Documentof The World Bank FOROFFICIAL USEONLY ReportNo: 30319-VN PROJECT APPRAISAL DOCUMENT ONA PROPOSEDGRANT INTHEAMOUNT OF SDR23.1MILLION (US $ 35.0 MILLIONEQUIVALENT) TO THE SOCIALIST REPUBLIC OF VIETNAM FOR THE VIETNAM HIV/AIDS PREVENTIONPROJECT March 7,2005 HumanDevelopmentSector Unit EastAsia andPacificRegion This document has a restricted distribution and may be used by recipients only in the perfonnance of their official duties.Its contents maynotbeotherwise disclosed without WorldBank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective January 31,2005) Currency Unit = Dong VND 15,689 = US$1 US$1.42169 = SDR1 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS I Culture DOLISA II Department o f Labor, Invalids and IPEPFAR IU S President's Emergency Plan for AIDS ~. Social Affairs 1Relief Course DPS Department o f Public Security PMTCT Prevention o f Mother to ChildTransmission FHI Family Health International TRT Technical Review Team FMR Financial Monitoring Report UNAIDS Joint United Nations Program for HIViAIDS FSW Female Sex Worker UNDP UnitedNations Development Program GDPMAC General Department o f Preventive UNODC United Nations Office on Drugs and Crime Medicine and HIV/AIDS Control GFATM IIGlobal Fundfor AIDS, Tuberculosis IURENCO IUrbanEnvironment Company . . and Malaria GVN Government o f Vietnam U S A I D United States Agency for International Development IDU Injecting DrugUser WHO World Health Organization HIV HumanImmunodeficiency Virus VCT Voluntary Counseling and Testing M&E Monitoring and Evaluation Vice President: Jemal-ud-din Kassum Country Director: Klaus Rohland Sector Director: Emmanuel Y. Jimenez Sector Manager: FadiaM.Saadah Task Team Leader: Maryam Salim FOROFFICIAL USEONLY VIETNAM HIV/AIDSPreventionProject CONTENTS Page A. STRATEGIC CONTEXT AND RATIONALE ................................................................. 1 1. Country and sector issues.................................................................................................... 1 2. Rationale for Bank involvement......................................................................................... 3 3. Higherlevel objectives to which the project contributes.................................................... 4 B. PROJECT DESCRIPTION ................................................................................................. 4 1. Lending instrument............................................................................................................. 4 2. [IfApplicable] Program objective andPhases.................................................................... 4 3. Project development objective andkey indicators.............................................................. 4 4. Project components............................................................................................................. 5 5. Lessons learned and reflected inthe project design......................... : .................................. 5 6. Alternatives considered and reasons for rejection .............................................................. 6 C . IMPLEMENTATION .......................................................................................................... 6 1. Partnership arrangements (ifapplicable) ............................................................................ 6 2. Institutional and implementation arrangements .................................................................. 7 3. Monitoring and evaluation o f outcomes/results.................................................................. 7 4. Sustainability....................................................................................................................... 8 5. Critical risks and possible controversial aspects................................................................. 9 6. Loadcredit conditions and covenants............................................................................... - 10 D . APPRAISAL SUMMARY ................................................................................................. 11 1. Economic and financial analyses ...................................................................................... 11 2. Technical........................................................................................................................... 11 3. Fiduciary ........................................................................................................................... 13 4. Social................................................................................................................................. 14 5. Environment...................................................................................................................... 14 6. Safeguard policies............................................................................................................. 15 7. Policy Exceptions and Readiness...................................................................................... 15 Annex 1: Country and Sector or ProgramBackground ......................................................... 16 This document has a restricted distribution and may be used by recipients only in the performance of their official duties I t s contents may not be otherwise disclosed without World Bank authorization . . Annex 2: Major Related Projects Financedby the Bank and/or other Agencies .................22 Annex 3: ResultsFramework and Monitoring ........................................................................ 23 Annex 4: Detailed Project Description ...................................................................................... 31 Annex 5: Project Costs............................................................................................................... 45 Annex 6: Implementation Arrangements ................................................................................. 46 Annex 7: FinancialManagement and DisbursementArrangements ..................................... 50 Annex 8: Procurement ................................................................................................................ 57 Annex 9: Economic and FinancialAnalysis ............................................................................. 63 Annex 10: Safeguard Policy Issues ............................................................................................ 73 Annex 11:Project Preparation and Supervision ..................................................................... 82 Annex 12: Documents inthe Project File ................................................................................. 84 Annex 13: Statement of Loans and Credits .............................................................................. 85 Annex 14: Country at a Glance ................................................................................................. 87 MapNo.33719 VIETNAM HIV/AIDSPREVENTION PROJECT APPRAISAL DOCUMENT EASTASIA AND PACIFIC EASHD Date: March 7,2005 Team Leader: Maryam Salim Country Director: Klaus Rohland Sectors: Health (80%); Other social services Sector Director: EmmanuelY. Jimenez (20%) Themes: HIV/AIDS (P); Poverty strategy, analysis andmonitoring (P); Other social protection and risk management (P); Vulnerability assessment andmonitoring (S); Other social development (S) Project ID: PO82604 Environmental screening category: Partial Assessment For Loans/Credits/Others: Total Bank financing (US$m.): 35.00 Borrower: State Bank of Vietnam Hanoi Vietnam Responsible Agency: Ministryo fHealth 138A GiangV o St. Hanoi Vietnam I h u a l 3.00 5.00 6.00 7.00 7.00 7.00 0.00 0.00 0.00 3umulative 3.00 8.00 14.00 21.00 28.00 35.00 35.00 35.00 35.00 0 Percent ofvulnerable groups inparticipating provinces reporting condom use insexual intercourse (from 40% at baseline to 80% at project end) Project description [one-sentence summary of each component] Re$ PAD B.3.a, Technical Annex 4 COMPONENT ONE: Implementation o fProvincial HIV/AIDS Action Plans will provide sub- grants to 18 provinces and 2 cities to support the design and implementation of Annual Provincial Action Plans. COMPONENT TWO: National HIV/AIDS Policy and Program: 0 Subcomponent 1: Policy and Program Development and Implementation will strengthen capacity at national andprovincial levels and promote the development o f innovative, effective prevention and treatment approaches and models among vulnerable groups through: (i)demonstration sites that will explore a community-based treatment model to integrate h a m reduction with comprehensive HIV treatment and care; (ii)policy studies and research; (iii) knowledge sharingand training; and (iv) other innovations 0 Subcomponent 2: Monitoring and Evaluation will support the development o f a national monitoring and evaluation results framework, operational planand system. 0 Subcomponent 3: Behavior Change CommunicationFocused on Reducing Stigma and Discrimination will support a 5-year nationwide BCC campaign to reduce stigma and discrimination against vulnerable groups. COMPONENT THREE: Project Management will provide support to the set up and management o f the Central Project Management Unit (CPMU) as well as the Provincial Project Management Units (PPMUs) located inthe 18 provinces andtwo cities. Which safeguard policies are triggered, if any? Re$ PAD D.6, TechnicalAnnex 10 Environment and Indigenous Peoples Policy Significant, non-standard conditions, if any, for: Re$ PAD C.7 Boardpresentation: None Loadcredit effectiveness: 0 First year project implementation plan for National Component acceptable to IDA, has been adopted. 0 Operations Manual for Provincial component, acceptable to IDA, has been adopted. 0 Terms o f reference for the Technical Review Team, acceptable to IDA, have been approved. 0 Short-list o f consultants for Technical Unit andM&EUnit within CPMU submittedto IDA. 0 Procurement Advisor with international experience for the CPMU, acceptable to IDAhas beenselected and is readyto sign contract; Appointment o fprocurement officer a each PPMU. 0 Two Accountants and one cashier for CPMU and one Accountant for each o f the 8 PPMU and 2 cities have been appointed. Covenants applicable to project implementation: ByDecember 1,2005, adopt a national Monitoring andEvaluationPlan acceptable to the Association. By no later than November 30, 2005, establish Technical Review Team, acceptable to IDA, to assist the CPMU and Provincial AIDS Steering Committee to review Provincial Action Plans. By no later than December 31, 2005 establish a National Monitoring and Evaluation Unit within the Department o f HIV/AIDS Control o f MOH; establish Regional Monitoring and Evaluation Centers inNIHE inHanoi, the Pasteur Institute inH o Chi MinhCity, the Pasteur Institute inNha Trang and the Hygiene and Epidemiology Institute o f the Highlands in Dak Lak Province. By October 31 of each year, beginning in 2005, provincial plans will be prepared and submitted to the CPMU for review and endorsement. ByOctober 31of each year, commencing in2006, prepare andprovide to the Association for review and comment annual implementation plan for National Component. Conduct mid-term review not later than April 30, 2008. A. STRATEGIC CONTEXT AND RATIONALE 1. Countryandsector issues The global pandemic o f human immunodeficiency virus (HIV) and the attendant epidemic o f acquired immunodeficiency syndrome (AIDS) present one o f the key public health challenges o f our time. With no effective vaccine or cure likely to be available in the mid-tenn future, the priority responses o f government remain prevention o f HIV infection and, increasingly, treatment o f AIDS. In Southeast Asia HIV/AIDS currently remains concentrated in particular vulnerable populations. Although effectively reaching these populations with prevention and treatment programs presents challenges, it also offers an opportunity to impact significantly on the progress o f the HIV/AIDS epidemic. According to UNAIDS, in East Asia, the 50% increase in HIV infections from 2002-2004 i s largely attributable to growing epidemics in China, Indonesia and Vietnam. In Vietnam in particular there i s clear potential for the epidemic to spread from vulnerable groups through bridge populations to the general population. The major burden o f disease i s being bome by young people, with 62% o f reportedHIV cases aged 20-29 years. This implies serious economic consequences for the nation, with an epidemic among the most economically productive age group. Global experience has taught that national preventive programs targeting epidemiologically significant risk behaviors can control transmission amongst high-risk groups and stop the generalized spread o f HIV. Vietnam presents a clear example o f a country inwhich the trajectory o f a concentrated HIVIAIDS epidemic may be greatly curtailed by a highly focused program aimed at stopping HIV/AIDStransmission. The anticipated success o f such a program i s based on comprehensive epidemiological data. Estimates and projections o f HIV in Vietnam have recently been prepared by The Vietnam Technical Working Group and disseminated by the Ministry o f Health (MOH). The report finds that the estimated number o f people living with HIV in Vietnam has been sharply increasing in the past 3-5 years - rising from approximately 96,000 to 245,000 during the four-year period between 1999 and 2003. HIV infection and deaths from AIDS have now been reported in all o f Vietnam's 64 provinces. Although the population prevalence in the country as a whole remains less than half o f one percent (0.44% in 2003), the prevalence o f HIV is high among particular vulnerable populations. Injecting drug users (IDU)dominate the epidemic with males and youth being more at risk. IDUs have a national prevalence o f approximately 33%, although this rate is much higher in areas such as H o Chi Minh City (HCMC), Hai Phong and Quang Ninh. After IDUs, female sex workers (FSWs) have the highest prevalence - approximately 3.1% nationally, again with higher rates in some cities including Hai Phong, HCMC, Hanoi and Can Tho, By 2005, it i s estimated that there will have been a cumulative total o f 60,000 AIDS deaths in Vietnam. The overlap o friskbehaviors is a critically important characteristic that is drivingthe HIV/AIDS epidemic in Vietnam. In Hanoi and H o Chi Minh City, 25% of commercial sex workers also inject drugs. The sharing o f needles and syringes is widespread. Almost two-thirds o f the IDUs in Hanoi (65.47%) and slightly fewer in Hai Phong (46.4%), Can Tho (51%), and HCMC (42.9%) reported two or more sexual partners inthe past 12 months. With the exception o f those surveyed in H o Chi Minh City, I D U s do not consistently use condoms in a majority o f their sexual encounters. The prevalence of HIV among male clients of sex workers is also steadily increasing. These and other findings from behavioral surveys are highly suggestive o f the pathway the epidemic i s taking from I D U s to Commercial Sex Workers (CSWs), and other heterosexual partners. Inmany AfricanandAsian countries the twinepidemics ofHIV/AIDSandTB are closely linked -withthevulnerability ofAIDSpatientsto TBinfectionthreatening toreversethegainsinTB control o f the last decade. Vietnam i s classified as a high TB burden country within the westem pacific region. With the support o f the WHO "STOP-TB" effort, the Vietnam National TB Control Program institutes directly observed treatment (DOTS) in 100% o f districts, with a high rate o f diagnosis, notification and cure. All TB medications are procured and supplied through this national program. Despite this success however, there has yet to be any decrease in notification o f new infections nationally. Multiple factors may contribute to this static pattem - including the masking o f gains by active case identification andpopulation mobility -however it is likely that the increasingprevalence o f HIV i s impacting on the picture o f TB inVietnam. The National TB control program has recommended the establishment o f a national TB/HIV coordinating committee and adoption o f a TB/HIV framework. Policy and Regulatory Issues: The Prime Minister's February 2003 directive designated functions by Ministry to strengthen HIV/AIDS prevention activities and coordination within government. The directive assigned M O H the key responsibilities o f strengthening structures for HIV/AIDS Prevention from central to community levels, and key interventions, e.g. h a m reduction, improving surveillance systems, promoting safe blood, prevention o f mother to child transmission (PMTCT). Four other ministries were given important roles as well. MPIand M O F were asked to arrange adequate andtimely fundingfor HIV/AIDSprevention. Ministryo fPublic Security would develop mechanisms to support infected children, work with sex workers and drug users in rehabilitation centers, and develop and implement action plans for effective interventions to prevent transmission from high risk groups to the community. The Ministry of Culture and Information would collaborate with other Ministries and Peoples Committees in provinces and cities to strengthen responsibilities o f all local levels o f the Party and Government; improve understanding o f HIV/AIDS; oppose discrimination towards PLWHAs and promote healthy lifestyles including practice o f safe sex and safe injection. Other ministries were assigned more limited roles. Inearly 2004, the Prime Minister approvedthe National Strategy on HIV/AIDSPrevention and Control for the period 2004-2010, with a vision to 2020. The strategy specifies achievements to date and remaining challenges. The Strategy identifies the following nine action areas: 1) Information, Education and Behavioral Change Communication; 2) Harm Reduction and Prevention: 3) Treatment, Care and Support for People Living with HIV/AIDS; 4) HIV/AIDS Surveillance; 5) Monitoring and Evaluation; 6) PMTCT; 7) STI Management and Treatment; 8) Safe Blood Transfusion; and 9) Capacity Buildingand International Cooperation Program. Donor Support to Vietnam: Vietnam is receiving assistance for a wide range o f activities from a number o f bilateral and multilateral donors, UNagencies and intemational NGOs. Some o f the major programs include the Global Fund for AIDS, Tuberculosis and Malaria, DFID/NORAD (WHOIMOH implemented), USAID and the US Centers for Disease Control (CDC). Since the commencement of this project preparation, the landscape o f donor support has changed 2 dramatically, with the announcement that Vietnam has been designated the 15th focus country under the U S President's Emergency Plan for AIDS Relief (PEPFAR). Preliminary indications are that PEPFAR will be allocating inthe order o f $20 million per year for support to Vietnam's HIV/AIDS programs. There is consensus among the donor community o f the need to work collaboratively andinways responsive to the major innovations inVietnam's National HIV/AIDS Strategy. Major strides are being taken towards strengthened donor coordination. Senior representatives o f major development partners are collectively encouraging the government to intensify its national AIDS response, develop coordinated capacity to implement AIDS programs and prepare a unified M&E system. At a wider level, coordination is strengthened by the Community o f Concerned Partners (CCP), which represents a wide range o f multilateral and bilateral donors, UNagencies, foundations and non-governmentpartners, working at both national and local levels and includes partners with extensive practical HIV/AIDS experience and skills. There are also numerous informal mechanisms to improve coordination. Key Constraints in the Implementation of National Strategy Targets: 1) Harm Reduction:The key constraint to the broad implementation o f Harm Reduction strategies remains the national legal environment. Clarification of the roles and responsibilities particularly o f law-enforcement, the Ministry o f Labor, Invalids and Social Affairs (MOLISA) are clearly needed; as well as a better understanding o f factors that lead to drug use and addiction. 2) Monitoring and Evaluation:The national systemfor HIVIAIDS surveillancerequires revision and upgrading. As a particular priority, information should flow from this to a national monitoring structure, with evaluation linked to evidence based decision-making and planning. 3) Stigma and discrimination remain a pervasive issue in all discourse surrounding HIV/AIDS and risk behaviors. 4) Capacity constraints at both national and provincial levels, pose difficulties for the implementation o fprograms. 2. Rationalefor Bank involvement As one o f the largest financiers o f HIV/AIDS control programs in the world, the World Bank bringssignificant global andregional expertise and experience to the task o f assisting Vietnam to implement its National HIV/AIDS Strategy. The World Bank's analytic work in Vietnam - including the joint Government-Donor 2004 Public Expenditure Review to contribute to the decentralization of responsibilities for planning, budgeting and service delivery - enriches the project design and implementation strategy. The World Bank's experience with HIV/AIDS investments in other countries has enriched its understanding o f the utility o f subgrant management approaches in the fight against HIV/AIDS. In addition to considerable technical expertise in HIVIAIDS, the World Bank has built capacity, including in the financial management and procurement fields which can contribute to the successful implementation of the project. Key issues in Vietnam include increasing coverage o f programs and strengthening capacity. The project builds on ongoing initiatives and will complement support from other donor programs. For example, PEPFAR investments in prevention preclude support for needle exchange programs but can still provide much needed resources for other aspects o f a comprehensive harm reduction program for IDUs. Similarly, PEPFAR will include major investments in treatment, while this project will focus more on prevention as well piloting of integrated approaches to prevention andtreatment. 3 3. Higher level objectivesto which the projectcontributes The World Bank's Country Assistance Strategy (CAS) Progress Report (2004) for Vietnam calls for more effective policy responses to address the growing HIV/AIDS epidemic. Vietnam's National Strategy on HIV/AIDS Prevention and Control calls for the rapid scale up o f action to address Vietnam's HIV/AIDS epidemic. The IDA Grant aims to reduce the transmission o f HIV/AIDS, which i s key for meetingthe goal o f the National Strategy and the CAS. B. PROJECTDESCRIPTION 1. Lendinginstrument A Specific investment loan (SIL) was selected for the following reasons: (i) although Vietnam has a sound National HIV/AIDS Strategy, there i s strong consensus that its success will rest on strengthening provincial level technical and managerial capacity to implement the agreed strategies, thus, a S I L i s the most appropriate instrument for the institutiodcapacity buildingthat this will require; (ii) scope o f the project is focused on a specified set o f activities; and (iii) the a SIL will enable the development o f multi-sectoral action at the provincial level. 2. [If Applicable]ProgramobjectiveandPhases Not applicable 3. Projectdevelopmentobjectiveandkey indicators The overall goal o f the proposed project i s to reduce transmission o f HIV/AIDS and to ensure that HIV prevalence remains below .3% -- this i s a key objective o f the Government o f Vietnam's National HIV/AIDS Strategy. The Government o f Vietnam's (GVN) strategy also seeks to increase awareness and change attitudes andbehaviors, including among policy makers, o f the risks and appropriate responses to HIV/AIDS. Achieving this objective will only be possible if Vietnam i s able to identify and interrupt the transmission dynamics that promote the spread o f the epidemic. HIV transmission in Vietnam i s currently heavily concentrated among IDUs and CSWs. Experience in other countries shows that halting the spread of the infection among these groups significantly attenuates wider scale heterosexual transmission. Successfully reaching these populations i s thus strategically vital, and requires action from multiple sectors and actors as well as locally driven programs and responses. The specific objective of this project i s to support programs designed to halt transmission o f HIV/AIDS among vulnerable populations (PLWHA, IDUs, CSWs, and their clients and sexual partners) andbetweenthese vulnerable populations and the general population. Key outcome indicators include': 0 Percent o f vulnerable groups inparticipatingprovinces reporting safer injection practices (from an estimated 20% at baseline to 70% at project end) 0 Percent o f vulnerable groups inparticipatingprovinces reporting condom use in sexual intercourse (from an estimated 40% at baseline to 80% at project end) Specific provincial targets to be set once baseline data is available. 4 4. Projectcomponents The project will support three mainComponents to be implemented at the National and Provincial levels. COMPONENT ONE: Implementation of Provincial HIV/AIDS Action Plans (US$21.616 million) will provide sub-grants to 18 provinces (An Giang, Bac Giang, Ben TreyCao Bang, Dong Nai, Hau Giang, Khanh Hoa, Kien Giang, Lai Chau, Nam Dinh, Nghe An, Son La, Thai Binh, Thai Nguyen, Thanh Hoa, Tien Giang, Vinh Long, and Yen Bai) and two cities (Hai Phong and Ho Chi Minh City) to support the design and implementation o f Annual Provincial Action Plans (PAPS).The provinces and cities will be allocated block grants based on specific criteria to determine the size o f each year's base allocation. The support from the project will complement and build on existing systems for allocating and monitoring the use of resources for HIV/AIDS, and will focus on supportingthe process o fpreparing, reviewing, implementingand assessing the success of provincial specific plans. Proposed activities are expected to reflect the diversity of the province needs as well as diversity in appropriate response. Plans are to be prepared by October of each year for allocations to cover the period between January - December. Grants will be disbursedintranches after the provincial plans are approved. Progress toward accomplishment of PAPSwill be monitored. COMPONENT TWO: NationalHIV/AIDS PolicyandProgram(US8.2 million): 0 Subcomponent 1: Policy and Program Development and Implementation will strengthen capacity at national and provincial levels and promote the development of innovative, effective prevention and treatment approaches and models among vulnerable groups through: (i)demonstration sites that will explore a community-based treatment model to integrate harm reduction with comprehensive HIV treatment and care; (ii) policy studies and research; (iii)knowledge sharing and training; and (iv) other innovations. 0 Subcomponent 2: Monitoring and Evaluation will support the development of a national monitoring and evaluationresults framework, operational plan and system. Subcomponent 3: Behavior Change Communication Focused on Reducing Stigma and Discriminationwill support a 5-year nationwide BCC campaign to reduce stigma and discrimination against vulnerable groups. COMPONENT THREE: Project Management (US$ 5.184 million) will provide support to the set up and management o f the Central Project Management Unit (CPMU) as well as the Provincial Project Management Units(PPMUs) located inthe 18 provinces and two cities. 5. Lessonslearnedandreflectedinthe projectdesign This project builds on key lessons leamed in designing and implementing HIVIAIDS projects in the region and around the world. Many Asian epidemics, including Vietnam's, require a major emphasis on reducing HIV transmission among drug users, through comprehensive interventions encompassing supply reduction, demand reduction andharmreduction. A second lesson, evident inthe World Bank's experience with HIV/AIDS programs, in addition to strong national commitment, clearly evident in Vietnam, project design and implementation arrangements must sharply focus on removing implementation obstacles through capacity 5 building that focuses on fiduciary issues and encourages a focus on managing for results. The project design, with its focus on block grants for provincial action plans with annual increments related to performance provides an incentive structure to focus attention on implementation and results. Third, stigma and discrimination against vulnerable populations, such as PLWHAs, IDUs and CSWs make the delivery o f information and services especially challenging. Information campaigns directed at the general public have not been shown to be effective in reducing stigma and discrimination against vulnerable populations, and are o f relatively low utility in settings where levels o f awareness o f the disease are relatively high, as in Vietnam. The project thus supports an aggressive and carefully targeted behavioral change and communication effort designed to reduce stigma and discrimination against vulnerable populations, focusing in particular on the settings inwhich these groups are likely to seek information and services. 6. Alternativesconsideredandreasons for rejection StrategicApproach Policy-based versus Investment Operation: Vietnam's National HIV/AIDS Strategy presents a well thought out, epidemiologically sound, approach, which might have been addressed through a policy-based instrument, managed by the central level authorities. This alternative was rejected in view of the need to focus on building provincial skill and capacity to translate national strategic guidance into specific programs responsive to local conditions. Central versus Provincial: There has been a shift in spending and revenue-raising powers from central government to provincial governments. Provinces now account for about 60% o f government health spending, drawing on a number o f locally-managed sources. They have also been given greater autonomy to generate revenues, as well as to decide how to spend revenues. The proposed assistance from the World Bank i s thus consistent with Government policy by encouraging a decentralized, province-based approach to the implementation o f the HIV/AIDS Prevention and Control Program. ProjectDesign Another alternative was to focus the project on the development o f systems to provide Opportunistic Infection (01) and Antiretroviral Therapy (ART) treatment primarily at tertiary level health facilities. This approach was rejected inanticipation of a major infbsion o f resources for clinically based treatment programs through the PEPFAR program and in order to focus attention on the prevention o f an acceleration o f the epidemic by helping the Vietnamese authorities develop approaches to reducing the risk o f further transmission from vulnerable groups to the general population. C. IMPLEMENTATION 1. Partnershiparrangements(if applicable) The World Bank is coordinating its M&E activities closely with other major development partners. It i s part o f a highlevel inter-agency advocacy group which i s urgingthe government to integrate its management units and adopt a single national M&E system. It is supporting the National Institute o f Hygiene Epidemiology (NIHE) to develop a draft M&E framework which other major M&E partners will support. Support to specific activities i s being coordinated as well. The World Bank and CDC will coordinate and complement each other's efforts to ensure 6 that comprehensive M&E training activities occur at both national and provincial levels. They will also coordinate and complement each other's investments to ensure comprehensive and harmonized surveillance and research, including biological surveillance, behavioral surveillance, health facility surveillance and evaluation research. Finally, the World Bank will continue to coordinate closely with other UN agencies and the wider Committee of Concerned Partners, to promote a harmonized and effective M&E system. 