Documentof The World Bank FOROFFICIAL USEONLY ReportNo: 28831 PROJECTAPPRAISAL DOCUMENT ON A PROPOSEDGRANT INTHEAMOUNT OF SDR4.7 MILLION(US$7.0 MILLIONEQUIVALENT) TO THE REPUBLIC OF GUINEA-BISSAU FORA HIV/AIDS GLOBALMITIGATION SUPPORTPROJECT May 12,2004 Environmental,Ruraland Social DevelopmentWest Africa CountryDepartment 14 Africa RegionalOffice This document has a restricteddistributionand may be used by recipientsonly in the performanceof their officialduties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate EffectiveMarch31,2004) CurrencyUnit = FrancCFA FCFA 1,000 = US$1.93 US$l.OO = SDR0.67 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS ACTafrica AIDS CampaignTeam for Africa ART Anti-Retroviral Treatment CBO Community-BasedOrganizations FMS FinancialManagementSystem GFATM GlobalFundto fight HIVIAIDS, Tuberculosis, andMalaria IHN IntegratedHealthNetwork ISS Interim Support Strategy MAP Multi-Country HIV/AIDS Program M&ES Monitoring and EvaluationSystem MDA Ministries,Departments, and Agencies MTCT Motherto Child Transmission MWMP MedicalWaste ManagementPlan NAC NationalAIDS Council NAS NationalAIDS Secretariat NGO Non-Governmental Agency 01 OpportunisticInfection PLWHA PersonsLiving With HIV/AIDS PMU Project ManagementUnit PSRDP PrivateSector Rehabilitationand Development Project RC RegionalCommittee SNP Strategic NationalPlan STI Sexually Transmitted Infection VCT Voluntary Counselingand Testing Vice President: Callisto Madavo Country Director: John Mclntire Sector Manager: Mary Barton-Dock Task Team Leader: Christian Fauliau This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. FOROFFICIAL USEONLY GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Table of Contents A. Strategic Context andRationale 1 1. Country and Sector Background 1 2. Rationale for Bank's Involvement 2 3. Higher level objectives to which the project contributes 3 B. Project Description 4 1. Lending instrument 4 2. Project development objectives andkey indicators 4 3. Project Components 5 4. Lessons leamed and reflected inthe project design 8 5. Altematives considered and reasons for rejection 9 C. Implementation 9 1. Partnership arrangements 9 2. Institutional arrangements 9 3. Monitoringand evaluation o f outcomes/results 10 4. Sustainability 10 5. Critical risks and possible controversial aspects 11 6. Grant effectiveness conditions and covenants 12 D. Appraisal Summary 12 1. Economic and financial analyses 12 2. Technical 13 3. Fiduciary 13 4. Social 15 5. Environment 15 6. Safeguard policies 15 7. Policy exceptions and readiness 15 Annex 1: Country and Sector or Program Background 17 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies 22 Annex 3: ResultsFramework andMonitoring 23 Annex 4: Detailed Project Description 26 Annex 5: Project Costs 35 Annex 6: ImplementationArrangements 36 Annex 7: Financial Management and Disbursement Arrangements 46 Annex 8: Procurement 55 Annex 9: Monitoring and Evaluation 63 Annex 10: Safeguard Policy Issues 68 Annex 11: Project Preparation and Supervision 69 Annex 12: Orphan Support 71 This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. I t s contents may not be otherwise disclosed without World Bank authorization. Annex 13: Project Supervision Strategy 72 Annex 14: Documents inthe ProjectFile 76 Annex 15: Statement ofLoans and Credits 77 Annex 16: Country at a Glance 79 GUINEA-BISSA U HIV/AIDS Global MitigationSupportProject PROJECT APPRAISAL DOCUMENT Africa Regional Office ESSD [ 7 Loan [ 3 Credit [XI Grant [ ] Guarantee [] Other: For Loans/Credits/Others: Total Bank financing (US$m.): SDR 4.7 million (US$7.0 million equivalent) I Remonsible anencv: I FY 2005 2006 2007 2008 Annual 1.5 2.0 2.0 1.5 I oYes XNo ::e these beenapproved by Bank management? oYes oNo Project development objective Re$ PADB.2, TechnicalAnna 3 The project will support the medium-termstrategy of the Government to expand and acceleratethe nationalresponse to HIV/AIDS by: (i) reducing the spread of HIV/AIDS infection; (ii) increasing access to treatment for STIs andHIV/AIDS; and (iii) decreasing the socio-economic impacts of HIV/AIDS at the individual, household, andcommunity levels. Project description [one-sentence summary of each component] Re$ PAD B.3.a, TechnicalAnnex 4 1. Community and Civil Society Initiatives, and Capacity Building, support to social mobilization and community level responses to HIV/AIDS 2. Government MultiSector Response, fundto scale up and strengthenprevention, care, support and mitigationof the social andeconomic impact ofHIV/AIDS through programdactivities ofthe public sector. 