
annual 
growth) 
GDP 
6.1 
3.5 
GDP 
per capita 
3.3 
1.0 
141.5 
430 
60.1 
2.4 
3.1 
33 
33 
63 
83 
38 
88 
56 
96 
117 
74 
1991 
45.5 
19.0 
17.0 
17.5 
20.0 
-4.4 
1.3 
51.4 
20.9 
2000 
4.2 
1.8 
South 
Asia 
1,380 
450 
616 
1.9 
2.4 
28 
62 
73 
49 
87 
44 
101 
109 
93 
2000 
61 
.O 
16.0 
16.3 
14.4 
16.2 
-3.5 
1.4 
52.8 
26.7 
43.6 
249.2 
2001 
2.7 
0.3 
Low- 
income 
2,511 
430 
1,069 
1.9 
2.3 
31 
59 
76 
76 
37 
96 
103 
88 
2001 
58.7 
15.9 
18.0 
14.6 
17.3 
-3.3 
1.8 
54.5 
25.3 
2001-05 
5.1 
2.6 
-1 
7 
Development diamond' 
Life expectancy 
I 
T 
, 
GNI 
1 
Access 
to 
improved 
water 
source 
I 
- 
Pakistan 
Low-income group 
1 
Economic ratios' 
Trade 
- 
indebtedness 
-Pakistan 
~ 
Low-income 
arouo 
Exports 
of 
goods and 
services 
9.1 
0.6 
16.0 
11.8 
... 
STRUCTURE 
of 
the ECONOMY 
("A 
of 
GDP) 
Agriculture 
Industry 
Services 
Private consumption 
General government consumption 
imports 
of 
goods 
and 
services 
Manufacturing 
(average 
annual 
growth) 
Agriculture 
Industry 
Services 
Private consumption 
General government consumption 
Gross 
domestic investment 
Imports 
of goods and 
services 
Manufacturing 
1981 
30.8 
22.6 
15.1 
46.6 
81.8 
10.2 
23.0 
1981-91 
4.2 
7.4 
7.5 
6.4 
4.3 
9.5 
5.1 
2.4 
1991 
25.8 
25.4 
17.1 
48.8 
68.2 
14.3 
18.6 
1991-01 
4.1 
3.8 
3.8 
4.3 
4.7 
0.6 
1.2 
1.4 
2000 
26.7 
23.1 
15.3 
50.2 
74.4 
11.2 
18.0 
2000 
6.1 
-0.1 
1.4 
4.8 
0.4 
7.5 
5.1 
-2.3 
2001 
25.0 
22.9 
15.8 
52.1 
75.2 
10.3 
19.4 
2001 
-2.7 
4.5 
7.7 
4.2 
2.2 
-5.3 
1.1 
1.5 
Growth 
of 
Investment 
and 
GDP 
(%) 
il0- 
Growth 
of 
exports 
and 
imports 
("4 
120 
Note: 
2001 
data are 
preliminary 
estimates. 
* 
The 
diamonds 
show four 
key 
indicators in 
the country 
(in bold) colrpared 
with its 
income-group 
average. 
If 
date are 
missing. the 
diamnd 
wili 
be 
incolrpiete 
- 
70 
- 
Page  77
PRICES 
and 
GOVERNMENT FINANCE 
PAKIS 
TE.RM)NIS 
(“A 
change) 
Consumer 
prices 
Implicit 
GDP deflator 
Ar 
IDeKl 
e 
TVvbkH 
(“A 
of 
GDP, 
includes current 
grants) 
Current revenue 
Current 
budget 
balance 
Overali surplus/deficit 
TRADE 
(US$ 
millions) 
Total 
exports 
(fob) 
Cotton 
Rice 
Manufactures 
Total imports (cif) 
Food 
Fuel 
and 
energy 
Capital goods 
Export price index 
(1995=100j 
import price 
index 
(1995=100) 
Terms of trade 
(1995=100) 
BALANCE 
of 
PAYMENTS 
(US$ 
millions) 
Exports of 
goods and 
services 
Imports 
of goods and 
services 
Resource balance 
Net income 
Net current transfers 
Current account balance 
Financing items 
(net) 
Changes 
in 
net 
reserves 
tI 
KAi 
Reserves including gold 
(US$ 
millions) 
Conversion rate 
(DEC, 
local/US$j 
EXTERNAL DEBT 
and 
RESOURCE FLOWS 
(US$ 
millions) 
Total debt outstanding 
and 
disbursed 
IBRD 
IDA 
Total 
debt service 
IBRD 
IDA 
Composition 
of 
net resource 
flows 
Official grants 
Ofkiai 
creditors 
Private creditors 
Foreign direct investment 
Podfolio equity 
World Bank program 
Commitments 
Disbursements 
Principal repayments 
Net 
flows 
Interest payments 
Net transfers 
1981 
9.9 
1981 
2,812 
1,663 
1981 
3,461 
6,467 
-3,005 
-261 
2,242 
-1,024 
9.9 
1981 
10,581 
310 
909 
54 
16 
275 
525 
-2 
1 
72 
0 
149 
105 
36 
68 
34 
34 
1991 
13.1 
16.9 
-2.4 
-8.8 
1991 
5,902 
41 
2 
346 
3,253 
8,385 
890 
1,691 
1,953 
111 
1991 
7,450 
10,563 
-3,113 
-1,160 
2,292 
-1,981 
1,987 
-6 
1,288 
22.4 
1991 
23,364 
2,181 
2,311 
1,961 
254 
37 
613 
998 
-2 
239 
-9 
540 
623 
122 
50 
1 
168 
333 
2000 
4.1 
2.7 
17.3 
-2.6 
-5.5 
2000 
8,191 
73 
540 
7,874 
9,602 
696 
2,783 
2,714 
84 
93 
91 
2000 
9,576 
11,763 
-2,187 
-1,932 
1,997 
-2,121 
1,913 
208 
1,516 
51.6 
2000 
32,182 
3,093 
3.828 
2,850 
408 
93 
926 
452 
-361 
471 
74 
0 
301 
291 
10 
210 
-201 
2001 
4.4 
5.7 
17.4 
-1.5 
-4.1 
2001 
8,934 
139 
525 
8,344 
10,202 
750 
3,327 
2,698 
86 
103 
83 
2001 
10,284 
12,535 
-2,251 
-2,160 
2,460 
-1,951 
3,039 
-1,088 
2,244 
58.2 
2001 
31,977 
2,796 
4,245 
2,906 
390 
96 
839 
967 
-561 
322 
0 
674 
669 
300 
369 
187 
183 
I 
inflation 
(x) 
15 
10 
5 
~ 
4 
96 
97 
98 
99 
00 
GDP 
deflator 
-0-CPI 
- 
I 
I 
Export 
and 
import levels 
(US$ 
mill,) 
~15000 
T 
10 
OtO 
5 
c2c 
I 
95 
96 
97 
98 
99 
00 
01 
Exports 
.Imports 
i 
I 
1 
Current account balance 
to GDP 
(%) 
-8 
- 
~ 
Composition 
of 
2001 
debt 
(US$ 
mill.) 
I 
G: 
1,314 
A 
2.796 
A. 
IBRD 
E 
- 
Bilateral 
B 
. 
IDA 
D 
-Other 
multilateral 
F 
- 
Private 
C 
~ 
IMF 
G 
- 
Short-term 
-71 
- 
Page  78