2. Institutionalandimplementationarrangements InstitutionalArrangements.The main organizations involved inoverseeing andimplementing the Vietnam HIV/AIDS Prevention Project is the Central Project Management Unit, in the General Department o f Preventive Medicine and HIV/AIDS Control (GDPMAC), Ministry o f Health; Provincial AIDS Steering Committees, Provincial Project Management Units in each project province and city, and relevant implementing agencies such as NIHE at the national level, and the Pasteur Institute in H o Chi Minh City, the Pasteur Institute inNha Trang, and the Hygiene and Epidemiology Instituteo f Highland at the regional level. CentralProject Management Unit (CPMU). The role o f the CPMU would be to: (i) manage the implementation o f the National Component; (ii) provide technical support as needed to Provinces; (iii)evaluate and monitor the implementation o f the Provincial Action Plans; (iv) coordinate with other central level line ministries; and (v) establish and maintaidupdate database and resources to be able to respond to requests for consultancy/advisory services, study tours, etc. as articulated inProvincial Plans. ProvincialProjectManagementUnits. The PPMUwill sit within the Department o fHealth at the provincial level and (i) facilitate the preparation o f locally responsive HIV/AIDS Action Plans; (ii) monitor the implementation o f the action plans; (iii) timely disbursement o f ensure funds; and (iv) assemble reports onperformance from implementingagencies. Provincial AIDS Steering Committee composed o f senior officials from provincial People's Committee, provincial Health Service, HIV/AIDS Standing Bureau, DOLISA, Department o f Public Security, Department Information and Culture, Department o f Planning and Investment, Department o f Finance and others as determined by People's Committee. The Steering Committee i s responsible for the overall direction o f the project, reviewing and approving provincial action plans; cand oordinating to ensure the participation o f multiple implementing agencies, includingDOLISA, DPS,DOIC, various mass organizations (e.g. Women's Union and Youth Union), and community-based groups o f affected individuals and other elements o f civil society in determining plan priorities and receiving resources to finance their contribution to implementingthe Provincial Action Plan (PAP). 3. Monitoringand evaluationof outcomes/results Vietnam's HIV/AIDS strategy recognizes the critical role that accurate biological andbehavioral surveillance as well as program activity monitoring will play in guiding local (province and below) responsesto the epidemic. At present, Vietnam i s undertaking numerous M&E activities, particularly in the areas o f biological and behavioral surveillance, but it does not have an institutional structure for M&E, sufficiently trained M&E personnel, a national M&E framework with indicators, an operational plan and budget, or a provincial program activity monitoring system, to monitor provincial services and program performance. The national component o f the 7 project includes the development o f a National HIV/AIDS Monitoring and Evaluation framework as well as specific tools and activities that are designed to meet the needs o f the national strategy (not just this project) and to support the design and improvement o f Provincial Action Plans on the basis o fregular assessments o fperformance. As stated above, component one supports the implementation o f Provincial Action Plans. PAPS will be prepared on an annual basis and will specify objectives, activities, target populations and sources o f funds. Progress will be monitored closely. Provinces/cities could receive incremental increases above their base allocation if they perform well. Under-performing provinces/cities will receive intensified technical support to improve their performance in future years (see annex 4 for details onproject components and Annex 6 for details on implementation). 4. Sustainability The project's sustainability is enhanced by several factors. At the level of political commitment, the Government o f Vietnamrecognizes and i s fully committed to responding decisively to AIDS. A major achievement was the approval of the National Strategy by the PrimeMinisteron March 17, 2004. The approved strategy elaborated specific activities for nine priority action plans. It also clearly defines the roles o f both central and local levels o f Government, ministries, mass organizations, the private sector, communities, families etc. The strategy i s both fonvard- thinking (clearly supporting a comprehensive approach to harm reduction, including 100% condom use and needle exchange programs) and comprehensive. It envisions a multi-sectoral approach to implementing the strategy. It i s a strategy that i s welcomed by the international community and provides a clear framework for all partners to work in collaboration with the Government. At the policy level, the General Department o f Preventive Medicine and HIV/AIDS Control is committed to working with political leaders to build a policy environment that supports a sustained and effective AIDS response. At the institutional level, the Government o f Vietnam is building the institutions required for a sustained and effective response to AIDS. It has strengthened the AIDS Department inthe Ministry o f Health. NMEi s developing an AIDS Unit. Provincial research institutions are strengthening their capacity as well. Above all, the Government o f Vietnam, supported by major development partners, including the World Bank, is buildingthe provincial capacity for effective implementation o f the strategy. It i s also working with civil society to increase the capacity o f mass organizations to contribute to the AIDS response. At the human resource level, Vietnam has a senior tier o f committed and dedicated AIDS professionals. This project will focus concertedly on training the next tier o f professionals and on decentralized training, to develop a greater reservoir o f expertise at the provincial level. With respect to financial sustainability, the Government o f Vietnam has already assigned significant personnel and resources from its own resources to the national response. It i s committed to allocating further resources to HIVIAIDS. Growingrevenues inan economy that i s expanding by approximately 8% annually provide the government with a growing revenue stream, which will enable them to build a sustainable AIDS response. Its multi-sectoral approach means that resources from several sectors are devoted to AIDS. For example, MOLISA already assigns considerable resources to AIDS prevention, care and treatment. Similarly, resources are being mobilized at the local level, with major local government agencies such as Ho Chi Minh City (HCMC) assigning significant resources to AIDS. 8 Thus, at several tiers - including the national, policy, institutional, human resource and financial levels -there i s a sound foundation for sustainability. 5. Critical risks and possible co troversial aspects Risks RiskRating RiskMitigationMeasures Politicalrisks: Inadequate focus on vulnerable and H 4ggressive BCC and advocacy campaigns will focus marginalized groups by commune mlocalpolitical andadministrative leadership. and provincial officials could undermine project effectiveness. Current approach to IDUand CSW M Efforts to address stigma; demonstrating effective "rehabilitation" may be ways to provide continuum o f care and a focus on accompanied by denial that there results will help address these issues. are feasible ways to prevent further transmission o f HIV by focusing o n these populations. Bank support to H Both GVN and the World Bank are committed to demonstratiodpiloting o f services establishing independent evaluation o f the for residents o f rehabilitation HWtreatment pilots, to include monitoring of program centers could entail reputational quality and ensuring the highest possible ethical risks ifmisinterpreted as World standards. Phasing o f pilot sites will also help mitigate Bank endorsement o f lengthy, poor risks. quality treatment inoverextended treatment settings. K e y constraint to the broad H A major focus o f capacity buildingefforts at both implementation o f HarmReduction national and provincial levels will be the development srategies remains the national legal o f supportive national and provincial policies and environment. programs for HIV prevention, care and treatment among vulnerable groups o f IDUs- specifically harm reduction interventions. Inaddition, there will also be support for evaluation research that will assist the Government o f Vietnam to develop evidence-based responses to injecting drug use. TechnicalRisks BCC for vulnerable groups may not S There will be a focus on behavior change as part o f the be effective. results measurement. There is the possibility while PAPs M Technical review o f plans and support provided to may support an overall program provinces as well as incentives offered will encourage they may not link adequately to better management o f results. Moreover, PAPs that do results. not meet minimumcriteria set forth inthe Operations Manual will not be supported. 0 National policies are aligned with a M GDPMAC will establish a small team o f technical focus on changing the behaviors o f specialists to provide guidance and support to vulnerable populations, but there is provinces. relatively little experience with the desien o f interventions to reach 9 Risks RiskRating RiskMitigationMeasures these groups at the provincial level. ImplementationRisks GDPMAC may have difficulty M A detailed Operations Manual and training to be adapting to a provincial approach in provided prior to appraisal and between appraisal and the context o f a long tradition o f Boardapproval will buildcentral level skills in very centralized planning. managing a block grant approach. The project design anticipates a H GDPMAC will establish a small team o f tripling o f provincial level finances `implementation specialists', trained inWorld Bank for HIV/AIDS programs, some approvedprocurement and fiduciary procedures who provinces may have difficulty will act as a problemsolving team, working with those absorbing the additional resources, provinces where slow disbursements andor low particularly inthe first and second quality or delayed reporting indicate skill gaps. Plans years o f the project. will also be assessed for institutional capacity as well to ensure provinces can implement proposedprograms The rapid acceleration o f donor M World Bank supervision missions will monitor the activity inHIV/AIDS inVietnam i s quality and continuity o f CPMU and PPMU staff, and creating multiplejob opportunities work with GDPMAC to identify methods for rapid inthe foreignNGOcommunity; recruitment and training o f replacements when there i s a risk o f highturnover necessary. among project management staff as demand for skilled administrators from other donor agencies intensifies. Delays inthe establishment o f S The NIHEi s a long established institutionwith an provincial level capacity to monitor established track record inHIV/AIDS surveillance and and evaluate harmreductionand capacity to lead the effort to develop national and BCC campaigns could undermine provincial level monitoring and evaluation guidance technical quality o f PAPS and depth and procedures. Work o n the definition o f indicators o f annual performance reviews. for monitoring PAPShas already started. Guidance and training materials should be available inadvance o f effectiveness. There will be insufficient learning M The project will support and actively encourage use of across provinces. cross-province learning through study visits. 6. Loadcredit conditions and covenants Effectiveness 0 First year project implementation plan for National Component acceptable to IDA, has been adopted. 0 Operations Manual for Provincial component, acceptable to IDA, has been adopted. 0 Terms o freference for the Technical Review Team, acceptable to IDA, have been approved. 0 Short-list o f consultants for Technical Unit and M&EUnitwithin CPMU submitted to IDA. 0 Procurement Advisor with international experience for the CPMU, acceptable to IDA has been selected and is ready to sign contract; appointment o fprocurement officer at each PPMU. 10 a Two Accountants and one cashier for CPMU andone Accountant for each o fthe 18 PPMU and 2 cities have been appointed. Covenants ByDecember 1,2005, adopt anationalMonitoring andEvaluationPlanacceptable to the Association. By no later than November 30, 2005, establish Technical Review Team, acceptable to IDA, to assist the CPMU and Provincial AIDS Steering Committee to review Provincial Action Plans. By no later than December 31, 2005 establish a National Monitoring and Evaluation Unit within the Department o f HIV/AIDS Control of MOH; establish Regional Monitoring and Evaluation Centers inNIHE inHanoi, the Pasteur Institute inH o Chi MinhCity, the Pasteur Institute in Nha Trang and the Hygiene and Epidemiology Institute o f the Highlands in Dak Lak Province. By October 31 of each year, beginning in 2005, provincial plans will be prepared and submitted to the CPMU for review and endorsement. By October 31o f each year, commencing in2006, prepare andprovide to the Association for review andcomment annual implementationplanfor National Component. Conduct mid-term review not later than April 30, 2008. D. APPRAISAL SUMMARY 1. Economic and financial analyses The 2004 update to the existing Vietnam CAS shares the concern that the epidemic i s moving into the general population and acknowledges that there i s a need for coordinated, multi-sectoral initiatives of sufficient scale inspecific settings. This i s precisely the project goal o f the Vietnam HIV/AIDS Prevention Project and demonstrates how this project i s well situated within the overall development context of Vietnam. Public financing of the project i s justified because o f the positive externalities associated with preventingHIV transmission and because o f the public goods nature o f both establishing a national HIV M&E framework and the piloting o f harm reduction and treatment programs in the rehabilitation centers and the communities associated with recovering IDUs. Without clear revenue possibilities for project activities, it is highly unlikely that the private sector would invest insuch services. The cost effectiveness o f reducing HIV transmission has been demonstrated in numerous global settings. Harm reduction interventions are most timely -many more infections are preventable - incountries where the epidemic is growingrapidly rather than incountries where it is stable or declining. This is the case in Vietnam where the epidemic is growing rapidly but still concentrated in several key sub-groups. CSWs and, especially I D U s are currently the main drivers o f the epidemic inVietnam. The economic analysis attempts to assess the net impact o f the program's package of behavioral interventions. Towards this goal it adopts a cost-benefit approach couched ina nationally recognized epidemiological framework. The estimated impact o f the project on transmission i s set at the deliberately conservative expected value o f a 25% reduction in infections for project provinces over the period 2005- 11 2010.2 The analysis then employs monte-carlo analysis to explore a range o f outcomes. The mean number o f infections i s determinedto be 21,904 with a standard deviation o f 2,920. The minimumnumber of infections averted is 10,555 while the maximum stands at 30,449. The total gross program cost i s $35 million over 5 years, yielding a net present value of $28.2 million given the disbursement schedule. The economic benefits that would accrue to society from the new HIV surveillance system are the costs of medical treatment foregone and the value o f avoided lost eamings for both HIV patients and unpaid caretakers. The median present value o f these total costs averted i s estimated to be $114.6 million, yielding a gross benefit-cost ratio o f 4.07. Indeed every point in the range o f possible outcomes i s associated with a substantially higher present value o f total costs averted - the gross benefit-cost ratio ranges over the interval (2.58, 5.25). A reduction in the disease burden o f the population will also reduce public expenditures on health care. The medianpresent value o f savings to the health care system due to reduced public expenditures on PLWHAs is estimated to be $13.8 million, resulting in a net program cost o f $14.3 million and a net benefit-cost ratio o f 8.00. The net benefit-cost ratio ranges over the substantially longer interval (3.82, 13.97) than the gross benefit-costratio. The burdeno f recurrent government expendituresgenerated by the proposedproject is estimated to equal $1,746,200 per year after project completion. (This figure i s determinedby summing the expected central level recurrent costs with 20 times the average provincial level costs.) This i s a very small amount in comparison with the total health sector government spending ($439.3 millionper year). The recurrent expenditures deriving from the continuation o f harm reduction and other relevant programs total $31,200, or 0.6% o f the average province health budget. Furthermore, although the increases in financing obligations due to increased HIV/AIDS related programming i s relatively minor, these increases represent a substantial increase in the total amount o fpublic funds spent at the province level for HIV/AIDS. 2. Technical The proposed project adheres to intemationally accepted best practices for HIV/AIDS response insettingswith a concentrated epidemic. Failure to base HIV/AIDS policies on epidemiological models specific to the country can lead to inaccurate assumptions about the future trajectory o f the disease, transmission dynamics, prevention, care and treatment priorities, inappropriate programming and ultimately reduction in Borrower commitment to effectiveness. The present project design i s based on estimates and projections o f Vietnam's HIV/AIDS epidemic, developed with extensive stakeholder and expert consultations and incorporating the most current available information on the epidemiology o f HIV in Asia. Experience elsewhere in South East Asia, notably Thailand and Cambodia demonstrates the effectiveness o f AIDS programs that focus intensively on the major drivers o f transmission. 'HIVprevalence i s an unsuitable indicator because o f measurement difficulties and delays. Changes in key behaviors are better medium-term indicators. Evidence from other South-East Asian and East Asian countries, including Thailand, Cambodia and Hong Kong indicate that a significant reduction in risk practices, through increased use o f condoms among sex workers and increaseduse of clean needles and condoms among injecting drug users can significantly reduce overall HIV infection, by an estimated 2540%. The economic analysis utilizes a conservative estimate of a 25% reduction in HIV prevalence, resulting from large-scale reduction in risk practices among vulnerable groups. 12 The main thrust o f the project is support for a decentralized, province-based approach to the implementationo f H N / A I D S programs. The project also places great emphasis on strengthening institutions, leaming and innovation, andmanaging for results (see Annex 4 for more details). 3. Fiduciary Financial Management: Financial management arrangements are summarized in Annex 7 while the procedures are detailed in the project's Operations Manual. The arrangements derive their foundation inthe existing financial management systems in the CPMU under the stewardship o f the M O H and direction o f the CPMU Director. Country financial management systems as promulgated by the M O F provide the basis upon which the project financial management arrangement and procedures are established. The existing systems will however be strengthened by installation o f a simple computer-based accounting system that shall interface with the broader existing systems inthe department as well as M O H and MOF. Provinces and cities will use simple spread sheet based systems which will be consolidated at the CPMU level. Duringthe life o f the project, it i s important that a sustainable, simple and sound fiduciary system is put in place. To this end, financial management capacity in CPMU will be enhanced with the recruitment o f a qualified chief accountant and two more accountants and a clerical accounting staff who may also serve as a cashier for the CPMU. At the provincial and city level, the PPMU will also boost the financial management capacity by recruiting an additional accountant under the project. Training will also be provided at national and regional level for the accounting staff to ensure they are well versed with modem accounting techniques and on specific World Bank aspects and procedures, especially inthe area o f disbursement. The project will adopt traditional (transaction based) disbursementwhich most IDA supported projects inthe country are familiar with. However, the CPMU will report on quarterly-based Financial Monitoring Reports (FMRs) from the beginningo f the project. The CPMU will have the responsibility o f preparing annual financial statements for the project, and arranging for the annual audit which will comprise a single audit report covering all aspects o f the project, including the Special Account and audit o f Statements of Expenditures (SOE), by an independent extemal auditor, selected through a competitive process, soon after effectiveness. The cost o f the audit will be financed from the project. Procurement: During project preparation, assessments were carried out o f the implementing agencies to evaluate their capacity to conduct procurement and to assess the risks. The Central Project Management Unit (CPMU) was established within the General Department o fHIV/AIDS Prevention and Control, MOH, to prepare and later implement the project. The team consists o f the director, deputy director, program managers, officers and some short-term consultants on procurement and financial management. The CPMU managers and staff have strong academic backgrounds, experience in the health sector, and relatively good management skills. However, they, includingtheir consultants, have limited experience in government, public or private sector procurement or international procurement and little knowledge of the World Bank procurement policy and procedures. In addition to the project, the managers and staff have other responsibilities inMOH and cannot be expected to work filltime on the project. The capacity at provincial levels and other implementation institutions are at best similar and most o f them have much less capacity, in term o f staffing, level o f technical assistance from local consultants and facilities. Given the current capacity and the general shortage o f qualified procurement staff in 13 the country, the overall procurement risk of the project is rated high. Multiple implementation agencies at central, provincial and national levels also increase the risk o f slow approval, reporting and disbursement process, potentially causing delays in project implementation. Risk mitigation could be achieved through clear documentation o f operating authorities, respective responsibilities, use o f the Operations Manual for provincial activities, recruitment o f qualified procurement officers and an advisor, extensive training throughout the project period, adequate technical assistance to implementation agencies, and intensive supervision, at least in the first two years, by the CPMU staff and its consultants. An action plan was discussed and agreed to supplement and strengthenthe capacity to carry out procurement activities. 4. Social Ethnic Minority Framework The project's 20 participatingprovinces and cities are homes to over 3 million ethnic minorities. Almost 70 percent o f them are located inthe project's eight northern provinces. The HIV/AIDs prevalence among ethnic minority i s lower than for other social groups. However, insome ethnic minority communities, especially near border areas, HIV i s prevalent and spreading quickly among injecting drug users and commercial sex workers. Awareness o f these health risks i s still limited among some ethnic minority communities. Three major vulnerabilities exist among ethnic minority groups that could exacerbate this situation: (i) Thelonghistoryofopiumuseamongthoselivinginthenorthemprovincesisseento have created a sense of tolerance for drug use. The traditional means o f consumption o f the mountainous regions are gradually being transformed and replaced by a drug scene closer to the urban practices in the country. Drug users tend to be younger, preferring heroin and, to a lesser degree, amphetamines while older drug users tend to use opium. High-riskbehaviors areprevalent among IDUs. (ii) There i s evidence that point to the increasingparticipation o f young ethnic girls inthe sex trade, working as CSWs in their home province, especially in the tourist areas. Minors from ethnic minority groups residing in border provinces are subject to cross-border trafficking. (iii) Ethnic minority women suffer from a high rate o f reproductive tract infections including gynecological diseases and sexually transmitted diseases (STDs). The objective o f the Ethnic Minority Framework is to provide guidance in the development o f provincial/city action plans i s to ensure that under the project ethnic minority groups are informed, consulted and mobilized to participate inits project activities. Notably, the framework will guarantee equity in representation, reduce social disparities, and overcome any obstacles such as language and cultural sensitivity for guaranteeing equal rights for ethnic minority women, men, adolescents and children in participating and achieving benefits from the project. Their participation will enable the provinces/cities to design better delivery and provision o f information and services suited to ethnic minority needs and circumstances. 5. Environment Health Care Waste Management Management o f health care wastes was identified as a possible area o f concern inthis Project. In addition to the safety of blood supply, the specific concerns are associated with the disposal o f contaminated blood, used needles, and other wastes generated at health care facilities. A health care waste management (HCWM) study undertaken as part o f project preparation indicates that 14 solid health care wastes are requiredto be segregated, with incineration or landfilling to be used as treatment/disposal technologies for infectious ("clinical") wastes. However, the actual practice i s that many health care facilities in Vietnam lack the necessary resources to procure even simple supplies such as colored bins or plastic bags. Therefore, inmany instances, wastes are not properly segregated, and the unsegregated health care wastes are either landfilled on-site or offsite (under contract by URENCO), incinerated, or undergo open-air burning on hospital premises. It is reported that only one third o f the health care wastes are incinerated and that incinerators, which do not perform up to standards, are likely to emit hazardous compounds. These practices present health risks to the patients and their visitors, the health care facility personnel, workers who handle health care wastes, and the general community. The study also provided recommendations on the appropriate mitigation measures to be taken during project implementation. Details on the mitigation measures and the monitoring program adopted can be found ina Health Care Waste Management Plan. 6. Safeguard policies Safeguard Policies Triggered by the Project Yes N o Environmental Assessment (OP/BP/GP 4.01) Natural Habitats (OP/BP 4.04) Pest Management (OP 4.09) Cultural Property (OPN 11.03, being revisedas OP 4.11) Involuntary Resettlement (OP/BP 4.12) Indigenous Peoples (OD 4.20, beingrevised as OP 4.10) Forests (OP/BP 4.36) Safety o f Dams (OP/BP 4.37) Projects inDisputedAreas (OP/BP/GP 7.60)* Projects on International Waterways (OP/BP/GP 7.50) 7. Policy Exceptionsand Readiness N o policy exceptions are being sought. * By supporting theproposedproject, the Bank does not intend toprejudice the$nal determination of theparties' claims on the disputed areas 15 Annex 1: Country and Sector or ProgramBackground VIETNAM HIV/AIDS PreventionProject Introduction The global pandemic o f human immunodeficiency virus (HIV) and the attendant epidemic o f acquired immunodeficiency syndrome (AIDS) present one o f the key public health challenges o f our time. With no effective vaccine or cure likely to be available in the mid-term future, the priority responses o f government remain prevention o f HIV infection and, increasingly, treatment o f AIDS. In Southeast Asia HIV/AIDS currently remains concentrated in particular vulnerable populations. Although effectively reaching these populations with prevention and treatment programs presents challenges, it also offers an opportunity to impact significantly on the progress o fthe HIV/AIDS epidemic. According to UNAIDS, in East Asia, the 50% increase in HIV infections from 2002-2004 is largely attributable to growing epidemics in China, Indonesia and Vietnam. In Vietnam in particular there is clear potential for the epidemic to spread from vulnerable groups through bridge populations to the general population. The major burden o f disease is being borne by young people, with 62% o f reported HIV cases aged 20-29 years. This implies serious economic consequences for the nation, with an epidemic among the most economically productive age group. Global experience has taught that national preventive programs targeting epidemiologically significant risk behaviors can control transmission amongst high-risk groups and stop the generalized spreado f HIV. Vietnam presents a clear example o f a country inwhich the trajectory o f a concentrated HIV/AIDS epidemic may be greatly curtailed by a highly focused program aimed at stopping HIV/AIDS transmission. The anticipated success of such a program is based on comprehensive epidemiological data. Estimates and projections of HIV in Vietnam have recently been prepared by The Vietnam Technical Working Group and disseminated by the Ministry o f Health (MOH). The report finds that the estimated number of people living with HIV in Vietnam has been sharply increasing in the past 3-5 years - rising from approximately 96,000 to 245,000 during the four-year period between 1999 and 2003. HIV infection and deaths from AIDS have now been reported in all o f Vietnam's 64 provinces. Although the population prevalence in the country as a whole remains less than half o f one percent (0.44% in 2003), the prevalence o f HIV i s high among particular vulnerable populations. Injecting drug users (IDU)dominate the epidemic with males and youth being more at risk. IDUhave a national prevalence o f approximately 33%, although this rate is much higher in areas such as H o Chi Minh City (HCMC), Hai Phong and Quang Ninh. After IDU,female sex workers (FSWs) have the highest prevalence - approximately 3.1% nationally, again with higher rates in some cities including Hai Phong, HCMC, Hanoi and Can Tho. By 2005, it i s estimated that there will have been a cumulative total o f 60,000 AIDS deaths in Vietnam. The overlap o friskbehaviors is a critically important characteristic that is drivingthe HIV/AIDS epidemic in Vietnam. In Hanoi and H o Chi Minh City, 25% o f commercial sex workers also inject drugs. The sharing o f needles and syringes i s widespread. Almost two-thirds o f the IDUs in Hanoi (65.47%) and slightly fewer in Hai Phong (46.4%), Can Tho (51%), and HCMC (42.9%) reported 2 or more sexual partners in the past 12 months. With the exception o f those 16 surveyed in Ho Chi Minh City, IDUs do not consistently use condoms in a majority of their sexual encounters. The prevalence o f HIV among male clients o f sex workers i s also steadily increasing. These and other findings from behavioral surveys are highly suggestive o f the pathway the epidemic i s taking from IDUs to CSWs, and other heterosexual partners. Key Elementsin the Vietnameseresponseto HIV/AIDS The government has responded to the threat o f the epidemic. A legal framework was developed to support implementation o f the national program; AIDS committees were set up in each province. These committees, together with their member organizations (Vietnam Women's Union, Vietnam Youth Union, and Vietnam Red Cross) became focal points for planning and delivering HIV/AIDS related services. In addition, HIV testing sites have been set up in all provinces; blood screening processes for HIV have been adopted and routine collection o f sentinel surveillance data (both behavioral and sero prevalence) i s now established. Furthermore, numerous localized prevention activities are under implementation; these employ a variety o f interventions applied solo or incombination, each aimed at changing risk behaviors. Policy and Regulatory Issues KeyPolicyDecisions 0 1987: Formation ofNational AIDS Prevention and Control Program (NAP). 0 1990: Creation o f National AIDS Committee (NAC) to guide national HIV/AIDS prevention and care. 0 1994: National AIDS Bureau(NAB)was created to bethe acting secretariat for NAC. 0 National AIDS Committee came under direction o f Deputy Prime Minister; National AIDS Bureaucreated to act as secretariat for the National Committee. 0 1995: Party's Central Committee issued Directive on HIV/AIDSprevention and control. 0 National Assembly adopts an ordinance on HIV/AIDS addressing IEC, health care, etc. 0 2000: Establishment of National Committee on AIDS, Drug and Prostitution Prevention and Control, chaired by Deputy Prime Minister. This Committee replaced the former N A C and has membership from highest levels o f Government. Earlyinto the HIVIAIDS epidemic, the government instituted legislation aimed at addressing the issue of stigma and discrimination against people living with HIV and AIDS (PLWHA). Moreover, through 2000, IEC campaigns raised understanding about HIV and AIDS among the general population in order to reduce fear and stigma. Inspite o f all these efforts, there has been an increasing level o f stigma and discrimination not only against PLWHA and their families, but also against other vulnerable groups, in health facilities, schools, the workplace, rehabilitation centers, incommunities and families. The government i s strongly concerned about the consequences o f stigma and discrimination, such as keeping away vulnerable groups from using health and social services and from jobs. Stigma and discrimination makes it more difficult to prevent the spread o f HIV infection. Stigma and discrimination i s also a gender issue. Women living with HIV/AIDS seem to suffer more stigmatization than men because o f the general assumption that women living with HIV/AIDS must have acquired the disease through immoral means. Society expects women to uphold the moral integrity o f family and society while men can be more self-indulgent. While women tend 17 to be "blamed" for acquiring HIV and AIDS, men are often forgiven by family and society. The consequences o f stigma are also more severe for women, who are more frequently sent away and separated from their children than are men. The Prime Minister's February 2003 directive designated functions by Ministry to strengthen HIV/AIDS prevention activities and coordination within government. The directive assigned MOH the key responsibilities o f strengtheningstructures for HIV/AIDS Prevention fi-om central to community levels, and key interventions, e.g. harm reduction, improving surveillance systems, promoting safe blood, prevention o f mother to child transmission (PMTCT). Four other ministries were given important roles as well. MPI and M O F were asked to arrange adequate and timely funding for HIV/AIDS prevention. Ministry o f Public Security would develop mechanisms to support infected children, work with sex workers and drug users inrehabilitation centers, and develop and implement action plans for effective interventions to prevent transmission from high risk groups to the community. The Ministry o f Culture and Information would collaborate with other Ministries and Peoples Committees in provinces and cities to strengthen responsibilities o f all local levels o f the Party and Government; improve understanding of HIV/AIDS; oppose discrimination towards PLWHAs and promote healthy lifestyles including practice of safe sex and safe injection. Other ministries were assigned more limitedroles. In 2003 the Government also decided to merge the National AIDS Standing Bureau with the Preventive Medicine Department to become the General Department o f Preventive Medicine and HIV/AIDS Control. Inearly 2004, the Prime Minister approved the National Strategy on HIV/AIDSPrevention and Control for the period 2004-2010, with a vision to 2020. The strategy specifies achievements to date and remaining challenges. The Strategy identifies the following nine action areas: 1) Information, Education and Behavioral Change Communication; 2) Harm Reduction and Prevention; 3) Treatment, Care and Support for People Living with HIV/AIDS; 4) HIV/AIDS Surveillance; 5) Monitoring and Evaluation; 6) PMTCT; 7) STI Management and Treatment; 8) Safe Blood Transfusion and 9) Capacity Buildingand International Cooperation Program. As o f September 2004, a draft Ordinance o f the Standing Committee o f the National Assembly on HIV/AIDSprevention and control was under discussion. Support for this i s beingprovided by the POLICY Project. The donor community is clearly signaling their interest inhelping the Government o f Vietnam to increase accessibility o f specific HIV disease treatment - antiretroviral therapy (ART). To make the best o f these opportunities, it will be important for the government to clearly identify and examine the costs of a range of different policy options. In particular, will the government procure branded or generic drugs, and by what mechanism? A seminar was held inJune 2004 to disseminate the report "Affordable ARV Drugs for People Living with HIV/AIDS in Vietnam: Legal and Trade Issues", co-sponsored by the Ford Foundation and the World Health Organization (WHO). 18 Key Programsand Constraintsto AddressingHIV/AIDS inVietnam Prevention. Small scale community based pilot projects and models receive support from the Government, bilateral and multilateral donors, UNagencies and intemational NGOs. About 85% o f them are concentrated in the seven provinces with the highest prevalence o f infection. They are targeted mostly to high-risk groups - IDUs, commercial sex workers, PLWHA and mobile populations (e.g. men in uniform, migrant workers, seafarers, long distance truck drivers, etc). Although stigma reduction activities have beenbuilt into IEC activities, the nationalprogram has not emphasized reducing discrimination to date. Behavior Change Communication. Face-to-face communication i s the principal method for communicating messages, including notably peer education. Some peer-to-peer programs have been quite effective in reaching high risk populations with key messages. The majority o f the communication campaigns, however, are stand alone IEC efforts, designed and implemented independent o f services or institutional support. The "Evaluation o f the National AIDS Program" conducted in 2002 reported that 70% o f people aged 15-49 have basic knowledge o f HIV/AIDS prevention. The study noted that IEC campaigns have been successful in improving people's knowledge on the modes of transmission and preventive measures were not sufficient to effect behavior change - indicating a need to go beyond delivering messages and addressing the root causes underlying risky behaviors (e.g., substance abuse). The same report noted insufficient coverage o f remote areas of the country as well as among hard to reach groups such as IDUs, CSWs and seasonal migrants. Voluntary Counseling and Testing (VCT). VCT i s an important element o f any HIV/AIDS program o f intervention. There are currently very few VCT sites in Vietnam. The majority o f testing takes place in rehabilitation centers, prisons, the military and other government institutions. Counseling services have proven to be inadequate with shortages o f professional counselors and insufficient training of staff. The US Centers for Disease Control and Prevention (CDC) is providing support to the Government for the rapid expansion o f VCT services. Drop-in Centers. After care using a community drop-in center model has been shown to be effective in pilot programs in several settings in Vietnam. The "B93" clubs are a successful example o f aftercare in Hanoi. The community-based pilot intervention modality o f mutual and self-help groups initiated ina UNODC-supported project (VIEh393) has led to the creation o f 82 post-treatment clubs inHanoi City. All club members are recovering drug users who volunteered to carry out peer education and drug/HIV prevention outreach activity in their community. FHI manages a program "Reaching Injecting Drug Users through Drop-In Centers" and the ECHO Peer Education Model has also been successfully implemented in several sites in Vietnam, as well as several other examples o f successful pilot programs for sex workers. Treatment. Under the MOH there are three key centers providing medical treatment o f HIV/ADS in Vietnam, situated inHanoi, HCMC and Hue. Additionally these centers function as reference institutes, providing guidelines and training for the surrounding provinces. The capacity to diagnose and treat 01s i s limited. The use o f ART follows M O H policy and national guidelines. Their use i s largely limited to post-exposure prophylaxis for H C W and PMTCT. Provincial and district level hospital and centers have more restricted capacity in diagnosis, treatment and care. 19 HIV/AIDS-TB Nexus. Inmany African and Asian countries the twin epidemics o fHIV/AIDS and TB are closely linked - with the vulnerability o f AIDS patients to TB infection threatening to reverse the gains in TB control o f the last decade. Vietnam i s classified as a high TB burden country within the westem pacific region. With the support o f the WHO "STOP-TB" effort, the Vietnam National TB Control Program institutes directly observed treatment (DOTS) in 100% o f districts, with a high rate o f diagnosis, notification and cure. All TB medications are procured and supplied through this national program. Despite this success, however, there has yet to be any decrease innotification o f new infections nationally. Multiple factors may contribute to this static pattem - including the masking o f gains by active case identification and population mobility - however it i s likely that the increasing prevalence o f HIV i s impacting on the picture o f TB in Vietnam. The National TB control program has recommended the establishment o f a national TB/HIV coordinating committee and adoption o f a TB/HIV framework. Monitoring and evaluation and HIV/AIDS Surveillance. The national HIV/AIDS program in Vietnam has made great advances inthe establishment of a system for the routine monitoring o f the epidemic, both through sentinel surveillance and behavioral surveillance surveys. Inconsistencies associated with increasing the number o f sites and consolidating data collection procedures in the sentinel surveillance system have diminished in recent years and the data appear to be more stable, although difficulties in securing sampling size continue to result in annual fluctuations o f rates. Caution i s advised ininterpretingthe results from this, as with other surveillance systems, due to selection biases associated with the difficulties reaching risk groups that practice illicit or illegal behaviors (e.g., CSWs and IDUs). The surveillance system i s urban based, so it cannot provide insights into the course o f the epidemic in rural areas, or in border areas. Additionally, the weak STI treatment program in Vietnam results in few cases o f STI being screened for HIV. Additional work on strengthening the use o f surveillance data in monitoring and evaluation i s also required inorder to gain a more complete understanding of the HIV/AIDS epidemic in Vietnam and to direct evidence-based programming, Improved surveillance and program monitoring is required for greater understanding o f HIV transmission inVietnam, priority responsesandmajor gaps. DonorActivity inVietnam Vietnam i s receiving assistance for a wide range o f activities from a number of bilateral and multilateral donors, UNagencies and intemational NGOs. Some o f the major programs include the Global Fund for AIDS, Tuberculosis and Malaria, DFID/NORAD ( W H O M O H implemented), USAID and the U S Centers for Diseases Control. Since the commencement o f this project preparation, the landscape o f donor support has changed dramatically, with the announcement that Vietnam was designated the 15th focus country under the U S President's Emergency Plan for AIDS Relief (PEPFAR). Preliminary indications are that PEPFAR will be allocating on the order of $20 million per year for support to Vietnam's HIV/AIDS programs. There is consensus among the donor community o f the needto work collaboratively and inways responsive to the major innovations inVietnam's National HIV/AIDSStrategy. Major strides are being taken towards strengthened donor coordination. Senior representatives o f major development partners are collectively encouraging the government to intensifyits national AIDS response, develop coordinated capacity to implement AIDS programs and prepare a unified 20 M&E system under the aegis of "The Three Ones."3 At a wider level, coordination is` strengthenedby the Community of Concerned Partners (CCP), which represents a wide range o f multilateral and bilateral donors, UN agencies, foundations and non-government partners, working at both national and local levels and includes partners with extensive practical HIV/AIDS experience and skills. This group prepareda valuable consensus paper on key issues in HIV/AIDS in Vietnam. There are also numerous informal mechanisms to improve coordination. Key Constraintsinthe Implementationof nationalstrategytargets: (i) Harm Reduction -- The key constraint to the broad implementation o f Harm Reduction strategies remains the national legal environment. Whilst both prostitution and drug use are defined as social evils and subject to prosecution, the status of harm reduction efforts designed to reduce the risk involved in these activities remains unclear. Cross-sectoral support and a better clarification o f the roles and responsibilities particularly o f law- enforcement and MOLISA are clearly needed; as well as better understanding o f factors that lead to drug use and addiction; (ii) Monitoring and Evaluation -- The national HIV/AIDS surveillance system requires revision and upgrading. As a particular priority, information should flow from this to a national monitoring structure, with evaluation linked to evidence based decision-making and planning; , (iii) Stigma and Discrimination remains a pervasive issue in all discourse surrounding HIV/AIDS and risk behaviors. Legislation and communication activities have had limited effect on reducing stigma and discrimination particularly in health facilities, the workplace, schools, rehabilitation centers, communities and family homes. There i s an urgent need for a consistent and relentless behavior change communication campaign; and (iv) Capacity constraints at both national and provincial levels, pose difficulties for the implementation of programs. Senior level capacity i s tightly stretched and there i s growing competition for existing capacity. Furthermore, provincial capacity varies considerably. There i s a need for development partners to work together to support the strengthening o f capacity at all levels. There has been significant growth in international resources for HIV/AIDS. While more resources are needed, there is an urgent need for greater support and collaboration with heavily-affected countries to avoid duplication and fragmentation o f resources. Inresponse to this challenge, in 2004, major international partners endorsed the "Three Ones" principles, to achieve the most effective and efficient use o f resources, and to ensure rapid action and results- based management. The core principles are: (i) One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; (ii) One National AIDS Coordinating Authority, with a broad-based multi- sectoral mandate; and (iii) agreed country level Monitoring and Evaluation System. One 21 Annex 2: Major RelatedProjectsFinancedby IDA and/or other Agencies VIETNAM HIV/AIDS PreventionProject /Completedproject [ - I ---l---ll_-___--- ____ __-I_-_-___--__________I Sector issue Proiect name OED's rating ~ ~ ~ e acare) t Population and Family Health Project l r---r---- -I__-- h Satisfactory ~ I j(Cr. 2807) I /Duration: 1996 -2003 ,_--I-_ ___ - /Ongoingprojects ~- " ~ l Sector issue Proiect name i Implementation bevelopment , I I /Duration: 1996 - 2005 I ~ " _l_.ll-__ll j ~ " _ _ _ II--________ ;Health(blood safety) Regional BloodTransfusion Centers S II r-- S I IProject (Cr. 3631) 1 IDuration: 2002 - 2008 Sector issues j Proiect name -~ Fundingagencies -I--- " H N / A I D S capacity inManagement, AusAID through UNDP Policy, Formulation and Coordination o f -~ ~H ~ _ s ~ d ~ n v i r o n m~ e -n t -; N / A I D S activities inVietnam" - ~ - - ~I_-_-___" - H N / A I D S AusAIDthrough UNDP Community basedAwareness Raising I land Behavior Change for Vietnamese /Youth" ~ "Community Action for Preventing Grant assistance from Japan HN/AIDS" Fundfor Poverty Reduction i (JFPR) through ADB _-"Strengthening - "- care, counseling, support `GlobalFunds to fight AIDS, related community - based activities to to People Living with H N / A I D S and ;Tuberculosis and Malaria i i(GFATM) I prevent HN/ A I D S inVietnam" I 22 Annex 3: ResultsFrameworkandMonitoring VIETNAM HIV/AIDSPreventionProject ResultsFramework4 PDO: Support programs designed to Percent o f vulnerable groups in YR 1-2:Determine vulnerable group halt transmission o fHIV/AIDS participating provinces reporting locations, population size, program among vulnerable populations safer injection practices (from an :overage and cleanneedle and (PLWHA, IDU, CSW, and their estimated 20% at baseline to 70% at :ondom use rates, develop clients and sexual partners) and project end) interventionmodels and use data to between these vulnerable :xpand improvement interventions Percent o f vulnerable groups in participating provinces reporting YR 1-2: Determine ifintervention condom use insexual intercourse strategies have adequate coverage (from an estimated 40% at baseline and effectiveness and make changes to 80% at project end) as required YR 3-4: Assess changing epidemiological and intervention dynamics, additional lessons and results o f extension to non- participating provinces and incorporate leaming infurther Programming ComponentOne: Implementation ComponentOne: ComponentOne: o f Provincial HIV/AIDS Action Plans YR 1-2: Information on the number and behaviors o f IDUs,CSWs and Ensure that 18 provinces and 2 cities An increasedpercentage o f their clientdsexualpartners i s used inVietnam have the policies and vulnerable groups (from an estimate to improve the epidemiological capacities to utilize block grants to 10%at baseline to 80% byproject relevance, quality and effectiveness design, implement and monitor end) are reachedby provincial o f provincial action plans HIV/AIDS programs which promote services safe injecting and sexual behaviors YR 2-3: Information on the inorder to reduceHIVtransmission An increasedpercentage (for an performance o f Provincial Action among vulnerable populations (IDU, estimated 10% at baseline to 90% at Plans is used to promote learning PLWHA, CSW, their clients and project end) o fprovinces prepare between provinces and to provide an families) highquality provincial plans informed overview o f Vietnam's AIDS response and major challenges An increasedpercentage o f provinces (from 0 to 90% at project YR 2-3: Review o finterventions, end) establish adequate M&E services and target groups will systems, including appropriate provide vital data on program biological and behavioral distribution, focus and reach and A s soon as the baseline data becomes available, targets will be reviewed and necessary revisions made. Each province will have a clear understanding of the targets they are trying to achieve. 23 surveillance, effectiveness research :nable program to identify and andprogramactivity and financial iddress gaps monitoring. tR 4-5: Coverage andimpact A n increased percentage o f iurveys will motivate quest for provinces (from an estimated 10%at ncreased coverage and impact baseline to 80% at project end) meet targets specified inprovincial plans Component Two: National ComponentTwo : ClomponentTwo: HIV/AIDS Policy and Program Subcomponent 1:Policy and ProgramDevelopmentand Implementation Capacity building needs assessment YR 1-2: Review coverage and Managerial, technical and research undertakenand capacity building :fficacy data and use results for capacity strengthened plan prepared and adopted reatment improvement and idvocacy for service expansion Leadership o f Vietnam's HIV/AIDS Key capacity buildingproducts, programs at national and provincial including provincial studytours, YR 3: Assess treatment level have a mechanism to policy papers, guidelines, training :ffectiveness and make encourage innovations, from all curricula and courses, research recommendations for sustaining and sectors, inthe development o f protocols and completed studies Expanding treatment effective prevention and treatment prepared inaccordance with approaches and models among capacity building plan Y R 4-5: Continue to monitor vulnerable groups changing AIDS treatment context to K e y outcomes, including improved maximize adherence and minimize Increase access to HIV/AIDS care policy and contextual environment treatment failure and interruption and support for vulnerable for interventions among vulnerable populations resident inrehabilitation groups achieved YR1: Capacity building needs centers assessment used to informcapacity At least 60 innovationgrants buildingplan awarded YR 2: Review o futilization and At least 20 activities initiatedwith results achieved by innovation fund innovation grants are subsequently will allow program improvements sustained with support from other sources YR 3-5: Ongoing review of utilization and results achieved by At least 10innovative prevention, innovation fund will allow care, support and treatment models continuous program improvements identified, evaluated and promoted YR 1-2: Ongoing review o fkey Healthproviders inpilot receive capacity buildingproducts used to appropriate training and supervision refine and enhance capacity building incomprehensive treatment, care strategy and to make implementation and support changes as required Clients inpilot receive appropriate YR 2-3: Evaluation o f effective comprehensive treatment, care and innovations will increase the range support, including integratedharm o f proven approaches that provinces reduction activities may use, and enable them to better target communities not reached through conventional approaches, 24 specially vulnerable communities IR4-5: Overall review of capacity iuilding to assess its effectiveness, he key outcomes achieved, lessons earned and to chart the course for uture capacity building activities KT Useresultstodevelop 1: :omprehensive care models, ncluding acceptability of integrating iannreductioninthe continuum o f :are Subcomponent2: Monitoring and Vational M&E framework, Y'R 1-2: National M&Eframework, Evaluation -- Comprehensive 3perational plan and budget adopted Aan and budget used to identify monitoring and evaluation system 3yYR1 )vera11M&E priorities, pinpoint established and used to improve zaps and mobilize resources for key decision making and programming National and regionalresearch uI&E products institutions' strengthened, through zstablishment o f AIDS M&E nuclei YR 1-2: Biological, behavioral and and recruitment and training o f nealth facility surveillance, research AIDS M&E staff indprogramactivity and financial monitoring constantly reviewed to Biological, behavioral and health znsure evidence-based facility surveillance strengthened, programming, learning by doing and effectiveness researchinitiated and :ontinuous performance functioning provincial program enhancement activity and financial monitoring systems establishedby YR 1 YR 1-2: Improved information flow fromprovinces to national level - Mechanisms developed to regularly and from national level to provinces. disseminate M&E results and to use data for program improvement YR 3-5: Ongoing M&Esystems usedto provide date for program improvement. Subcomponent3: Behavior Health workers and communities YR 1:Use formative researchto ChangeCommunication -- report reduced stigma and identify key message and Reduced stigma and discrimination discrimination towards PLWA, IDU, communication channels and to towards vulnerable groups S W and communities design well informed and targeted interventions Increasednumber o f published or aired (TV, radio) materials on YR 1-2: Review intervention HIV/AIDS by trained journalists evaluation data and trend data o n from 2005 stigma and discrimination and make tactical changes as required Increased o f number o f PLWHA who appeared on radio, TV or print YR 3-5: Continue to assess to share their stories from 2005. interventioneffectiveness and make ongoing recommendations for Increasednumber o f PLWHA who further efforts to address stigma and are members o f PLWHA discrimination associations inparticipating provinces 25 Component Three: Project Component Three: Component Three: Management GDPMAC and associated C P M U Project management unit and YR 1: Key management milestones and PPMUs coordinating the administrative, technical, financial are sets and reviewed to ensure provincial level are efficiently and procurement sub-units implementation progress in managing andproject resources established, bank account opened, accordance with implementation staff and consultants recruited, plan systems established, implementation plan prepared and improved, YR2 onward: Monitoring o f annual coordination and technical support implementation targets will promote provided to provinces and results orientation and enable coordination services provided to implementation challenges to be implementation partners addressed Project management units prepare adequate plans, meet annual implementation targets and provide timely financial and activity reporting Baseline, mid-term and end-of- project management and capacity reviews demonstrate enhanced project management and institutional capacity, evidencing an increase in the number o f provinces judged to have adequate managerial and institutional capacity (0-80%) by year 5 Government demonstrate increased capacity to effectively coordinate development partners' contribution to AIDS response 26 W ....1e e e 1 -b u F: 3 W c 1 % 0 Do BL 5L -b I I: I:: 0 In 0 In ecLL 0 2 2 1 - + I- I- c - I-I- 1I-- 3 3 e I- F i I- I- I- I - 0 m P x " J w e, 2 & f no Annex 4: DetailedProjectDescription VIETNAM HIV/AIDSPreventionProject COMPONENT ONE: Provincial Implementation of HIV/AIDS Action Plans (ApproximatelyUS$21.616 million) This component will provide subgrants to eighteen provinces (An Giang, Bac Giang, Ben Trey Cao Bang, Dong Nai, Hau Giang, Khanh Hoa, Kien Giang, Lai Chau, Nam Dinh, Nghe An, Son La, Thai Binh, Thai Nguyen, Thanh Hoa, Tien Giang, Vinh Long, and Yen Bai) and two cities (Hai Phong and Ho Chi MinhCity) to support the preparation and implementation o f Provincial Action Plans (PAPS). The 18 provinces and two cities are broadly distributed across Vietnam, encompassing rural and urban areas (including Ho Chi MinhCity) as well as border regions inthe south and north o f the country. They also represent a balance o fprovinces with highand low HIV prevalence and donor presence ranging from intensive to minimal. Five o f the provinces without existing international donor support are included- although these provinces are largely o f small population and with HIV prevalence and vulnerable populations less than that of the national average. Nevertheless, their geographic location indicates a potential for increased prevalence. The 20 provinces and cities account for approximately 42% o f the total population and about 55% o f all reported HIV cases. The set includes two o f the most populous and most severely affected cities inthe country -HoChiMinhCityandHaiPhong. Theirinclusionwillenabletheprojecttogainmanylessons that can be effectively translated to other provinces. It i s particularly in these two centers that project interventions will produce the greatest gains and from which lessons learned will be most effectively translated to other provinces. TheNational Strategy places the responsibility for implementationwith the People's Committees o f the provinces and cities. The local authorities are expected to develop and identify HIV/AIDS prevention activities that will be mainstreamed into their development plans; in addition to the funds allocated by centralgovernment. They are expected to allocate funds, humanresources and infrastructure for the programs. In 2004 the state budget for the National HIV/AIDS program was allocated in a manner to support the aforementioned objectives through the signing o f a contract between the Ministry o f Health and provincial authorities as well as other Ministries to carry out their HIV/AIDS prevention program. This initiative i s viewed as a promising start to a province-basedapproach. The support from the project will complement and build on existing systems for allocating and monitoring the use o f resources for HIV/AIDS, and will focus on supporting the process o f preparing, reviewing, implementing and assessingthe success o fprovincial specific plans. Plans are to be prepared by October of each year for allocations to cover the period between January - December. Grants will be disbursed in tranches following approval by the Provincial Steering Committee, CPMU, and the People's Committee. During the first year, IDA will review all twenty plans prior to approval o f the People's Committee. An independent Technical Review Team will be established to review plans during years 2-5. 31 In developing its approach, the project team recognized that several other donors, including specifically the GFATM, DFID/NORAD, and the CDC Life-GAP program, and the Ministry's own support operate through provincial plans and action. Accordingly, the templates for PAPs designed for the project are consistent with the structure o f the National HIV/AIDS Strategy. They have also been designed to facilitate coordinated planning o f government and external finance inbudgetingthe provincial plan. Provincial Action Plans will be prepared on an annual basis and will specify objectives, activities, target populations and sources o f funds. The overall guiding framework for the plans i s based on the nine action plans specified inthe National HIV/AIDS Strategy. Activity selection and support must be guidedby one basic principle: impact on reducing HIV/AIDS transmission. Moreover, in reviewing the overall plan for HIV/AIDS, overlap with other activities should be avoided. Activities that do not meet these minimumcriteria will not be supported. The project will be managed on a block grant basis usingspecific criteria (HIV/AIDSprevalence as measured by the Estimates and Projections 2004 Report; population; and availability o f resources from other sources) to determine the size o f each year's base allocation. The M O H and the Bank have agreed to the first year base allocation. Progress toward accomplishment of PAPs will be monitored on an annual basis. Provinces could receive incremental increases above their base allocation ifthey perform well (likely criteria to be measured include: (i) quality o f plan; (ii) level o f disbursement, and (iii) to which targets are met). Under-performing extent provinces will receive intensified technical support to improve their performance in future years (see annex 6 for details on implementation and approval processes). Guidelines for preparing templates and for provincial reporting requirements will be in the project's Operations Manual. Key elements o fthe planning template include: 0 Background and situation analysis to encourage provincial planners to assemble and analyze available demographic and epidemiological data to enable 1) an understanding o f the characteristics and transmission dynamics o f the epidemic within their province, 2) identification o f the size, location and demographic characteristics o f the most vulnerable (highrisk) populations within their boundaries, and 3) an overview o f the characteristics o f the service delivery channels available in the public and private sectors for developing responsive HIV/AIDS activities within the province. 0 Current provincial response to HIV/AIDS to get insights on what i s happening on the ground to lay the foundation for provincial planning (including summary o f activities undertaken and lessons learned). Proposed Planning section seeks information on goals, objectives and expected results. Plannersare expected to provide a 5 year strategy and implementation plan for first year. 0 The development o f a five year management and sustainability plan outlining the staff andresources required to achieve the plan. As stated above, indicators collected at the provincial level will be usedto determine subsequent year allocations. The PAP thus becomes the key instrument that M O H and others will use to ensure that provinces are managing their HIV/AIDS resources by specific measures o f performance andresults. 32 Approval Process. Procedures for reviewingand approving annual Provincial Action Plans are described below: The Comprehensive Provincial Action Plan is assembled from sub-action plans of provincial implementingagencies, and submitted to the Director o fthe PPMU. The Director of the PPMU submitsthe Provincial Action Planto the CPMU for technical quality review and revises the plan ifrequired.A technical working group will be formed to review. First year plans -- CPMU sends the revised Provincial Plan to the World Bank for no objection. World Bank will review all plans for the first year. Subsequent Year Plans- Technical Review Team will be inplace, meeting every year to review all 20 plans (see below). As and when needed, the World Bank mayprior review a random selection o fplans. The PPMU then submits the final revised provincial plan to the Vice Chairman o f the People's Committee, also being director o f the Steering Committee, signs to approve the plan. The PPMU will officially submit the annual Provincial Action Planto the CPMU for first payment. Following the first year, each Provincial Action Plan will report on provincial performance, using provincial level monitoring indicators developed as part o f the National M& E Framework. Subsequent year budget allocations will be determined on the basis o f the base calculation (see above) with adjustments made based on assessment o f the previous year' s performance. Any adjustment inAction Plan that lead to less than 15% o f total budget change may be decidedby the CPMUwithout approval from the World Bank. TechnicalReview Team.The primary proposedrole of the Technical Review Team (TRT) is to first develop formal criteria for the review process and second review plans to ensure the following: (i)quality o f plans; (ii)epidemiological relevance and probable impact on HIV transmission dynamics; (iii) consistency o f proposed activities with international good practice; (iv) optimal use o f existing resources; and (v) technical expertise and level o f specificity and feasibility o f plans. The TRT will recommend how provincial action plans may be made more effective, before they are accepted for referral to the next tier. The TRT may also review other proposedactivities, including research priorities. Criteria usedto review the plans might include: First, does the plan identify and address the major drivers o f transmission in each province? Second, are the allocations o f effort and resources directly linked with the major drivers? Third, does the plan specify clearly how to measure/estimate the size o f populations requiring essential services and does it specify how it will both achieve andmeasure high coverage o f essential interventions? Fourth, do the interventions proposed reflect the best possible effectiveness evidence we have? Composition. A seven person Team will be created. The TRT should be chosen to ensure diverse representation, with a particular focus on expertise in injecting drug use and sex worker issues. 33 The members should have excellent HIV/AIDS technical skills, including an understanding o f the major drivers o f HIV transmission in each context and evidence-informed and contextually appropriate interventions. They should also have extensive practical experience implementing HIV/AIDS interventions in Vietnam. In addition, the Technical Review Team may co-opt specialist expertise on an ad hoc basis. The specific TOR for the team will be agreed upon by effectiveness. Frequency of Meetings. It i s suggested that the TRT meet once annually, prior to October, to permit sufficient time for decision to be incorporated into the government planning cycle, for a period o ftwo days. Proposed Disbursement Eligibility and Performance Incentives. The provincial component will include a disbursement eligibility and performance incentive component from Years 2 to 5. To be eligible for further disbursements,provinces mustmeet disbursement eligibility criteria. In addition, a performance incentives component may result in annual performance increases o f up to 20% above the base allocation. The disbursement eligibility and performance incentives will be based on three major criteria: 0 Disbursementof Previous Allocation: To be eligible for further disbursements, provinces musthave spent at least 50%of their existing disbursements. 0 Quality o f Provincial Plans: To be eligible for further disbursements, provinces must have an adequate provincial plan. Provinces with exceptional provincial plans may receive a performance incentive o f up to 10% over the base allocation. An adequate plan .meets the majority o f the quality requirements below with sufficient rigor. An exceptional plan meets all o f the quality requirements below with exceptional rigor. The quality o fprovincial plans will be assessedusingfour criteria: o The strategic relevance o fthe planinaddressing andprioritizing the major drivers o fHIV transmission, usingevidence-informed approaches ineach province (increased provision of, and access to, services proven to reduce HIV transmission) o The specificity and measurability of the performancegoals set inthe plan o The ambitiousness andachievabilitv o fthe targets set inthe plan o The extent to which the budget represents an optimal allocation o f resources in order to achieve the priorities defined inthe plan 0 Previous year's implementation: To be eligible for further disbursements, provinces' previous year's implementation must be judged to be adequate in relation to the targets set in their plans. Provinces whose previous year's implementation i s judged to be exceptional in relation to the targets set in their plans may receive a Performance incentive o f up to 10% over the base allocation. Adequate implementation means that the majority of targets have been met, with activities o f adequate quality. Exceptional implementation means that all the targets have been met or exceeded, with activities o f consistently high quality. The Provincial Monitoring Form will be used to monitor performance. The form contains the major monitoring and service indicators and contains 34 three categories o f ratings for each item: (1) not adequate (2) adequate and (3) exceptional. Overall performance ratings will be derived from individual itemratings. This system is outlined inthe table below: Criteria N o Yes 1.Hasthe province Defer until50% i s spent The province's eligibility i s disbursedat least 50% o f its thenassessedagainst previous year's allocation second and third criteria 2. I s the quality o fthe Refer planfor revision with [fthe plan i s adequate, the provincial planeither suggestions for province i s eligible for a improvement further disbursement. Ifthe plan i s exceptional, the province i s eligible for further disbursementand a performance incentive of upto 10%above the base allocation 3. I s the province's Refer report o fperformance Ifperformance is adequate, previous year's limitations to province to the province i s eligible for a implementation record prepare corrective action further disbursement.If adequate or exceptional? plan for re-submissionand Performance i s exceptional, provide coaching and the province i s eligible for Performance improvement further disbursement anda support as required performance incentive o f upto 10%above the base allocation Summary Provinces must meet all Provinces meeting all three three criteria to be eligible criteria with adequate plans for further disbursement andperformance may receive fullbase disbursement. Provinces with exceptionalplanand performance may receive additional performance incentive totaling up to 20% over base allocation COMPONENT TWO: National HIV/AIDS Policy and Program (Approximately US$ 8.2 million) The focus o f the national component will be to improve the capacity o f the National level to respond to the needs of the Provinces through coordination and technical support in implementation o f the National Strategy by: 1) promoting policy and program development and 35 implementation; 2) developing and implementing a national M and E framework and system; and 3) leading the development o f a national campaign against stigma and discrimination. Subcomponent 1: Policy and ProgramDevelopment and Implementation(Approximately US$3.84 million) Increased institutional and human resource capacity i s essential for the effective implementation o f the National AIDS Strategy and i s a central component of the proposed project. While there i s considerable capacity at the national level, capacity at the local level (provincial and lower) i s more variable. Large, relatively well resourced provinces such as H o Chi Minh City have far greater capacity than small provinces, particularly those with limitedHIV epidemics. Therefore, the project will focus particularly on the development o f decentralized capacity, at provincial and field levels. However, it is recognized that the effective development o f decentralized capacity requires a supportive nationalpolicy environment. This subcomponent will strengthen capacity at national and provincial levels and promote the development o f innovative, effective prevention and treatment approaches and models among vulnerable groups through: (i) demonstration sites that will explore a community-based treatment model to integrate harm reduction with comprehensive HIV treatment and care; (ii)policy studies and research; (iii) knowledge sharing and training; and (iv) encouragement o f other forms of innovation. (i) DemonstrationSites: IntegratingHarmReductionwith TreatmentandCare A large number of accessible IDUs are residents in Government rehabilitation centers. Druguse treatment activities in Vietnam are based on the detoxification and rehabilitation regimen outlined in Government resolution N0.06. The institutional base for drug treatment and rehabilitation was set in the Law on Narcotic Prevention and Suppression adopted by the National Assembly in December 2000. The current management o f HIV within rehabilitation centers i s failing to prevent transmission. The pattern o f HIV transmission when introduced to a new IDU population i s characteristically explosive and extremely rapid. What data there are suggest that prevalence rates within centers can rise sharply within a short period o f time. Sentinel surveillance of HIV within government rehabilitation centers indicates that current programs to control injection drug use are doing little to prevent the transmission o f HIV within camps (more details on IDUs and government rehabilitation centers can be found in the project files). An extension of community-based care. The program will operate primarily through a community-based HIV clinic (which would have the potential to be co-funded by other donors) positioned within and catering to the IDU community in the centers and surrounding localities. This clinic would draw on existing models for strengthening treatment and care at the district level. This clinic would include a drop-in center for I D U s and a fixed-site harm reduction program, comprising needle syringe exchange and potentially drug substitution. Should the program include drug substitution, a separate facility may be funded for the provision o f methadone maintenance therapy, inorder to separate the two client populations. Close support from specialist treatment facility. Formal supervisory links will be supported between the community-based clinic and a specialist HIV/AIDS Treatment Facility with access to trained health care workers and laboratory support. Inthe first instance, this may be a national 36 center such as the Clinic Service at NICRTMBach M a i Hospital, or a regional center with expertise inHIV treatment and care. As expertise and diagnostic facilities become more broadly available, these services would be more appropriately provided by a provincial or district hospital. This facility will provide: (i) training and ongoing supervision o f community clinic health care workers to ensure a high standard o f clinical care; (ii)weekly formal outpatient services conducted by specialist medical staff within the community clinic; (iii) weekly formal outpatient services conducted by specialist medical staff within the rehabilitation center clinic; and (iv) referral privileges for clients attending the community clinic and requiring laboratory investigation, urgent specialist review or inpatient care. Clinic for HIV treatment and care within local rehabilitation center. The program will support expansion and upgrading o f the existing rehabilitation center clinic to provide: (i) training and hiringofmedical, nursingandpharmacy staffandhiring ofpeer educators (to work on a rotating basis with community drop-in center clinic) for day to day medical care o f HIV-positive residents and VCT services. Medical care would include prophylaxis and treatment o f opportunistic infections (including TB) and ART; (ii)potential introduction o f methadone substitution on a trial basis; (iii) weekly formal outpatient services conducted by specialist medical staff within the rehabilitation center clinic; (iv) weekly transport o f blood specimens from rehabilitation center outpatient clinic to hospital laboratory; (v) referral privileges for rehabilitation center residents attending the clinic and requiring urgent specialist review, inpatient care or clinical investigations; and (vi) integration o f clinical records with community drop-in center clinic with maintenance o f patient confidentiality. Number and selection of program sites. The selection o f pilot sites for integrated treatment and harm reduction programs should be guided by the presence o f an enabling provincial political environment - particularly from the non-health sectors. A pilot site would also need to be within ready access to a center with expertise and facilities inHIV treatment and care with a willingness to support the program. The centers should also be chosen to have a resident population drawn largely from the location in which the community clinic i s based. Finally, the rehabilitation centers selected for pilot project implementation should be o f a moderate size, to ensure that all residents requiring access to ART are eligible for enrollment. The program would largely be strengthening existing clinical facilities within rehabilitation centers and establishing community-based clinics. A maximum o f three sites could be selected for pilot program introduction. After discussion with the MOH, the three proposedpilot study sites are likely to be Hai Phong, Hanoi and Khanh Hoa. The population o f these centers currently comprises: Hai Phong City: 483 residents (273 HIV positive), Khanh Hoa province: 141 residents (79 HIV positive and H a Noi: 1100 residents (200 HIV positive). Implementation o f this pilot program will be undertaken in a phased manner, with concentrated efforts on one site initially. Start up would likely occur in year two, and expansion beyond the first site would depend on implementation progress inthe first site. Assurances will also be sought regarding continuation o f treatment after the project closes. Monitoring, evaluation and verijkation of pilot program. The circumscribed area covered by the program and the small number o f pilot sites will make development and monitoring o f verifiable indicators relatively straightforward. Indicators will include specific monitors o f program activities (such as the numbers of residents tested, ART and 01medications dispensed, patient consultations performed and injecting equipment exchanged and appropriately disposed of) as well as indicators developed to gauge the efficacy o f this model o f harm reduction integrated 37 with treatment and care (including rates o f recidivism, and continuity o f patient care). To establish this, a comprehensive baseline study o f biological and behavioral parameters will be undertaken at each pilot rehabilitation center and associated community before activity commencement. In addition to program monitoring, there will be a review o f the pilot sites on a regular basis by an independent agency to verify that treatment, care and harm reduction activities meet the highest ethical standards. (ii)PolicyResearchandStudies The development o f supportive national and provincial policies and strengthening research capacity i s a priority. Resources would be made available to help identify research priorities, conduct research needs assessments, and strengthen capacity to conduct research that aids intervention design and development. Research which improves local level implementationwill be emphasized and the participation of provinces and their implementing partners will also be encouraged. The development o f national and provincial policy guidelines for HIV prevention, care and treatment among vulnerable groups o f IDUs,CSWs and their clients will be promoted. (iii)KnowledgeSharingandTraining Support will be provided for study tours comprising national and provincial representatives to review good practice; preparing technical guidelines; developing intervention models; printing and disseminating products; training HIV/AIDS personnel (including doctors, nurses, laboratory staff, counselors, pharmacists and social workers) at national, provincial, district and commune level. The training will focus particularly on service providers at field level inprovinces and on under-served provinces. Design o f planning, management, monitoring and evaluation materials will be supported; as well as short management training courses for project managers. Since implementation will be done primarily at provincial, district and commune level, the primary beneficiaries of project management training materials and courses will be provincial and district personnel. (iv) Innovation Support By encouraging innovative thinking at all levels it is expected, activities financed here would help build public responsibility towards the fight against the HIV/AIDS epidemic in the country by stimulating social participation on a national scale and by attracting public attention to the development and implementation o f innovative ideas. This will also provide an opportunity for policy makers to experience how a "public need" approach can galvanize efforts to fight HIV/AIDS. Stakeholders from diverse backgrounds (general public, PLWHA, professionals, private sector, mass organizations, NGOS, schools, etc.) will be encouraged to participate. The topic for each year will be guidedby the country's National Strategy Action Programs. Proposals will be reviewed by a panel; winners o f the competition will be awarded grants to implement their proposals and disseminate lessons leamed. Awards will be for a minimum o f US$lO,OOO and a maximum of US$20,000. Innovation support is expected to be sustainable beyond the project life by mobilizing additional resources from local and intemational institutions early in the development o f the activity implementation. Implementation would likely begininyear two. Subcomponent 2: Monitoring and Evaluation (Approximately US$2.1 Million) The project emphasizes ongoing program improvement and learning by doing. Perfomance measures will feed into the management of block grants for the Provincial Action Plans. This 38 requires an effective monitoring and evaluation system, to guide continuous project adjustments. Vietnam is committed to rapidly buildingits capacity inmonitoring and evaluation. The Vietnam HIV/AIDS Prevention Project's support to M&E will be guided by the following criteria: (i) Support for the development o f a single national M&E system, under the rubric o f the "Three Ones" principles agreed by UNAIDS and all o f the major development partners; (ii) Support for decentralized M&E systems, that enable provinces to monitor and improve their performance; (iii)Support for institutional, human resource and systems development, particularlythrough the involvement o f specialist government institutions with a specific monitoring and evaluation remit and significant institutional capacity; (iv) Support for the development o f M&E systems that address the needs of vulnerable communities, particularly IDUs, CSWs and their clients, and other vulnerable populations; and (v) Support for activities which are not being financedby other development partners. A draft nationalmonitoring and evaluationreport andplanhas beenprepared,which summarizes existing monitoring and evaluation structures and capacities in Vietnam, identifies specialist government institutions who may play a greater role in monitoring and evaluation, proposes a draft set o f approximately 30 national monitoring and evaluation indicators and indicates how indicator data will be collected. The draft plan is now being circulated to stakeholders for review and revision. The document notes that Vietnam has no formal H N / A I D S monitoring and evaluation unit and that the role o f government specialist institutions has been somewhat uncoordinated and focused primarily on surveillance. It identifies four major government institutions with the capacity to support national andprovincial monitoring and evaluation. The following activities will be undertaken to develop an effective national M&E system: The draft Monitoringand Evaluation Plan will be revisedand formally adopted. This provides an agreed monitoring and evaluation structure, agreed national indicators and a clear roadmap for the collection and use of indicator data. Specifically, the plan outlines national indicators, M&E products, roles and responsibilities, timelines and costs. The plan includes a guiding flowchart and data base, to ensure that all M&E information flows logically to a single, national repository. Information received will be shared by website, electronic and print distribution and regular M&E disseminationmeetings. Underthe aegis o fthe nationalplan described above, a National M&EUnitwill be established in the Department o f AIDS, with an initial staff o f five, including an IT Specialist and Assistant, a Provincial Monitoring and Evaluation Specialist and Assistant and an Epidemiologist. The Unit's role will intentionally be defined as coordination not implementation o f the national monitoring and evaluation system. Specifically, its role will be to coordinate national M&E activities, to coordinate the implementation o f the national M&E framework, to supervise and support the specialist government institutions involved in monitoring and evaluation, to commission and supervise major monitoring and evaluation products, including surveillance products, to review and disseminate national M&E data, to assist the program to use data to improve decision making and programming and to support and monitor provincial HIV/AIDS plans and Performance reporting. The Unit will be assisted by a national specialist government institution, the National Institute for Hygieneand Epidemiology (NIHE), which serves a national monitoring and evaluation reference center. NIHEwill be responsible for collecting, collating, analyzing and forwarding monitoring and evaluation data to the National M&E unit. It will also coordinate biological, behavioral, health facility and programmatic monitoring, evaluation and surveillance 39 and has already demonstrated the capacity to do so. Inpreparation for an expanded role, NIHEi s establishing a permanent AIDS unit and i s already usingits resources to staffthis unit. The national monitoring and evaluation report and plan recognizes the need to strengthen decentralized regional and provincial capacity to undertake monitoring and evaluation. The report's institutional analysis identified the need to establish and develop strong regional institutional monitoring and evaluation institutional capacity, to support provincial monitoring and evaluation. Four Regional M&E Centres will be established in major regional institutions, including NIHE in Hanoi (which also serves the national role described above), the Pasteur Institute in Ho Chi Minh City, the Pasteur Institute in Nha Trang and the Hygiene and Epidemiology Institute o f Highland inDak Lak Province. Each center will have an initial staff o f three, including an IT Specialist, a Provincial Monitoring and Evaluation Specialist and an Epidemiologist. The Unit's role will be assist with major M&E products, including surveillance products, to train and support approximately 15 provinces each to design, plan, monitor and evaluate provincial responses, to verify the accuracy and quality of provincial reports and to gather, enter and analyze, provincial M&E data, forward these data to the National M&E and work with provinces to use these data for program improvement. Each province will designate a management focal point, as a pre-requisite for provinces to receive national funding. The focal point will ensure project management information is collected and forwarded to each regional center. Most provinces already have such structures inplace for existing activities. The regional centers will ensure that provincial reporting i s circumscribed and that provinces are adequately supported to collect the minimal project management information required. Training Courses for National, Regional and Provincial Personnel will be developed and conducted inthe first year, to equip personnel with the key skills requiredto discharge their responsibilities. The Project will assist Vietnam to strengthen: (i) Biological Surveillance supporting activities that other development agencies do not finance. Above all, it will seek to support, high quality biological surveillance of priority communities, including IDU, SW and their clients, and other vulnerable populations; (ii)Behavioral Surveillance in areas that other development agencies do not fund. Its priority will be to promote integrated bio-behavioral surveillance o f priority communities, including IDU, SW and their clients, and other vulnerable populations; and (iii) Health Facility Surveillance primarily in areas that other development agencies do not fund. It will particularly seek to strengthen health facility surveillance o f health-related HIV/AIDS services among priority communities, including IDUs, CSWs and their clients, and other vulnerable populations. In light o f the urgent need to identify evidence-based approaches, prevention and treatment approaches, Effectiveness Research will be undertaken, among IDU, SW, their clients and other vulnerable populations. Research priorities will be guided by a state-of-the-art synthesis paper currently under preparation. The project will assist NIHE to establish Provincial Program Activity and Financial Systems, to monitor the quantity, quality, relevance and cost o f provincial AIDS services and provincial program performance in relation to plans and targets. Finally, regular M&E Dissemination and Data Use Mechanisms will be established, including website, electronic and print distribution and annual M&E dissemination meetings, at national, regional and provincial levels. 40 Subcomponent 3: BCC focused on Reducing Stigma and Discrimination(Approximately US$2.26 million) The national BCC component will address issues on stigma and discrimination, revealed to be a major reason why many vulnerable people shied away from accessing preventiveand life-saving interventions and needed social services when they heard o f or personally experienced acts o f stigma and discrimination. Unless these are reduced, ifnot totally eliminated, the push for more provincial programs offering prevention and harm reduction, treatment, and care and support interventions under this project, would be injeopardy. The campaign i s national inscope because studies have shown that the issues related to stigma and discrimination are the same all over the country. Reaching out beyond the project provinces could have the positive effect of encouraging local authorities to heightentheir own focus on stigma and discrimination using other resources. The project will fund the development and implementation o f a 5-year nationwide BCC campaign to reduce stigma and discrimination against vulnerable groups - PLWHA and their families, injecting drug users, commercial sex workers, their clients and sexual partners. By the end o f the campaign, stigma and discrimination against the vulnerable populations will be reduced. The campaign will be two-tiered: the first, a national umbrella program, carrying messages and executions with general appeal, usingnational mass media channels to reach the largest number of its target groups. The second will see the provinces planning and implementing a simultaneous but "customized" campaign, using the same basic messages and execution, but employing interpersonalcommunication, special media and special events. As needed, materials will berevised to suit variedcultures and traditions. The BCC Campaign Framework. For this campaign, the BCC efforts will focus on two key target audiences at the provincial and central levels: (i) People whose professions or official positions put them in close proximity and/or authority over vulnerable groups because they provide or coordinate the provision o f services necessary to the well-being o f vulnerable populations, specifically (a) health and non-health staff in health facilities; (b) the management, staff, and trainees in rehabilitation centers; and (c) community leaders and residents who are called upon to provide community-based care and support. For purposes o f this document, they will be referred to as "service providers". BCC Obiective: By knowing and understanding stigmatizing behaviors and discriminatory actions and the impact on vulnerable populations, this target group will be able to reduce, ifnot discontinue, such practices. Indicators: (a) higher percent o f health workers, rehabilitation workers, and community leaders reporting decreased cases o f discrimination; (b) increased membership in PLWHA associations; and (c) increased number and frequency o f PLWHAs appearanceson radio, TV, inprint to share their stories. (ii) National and local policy and decision makers who are responsible for creating and amending laws and regulations and/or for allocating resources for HIV/AIDS. For purposes o f this document, they will be referred to as "decision makers". 41 BCC Obiective: By understanding stigma and discrimination and its impact on vulnerable populations, they will be able to review, repeal or enact new regulations and allocate more resources for HIV/AIDSprograms. Indicators: Clearer regulations pertainingto stigma and discrimination and increased resources for its implementationat local and central levels. The Approach. Communication i s a powerful tool for helping change behavior. However, by itself, it cannot effect behavior change. For it to happen, two other components are equally necessary: Institutional and Social Support creates the enabling environment for changing behavior while Service Delivery refers to sources o f services, information, consultation, or counseling for the target audiences. The BCC campaign therefore will be a combination o f communication and advocacy activities and interventions tailored to the needs o f the identified target audiences and developed with them to help reduce stigma and discrimination by creating an enabling environment for individual and collective change. Steps in Building the Campaign. To develop the campaign, the following are some o f the necessary steps to be undertaken. Each step will be actively participated inby concemed groups inthe 20 selectedprovinces/cities: 9 Conduct formative researchon(a) who/what, how, andwhy stigmaanddiscrimination occur; positive behaviors to reduce stigma and discrimination; existing/future institutional and social determinants; existing/future supplies and services necessary to practice positive behaviors; barriers and/or facilitators to desired behaviors that messages need to either overcome or strengthen; central themes and messages. (b) background o f the target audiences; messages per audience; convincing evidence to be presented to support the messages; message presenters; channels (media mix) will the used. Initiate a campaign design andplanning workshop. 9 Participants will be ministries named inthe National Strategy, representatives of PLWHA groups, NGOs involved in this area, and representatives o f the settings where stigma and discrimination commonly occurs. 9 Assessthe capacity ofthosewho willbeinvolvedinthe campaign's implementation. 9 Conduct capacity building based on results of the assessment. One of the key capacity buildingneeds is on behavior change. This will be provided to all provincial AIDS Bureaus and other concemed organizations and institutions to ensure that there is one understanding o f the approach. Expertise will be sought from organizations that have the utmost experience inthis subject. 9 Developmonitoring -- A tracking systemwillbeinstalledto measurethe effectiveness ofthe campaign at various milestones with findings used to inform the regular campaign review. (Part o fthe overall Mand E system) 9 Develop evaluation-- A final evaluation will be conducted usingan outside organization to guarantee objectivity. (Part of the overall Mand E system) Managing the Campaign. The provincial AIDS bureaus will manage and have responsibility for the provincial implementation o f the BCC Campaign. The national implementation will be the responsibility o f the General Department o f Preventive Medicine and HIV/AIDS Control (GDPMAC). Technical and administrative support will be provided by the PPMU and the CPMU. Providing guidance will be an Advisory Group to be made up ofrepresentatives from the 42 following organizations: Ministry o f Culture and Information, Ministry o f Public Security, Ministryo f Education and Training, Vietnam Women's Union, Vietnam Youth Union, Ministry o f Labor, Invalids, and Social Affairs, and the Vietnam FatherlandFront. The GDPMAC will be assistedby a Panelo f Expertsmade up o f stakeholders with expertise and experience in stigma and discrimination reduction efforts, such as media organizations, hospitals and medical associations, the Vietnam Chamber o f Commerce and Industry, NGOs (Bright Futures, a PLWHA group, VCOMC, the Center for Social Development Studies or CSDS), and others. GDPMAC may also tap international NGOs and commercial advertising consultants in developing portions o f the campaignpreparation andor implementation. COMPONENT THREE: ProjectManagement(ApproximatelyUS$5.184 million) The key institutions involved in managing and implementingthe project are the Central Project Management Unit (in the Ministry o f Health), Provincial AIDS Steering Committees; Provincial Management Units, and relevant implementing agencies. This component will provide support to the set up and management o f the Central Project Management Unit (CPMU) as well as the Provincial Project Management Units (PPMUs) located inthe 18 provinces and 2 cities. 43 Annex 4A: Review and Approval Processof PAPS VIETNAM HIV/AIDS Prevention Project FirstInstallment ofBlock Grant transferred to PPMUaccount I I World Bank Reviews and Vice Chairman of the People's Committee Approves Plans (Director of provincialAIDS Steering b Committee) approves PAP Proposed PAP sent to PMU, reviewed by -- Ptechnical M U staff consultants hiredby PMU T TA from Provincial AIDS Steering Committee Review Comprehensive PAP (Committee consists o frepresentatives o f different departments, including b People's Committee, DOH, AIDS Bureau, DOF, DPI, andDOLISA) I PPMUDevelop a Comprehensive ProvincialAction Plan PAP - (including activities, monitoringplan, budget): Sub-action plans from provincial implementing agencies collected and coordinatedbyPPMU T I ProvincialPlanning Workshop Guidelines/Manual for Technical Assistance Provincial Planning from PMU (ifneeded) 44 Annex 5: ProjectCosts VIETNAM HIV/AIDS PreventionProject Local Foreign Total Project Cost By Component and/or Activity us us us $million $million $million 1. Implementation ofProvincialHIV/AIDS 21.60 0.00 21.60 Action Plans 2. National HIV/AIDS Policy andProgram 2.1 Policy andProgramDevelopment and 1.45 1.41 2.86 Implementation 2.2 Monitoring andEvaluation 2.03 0.07 2.10 2.3 Behavior Change Communication 2.17 0.09 2.26 Focusedon Reducing Stigma and Discrimination 3. Project Management 4.69 0.49 5.18 Total Baseline Cost 31.94 2.06 34.00 Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.42 0.58 1.oo TotalProjectCosts' 32.36 2.64 35.00 Interest during construction Front-end Fee TotalFinancingRequired 32.36 2.64 35.00 'Identifiable taxes andduties are 0 (US$m), andthe total project cost, net o f taxes, is US$35.0 million. Therefore, the share o fproject cost net of taxes i s 90.9%. 45 Annex 6: ImplementationArrangements VIETNAM HIV/AIDS PreventionProject InstitutionalArrangements. The main organizations involved inoverseeing and implementing the HIV/AIDS Prevention Project is the Central Project Management Unit, in the General Department o f Preventive Medicine and HIV/AIDS Control, Ministry o f Health; Provincial AIDS Steering Committees, Provincial Project Management Units in each project province and city, and relevant implementing agencies such as NME at the national level, and the Pasteur Institute in H o Chi Minh City, the Pasteur Institute in Nha Trang and the Hygiene and Epidemiology Institute of Highland (Dak Lak) at the regional level. Their roles and responsibilities are described below: Central Project Management Unit (CPMU). The role o f the CPMU would be to: (i) manage the implementation of the National Component; (ii)provide technical support as needed to Provinces; (iii) evaluate and monitor the implementation o f the Provincial Action Plans; (iv) coordinate with other central level line ministries and (v) establish and maintaidupdate database and resources to be able to respond to requests for consultancy/advisory services, study tours etc. as articulatedinProvincial Plans. Responsibilitiesby CPMU members: a. Project Director: appointed by the Ministry o f Health to administer the project, responsible for performing all tasks and functions to implement the project. The director will communicate with IDA and other agencies on behalf o f the Ministry o f Health, with proper consultationwith management o f the Ministry.The director i s delegated with the authority to clear all procurement documents, including signing o f contracts for consulting services, procurement o f goods and minor works, and handling procurement complaints. H e i s also responsible for the annual project implementation report. The director will undertake intensive training on procurement policies to be fully empowered and accountable for all procurement decisions. b. Project Vice Director: responsible for ensuring timely work plan submission from other line ministries, and project provinces; signing disbursement applications as one o f two authorized signatories; revising and approving reports for public dissemination; evaluating and replacing CPMU staff whenever necessary; coordination with the other ministries and agencies, providing project implementation advise and guidance to the provinces; and ensuringthe project's operations manual are maintained and updated. c. Project Coordinator: responsible for supporting the director and vice director in coordinating with the project provinces for all project activities. d. Technical consultants (5): responsible for harm reduction, BCC, care and treatment, capacity building, and M&E component. These consultants are responsible for guiding and assisting the CPMU in the design and implementation of the work plans directed toward corresponding central project components. They are also responsible for providing technical assistance to provinces as needed as well as reviewingtechnical content for provincial plans 46 before they are submittedto the IDA for review. They report directly to the vice director and the director. e. Chief Accountant: responsible for organizing the financial and accounting systems and procedures; preparing all related financial statements and finance management reports responsible for supervising the maintenance practice o f all accounts and records according to Government regulations; revising and authorizing project disbursements; giving guidance to accountants at the central level; and providing training to the accountants at provincial level, inparticular inthe first two years ofproject implementation. f. Accountants (2): responsible for performing accounting transactions and procedures according to local government and donor policies; supporting the Chief Accountant in preparing all related financial statements and financial monitoring reports; maintaining all accounts and records according to local government regulations; preparing project disbursement withdrawal applications and special account replenishment requests; maintaining local commercial bank accounts; maintaining personnel payroll and fixed assets inventory; maintaining archives and documents collected and produced during all phases o f the project; and providing on the-job-training to accountants at provincial levels inparticular inthe first two years ofproject implementation. g. Cashier (1 in CPMUand 1 in each PPMU): responsible for handling petty cash, including keeping a balance sheet andproper receipts. h.ProcurementAdvisor (with international experience;for at least oneyear): responsible for developing the annual procurement plan for project; preparing bidding documents for procurement o f goods and minor civil works for the first two years; draft bid evaluation reports, contracts, requests for clearance from the World Bank and/or other donors; preparing procurement guidelines and training materials, including delivering o f procurement training to procurement staff in CPMU and project staff in project provinces and supervising all procurement stafc advising the director in handling procurement complaints; and providing procurement progress report covering all provinces. The report i s part o f the annual project implementation report. The procurement advisor will advise the director and vice director on policy issues inprocurement and ensure that the World Bank procurement policy and proper procedures are followed under the project. i. Procurement ofleers (2): assist the procurement advisor indraftingbiddingdocuments, bid evaluation reports, contracts, request for clearances at the CPMU and the PPMU levels. In the first year, they will undertake training under the procurement advisor. They are expected to take over the responsibilities from the procurement advisor in the second year and will work together with the provincial procurement staff throughproject implementation. ProvincialProjectManagementUnits (PPMU). The PPMUwill sit within the Department o f Health at the provincial level and (i) facilitate the preparation o f locally responsive HIV/AIDS Action Plans; (ii)monitor the implementation o f the action plans; (iii)ensure timely disbursemento f funds; and (iv) assemble reports on performancefrom implementingagencies. 47 Responsibilitiesby PPMUmembers: 0 Project Director: The People's Committee will appoint the Director, based on recommendation by the Minister o f Health. The Director will have overall responsibility for coordinating the development o f the provincial action plan; coordinate with relevant agencies (DOLISA, etc) to develop plans; obtaining technical advice on quality o f plans from CPMU and others; organizing meetingwith local steering committee to approve the plan; seeking approval o f plan from CPMU; monitoring the plan's implementation; ensuringtimely disbursements and assembling reports onperformance. 0 (1 program manager and 1project coordinator in each PPMU): The program manager will support the project director in decision making, lead the discussions with other agencies at planning workshop annually. The project coordinatorwill be responsible for coordinating with other implementing agencies as well as monitoring the plan's implementation and supporting the program manager on day to day management. 0 Procurement of$cers at theprovincial level (1 in each PPMU). With assistance from the CPMU procurement advisor and procurement office, they will be responsible for handling limited, minor procurement activities such as local shopping and refurbishing o f clinics at the provincial level; 0 Accountant (1 in each PPMU): responsible for performing accounting transactions and procedures according to local government and donor policies; 0 Cashier (1 in each PPMU): responsible for handling petty cash, including keeping a balance sheet and proper receipts. ProvincialAIDS Steering Committee composed o f senior officials from provincial People's Committee, provincial Health Service, HIVIAIDS Standing Bureau, DOLISA, Department of Public Security, Department Information and Culture, Department o f Planning and Investment, Department o f Finance and others as determined by People's Committee. The Steering Committee i s responsible for the overall direction o f the project, reviewing and approving provincial action plan; coordinating to ensure the participation o f multiple implementing agencies, including DOLISA, DPS,DOIC, various mass organizations (e.g. Women's Union and Youth Union), and community-based groups of affected individuals and other elements of civil society in determining plan priorities and receiving resources to finance their contribution to implementingthe ProvincialAction Plan. Implementation of Grant Program At Provincial Level. Provincial Action Plans are to be prepared by October each year for allocations to cover the period between January - December. Project fund allocation for implementation i s based on the Memorandum o f Understanding (MOU) signed between the CPMU Director and PPMU Director, and between the PPMU Director and implementing agencies. The MOU is the basis for fund disbursement and the Operations Manual will be used for grant management. An Annual Report on the grant program and management will be preparedby each project province and sent to the government and the World Bank. The grant accounts will be audited annually as part of the project account audit. A draft Operations Manual is under discussion with the government and will be approved before 48 effectiveness. Workshops on the use o f the Operations Manual will be organized after Board presentation. Tranche Release of Grant Funding. Grants will be disbursed in tranches after the provincial plans are approvedby the CPMU andthe World Bank and the Memorandum o fUnderstandingis signed betweenthe CPMU and the PPMU. The first tranche i s 50% o f the total grant amount, the second tranche i s up to 25% upon receiving the first progress report, satisfactory to the CPMU and the World Bank, and the last tranche i s up to 25% upon receiving second progress report. The first tranche i s expected to be released inJanuary o f each year; second tranche in JuneIJuly, and last tranche in September. The request for disbursement i s sent from PPMU to CPMU and it i s verified by the Cost Control Unit in the provincial Finance Department before the fbnd is released from the Service World Bank inthe province to the PPMU. Workshops on the tranche release procedures will be organized for staff in CPMU, PPMU and Cost Control Unit.Standard documents for tranche release are being developed following the government and the World Bank requirements. Documents will be finalized and will be used as training materials at the workshop. All receipts and related documents including detailed progress report are kept in PPMU and they are subject to annual audit by internal and external auditors, and by the World Bank on sample basis. Unused funds from the previous year will be rolled over to the following year, and the same amount will be deducted from the provincial plan o f the following year. Misuse o f grant funding, once substantiated, will be returnedby the PPMUto the project account and the same amount may be cancelled from the project. Detailed disciplines procedures are included inthe Operations Manual. Negative List: A `negative list' i s employed to clarify what, if any, activities would not be eligible for IDA grant financing under the Provincial Grants. This negative list includes: purchase o f ART; vehicles; new civil works in rehabilitation centers or hospitals, and blood safety component. The negative list would also'place limits on expenditures on equipment -- no more than 10%for laboratory or hospital equipment andno more than 10%o f office equipment. 49 Annex 7: FinancialManagementandDisbursementArrangements VIETNAM HIV/AIDS PreventionProject FinancialManagementArrangement Basic Project Financial Management Infrastructure A review of the implementing entity's financial management capacity and its adequacy was assessed during the project preparation. The assessment was based on detailed discussions with the accounting staff and consultant working in the CPMU and selected provincial PPMU on a sample basis and confirmed with the management of the CPMU. This involved reviewing the system o f planning and budgeting in a decentralized structure culminating in the consolidated project plans and budget at the CPMU level. The basic system o f initiating transactions, approval arrangements, documenting the supporting evidence o f the transaction and recording the transaction inthe accountingbooks was accordingly reviewed. The intemal control environment was found to provide reasonable basis for placing reliance on the system. The amount of checking and signing off any transaction from initiation to payment i s evidence that there i s distinct separation o f duties and .participation, which helps to enhance transparency. The inference drawn from the review i s that the implementing entity responsible for the management o f the project inthe Ministry o f Health at CPMU and PPMUprovide an adequate framework to handle the accounting and disbursement aspects o f the project, and meets the minimum requirements o f OPBP 10.02, especially with the support o f a simple computerized system expected to be in place and operating by effectiveness and with competent and qualified accounting staff in place by that date. Specific relevant country issues that were highlighted in the Country Financial Accountability Assessment o f 2001 will be taken into account as appropriate within the context and limits o f this project. In particular, capacity building interventions will be addressed to ensure that qualified staff andimproved facilities as well as the enhanced system are inplace at the two levels prior to effectiveness. The financial management function for the project will therefore embrace the country systems as much as i s practical and prudent which are govemed by the policies, rules, accounting and disbursement procedures and guidelines promulgatedby the MOF. These are refined inthe draft circular which has documented the agreed financial infrastructure between MOF and MOH specifically to be usedfor this project. Financial Management Arrangements by Components Component I: Provincial Implementation of HIV-AIDS Interventions - the activities under this component will be managed at the provincial level in 18 provinces and 2 cities which have already been identified and agreed upon. IDA Funds under this component will in principle be released by the CPMU inthree unequal tranches o f 50%; 25% and the final 25% ratio to finance the approved PAP and facilitate the implementation o f project activities for the year, based on a binding Memorandum o f Understanding (MOU) or contract to be signed between the CPMU Director and the PPMU Director. Subsequent release o f the second and third tranches expected around the month o f JuneIJuly and September respectively, will be subject to the submissiono f implementation progress and financial report to the CPMU on a quarterly basis. However, PPMU will submit a special financial report to CPMU based on the advances made to non- governmental Implementing Agents soon after disbursing about 80% o f the funds. CPMU will 50 use the special reports from the PPMUs to compile a replenishment withdrawal application. This arrangement i s based on the `DISBURSEMENT POLICIES AND PROCEDURES APPLICABLE TO HIV/AIDS PROJECTS' issuedbythe LoanAdministration Department in November 2003. Details relatingto this arrangement can be found inthe Operations Manual. At the provincial level, finds will similarly be advanced to the Implementing Agents, on the basis o f the approved PAP and terms o f contract to be signed between the PPMU Director and each Implementing Agent subject to the maximum based on the same ratio. All eligible expenditures incurred by the Implementing Agents will be accounted for and supported by relevant documentation to the PPMU, preferably on a monthly basis. The reports should be made following a simple format in the local language and requiring basic data o f amounts received, amounts spent, brief description o f the nature of expenditure, and amount remaining inthe bank account. The appropriate template for this use will be designed by the CPMU and issued to all the Implementing Agents. The PPMU will consolidate reports submitted by the Implementing Agents under its supervision for submission to the CPMU on a quarterly basis and retain the supporting documentation at the PPMU for review by the internal auditor/inspectors and IDA supervision missions as well as the external auditor. The PPMU accountant will be responsible for maintaining the accounting system at the provincial level and ensure the periodic financial expenditure reports and the request for funds are prepared, reviewed by the Cost Control Unit and submitted to the CPMU in a timely manner. Component II:' National HIV/AIDS Policy and Program - there are three sub-components which will be coordinated from the center and financed fi-om the center. Funds for supporting this component will therefore be planned and budgeted for at the CPMU, though each specific area o f work will be individually budgeted for. In view o f this, budgetary control for the component i s on the basis o f each o f the specific areas o f the component, and managed by the specialist responsible for the area. The CPMU Director will have overall oversight on the entire component budget and expenditure. Expenditures under this component will be accounted for centrally by the CPMU and the related accounting data and information will be processed in the IFMS, on the basis o f the sub-components. The commitments andexpenditures will therefore be automatically recorded and reflected in the budget as they are incurred. Payments for expenditures incurred invarious activities under sub-components will be disbursedby the CPMU from the local bank account. Institutions that are contracted to provide services under any o f the sub-components will be paid on the basis o fthe terms agreed insigned service contracts. Component ID: Project Management - i s basically intendedto accommodate the administrative costs related to the coordination and management o f the project by the CPMU under the stewardship o f the Director with the assistance of the Project Coordinator who will mindthe day to day management aspects o f the project. The CPMU will have the overall oversight o f the project budget and will monitor its execution on a continuous basis. The accounting and finance function in the CPMU will be managed by a project chief accountant supported by two other accounting staff and a clerical officer who will serve as a cashier andmaintain the computerized cashbook for the project. Details of their respective responsibilities will be articulated intheir job descriptions and TORSwhich will be spelt out inthe project Operations Manual. 51 Special Account and Project Accounts Special Account - A project Special Account (SA) will be opened in a commercial bank acceptable to IDA by the recipient into which the advance withdrawn by the recipient will be deposited and managed by the CPMU. The authorized allocationwill be US$3.5 million with an initial withdrawal o f US$1.5 million equivalent to be withdrawn from the Grant Account and deposited inthe SA. Project Accounts - A local currency (Vietnamese Dong) bank account will be opened in the same commercial bank holding the Special Account, and be operated by the CPMU. Funds in this account will be withdrawn from the Special Account from time to time on needbasis for meeting local expenditures at the CPMU level and for payment to the national implementing institutions and contractors supervisedby the CPMU. Similar bank accounts will be opened in provinces, preferably in the branch o f the same commercial bank to facilitate smooth and efficient transfer o f funds to each of the 18 provinces and 2 cities. Government contribution (counterpart funding) will be channeled through the State Treasury system andbe withdrawn by the CPMU usingthe normal government procedures for the purpose o f supporting the CPMU for its administrative expenditures. CPMU in liaison with MOF will advise the State Treasury on the counterpart funds to be transferred to the provinces. Counterpart funds in provinces will be located in the Provincial Treasury for financing operations in the PPMUin accordance with government financial regulations. Inboth cases, the procedure will be set out in the Operations Manual and in the joint MOH and MOF Circular that has been agreed for the Vietnam HIV/AIDS Project. Flow of Funds - The flow o f funds under this project is designed to follow the country system used for IDA projects and for the counterpart funds for central and provincial operations under the decentralized policy o f the government. The government funds will be channeled through the State Treasury and the Provincial Treasuries which hold the counterpart funds from where they will be withdrawn by the CPMU and PPMU for their respective operations. IDA Grantproceeds will be withdrawn from the Grant account on basis o fWithdrawal Applications to be duly signed by the authorized representative o f the government. The flow of funds mechanism is illustrated inthe diagrambelow. LEGENDFORTHE FLOW OFFUNDSILLUSTRATION e e e e e e e e e, Flow of IDA Funds Flow of CounterpartFunds IDA Grant CashManagement & Controlby PPM Provide Oversightand SupervisionRole CounterpartFunds CashManagement& Controlby PPMU 52 FLOWOF FUNDS ILLUSTRATION IDA GRANT Funds(SDR) I 0 I 0 0 0 0 IMPLEMENTING INSTITUTIONS & CONTACTORS IMPLEMENTINGAGENTS inPROVINCES (Community Sub-projectsinHIV-AIDS 53 Disbursement Arrangement Statement o f Expendituresprocedure will also be usedfor both goods and services as appropriate under certain categories which will be indicated in the Disbursement Letter to be issued soon after effectiveness. Use o f the SOE procedure will apply to expenditures falling below the prior review threshold levels o fUS $26,000 for goods and consultants' services subject to a maximum o f U S $50,000 and U S $100,000 for individual consultants and firms respectively. Disbursement of Grant proceeds under the SOE procedure may be made from the Special Account. Direct payment method and Special Commitment (SC) will be used insupport o f Letters o f Credit (LC) opened by the Grant recipient's bank inprocurement o f goods. Financial ManagementRisksAnal tis Risk Rating Mitigating Measure C P M U staff lack sufficient financial A qualified Chief Accountant and two other Accountants management capacity to perform the will be hired o n contract basis to undertake the financial required financial management functions H management function, including disbursements and and provide oversight o f financial provide guidance to the Director o n all project financial management aspects at P P M U matters. They will mentor and train existing accounting staff in the CPMU and P P M U and transfer skills to them through the entire project life, thereby creating a I potentially sustainable adequate financial management capacity in CPMU, P P M U in particular and in MOH in general Implementing Agents may lack staff with The amounts channeled to these levels will be small and in basic knowledge o f financial management piece meal, and closely monitored by the accounting staff practice and project management, which M in the PPMU. Selection criteria o f the Implementing may result in delayed project Agents include evidence o f staff with basic book keeping implementation, late reporting with skill. Reporting formats at this level will be simple and inadequate financial data and information, guided through a template to be designedby CPMU, which and possible loss o f financial resource will simply require filling in the amounts. Training o f through lack o f know-how implementing Agents where needed will also be arranged and providedby PPMUwith support o f CPMU as needed Counterpart Funds may be delayed which Government commitment i s fairly high, and its may impact negatively on project contribution is assured. In the initial 2-3 years, delay in implementation especially where the H counterpart funding will have nil effect on project proportion o f government contribution i s implementation as IDA financing in most categories will substantial, e.g. later project years be at loo%, at a time when implementationwill be critical. Close monitoring o f timeliness inthe release o f counterpart funds will indicate if additional mitigation is necessary and appropriate action taken ingood time Internal Controls adequacy to the desired Ministry o f Health has a general Inspection mechanism, level compromised by lack o f a robust which i s expected to cover aspects o f internal audit. Plans and reliable internal audit fimction for the M to strengthen the inspecting capacity with skilled staff in project financial aspects are being considered for implementation inthe shortrun Sustaining the developed capacity among Incentive policy for skilled staff in the CPMU and PPMU, the government accounting staff in the to retain them after acquiring skills in financial CPMU and PPMU over the entire project H management i s a high priority o f MOH and the project. There will be close monitoring o f the local labor market from time to time to keep incentives at a competitive level inthe Dublic sector 54 Financia1Management System The financial and accounting policies for the project are beingdeveloped, andkey aspects will be completed by negotiations while the complete system i s expected to be installed and tested by effectiveness. K e y accounting procedures such as preparation o f monthly trial balance extracted from the balances derived from the general ledger, reconciliation o f all the active bank accounts on a monthly basis, are a basic prerequisite for sound cash management practices in a cash accounting system. The accounting system would cover all the sources and uses o f funds irrespective o f the source of funds (financier). All PPMU in the provinces and cities will maintain separate books o f accounts and records for the transactions relating to the project. PPMU will be responsible for maintaining columnar cash book and simple spread sheet based records o f the amounts advanced to each Implementing Agent, and amounts accounted on a month by month basis. PPMU will then compile the report and submit it to the CPMU on a quarterly basis. The system should be capable o f generating reports and information for use by the management and for public disclosure o f financial information and implementation progress in keeping with the spirit of participation and transparency. A Chart of Accounts would be developedto ensure all expenditures are correctly classified by project component and activity as well as by expenditure category. Clear records o f project financial data will facilitate easy monitoring and tracking financial transactions and linkages with physical progress, which i s a key element o f the monitoring system. This will facilitate the preparationo f quarterly FMRs, by the CPMUinatimely manner. Standard internal controls will be put inplace, however due care shouldbe exercised not to stifle the smooth implementation o f the project bearing inmindthe primary objective, is to save life, reduce the suffering of the infected populations, reduce the infection rate and support the prevention efforts. The amount of checking and signing o f f requirements o f expenditures should be reasonable and at the bare minimum that will add value to the intemal control environment. Appropriate supporting documentation befitting the circumstances, segregation o f duties, levels o f authorization and approvals and periodic reconciliation and physical verification should meet the required standard of intemal control for this project, especially as enhanced by a computerized environment using a suitable and simple off-the-shelf accounting software, that will be customizedto meet the needs ofthe project. Financial Reporting The periodic reporting under FMRs will be prepared on a quarterly basis and will cover all the three components of FMRs, i.e. financial monitoring aspects, procurement contract monitoring and physical progress monitoring. The CPMU will be responsible for preparing and submitting the FMRs within 45 days after end o f the quarter being covered. Annual financial statements comprising the Source and Uses o f Funds Statement, Receipts and Expenditure Statement, Statement o f Expenditure Schedule, Statement o f activities o f the Special Account. All these different statements will be submitted for audit along with any additional information that the auditor may require for purpose of the audit. Annual financial statements should as a matter o f good practice be signed by the Director and Chief Accountant and submitted for audit not later than end o f the second month following the financial year end date (each February 28 or 29). Auditing Arrangement The external auditor for the project will be contracted soon after effectiveness, while the TOR will be finalized by effectiveness. The contracted auditor will be expected to conduct the audit o f the project and verify the financial management statements prepared by the CPMU within a 55 period o f two months to ensure the audited financial statements and the auditor's report thereon as well as the management letter detailing areas o fweakness, are submittedto MOF and the IDA not later than six months after the end o fthe financial year to which they relate (each June 30). FinancialManagementTime BoundActic Issue Action By BindingDueDate Selection o f Financial Management (FM) Consultant CPMU February 22,2005 to design and install a suitable FMsystembased on (prior to Negotiations) a suitable off-the-shelf accounting to be customized for the project i. ChiefAccountant-Technical CPMU MidFeb 2005 Assistance for the C P M U 11. Hire Two Accountants and Cashier for CPMU Effectiveness Date CPMU and one Accountant for each o f the 18 PPMU and 2 cities Preparation o f external Auditor's TOR by C P M U CPMU Negotiations (February, 22 2005) Finalization o fproject Operations Manual which CPMU and TTL Effectiveness Date shall include the financial procedures section Hiringthe external auditor and signcontract withthe CPMU October 31,2005 selected firm Prepare for Project Launch workshop by making a presentationto articulate the FMrole inthe project supportedby F M S Disbursement and the key procedures as well as Grant recipient's and PS on Country (Oct. 15,2005) obligationunder the financial covenants Office ExpenditureCategory AmountInUS$ Millions FinancingPercentage Provincial Grants 21.6 100% Innovation Grants 0.5 100% Consultant Services 5.2 100% Goods 1.93 100% foreign, 100% o f local expenditures (ex- factory costs) and 90% costs Works .07 100% Unallocated 1.o TotalProjectCosts 35.0 56 Annex 8: Procurement VIETNAM HIV/AIDS PreventionProject General Procurement for the proposedproject would be carried out inaccordance with the World Bank's "Guidelines: Procurement under IBRD Loans and I D A Credits" dated May 2004; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004 and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for pre- qualification, estimated costs, prior review requirements, and time fiame are agreed betweenthe Borrower and the World Bank inthe Procurement Plan. The Procurement Planwill be updated at least annually to reflect the actual project implementation needs and improvements in institutional capacity. Procurement of Works ($70,000): Works procured under this project would include: rehabilitation o f three community based treatment centers. The contracts are estimated to cost less than $30,000 each and will be procured through shopping procedures using model Request for Quotation documents satisfactory to IDA.There are no N C B or ICB contracts. Procurement of Goods ($2,000,000): Goods procurement under this project would include: office equipment (computers, printers, copiers and etc), fumiture, medical equipment, vehicles, drugs, and medical supplies. For goods contracts valued at and above $100,000 each, International Competitive Bidding (ICB) procedures will be followed and World Bank's standard bidding (SBD) and evaluation documents will be used. Domestic preference will apply for all I C B contracts. For contracts valued between US$26,000 to US$lOO,OOO each, National Competitive Bidding (NCB) procedures will be followed incorporating the improvements specified inthe Annex to Schedule 3 of the Development Grant Agreement, and using model bidding documents satisfactory to IDA. National Standard BiddingDocuments o fthe Government ofVietnam, when available and satisfactory to IDA, may also be used. For procurement o f ARV drugs, Limited International Bidding(LIB) procedures will be followed and WHO pre-qualified suppliers or manufacturers will be invitedto bid. For ARV drugs, single source procurement methodmay also be usedwhen there i s only one supplier for any particular item which could not be purchased through LIB procedures. Once the country enters an agreement with the Clinton Foundation, the drugs could be procured from the suppliers under the Clinton Foundation agreement. For vehicles to be provided to implementation agencies, the procurement will be done through IAPSO. At the start- up of the project, a small number of office equipment, estimated to cost less than $26,000 per contract, i s expected to be procured through Shopping procedures. The majority o f the office equipment will be packaged and procured through NCB and ICB procedures inaccordance with the N C B and ICB thresholds. Medical supplies and office supplies which are readily available off-the-shelf and estimated to cost less than $26,000 per contract will be procured through shopping duringthe project life time. Selection of ConsultingServices ($5,300,000): Quality and Cost Based Selection (QCBS) is the default method under the project. The threshold for shortlists to be comprised entirely o f national 57 consultants i s $200,000. Under the project, most o f the consulting services are small and clearly defined assignments in the area o f monitoring and evaluation, studies, training, program management, procurement and financial management, capacity building, and auditing. Firm contracts valued less than $100,000 will use the Selection Based on Consultant's Qualifications (CQ) method. The audit contract will follow Least Cost Selection (LCS) method. Individual consultants will be procured based on qualifications in accordance with the provisions o f paragraphs 5.1 through 5.3 o f the Consultant Guidelines. Sole source contracts for both individuals and firms, regardless o f contract value, are subject to prior review and approval o f IDA. Single Source Contracting: Several agencies specialized in HIV/AIDS field will be hired on single source basis. These include: (i)Vietnam Television to produce, pre-test, finalize and air TV spots based on a prepared media plan for an estimated amount o f $647,000 for 5 years; (ii) Voice o f Vietnam to produce, pre-test, finalize and air the radio spots for the campaign against stigma and discrimination as well as the special audiotape materials for the village speaker system, The estimated amount i s $304,064 for 5 years; (iii) National Institute for Clinical Research and Tropical Medicine to provide support to the Pilot Integrated Treatment and Harm Reduction sub-component by conducting training workshops, resident training and certification o f physicians and nurses, regular supervision o f clinical care at the pilot site and provision o f diagnostic laboratory testing. The estimated amount i s $87,960 for 5 years; and (iv) National Institute for Hygiene and Epidemiology (NIHE) i s responsible for surveillance and monitoring and evaluation research inVietnam. It will carry out M&E activities over the five years with an estimated cost o f $1.93 million. Its major responsibility i s to collect, collate, analyze and forward monitoring and evaluation data to the General Department o f Prevention and HIV/AIDS Control. It will also coordinate biological, behavioral, health facility and programmatic monitoring, evaluation and surveillance and has already demonstrated the capacity to do so. Detailed justifications for above single source contracts and description o f the services were provided separately to the Regional Procurement Manager and OPCR and approvals have been received. Training and IncrementalOperatingCosts ($4,700,000): There will be a large and extensive training program including in-country and overseas training such as study tours, workshops, seminars and training courses and other miscellaneous cost related to operations o f the project offices. Consultant services for training purposes must be procured using the allowed consultant procurement methods. The training programs shall be reviewed and approved by IDA. This includes the objectives, criteria for selection o f participants, venue and institute selected, estimated costs such as conference hall renting, translation services, office and training supplies. Eligible activities under incremental operating costs include travel related expenses and per diem for the project implementation staff, office consumables, office communication expenses, courier service costs, costs related to bidding and etc. The annual expenditures plan on incremental operating costs shall in general follow the relevant government norms and be subject to prior review and approval by the Bank. Sub-Grants to Implement the Provincial HIV/AIDS Action Plans ($21,616,000) and Innovation Grants ($500,000): Under the project there will be sub-grants for Provincial HIV/AIDSAction Plans and sub-grants for innovative activities. $21.616 million sub-grants will 58 be given to implementation agencies or entities over five years to carry out the activities under each annual Provincial Action Plan. The Action Plans are approved by the Bank following the detailed procedures summarized in the Operations Manual. The Operations Manual i s drafted and will be adopted by effectiveness. Five hundred thousand dollars in sub-grants will be awarded to institutions, NGOs, and/or individual for their innovative ideas to preventHIV/AIDS. Under all sub-grants,iftangible goods and works are to be procured, the applicableprocurement procedures o f the Development Grant Agreement shall be followed. Assessment of the Agency's Capacityto ImplementProcurement Duringproject preparation andpre-appraisal, assessmentswere carried out o f the implementing agencies to evaluate their capacity to conduct procurement and to assess the risks. The assessment was conducted by a Senior Procurement Specialist. The Central Project Management Unit (CPMU) is newly established within the GDPMAC, MOH, to prepare and later on implement the project. The CPMU i s currently managing the activities financed by the PHRD grant. These include procurement o f office equipment, selection o f individual consultants and international and local consulting firms. Most o f the contracts are less than $100,000 each through simple competitive procedures. The team consists o f the director, coordinator, program managers, officers and some short-term consultants on procurement and financial management. The CPMU managers and staff have strong academic backgrounds, experience in the health sector, and relatively good management skills. However, they, including their consultants, have limited experience in government, public or private sector procurement or international procurement and little knowledge o f the World Bank procurement policy and procedures. In addition to the project, the managers and staff have other responsibilities inMOH and cannot be expected to work full time on the project. The capacity at provincial levels and other implementation institutions are at best similar and most o f them have much less capacity, interm o f staffing, level o f technical assistance from local consultants and facilities. Given the current capacity and the general shortage of qualified procurement staff in the country, the overall procurement risk o f the project i s rated high. Multiple implementation agencies at central, provincial and national levels also increase the risk of slow approval, reporting and disbursement process, potentially causing delays in project implementation. The risks will be mitigated through clear documentation of operating authorities, respective responsibilities, use o f the Operations Manual for provincial activities, recruitment o f qualified procurement officers and an advisor, extensive training throughout the project period, adequate technical assistance to implementation agencies, and intensive supervision, at least in the first two years, by the CPMU staff and its consultants. An action plan was discussed and agreed to supplement and strengthen the capacity to carry out procurement bothunder PHRD grant and under the project. It is agreed that CPMU will hire two procurement officers, one procurement assistant, and one international procurement advisor who will assist the CPMU in carrying out all major procurement activities and train the local staff and consultants. ProcurementManagement The Central Project Management Unit within the GDPMAC, MOH and the Provincial Project Management Units (PPMUs) are responsible for implementation of the project. However, most o f the project procurement activities will be the responsibility o f the CPMU. The CPMU will be assisted by one international advisor and two local procurement consultants. Together they will carry out all ICB, NCB, and LIB procurement for goods, and shopping contract for goods and works in provinces before the PPMUs build up its capacity. The PPMUs will hire one 59 procurement assistant at appropriate time based on the needs o f their programs and schedule o f activities, The PPMUs will handle, gradually, small value contracts for medical equipment, medical supplies and office consumables only after their staff have received adequate training and their capacities are assessed by the CPMU in consultation with the World Bank. The transition period i s expected to be about two years and the gradual decentralization o f procurement i s to ensure that procurement will be carried out according to applicable procedures o f the Development Grant Agreement and i s also for long term capacity building at the provincial level. An Operations Manual is drafted and it includes standard application templates for block grants, standard Memorandum o f Understanding and contract forms between the CPMU and PPMUs, or any other agencies for the block grants and detailed financial reporting and control procedures. Training workshops for all staff at various levels will start after appraisal. Selection of a procurement advisor (with international experience) through a competitive process will start soon. The procurement advisor will assist the CPMU in preparation o f all major bidding documents and evaluation o f bids and proposals. It is critical that the bidding documents for office equipment for over 20 implementation agencies i s drafted by effectiveness and equipment could be purchased in time for project implementation. In addition, the international procurement advisor needs to mentor the project staff and set up a training program for staff and local consultants at CPMU, PPMUs and other implementation agencies. The international procurement advisor reports to the Project Director. The CPMU Director i s authorized by the government to sign all contracts and i s accountable for all procurement actions. This i s the first project in MOH where the Project Director will be empowered for project procurement decisions therefore appropriate training on World Bank procurement policy and procedures i s essential for the Project Director and DeputyDirector. ProcurementPlan:The draft Procurement Plan covering the first 18 months o fthe project was developed and discussed during appraisal and finalized by negotiations. The Procurement Plan will be updated in agreement with the Bank annually or as required to reflect the actual program implementation needs and improvements ininstitutional capacity. Frequency of Procurement Supervision: In addition to the prior reviews, procurement supervision will be carried out from Bank offices every six months, and procurement post reviews will be conducted by the Bank at least once every year, including review o f fiduciary aspects and end-usage. Other ProcurementIssues General Country Procurement Context and Fiduciary Risk Mitigation Action Plan: The Country Procurement Assessment Review (CPAR) for Vietnam was updated in 2004 and its report can be found in the project files. The CPAR diagnosed weaknesses in the government I procurement system and proposed specific recommendations for transforming public procurement towards international procurement procedures. The government regulations governing public procurement in Vietnam are Decree No. 88/1999/ND-CP dated September 1999, and amended and supplemented by Decree No. 14/2000/ND-CP dated May 2000, and Decree No. 66/2003/ND-CP dated June 2003. Although the government has recently improved its procurement procedures in an effort to align them to international good practice, the current 60 procurement decrees still contain a number o f provisions that needto be waived or modified to be acceptable to the Bank under N C B procedures. These exceptions will be included in an annex to the legal agreement. However, the CPAR found out that some major problems o f poor procurement performance inthe country are not necessarily due to the deficiencies inthe current procurement regulations, but inpoor compliance and enforcement o f existing laws, shortage o f qualified professional staff, low salaries, and cumbersome approval procedures. Unless the general environment in the country i s improved, the risk o f misuse of funds cannot be easily avoided. In addition to the procedural improvements introduced in the Project design, such as rationalized use o f the less competitive procurement methods, increased disclosure, etc., a detailed action plan for mitigating fiduciary risks during project implementation i s also being developed. This will focus on increasing awareness, capacity building, beneficiary feedback, andoversight. Furthermore, the Government has already committed to develop and introduce by September 30, 2005, a complaint handling mechanism that i s expected to be used on all World Bank assisted projects inVietnam. EligibilityIssues: Government-owneduniversities or research institutes generally may not fully meet the eligibility requirementsand therefore may not be eligible to participate or be hired as consultants. However in addition to the institutions which were identified during project preparation as implementation agencies or will be hired on sole source basis as exceptions, if during project implementation, services from government owned universities or research institutes are needed because o f their unique expertise and no suitable alternatives from private sector consultants are available, such institutions may be hired provided that the Bank's prior concurrence i s obtained. Civil servants can be hired as individual consultants if they (i) are on leave o f absence without pay; (ii) are not being hired by the agency they were working for immediately before going on leave; and (iii) their employment would not create a conflict o f interest. Universityprofessors or scientists from research institutes canbe contracted individually under the project provided that they have full time employment contracts with their institution and have regularly exercised their function for a year or more before they are contracted under the project. Detailsof the ProcurementArrangementsInvolvingInternationalCompetition Ref. Contract Estimated method P-Q Domestic Review Expected comments No cost Preference by bid- Bank opening 1 Office 1million I C B no yes prior Jan. 2006 equipment 2 ARV $300,000 LIB yes n/a prior Jan. 2008 drugs Prior Review Thresholds: In respect o f contracts for goods, works and services (other than consultants' services): (i)each contract estimated to cost the equivalent of US$lOO,OOO or more, and each contract procured on the basis of direct contracting regardless o f value; (ii) the first two 61 contracts procured on the basis o f NCB, regardless of value, and the first two contracts procured on the basis o f Shopping, regardless o f value, will be subject to prior review by the Bank. Consultant services estimated to cost more than US$lOO,OOO per contract for firms, and US$50,000 per contract for individuals, and single source selection o f consulting firms and individual consultants, regardless o f value, will also be subject to prior reviewby the Bank. The selection o f technical consultants for Harm Reduction and Monitoring and Evaluation will be subject to prior review by the Bank. All other contracts will be subject to Post-Review by the Bank. The percentage will be at least 2 in 10. 62 Annex 9: EconomicandFinancialAnalysis VIETNAM HIV/AIDS PreventionProject I.ProjectRelationtoVietnameseDevelopmentContext The Vietnam HIV/AIDS Prevention Project is well situated within the overall development context o f Vietnam as expressed inthe CAS, the Comprehensive Poverty Reduction and Growth Strategy (CPRGS), and Government o f Vietnam (GOV) institutional and policy initiatives. -TheThe CASand the Recent Update to the CAS Vietnam HIV/AIDS Prevention Project's focus on harm reduction programs as well as the enhancement o f treatment capabilities of Vietnamese health providers clearly reflects a major theme o f the current CAS: To enhance equitable, inclusive, and sustainable development including makingbasic social services accessible and affordable for the poor. - Both the GoV and the donor community views the need to address the accelerating HIV/AIDS epidemic with increasing urgency. The 2004 update to the existing CAS shares the concern that the epidemic is moving into the general population and acknowledges that there i s a needfor coordinated, multi-sectoral initiatives o f sufficient scale inspecific settings as well as a need to remove social stigma attached to HIV-positive status. All o f these stated needs are project goals. -TheThe CPRGS project goals are also directly situated in the Vietnam Development Goals as stated in the CPRGS. The CPRGS targets include slowing the increase inthe spread o f HIV/AIDS by 2005 and halving the rate o f increase by 2010. Decentralization of Health Sector Governance - The decentralized nature o f project implementation, where provinces devise HIV prevention strategies suitable to the local conditions, strengthens and enhances the government's recent promotion of government decentralization through a series o f laws, decrees, and regulations. -GoVAnti-Poverty Strategies A recent UNDP sponsored Vietnam study has determined that, with the exception of households inthe richest quintile, all households with a person with AIDS will fall below the poverty line as a result o f the income and expenditure effects o f HIV/AIDS. Households in the 3`d or 4th quintiles with a person with AIDS will become newly poor. In addition, the economic impact o f HIV/AIDS will cause many households in the poorest two quintiles to fall below the food poverty line. Poor Vietnamese households lack education and the evidence suggests that they are at greater risk o f HIV infection - they are less likely to use condoms during sex, more likely to report sex with sex workers, and less likely to have knowledge o f the benefits o f condoms. Addressing these behaviors through harm reduction interventions andreducingHIV transmission i s an importantcomponent o f the Government's overall anti-poverty strategy. 63 11.Justificationfor GovernmentFinancing Public financing o f the Vietnam HIV/AIDSPrevention Project i sjustified because o f the positive externalities associated with preventing HIV transmission andbecause o f the public goods nature o f both establishing a national HIV M&E framework and the piloting o f harm reduction and treatment programs inthe rehabilitation centers and the communities associated with recovering IDUs. Equityconsiderations are also relevant as part o f the overall economic justification for the project - as suggested above the microeconomic impact o f HIV infection on households i s severe. An additional important externality o f the project arises as a consequence o f a reduction in the incidence of HIV/AIDS - there will be a corresponding reduction in opportunistic infections and costly diseases such as pulmonary tuberculosis. The services provided to society by HIV harm reduction programs and a national HIV surveillance system are either in the nature o f a public good (in the case o f disease surveillance) or in the nature of a private good with significant positive externalities (in the case o f transmission reduction). In the case o f a public good, the consumption o f these services by an individual or household does not affect the consumption choice or consumption quality o f other individuals or households. In the case o f a private good with significant positive externalities a successfully treated individual (Le. infection averted) no longer presents a danger to others. Without clear revenue possibilities for project activities, it is highly unlikely that the private sector would invest in such services and so the private sector equilibrium o f many o f these activities would be zero provision o f these services. Given the public health nature o f the interventions supported through the project and their large externalities, the government should in any case be supporting activities in HIV/AIDS, even if that means reducing spending on other health activities for which public finance is lessjustified. 111.EconomicAnalysis The project will fund activities in three HIV related components: (1) harm reduction programs and other behavioral interventions (including BCC focused on reducing stigma and discrimination) that aim principally to reduce the transmission o f HIV; (2) a national M&E surveillance framework; and (3) policy and program development, including treatment assistance to HIV positive residents o f rehabilitation centers. Each o f these three components will be discussed separately inthis economic analysis. Harm Reduction Interventions The cost effectiveness o f reducing HIV transmission has been demonstrated innumerous global settings. These findings are partly due to the simple fact that the disease largely affects prime age adults and the associated costs of an adult death constitute the key microeconomic impact o f the HIV/AIDS epidemic. Over the course o f the disease, household labor quality and quantity are reduced, initially as the infected person i s less productive, and subsequently with their death. This cost o f foregone earnings is one major microeconomic cost o f the disease. The costs are exacerbated when there i s more than one infected person in the household, which is not unusual given the nature o f transmission. Other major costs include health care needs and the foregone earnings o f family caretakers. 64 The efficacy o f harm reduction interventions i s another clear reason for its general cost- effectiveness. International and regional evidence demonstrates harm reduction interventions do indeed reduce HIV transmissions. For example, due to aggressive and well targeted harm reduction interventions (mostly condom promotion), Brown (2003) estimates that 200,000 infections were averted in Thailand between 1993-2000. The benefit-cost ratio for Thailand's 100% condom promotion was estimated at 14.91. Harm reduction interventions are most timely - many more infections are preventable - in countries where the epidemic i s growing rapidly rather than in countries where it i s stable or declining. This i s the case in Vietnam where the epidemic i s growing rapidly but still concentrated in several key sub-groups. CSWs and, especially, IDUs, bothwith a median age o f approximately 25, are currently the main drivers of the epidemic inVietnam. IDUshave beenthe starting point o f the epidemics in many Asian countries and the focus o f this project on the reduction in HIV transmission among IDUs as well as across to other groups i s well justified. Using the Asian Epidemic Model, Saidel et a1 (2003) demonstrated that in countries where the epidemic among IDUs starts in advance o f a generalized (non-IDU) heterosexual epidemic there i s a 171percent increase over a 15 year period ininfections if l D U s prevalence i s not kept under control. The total program costs are well-anticipated, however the proposed program will occur in an environment with many government and donor supported HIV/AIDS programs. Nevertheless, the project focus on reducing transmission among the very groups most important for spreading the disease, including the piloting o fharm reduction programs inrehabilitation centers, is unique among the existing large-scale HIV related donor responses. The Government o f Vietnam has recently approved the National Strategy on HIV/AIDS Prevention and Control for the period 2004-2010, which identifies nine priority action areas. Government and donor programs are now engaging each o f the nine action areas. However, many o f the action areas such as preventing mother to child transmission and ensuring blood safety, are not easily focused on the main transmitters o f the disease. Voluntary counseling and testing i s also rarely focused on hightransmitters, but instead made available to the general public. Inaddition, VCT's ultimate effects on risk behavior are unclear, especially if individuals are tested without the knowledge o f their partners (this may increase the asymmetry o f information between the tested persons and others and thus, inthe absence o f altruism, may have perverse effects on risk behavior and on various social contracts). Previous studies such as Kahn (1996) have demonstrated that the most cost-effective use o f funds i s to focus prevention expenditure on those most likely to contract and spread HIV. The program area most relevant to the reality o f HIV transmission in Vietnam today i s harm reduction and prevention, especially those activities aimed at IDUs. It i s precisely these actions on which the project will focus. Through the targeted interventions, the project will directly benefit socially excluded groups such as I D U s and CSWs. This i s true for harm reduction as stated above. It should also be true for behavioral change communication and stigma reduction since changing popular attitudes towards PLWHAs should at the very least increase the effectiveness o f harm reduction interventions. As these socially excluded groups find increased social acceptance, at least among important contact populations such as health workers, they will be more likely to respond to public or NGO sponsored interventions. 65 The economic analysis here attempts to assess the net impact o f the program's package o f behavioral interventions. Towards this goal it adopts a cost-benefit approach couched in the epidemiological framework developed by the Vietnam Technical Working Group on HIV Estimates and Projections, which has already provided population-based projections for HIV prevalence through 2010. Inthis framework there are 6 population groups - IDUS,CSWs, clients o f CSWs, other men, urban women, and rural women. The Technical Working Group has already estimated the HIV prevalence for each group, relative size o f each group, transmission rates withidacross groups, and life expectancies o f each group. These projections will serve as a .counterfactual progression o f the disease in the absence o f the proposed programs to be conductedunder the project. The program impact can be modeled as a series o f harm reduction interventions that affect the transmission rates both within and across groups. The interventions will focus on the current drivers o f infection in the Vietnamese context: intravenous drug use and commercial sex work. The likely impact o f the proposed interventions on transmission are treated as random variables with hypothesized distributions. The analysis then adopts monte-carlo methods to generate a distribution o f anticipated total benefits, at the national level, to compare with costs. The assumed impact on transmission o f the project in its entirety i s set at the deliberately conservative expected value o f a 25% reduction in infections for project provinces over the period 2005-2010. Ifthe targets in the results framework are met, then the number o f infections averted inproject provinces should be significant. However this analysis adopts the conservative estimate o f project impact to reflect uncertainty over whether all targets will ultimately be met, as well as other causes o f uncertainty that may affect outcomes. Clearly, ifthe results framework targets are achieved, then the analysis presented here may in fact underestimate the true project benefits. Due to the cross-province spillover nature o f the epidemic, the expected reduction in HIV infections innon-project provinces as a result o f the project i s set to 2.5%. These assumptions on project provinces and non-project provinces impact together yield an expected reduction at the national level in infections o f 14.9%. To account for heterogeneity in project outcomes, we assume a standard deviation o f 4.5%, or roughly one-third o f the expected value. In each simulation, the intervention impacts on transmission are allowed to vary separately across the 6 population sub-groups. The Vietnam Technical Working Group estimates 144,982 new infections over the period 2005- 2010. Figure 1 depicts the probability density function of infections averted due to the program as determined by 500 simulations o f the epidemiological model after accounting for anticipated project impacts. The analysis finds that the mean number o f infections averted to be 21,904 with a standard deviation o f 2,920. The minimum number o f infections averted i s 10,555 while the maximum stands at 30,449. 66 1ODDO Figun1.Distnbutionofnumber of H1V infections avertedas ares& ofharm reduction interventionssponsured byVietnam HlV/AIDS PreventionProject, derived from 500 simulations o f epidemiological model The projected influence o fthe project on adult prevalence o fHIV is shown inFigure2. By 2010, the model used by the Vietnam Technical Working Group projects prevalence to equal 0.628% o f the total adult population, increasing sharply from the 2005 value o f 0.484%. In contrast, the adult prevalence i s expected to stand at only 0.592% as a result o f the infections averted under the project. The upper and lower extreme bounds on the adult prevalence are estimated at 0.581% and 0.604% respectively. The monetizedbenefits from a reducednumber o fHIV infections are here determined as the sum o f three factors: the costs o f medical treatment foregone, the value o f lost eamings for PLWHAs given increased mortality, and the value o f lost earnings for the typically familial and unpaid caretakers. The analysis makes no attempt to directly value the years o f life lost due to premature mortality. Table 1 gives the summary cost parameters used inthe analysis. The number o f productive work years lost to premature HIV-related death i s assumed to average 20 years across individuals. However the distribution o f the reduction in annualized earnings is not uniform across the 6 population subgroups. The income loss i s smallest among I D U s since only approximately a third o f PLWHAs were employed before contracting HIV. Thus the average annual eamings o f I D U s is set at one-third that o f Vietnamese men in general. Since CSWs tend to congregate in urban areas, their annual eamings are set equal to the earnings o f urban women ingeneral. Group specific real wages are set to grow an average o f 2% a year, with a standard deviation o f 0.5%, thus ensuring that every simulation will have unique real wage growth rates. 67 -a, u E: a, E Q. 2 8 2005 2006 2007 2008 2009 2010 Year Figure2. Baseline adultHIV prevalence (i.e. prevalence inthe absence ofthe program) and mean projectedprevalence as a result o fharm reductioninterventions sponsored byVietnam HIVlAIDSPreventionProject, alongwiththe top andbottompercentile o fpossible outcomes Three-quarters o f Vietnamese PLWHAs interviewed in a recent UNDP sponsored qualitative study claimed they required the assistance of a caregiver. This responsibility falls disproportionately on women in the household -- 74% o f caregivers were mother, sister, and wife, and caregiving took on average 5 hours a day. A quarter o f caregivers reported having to give up a job in order to spend time with the infected person. The annualized income o f these caregivers who gave up their employment was $396. An additional third reduced hours o f work equaling an annual loss o f $382. The expected earnings loss for caregivers i s thus estimated at $228.28, and this loss occurs inthe final year o f life for PLWHAs when they are most inneed o f homecare. The expected lifespan o f a PLWHA i s assumed to be 5 years, with the final year o f life preoccupied with increased medical care. The same UNDP sponsored qualitative study found that the average per capita health expenditure per PLWHA was the equivalent o f $172 for the four years before the onset o f serious illness. In the last year o f life this rises to $1185. As a national average, household spending accounts for 62.4% o f all health care costs in 2002 (Vietnam National Health Survey 2001-2). Ifwe assume that this proportion holds for PLWHAs (note that none o f these costs includes ARV therapy), then public health care costs in the first four years average $103.64, and final year costs are $714.04. The analysis also adopts a discount rate o f lo%, a relatively large and conservative value for the evaluation o f health projects. Table 2 presents the range o f benefit-cost figures as determined in the monte-carlo analysis. The total gross program cost i s $35 million over 5 years, yielding a net present value o f $28.2 million given the disbursement schedule. The median present value o f total costs averted i s estimated at $114.6 million, yielding a gross benefit-cost ratio o f 4.07. Indeed every point in the range o f possible outcomes is associated with a substantially higher 68 present value o f total costs averted. The gross benefit-cost ratio ranges over the interval (2.58, 5.25). The median present value o f savings to the health care system due to reduced public expenditures on PLWHAs i s $13.8 million resultingina net program cost o f $14.3 million and a net benefit-cost ratio o f 8.00. The net benefit-cost ratio ranges over the substantially longer interval (3.82, 13.97). These ranges of gross and net benefit-cost ratios calculated here are entirely consistent with the ratios found inother countries inthe region. National HIV Monitoring and Evaluation System The cost to Vietnamese society o f the proposed new national system o f evaluation and surveillance for HIV/AIDS, which the project would support over the first five years o f operation, would be the cost o f establishing the new system and subsequently the cost o f operating the systemas per its design. This component is currently valued at a total cost o f $2.1 million. On the benefits side, the economic benefits that would accrue to society from the new HIV surveillance system are those discussed above, namely the costs o f medical treatment foregone and the value o f avoided lost earnings for bothHIV patients and unpaid caretakers. Inpractice, estimating distinct benefits as a direct result of the M&E framework independentof the overall package o f interventions and investments would be very difficult. Instead the influence o f the M&E system on actual health outcomes i s reflected in the analysis above in so far as a functioning HIV surveillance system will increase the efficacy and targeting o f harm reduction programs. Indeed if the national M&E framework does substantially improve the effectiveness of interventions, then the true benefits estimated above may be even greater than depicted. Nevertheless there are several dependent processesnested inthe establishment andoperation o f a surveillance system that need be made explicit. For any economic benefits to arise it would be necessary that: 0 Competent and qualified personnel are identified and recruited to the four organizations charged with establishing and maintaining the surveillance system; 0 The surveillance system collects reasonably accurate information on HIVIAIDS as per its design; 0 Relevant personnel process such information into meaningful reports and ensures the dissemination o f the reports to those officials inplaces that are able to utilize them for policy purposes; and 0 The reports result in effective action taken by the relevant decision makers in the public or private sectors, which in turn improves the delivery o f services on the ground in a way that results in the prevention of a number of cases of the diseases or a more effective treatment for those already afflicted. Program design must be such to ensure that these steps are accomplished. 70 Pilot TreatmentPrograms in Rehabilitation Centers The program and policy component o f the HIV project includes the establishment o f harm reduction and treatment programs among I D U s currently residing in 06 rehabilitation centers. Given the lack o f such programs inthese centers, and the importance o f IDUs as a group in the transmission o f the disease, the need to develop cost-effective procedures to treat PLWHAs while in these centers as well as to develop procedures so that care can be continued and combined with harm reduction programs following release i s an important component in the government's overall response to the HIV epidemic. The chief economic benefit o f the pilot arises from the externalities from learning-by-doing. It is expected that after several years o f experience with the treatment o f IDUs, initiated in the rehabilitation centers and then continued in the communities upon release, GoV will be able to implement effective care programs for I D U s that treat underlying infections, possibly treat HIV directly through the introduction o f ARVs, and then continue such care through health centers in the communities o f those IDUs released, all the while continuing to engage in harm reduction programs. Because the value o f the pilot lies in the learning opportunities, a formal cost-benefit analysis i s not applicable unless the externalities are adequately understood and converted to a monetary value. However the analysis notes that the project should ensure as many key preconditions as possible so that the pilot exercise will indeed be a valuable leaming tool for the GoV. The key preconditions for a successful treatment pilot include the following: 0 Thorough training o f medical andnursingstaff inHIV treatment and care, including ART; 0 Verification o frehabilitations center clinic readiness from an outside panel o f experts; 0 The establishment o f clinical facilities in linked CHCs, as well as the recruitment o f and training o f harm reduction staff for these facilities; and 0 Since there i s an immediate need to treat AIDS related 01and reduce HIV transmissions in the rehabilitation centers, it is possible to beginthese activities before the links to CHCs are fully established. IV.Financial Sustainability The completion o f the project will bequeath modest recurrent costs at different levels o f government. The estimated recurrent costs engendered by project activities are presented separately for the central andprovincial levels in Table 3. The province level recurrent costs are estimated for an average sized project province o f approximately two millionpeople. The burdeno f recurrent government expenditures generated by the proposedproject i s estimated to equal $1,746,200 per year after project completion. (This figure is determinedby summingthe central level costs with 20 times the average provincial level costs.) This i s a very small amount in comparison with the total health sector government spending, which is currently $439.3 million per year. Total government revenue i s also increasing at a rate o f 8% per year and so real health sector government spending i s likely to be even greater at the time o f project closure. 71 Table 3. RecurrentAnnual Expenditures Central level activity BCC Treatment pilot M&E Framework Total Consultant Services (International) $0 $0 $0 $0 Consultant Services (National) $5,000 $5,000 $403,000 $413,000 Civil Works $0 $0 $0 $0 Goods $0 $280,000 $0 $280,000 Operating Costs $202,500 $36,700 $160,000 $399,200 Training $20,000 $10,000 $0 $30,000 Total $227,500 $331,700 $563,000 $1,122,200 Average province level activity Harm reduction programs $7,600 VCT $6,400 Province level M&E activities $4,500 BCC $12,700 Total $31,200 Province level spending on HIV in 2005- center originated funds $54,800 Provincial level spending on HIV in 2005- province originated funds $5,400 The uses o f recurrent expenditures falling to the central government include the continuing activities o f national BCC, the national M&E framework, and the treatment programs established in the rehabilitation centers. Total central level health spending is anticipated to be $146.8 million, so central level recurrent expendituresderiving from the project represent only 0.8% o f total central health expenditures. At the province level, the average provincial level health spending i s anticipated to be $4.87 million. The recurrent expenditures deriving from the continuation o f harm reduction and other relevant programs total $31,200, or 0.6% o f the average province health budget. Furthermore, as can be seen in the bottom of Table 3, although the increases in financing obligations due to increased HIV/AIDS related programming i s relatively minor, these increases represent a substantial increase in the total amount o f public funds spent at the province level for HIV/AIDS. Recurrent spending would vary among the provinces, with the largest financial burdenfalling on those provinces with the highest prevalence o f HIV, such as H o Chi Minh City. However the highest prevalence provinces are also typically wealthier provinces more able to absorb an increase in health spending on harm reduction programs. Table 3 presents the estimated mean expenditures only for the typical province. Furthermore, the budgetary impact o f the project recurrent expenditures may very well by over-estimated. The economic analysis for this project determined that the direct costs averted within the public sector as a result o f fewer infections would also lessen the budgetary burdenby a significant proportion due to savings in the public health sector. One project risk concems the response o f central level HJY spending channeled through the provinces. Since financial resources are fungible, it i s unclear what a project's estimated net benefits convey about the grant's effect on development. This project might well have been undertaken without extemal financing. Ifthis i s the case, the donor's funds are actually financing some other project that would not have been carried out otherwise. Because o f this possible governmental reallocation, it will be necessary to monitor central funding o f HlV activities in project provinces after the onset of the project to ensure that they are not redirected to other purposes without good cause. 72 Annex 10: SafeguardPolicyIssues VIETNAM HIV/AIDS PreventionProject PART I:ETHNIC MINORITY FRAMEWORK5 Inlinewith the World Bank's Operational Directiveson IndigenousPeople (OP 4.20) this Policy Framework (PF) i s developed to guide the preparation and implementation o f provincial/city action plans, taking into account its ethnic minority population. The PF sets out policy objectives and guidelines for the design and implementation o f the provincial/city action plan provisions regarding ethnic minorities. The PF will also provide guidance in the overall implementation andmonitoring and evaluation o fthe project. I. Background Vietnam has 53 ethnic minority groups6 from different family and language sets. They comprise about 14 percent o f the total population or about 10.5 million people. The Kinh group i s the majority in the country. In a review o f data on ethnic minorities, it was found that the 20 provinces and cities participating in the Project have 32 ethnic minority groups, with a total population o f 3,250,000. Almost 70 percent o f them are located in eight northern provinces. Eachparticipatingprovince/city i s home to not one but several ethnic minority groups. Inorder to gather ethnic minority group insights on the development ofthe PF, andto get initial information from them on paramount issues and concerns related to HIV/AIDS prevention control, Focus Group Discussions (FGD) were conducted in 2 northern provinces. In Thai Nguyen, the FGD was held inthe village o f Pham KO,Hau Teung commune among female and male members o f the Tay, Nung and San Dui ethnic minority groups. InBac Giang, it was at NghiaPhuong commune among female andmale members o f the Cao Lan ethnic minority group 11. Vulnerabilityto HIV/AIDS The HIV/AIDS prevalence among ethnic minority is lower than for other social groups. However, in some ethnic minority communities, especially near border areas, HIV i s prevalent and spreading quickly among drug addicts andprostitutes. Awareness o fthese healthrisks is still limited among some ethnic minority communities. Gynecological diseases make ethnic minority women more vulnerable to HIV/AIDS infection. They suffer frequently from a number o f reproductive tract infections such as sexually transmitted diseases (STDs). The percentage o f women reported suffering from gynecological diseases i s high (70 to 80 percent) in rural and ethnic minority areas. The national average for gynecological check ups at health clinics i s a high 80 percent. However, the rate for ethnic minority women in mountainous areas i s much lower thanfor the Kinhwomen. The lowest rate ofhealth check ups was for ethnic minority women in the southern area (56 percent) and in the Central Highlands (63 percent). Most poor women indicated that they had never had a gynecological check up. A summary of the Ethnic Minority Framework i s provided in this section. The complete Framework has been made available to all project provinces, and i s available at the M O H and inthe World Bank Infoshop as well as the project files. Ethnic minority i s the term used inthis Policy Framework for Ethnic Minority Groups for which the World Bank's policy OD 4.20 on Indigenous Peoples applies. 73 Increasingly, males from ethnic minority groups engage in circular migration, traveling to other provinces and cities for seasonal work and returning to their villages after the season i s over. Because they usually leave their families at home, many men take up with casual sex partners, who may either be CSWs or not. Although no studies have been done specifically on ethnic minority migrant workers and condom use, other studies have shown that the majority o f male migrant workers are errant intheir use o f condoms during sex with a casual partner. Drug UseAnd Harm Environment. A UNODC study on drug use among ethnic minorities inthe provinces o f Son La, Lai Chau and Lao Cai reveals that "the traditional means o f consumption of the mountainous regions are gradually being transformed and replacedby a drugs scene closer to the urban realities o f Vietnam. Drug users tend to be younger; heroin and, to a lesser degree, amphetamines are fast supplanting opium." The study confirms that a) older drug users tend to use opium as their exclusive drug of choice, though, consumption o f heroin and amphetamine has been reported; b) the centuries old uses o f opium among the ethnic minorities as a therapeutic drug and a social tool appear to have become more and more marginal; c) the presence o f IDUs has been confirmed; so are high-risk behaviors by IDUs, even though information on the means o f transmitting HN appears to be available; and d) services for HIV detection among IDUs and their spouses, and the distribution o f injection equipment and condoms, are not apparent. The same study points to the preference by drug users to access treatment and rehabilitation within the community. However, there are several obstacles to this: primarily, cost (investment in terms o f infrastructure), the availability o f skills (training o f local medical staff and availability o f outside expertise) and the effectiveness itself o f an on-site treatment regimen. Although the preference for community-based treatment and rehabilitation remains high among drug users from ethnic minority groups, many o f them enter rehabilitation centers. In Thai Nguyen province, officials estimate that about one-fifth o f the residents in its rehabilitation center are ethnic minorities. Sex Work and Harm Environment. There is a dearth o f data related to ethnic minority groups and sex work. There are a few studies that point to the increasing participation o f young ethnic girls in the sex trade. They usually work as commercial sex workers in their home province, especially in the tourist areas. In the northem mountain resort o f Sapa, two studies claim that girls below 16 years old are engaging in sex work. Most are from the Hmong ethnic group. The UNODC study points to the absence o f ethnic CSWs in its subject communes. However, it verifies their presence inthe bigger communes and the capital towns. It reports that they receive business from the subject communes. This mirrors the situation in the village and commune in Thai Nguyenand Bac Giang. Women and minors from ethnic minority groups residinginborder provinces are subject to cross-border trafficking. While some do it voluntarily, many are forced into it. They usually end up in foreign countries as sex workers while others are exploited as work slaves infactories and sweat shops. 111. Guidelinesfor the Developmentof ProvinciaVCityAction Plans The objective o f the guidelines for the development o f provincial/city action plans i s to ensure that under the VHAPP ethnic minority groups are informed, consulted and mobilized to participate in its project activities. Notably, the guidelines will guarantee equity in representation, reduce social disparities, and overcome any obstacles such as language and cultural sensitivity for guaranteeing equal rights for ethnic minority women, men, adolescents and children in participating and achieving benefits from the VHAPP. Their participation will 74 enable the provinces/cities to design better delivery and provision o f information and services suited to ethnic minority needs and circumstances. The process o f guiding provincial/city action planpreparation will consist o f the following: (i) data gathering; (ii)guidelines for provincial/city action plan preparation workshop; (iii) integrated institutional arrangements; and (iv) integrated monitoring and evaluation. During the process o f development, continuous efforts will be made to gather feedback for better planning and execution, Consultation with and participation o f the ethnic minority population, their leaders and local government officials will be an integralpart o f the process. PART11: HEALTHCARE WASTE MANAGEMENT' I. Background Management o f health care wastes was identified as a possible area o f concern inthis HIV/AIDS Prevention Project. Inaddition to the safety o fblood supply, the specific concerns are associated with the disposal o f contaminated blood, usedneedles, and other wastes generated at health care facilities. As this project supports demonstration o f a community-based treatment model to integrate harm reduction with comprehensive HIV treatment and care at selected rehabilitation centers (which are not part o f the MOH system, but are run by the Ministryo f Labor, Invalids and Social Welfare), the environmental component of this project will also focus on the same rehabilitation centers interms o f health care waste management. The Vietnam HIV/AIDS Prevention Project was assigned a Category B for environmental assessment purposes. Accordingly, during project preparation, a study was conducted to review the health care waste management (HCWM) legislation and practices at health care facilities as well as rehabilitation centers, identify environmental issues relevant to health care waste management, and recommend measures that would be incorporated into the design o f this project. This study has benefited from visits to selected health care facilities and rehabilitation centers as well as reviews o f the following documents: (i)health care waste management legislation in Vietnam, (ii) Ministry o f Health's H C W M Master Plan, which was prepared in 2002 and is still valid today, (iii) proceedings from an international conference on H C W M in Vietnam, and (iv) selected studies on H C W generation in Vietnam. Main findings and recommendations from this review are presented inthe following sections. 11. Existing Legislation and Regulatory Framework at the National and Local Level for Health care Waste Management Vietnam has not developed a master plan on health care solid waste management for the country, although H C W M regulations have existed since 1999.Approximately, 30% o fprovinces lack the appropriate technology for health care waste treatment, particularly in remote and mountainous areas. Some laws and regulations directly related to health care waste management are summarized below: I Table 1:The Summarv of RegulationsDirectlv Relatedto Health care Waste Management LegalRecluirement I Date issued I Main ActivitiesDescribed I ~~ ~~ ~ 'The Health Care Waste Management Plan and appropriate guidelines will be made available to all project provinces. The HCWMP is available at the MOH, at the World Bank Infoshop, and the project files. 75 Official letter N o 4527-BYT by June 8, 1996 Guidelines on health care solid waste treatment in Ministry o f Health hospitals DecisionNo. 1895/1997/BTY-QD by September 19, 1997 Waste management at health care facilities Ministryo fHealth DecisionN o 152/QD-TTg by Prime July 10, 1999 Strategy for solid waste management inurban and Minister industrialzones by 2020. Target 2005 -2020: Collection and incinerationo f solid health care waste inbig cities - Official letter N o 1153/VPCP-KG March22, 1999 These two letters assignthe Ministryo f Health to actively Government Office coordinate with concerning sectorsiministers to develop a - Official letter No 1069 CPiQHQT master plan for health care solid waste management in by Government Office October 11, 1999 Vietnam DecisionN o 2575/1999/QD-BYT by August 27, 1999 Regulationo n health care waste management Ministry o f Health Inter-ministerial circular No. December 28, 1999 Guidance on the implementation o fregulations on safe 2237/1999/TTLT/BKHCN-MT-BYT application o f radioactive techniques inmedical wastes Decision N o 62 /2001/QD-Ministry November 21, 2001 Regulation o n technical requirements o f incinerators for o f Science, Technology and health care waste Environment Decision No. 2575/1999/OD-BYT, August 27. 1999, o f the Minister o f Health promulgating the regulations on health care waste management This decision applies to all hospitals, institutions and provincial/district health centers, general health clinics, maternity hospitals, health stations, private health services, preventive medicine centers and health workers training services. It provides details onwaste classification, as well as guidance on collection, treatment and disposal o f waste from health facilities. 0 Waste Classification: Health care wastes are divided into 5 groups: General waste; clinical waste; chemical waste; radioactive waste; and pressurized containers. Examples for each health care waste group are shown inTable 2. Types of Health Care Wastes Examples General Waste Cardboard boxes, paper, food waste, plastic and glass bottles Group A: Infectious waste Soiled surgical dressings, cotton wool, gloves, swabs, all other contaminated waste from treatment areas; plasters, bandaging which have come into contact with blood or wound; cloths and wiping materials used to clean up body fluids and spills o f blood; material, other than reusable linen, from cases o f infectious disease Group B: Sharps Used syringes, needles, cartridges, broken glass, scalpel, blades, saws and any other sharp instruments that could cause a cut or puncture Group C: Clinical waste from laboratories Waste from laboratories (for pathology, hematology, blood transfixion, microbiology, hstology) such as: gloves, test tubes, cultures and stocks o f infectious agents and blood bags Group D: Pharmaceutical wastes Expired drugs that have been returned from wards, drugs that have been spilled or contaminated, or are to be discarded because they are n o longer required; and 76 cytotoxic wastes Group E: Pathological waste Human tissues (whether infected or not), organs, limbs, body parts, placenta and human fetuses, animal carcasses and tissues from laboratories ChemicalWaste Chemical solid, liquid and gas. The chemical waste i s divided into non-hazardous waste such as glucose, fatty acid, salt, organicinon organic salts and chemical hazardous waste such as formaldehyde, photochemical, and chemical solvents, oxide ethylene, mixed chemicals (disinfection agents, phenols., .) RadioactiveWaste Waste emitted from activities o f diagnosis, therapy & research such as needles, syringes, compress, glassware, absorbent paper, swabs, bottles that are diffracted with the radioactive material Explosiveor PressurizedContainers Compressed gas cylinders, aerosol cans and disposal compressed gas containers. They are inflammable and explosive hence they are handled carefully and separately General PrinciDles: Segregation should take place as close as possible to where the waste i s generated. Clinical hazardous waste should not be mixedwith the general waste. Color coding o f waste bans and containers: Yellow for biological hazardous wastes; green for general wastes; and black for chemical, radioactive and cytotoxic wastes. Standards for waste bags: Waste bags should be PE and PP plastic bags with a maximum volume o f 0.1 m3and shouldbemarked at three-quarter full level. Standards for sharp containers: Sharp containers should be puncture-proof containers that are flammable. These containers should have a volume suitable with the amount o f sharps generated, a cover, a yellow label clearly marked "sharps", and a mark at three- quarter full level. Standards for waste containers: Waste containers should be made o f polyethylene (PE). Ifthe containers are big, they should beput on a trolley. The container should have the same color as the waste bag and should be markedat three-quarter full level. Waste collection: Nurses are responsible for collecting waste from the generating source to the storage area. The waste bagmust be closed while being transported. Waste storage at health care facilities: The storage area: (i) should not be situated in the proximity o f fresh food storage or food preparation areas; (ii) be locked to prevent should access by unauthorized persons; (iii) should contain a supply of cleaning equipment, protective clothing, and waste bags or containers located conveniently; (iv) should have easy access to the waste collection vehicles; and (v) should be close to water supply for cleaning purposes. All stored wastes should be protected from the sun, and hazardous wastes should be kept separately from the general waste. Storage times for health-care waste: In hospitals, waste should be disposed daily. However, for small health care facilities: storage time for Group A, B, Cyand D wastes should not exceed one week; and Group E waste should be incinerated or buried immediately. Off-site transportation of clinical waste: Health care facilities should contract waste transportation and disposal services approved by local authorities for off-site transportation of clinical waste. Use o f a waste manifest system i s required. Treatment and Disposal Technologies: Incinerators are recommended for all health care facilities inthe city or for a group o f hospitals. Sanitary landfill i s only recommended for 77 health care facilities that cannot incinerate the waste. Waste shouldbe buriedat permitted locations that meet the prescribed environmental requirements. Primary treatment i s only recommended for Group C waste and materialdequipment used in the treatment o f HIVAIDs patients. Primary treatment techniques include boiling, chemical disinfection andwet anddry thermal treatment. 111. CurrentHCWMPracticesat ClinicalSettings Approximately, 30 percent of provinces in Vietnam, particularly those in remote and mountainous areas, lack the appropriate technologies for health care waste treatment and disposal. The current H C W M practices for general and clinical wastes are described below. General Waste Two methods are used in Vietnam to dispose o f solid general waste from health care facilities. At most large provincial general hospitals, the general waste is collected by the medical waste officer inside the hospitals and then transported to the landfill by environmental companies. However, at most o f the small/district hospitals - particularly in the mountainous provinces - general waste i s dumped inthe backyard of the hospitals. Clinical Waste 0 Group A: Infectious Waste. A 2001 survey conducted at 280 representative hospitals concluded that: (i) Group A waste i s collected inplastic bags in 84% o f the hospitals; but put directly inwaste bins inthe remaining 16% of the hospitals; and (ii) was lack of there uniformity inthe type o f material usedand inthe color o fbags and containers. Disposal practices o f Infectious Wastes include: (i) land disposal in a burial pit on hospital premises (most commonly in middle land and mountainous district provinces); (ii) disposalwithout treatment atamunicipallandfill;(iii) land incineration (only one- third o f the hospitals surveyed indicated that clinical waste was being destroyed in incinerators on-site or off-site at city's incinerator); (iv) open-air burning (commonly at small hospitals and district andbranchhospitals). 0 Group B: Sharps. Sharps are segregated from other wastes at several central hospitals that have enough financial resources to buy "boxes for sharp items". In some hospitals, nurses reuse PEbottles or metal cans to contain the needles. However inmany hospitals, sharps are not segregated from other clinical waste or general waste. As sharps are collected inthinplastic bags, they present a risk for workers handlingthese wastes. 0 Group C: Clinical Waste from Laboratories. Most hospitals sterilize clinical waste from laboratories. These wastes are either buried at hospital premises or sent to a landfill. However, at some hospitals, these wastes are not sterilized because o f the lack o f disinfectionreagents. 0 Group D: Pharmaceuticals. The current practices used for solid pharmaceutical wastes include: (i)burial at the hospital site, (ii) placement at a public location for waste collection, (iii)incineration in furnaces/incinerators, and (iv) open air burning. Liquids pharmaceutical wastes are discharged through drains without any treatment. 78 0 Group E: Pathological Waste. The current practices used for disposal o f pathological waste include: (i) cremation in a fumace, (ii)buming in the open air, and (iii) land disposal. IV. CurrentHCWMPracticesat Non-ClinicalSettings Non-hospital settings for HIV/AIDS infected people include rehabilitation centers (RCs), clubs for the HIV/AIDS infected, and temples. There are about 80 Rehabilitation Centers (RC) in Vietnam managed by Local Departments o f Labour, Invalids and Social Affairs - Ministry o f Labours and Invalid and Social Affairs. Although information on HIV/AIDS H C W M 'under these settings i s very limited, the available information reveals that waste management practices and stafftraining at non-hospital/clinical establishments are often very poor compared to those at medical establishments. Three RCs located inHanoi, Hai Phong, and Khanh Hoa have been selected as the pilot sites for H C W Munder this project. The main findings about these RCs are presentedbelow. H C W M at Hanoi RC General information. Hanoi RC i s located in the Socson District, 52 km from Hanoi and 7 km from the Namson Landfill site. There are 120 staff members working at this RC, of which 18 are medical personnel. All medical staff are involved in the segregation, collection, and transportation o f the waste to the newly installed on-site incinerator. There i s one person trained to operate the incinerator. Waste segregation. Health care personnel collect the needles and place them in a plastic waste bottle. Other waste at this RC i s not segregated. Therefore, syringes, bandages, and swabs are collected along with the general waste ina plastic waste bin. Waste i s stored first ina plastic bin without a lid located in a comer o f the building, and then in the incinerator. Plastic bags for clinical HCSW are not available at this RC. Clinical waste destruction in the incinerator. There i s one medical incinerator installed at this RC for the destruction o f clinical waste. The incinerator has a highfuel consumption (1.1 to 1.3 kg gasoline/kg o fwaste), resulting inhighoperatingcosts. As this incinerator lacks a proper flue gas cleaning system it i s likely to emit hazardous pollutants (such as dioxins, furans, and heavy metals) to the environment. The incinerator i s run about once a month by one assigned staff member. The staff member is not cognizant about the potential hazards associated with environmental discharges from the incinerator. Liquid waste management. Liquid infectious waste and liquid expired pharmaceuticals are both discharged from the drain flowing to the paddy field next to the RC. N o disinfection o f the liquidinfectiouswaste is practiced. There is no wastewater treatment systemat this RC. H C W Mat Hai P R C General information. Hai Phong RC i s located in Hai Phong City at Cat Bi District. This RC, which was established in 1992, has an increasing number o f trainees admitted. N o clinic is available within the Hai Phong RC. However, there are two health rooms with four health care staffmembers. 79 Four health care workers are responsible for HCWM. Among these workers, only one has been trained in HCWM. The health care workers are in charge o f segregation o f the syringes at the medical consultancy room and for hand-carrying the wastes to the corner o f the yard to burnafter soaking with alcohol. Waste segregation. Sharps and clinical wastes are collected separately at source and stored in their respective plastic waste containers. There is one needle destroyer, but is no longer inuse. Plastic bags are rarely used to collect the waste. Waste bins do not follow recommended color- coding or labeling requirements. Liquid waste management. Liquid infectious waste and liquid expired pharmaceuticals are both discharged to the city drainage system. No disinfection o f the liquid infectious waste i s practiced. There i s no wastewater treatment system at this RC. H C W M at KhanhHoa RC General information. Khanh Hoa RC i s located in the Khanh Vinh District o f the Khanh Hoa Province. It i s about 62km from Nha Trang City. This RC i s 20km from Khanh Vinh District Medical Center; 6 km from the community medical station, and 8 kmfrom the district policlinic. This RC was established in 1994. There is one health room inthe administration buildingand two other health rooms inthe trainees' building.Four health care workers are responsible for the HIVpositive patients. Only one healthcare worker is incharge o fwaste management. The general waste is separated from the clinical waste. Clinical wastes (group A, B) are placed in plastic bags and are sent to the dumping site where the both clinical waste and domestic waste are dumped. Then the waste i s burned in the open air after several days. The dumping site i s about 50-60 meters from the administration building. Waste segregation. Boxes for sharp items are not available. Waste i s carried by hand to the dump site. V. Action Plan Proposed under the HCWMP for the Vietnam HIV/AIDS Prevention Project Based on recommendations of the environmental study conducted during preparation o f this project, the following activities have been incorporated into the design o f this project. These activities include drafting o f H C W M regulation and technology standards and strengthening o f three RCs inthe area of health care waste management. Draftinn HCWM remdation and technolom standards. The proposed Project will likely support three RCs (Hanoi RC, Hai Phong RC, and Khanh Hoa RC). As the national H C W M legislation and associated technical standards will form the basis o f H C W M at these RCs, preparation o f the draft H C W M legislation and technical standards will be undertaken under this project. Bringing the incinerator at Hanoi RC under compliance. The incinerator at Hanoi R C will be assessed inlight of the technical standards. The assessment should specify ifthe existing incinerator complies with the proposed technology standards, and if not, should identify the deficiencies and make recommendations for improvement (and compliance) with a specific action plan, schedule, and budget. The recommendations should bebased on life-cycle cost analyses for operating this incinerator (with or without upgrading) 80 versus investing in and operating an alternative technology (such as autoclave or microwave). Implementation o f the recommendations will be carried out under this project. Brinaing- wastewater discharges from the three RCs under compliance. A study will be undertaken to bringwastewater discharges from each o f the three RCs under compliance through low-cost solutions. Specific action plans and designs, implementation schedules and budgets will be prepared. The proposed investments will be carried out under this project. Implementing sound HCWM at three RCs. A H C W M organization will be established and a HCWM plan will be prepared and implemented at all three RCs. The implementation will include procurement o f goods and services (supplies like personal protection equipment, equipment like needle destroyers, construction materials like cement and iron, consulting services for the preparation o f plans and training o f R C personnel and awareness and information education communication), and arrangement for waste disposal. 81 Annex 11:ProjectPreparationand Supervision VIETNAM HIVlAIDS PreventionProject Planned Actual PCNreview December 18,2003 December 18,2003 InitialPlD to PIC January 26,2004 Initial ISDS to PIC Appraisal December 1,2004 December 6,2004 Negotiations February 22,2005 February28,2005 Board/RVP approval March29,2005 Planned date of effectiveness July 29,2005 Planneddate of mid-termreview April 30,2008 Planned closing date December 31,201 1 Key institutions responsible for preparation ofthe project: 0 AIDS Departmentofthe GeneralDepartmentofPreventiveMedicineandHIV/AIDS Control (GDPMAC), Ministry of Health 0 National Institute ofHygiene and Epidemiology World Bank staff and consultantswho worked on the project included: Name Title Unit Maryam Salim Sr. Human Development EASHD Specialist/Team Leader Samuel S. Lieberman Lead Economist EASHD Mai Thi Nguyen Sr. Operations Officer EASHD SusanA. Stout Manager OPCSRX David Wilson Sr. Monitoring and Evaluation HDNGA Specialist Jed Friedman Young EASHD Professional/Economist Lingzhi Xu Sr. Procurement Specialist EASHD Hoi-ChanNguyen Sr. Counsel LEGEA HungKimPhung Sr. Financial Officer LOAGl Jennifer K.Thomson Sr. Financial Management EAPCO Specialist HungViet L e Financial Management EAPCO Specialist JohnNyaga Sr. Financial Management AFTHV Specialist BekirA. Onursul Sr. Environment Specialist EASEN Lars C. Lund Sr. Social Scientist EASSD NinaBhatt Social Scientist EASSD Quyen Do Duong Financial Analyst LOAGl A. MeadOver Lead Economist, Health(Peer DECRG 82 Reviewer) Olusoji 0.Adeyi Coordinator (Peer Reviewer) HDNHE Rosario Aristorenas Program Assistant EASHD Nga QuynhNguyen Program Assistant EACVF A. JulianaWilliams Senior Program Assistant EASHD Tram Bao Nguyen Team Assistant EACVF Dale Huntington Sr. Health Specialist Juliana Riparip Behavior Change Consultant Communication Robert Oelrichs Harm ReductiodTreatment Consultant TrinhThuHang Implementation Consultant Lien Quach Implementation Consultant World Bank funds expended to date onproject preparation: 1. Bank resources: US$476,601 2. Trust funds: US$ 542,000 (PHRD managedby the Ministry ofHealth) 3. Total: US$1,018,601 Estimated Approval and Supervision costs: 1. Remaining costs to approval: $100,000 2. Estimatedannual supervision cost: $85,000 83 Annex 12: Documentsinthe ProjectFile VIETNAMHIVlAIDS PreventionProject 9 Ethnic MinorityFramework 9 HealthCareWasteManagementPlan 9 TheNationalStrategyonHIV/AIDSPreventionandControlinVietnamwith aVisionto 2020 9 BriefingPaperOnVietnam EstimatesAndProjections2003 9 OperationsManualandProjectImplementationPlan 9 Report onthe InstitutionalAssessmentoftheMinistryofHealthandthe HIV/AIDS System 9 Synthesis PaperonHIV/AIDS inVietnam: EpidemiologyandResponses 84 Annex 13: Statement of Loans and Credits VIETNAM HIV/AIDS PreventionProject Differencebetween expectedand actual Original Amount in US$ Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev'd PO44803 2003 VN-PRIMARY EDUC FOR 0.00 138.76 0.00 0.00 0.00 142.14 0.00 0.00 DISADVANTEGED CHILRE PO75398 2003 Vietnam PRSC I1 0.00 100.00 0.00 0.00 0.00 101.77 0.00 0.00 PO75399 2003 Public Financial ManagementReform 0.00 54.33 0.00 0.00 0.00 55.93 0.00 0.00 Proj, PO51838 2002 VN-PRIMARY TEACHER 0.00 19.84 0.00 0.00 0.00 20.73 3.92 0.00 DEVELOPMENT PO66396 2002 VN-SYSTEM ENERGY, 0.00 225.00 0.00 0.00 0.00 253.36 14.23 0.00 EQUITIZATION & RENEWAB PO59936 2002 Northem Mountains PovertyReduction 0.00 110.00 0.00 0.00 0.00 116.45 18.59 0.00 PO73305 2002 VN-Regional Blood Transfusion Centers 0.00 38.20 0.00 0.00 0.00 42.27 7.13 0.00 PO72601 2002 Rural FinanceI1Project 0.00 200.00 0.00 0.00 0.00 194.67 -29.97 0.00 PO52037 2001 VN-HCMC ENVMTL SANIT. 0.00 166.34 0.00 0.00 0.00 170.77 6.68 2.44 PO62748 2001 COMMUNITY BASED RURAL 0.00 102.78 0.00 0.00 0.00 110.34 -4.16 0.00 INFRASTRUCTURE PO42927 2001 VN-MekongTransporVFlood Protection 0.00 110.00 0.00 0.00 0.00 108.47 59.94 0.00 PO42568 2000 COASTAL WetVProt Dev 0.00 31.80 0.00 0.00 0.00 29.87 20.80 0.00 PO56452 2000 VN-RURALENERGY 0.00 150.00 0.00 0.00 0.00 82.81 70.14 0.00 PO59864 2000 VN-Rural Transport I1 0.00 103.90 0.00 0.00 0.00 51.65 20.19 0.00 PO04828 1999 VN-HIGHER EDUC. 0.00 83.30 0.00 0.00 0.00 64.72 43.62 13.36 PO04845 1999 MEKONG DELTA WATER 0.00 101.80 0.00 0.00 0.00 83.74 69.87 0.00 PO04833 1999 VN-Urban Transport Improvement 0.00 42.70 0.00 0.00 8.19 22.02 29.65 0.03 PO51553 1999 VN-3 CITIES SANITATION 0.00 80.50 0.00 0.00 0.00 64.72 27.91 0.00 PO04839 1998 FORESTPROT.& RUL DE 0.00 21.50 0.00 0.00 0.00 17.79 15.02 5.94 PO04843 1998 VN-Inland Waterways 0.00 73.00 0.00 0.00 0.00 53.00 51.56 0.64 PO04844 1998 AGRI DIVERSIFICATION 0.00 66.90 0.00 0.00 0.00 36.43 16.81 4.36 PO45628 1998 VN-TRANSMISSION & DISTR 0.00 199.00 0.00 0.00 0.00 124.13 122.92 7.63 PO04830 1997 VN-WATER SUPPLY 0.00 98.61 0.00 0.00 31.28 17.68 53.88 3.00 PO04841 1996 VN-POPULATION & FAMILY HEALTH 0.00 50.00 0.00 0.00 0.00 3.54 8.67 0.00 PO36042 1996 BANKING SYSTEM 0.00 49.00 0.00 0.00 0.00 24.33 28.56 28.55 MODERNIZATION PO04838 1996 VN-NATIONAL HEALTH SUPPORT 0.00 101.20 0.00 0.00 0.00 36.77 45.50 0.00 Total: 0.00 2,518.46 0.00 0.00 39.47 2,030.10 701.46 65.95 85 VIETNAM STATEMENT OF IFC's Heldand DisbursedPortfolio InMillionsofUSDollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 2002 AUAGF Vietnam 0.00 1.32 0.00 0.00 0.00 1.32 0.00 0.00 2002 CyberSoft 0.00 1.25 0.00 0.00 0.00 1.25 0.00 0.00 2002 Dragon Capital 0.00 2.00 0.00 0.00 0.00 2.00 0.00 0.00 2002 F-V Hospital 5.00 0.00 3.00 0.00 4.21 0.00 3.00 0.00 1998 MFLVinh Phat 0.15 0.00 0.00 0.00 0.15 0.00 0.00 0.00 1996 Momstar Cement 20.48 0.00 0.00 34.96 20.48 0.00 0.00 34.96 1997 NATL 16.80 0.00 0.00 13.16 16.80 0.00 0.00 13.16 1995197 Nghi Son Cement 16.99 0.00 0.00 12.43 16.99 0.00 0.00 12.43 2001 RMITVietnam 7.25 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1996 SMHGlass Co. 6.11 0.00 0.00 0.56 6.11 0.00 0.00 0.56 2003 Sacombank 0.00 2.93 0.00 0.00 0.00 2.77 0.00 0.00 2002 VEIL 0.00 0.00 12.00 0.00 0.00 0.00 12.00 0.00 1996 VILC 0.00 0.75 0.00 0.00 0.00 0.75 0.00 0.00 Total portfilio: 72.78 8.25 15.00 61.11 64.74 8.09 15.00 61.11 Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic 2002 F-V Hospital 1.50 0.00 0.50 0.00 2003 Glass Egg 0.00 1.75 0.00 0.00 2000 Interflour 8.00 0.00 0.00 5.00 1999 MFLChau Giang 0.00 0.00 0.00 0.00 1999 MFLMinhMinh 0.00 0.00 0.00 0.00 2000 MFLMondial 0.00 0.00 0.00 0.00 2000 MFL-AA 0.00 0.00 0.00 0.00 Total pendingcommittment: 9.50 1.75 0.50 5.00 86 Annex 14: Countryat a Glance VIETNAM HIV/AIDS PreventionProject East POVERTY and SOCIAL Asia & Low- Vietnam Pacific income Ievelopment diamond' 2001 Population,mid-year(millions) 78.7 1,826 2511 Life expectancy GNI percapita (Atlas method, US$) 420 900 430 GNI (Atlas method, US$ billions) 33.4 1,649 1,069 T Average annual growth, 1995-01 Population (%) 1.5 1.1 1.9 Labor force (%) 1.7 1.3 2.3 ZNI Gross Most recent estimate (latest year available, 199561) ier primary :apita nrollment Poverlv (% ofpopulation belownationalpoverty line) 32 Urban population(% of totalpopulation) 25 37 31 Life expectancyat birth (years) 69 69 59 1 Infantmortality(per 1,000live births) 37 36 76 Child malnutrition(% of children under 5) 34 12 Access to imDrovedwater source Access to an improvedwater source (% ofpopulation) 56 74 76 Illiteracy(% ofpopulation age 75+) 6 14 37 Gross primaryenrollment (% of school-agepopulation) 110 107 96 *-*-,*.I Vietnam Male 113 106 103 Low-incomearou~ ~ Female 107 108 88 KEY ECONOMICRATIOS and LONG-TERMTRENDS 1981 1991 2000 2001 Economlc ratlos' GDP (US$billions) 9.6 31.2 32.7 Grossdomestic investmenffGDP 15.0 29.6 30.9 Exportsof goods and sewicedGDP 32.6 55.0 54.7 Trade Grossdomestic savingdGDP 16.5 27.1 28.9 Gross nationalsavings/GDP 16.9 31.4 32.2 Current account balance/GDP -2.0 1.6 1.8 interest pavmentdGDP 0.3 0.9 1.1 Total debffGDP 243.4 41.2 38.4 Total debt service/exports 6.3 7.5 6.7 J. Presentvalue of debtlGDP 35.7 Presentvalue of debtlexports 64.3 Indebtedness 1981-91 1991-01 2000 2001 200165 (averageannualgrowth) -">-.m GDP 4.9 7.7 6.8 6.8 7.0 Vietnam 5.4 5.4 5.6 Low-incomeorouo ~ STRUCTUREof the ECONOMY I 1981 1991 2000 2001 (% of GDP) Growth of investment and GDP (X) Agriculture 39.5 24.5 23.6 30T Industry 23.8 36.7 37.8 Manufacturing 13.3 18.6 19.6 Services 36.7 38.9 38.6 Private consumption 77.1 66.5 65.0 96 97 98 99 W Generalgovernmentconsumption 6.3 6.4 6.2 I Importsof goods and services 31.1 57.5 56.8 ="GDI - O ' G D P 1981-91 1991-01 2ooo 2o01 (average annualgrowth) Growth of exports and Imports (Oh) Agnculture 4 3 4 7 4 6 2 8 Industry 11 7 101 103 t: Manufactunnq 12 1 11 7 11 3 30 Services 7 4 5 3 6 1 :: Pnvateconsumption 11 1 3 1 4 5 0 Generalgovernmentconsumption 10 6 5 0 5 5 96 97 98 99 W 01 Grossdomestic investment 18 6 101 1 0 5 ---Exports --(>-Imports Importsof goods and sewices 29 1 27 3 2 3 87 Vietnam PRICES and GOVERNMENT FINANCE 1981 1991 2000 2001 lnflatlon (Oh) Domestic prices (% change) 30 T I Consumer prices 82.7 -1.7 -0.4 Implicit GDP deflator 72.5 3.4 2.7 Governmentfinance (% of GDP, includes current grants) Current revenue 13.5 20.4 20.4 Current budget balance 0.0 4.5 4.3 '"--GDP deflator +CPI Overall sumlus/deRcit -2.8 -3.3 I I TRADE 1981 1991 2000 2001 (US$ millions) Exportand Import levels (US0 mill.) Total exports(fob) 2,042 14,448 15,100 Rice 225 667 588 Fuel 581 3,503 3,175 Total imports (cif) 2.377 15,635 16,000 Food 82 Fuel and energy 485 2,056 1,871 I Capital goods 714 Export price index (1995=100) 95 96 97 98 99 W 01 Import price index (7995=100! 0Exports w Imports Terms of trade (7995=100) BALANCE of PAYMENTS 1981 1991 2000 2001 (US$ millions) Current account balanceto GDP (%) Exportsof goods and services 2,491 17,144 17,910 ~ 5 7 Importsof goods and services 2,377 17.381 17.782 Resource balance -720 114 -237 128 0 Net income -72 -339 -597 -635 Net currenttransfers 17 35 1,341 1,100 5 Current account balance -775 -190 507 593 -io Financingitems (net) 534 472 -391 -266 Changes in net reserves 241 -282 -116 -325 Memo: Reserves includinggold (US$millions) Conversionrate (DEC. iocaVUS$) 0.6 7,979.2 14,170.0 14,806.0 EXTERNAL DEBT and RESOURCEFLOWS 1981 1991 2000 2001 (US$ millions) 1 Composition of 2001 debt (US$ mill.) Total debt outstanding and disbursed 26 23,395 12,635 12,578 IBRD 0 0 0 0 IDA 19 50 1,113 1,344 G: 784 8: 1,344 Total debt service 0 160 1,303 1,216 IBRD 0 0 0 0 IDA 0 1 9 10 Compositionof net resourceflows Official grants 104 126 236 Official creditors 19 -45 1,022 973 Private creditors 0 50 -717 -590 Foreigndirect investment 18 229 1,298 Portfoiioequity 0 10 0 1 E 6,961 World Bank program Commitments 0 0 266 739 A - IBRD E Bilateral - Disbursements 17 0 174 279 B -IDA D Other multilateral - F Private ~ Principalrepayments 0 1 2 2 C IMF - G-Short-term Net flows 17 -1 173 277 Interestpayments 0 0 8 8 Net transfers 17 -1 165 268 88 MAP SECTION IBRD 33719 102° 104° 106° 108° 110° VIETNAM C H I N A HIV/AIDS 4 Hà Giang Cao Bang ` PREVENTION 5 Lào Cai Phong Tha PROJECT 9 1 3 8 `BacCan 22° 22° Tuyên 7 Lang Quang Thai Son Yên Bái Nguyen 10 2 13 Viêt Trì 12 Diên Vinh Yen 14 PROJECT PROVINCES Són La 15 Biên Phú 11 Bác Giang Bác Ninh AND CITIES 6 16 HA NOI 17 Ha Long Hà Dông 19 20 Hòa Bình Hung Haí Hai Phong 22 18 Yen Dúóng21 PROVINCE CAPITALS Hà Nam 23 24 Nam Thái Bình NATIONAL CAPITAL 25 Dinh26 20° Ninh Bình 20° PROVINCE BOUNDARIES 27 LAO PEOPLE'S Thanh Hóa INTERNATIONAL BOUNDARIES DEMOCRATIC Gulf 28 REPUBLIC Hainan I. of (China) Vinh Tonkin 29 Hà Tinh ~ 18° 18° PROVINCES: Mekong 1 Lai Chau 32 Thua Thien Hue Dông Hói 2 Dien Bien 33 Da Nang 30 3 Lao Cai 34 Quang Nam 4 Ha Giang 35 Quang Ngai 5 Cao Bang 36 Kon Tum Dông Hà 6 Son La 37 Gia Lai 31 7 Yen Bai 38 Binh Dinh Hué 8 Tu Yen Quang 39 Phu Yen 32 9 Bac Can 40 Dac Lac 33 16° Dà Nang 16° 10 Lang Son 41 Dac Nong T H A I L A N D 11 Phu Tho 42 Khanh Hoa 34 Tam Ky 12 Vinh Phuc 43 Binh Phuoc 13 Thai Nguyen 44 Lam Dong 14 Bac Giang 45 Ninh Thuan Quàng Ngai 35 15 Quang Ninh 46 Tay Ninh 16 Ha Noi 47 Binh Duong 36 17 Bac Ninh 48 Dong Nai Kon Tum 18 Ha Tay 49 Binh Thuan 38 19 Hung Yen 50 T.P. Ho Chi Minh 20 Hai Duong 51 Ba Ria-Vung Tau 14° Play Cu Quy Nhon 14° 21 Hai Phong 52 Long An 37 22 Hoa Binh 53 Tien Giang 23 Ha Nam 54 Dong Thap 39 24 Thai Binh 55 Ben Tre 25 Ninh Binh 56 An Giang C A M B O D I A 40 Tuy Hòa 26 Nam Dinh 57 Vinh Long Buôn Ma 27 Thanh Hoa 58 Tra Vinh Thuôt 28 Nghe An 59 Kien Giang 42 29 Ha Tinh 60 Can Tho 41 Nha Trang 30 Quang Binh 61 Hau Giang Gia Nghia 12° Dà Lat 12° 31 Quang Tri 62 Soc Trang 43 63 Bac Lieu Dông Xoái 44 45 64 Ca Mau Phan Rang- Mekon 46 Tháp Chàm Tây Ninh 48 47 g Thu Dãu 49 Môt 50 Biên Hòa Phan Thiêt 54 Ho Chi Minh City 52 Cao Lanh Tan An 51 56 53 Long Xuyên My Tho Bên Tre, ~ Vung Tàu ~ Phu Vinh Long Quoc 60 57 55 10° VIETNAM 10° Rach Giá Cân Tho' 59 Gulf 61 Trá Vinh Vi Thanh 58 of 62 Sóc Trang 63 Thailand Cà Mau Bac Liêu 0 50 100 150 Kilometers The boundaries, colors, denominations and any other information 64 shown on this map do not imply, on the part of The World Bank 0 50 100 Miles Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 102° 104° 106° 108° DECEMBER 2004