3, InstitutionalDevelopment for ProgramManagement, support to NationalAIDS CommitteeNational AIDS Secretariatto managethe program. Which safeguardpolicies are triggered, ifany? Re$ PAD D.6, TechnicalAnnex 10 Environmental Assessment (Medical Waste Management Plan) Significant, non-standard conditions, if any, for: Re$ PAD C.7 Board presentation: N.A. Loadcredit effectiveness: Adoption of: (i) accounting and financial management system for the project; an and (ii)the project implementation manual (including specific manuals for financial management and accounting, procurement andM&E); Each Public Sector Organization (in particular Ministry of Health, Ministry of Education, Ministry of Defense, Ministry o f Agriculture, Forestry and Livestock, and the State Secretariat of Youth Culture and Sports) have presentedaction plans for HIV/AIDS for the first year of project implementation, in form and substance satisfactory to the Association; The Government has appointed anindependent auditor; and All technical staff ofNAS havebeen appointed. Covenantsapplicable to project implementation: N.A. A. STRATEGIC CONTEXT AND RATIONALE 1. Country and Sector Background According to the most recent United Nations' Human Development Index, Guinea- Bissau i s one of the world's poorest countries, and was ranked 156thout o f 162 countries in2001. The poverty rate in2002 was estimated at 80 percent ofthe total populationand the growth domestic product (GDP) at around US$250 million with GDP per capita over the period 1997-2000 averaging US$l95 per annum. Guinea-Bissau became independent from Portuguese rule following a liberation struggle from 1963-1974. The eruption of an armed conflict in 1998-1999 brought to an end progress that had been made ineconomic development inGuinea-Bissau inthe early 90s. The conflict reduced real GDP by 28 percent and agricultural production by 17 percent. Much o f the physical infrastructure was severely damaged. Fiscal problems have hampered the implementationof all publicly financed programs, including activities to fight HIV/AIDS. Access to modern healthcare i s limited and the health system i s weak with one central hospital, four regional hospitals, and a patchwork o f about 135 health centers and health posts o f varying quality. Much o f the rural population have no or limited access to modernhealth care and use the services o ftraditional healers. Availability of financial resources remains a serious problem. Health services, which are crucial for HIV/AIDS mitigation, are in disarray and will take a long time to recover given the poor state of the physical infrastructure. The displacement o f people fuels transmission rates, which have increased following the civil war, especially among the under 30 age group. Some limited actions to prevent HIV/AIDS and mitigate its impact are being carried out by a few NGOs. However, these NGOs are motivated only by goodwill and donor support has beenweak. There are no comprehensive andreliable HIV statistics. Available data from the Ministry o f Health show that from 1994 to 1996, there were between 600 to 900 new cases per year, and 1101 in 1999. The disease i s continuing to spread mostly along the main transportation axes from Bissau to Bafata, Gabu, and Cacheu. According to the 2001 WHO EPMODEL calculations, health centers were only capturing around 16 percent of estimated cases. It i s projected that inthe next years HIV-1 would infect 24 to 40 persons daily, while HIV-2 rates would continue to decline. The Government's response: The importance o f the HIV/AIDS epidemic is clear to the Government, which notes that "further evolution of this epidemic would be disastrous for the country's development" and that "AIDS i s not a problem pertaining to the health sector alone, it i s also a social problem o f national and global proportions, which requires alerting society more forcefully about the current epidemic inthe country and mobilizing support from all partners to intensify the fight against the disease". 1 In a difficult environment during the last two years, the national team supported by donors has completed a Strategic National Plan (SNP) and a National Program for SNP implementation. The Government has also confirmed its commitment to a decentralized participatory approach, a multi-sectoral strategy, and a reliable and fully transparent financing system. Each o fthese elements are crucial to buildingan efficient Project. 2. Rationale for Bank's Involvement The Bank addresses HIV/AIDS as a developmental issue. The September 1999 launch o f the Bank's regional AIDS strategy, Intensifiing Action Against HIUAIDS inAfrica, was well received by governments, private sector, and donors. Through the Bank's Global HIV/AIDS Unit and the regional AIDS Campaign Team for Africa (ACTufrica), UNAIDS, and other partnerships, the Bank is well positioned to contribute its regional experience to the project. The Government has requested access to IDA resources within the framework o f the first phase o f the Multi-Country HIV/AIDS Program (MAP) for the Africa Region. Guinea- Bissau i s eligible for MAP funding and has satisfied the four eligibility criteria as follows: Guinea-Bissau already has a coherent national strategy and has developed a comprehensive medium-term, multi-sectoral plan in a participatory manner with all concerned stakeholders; It has created a National HIV/AIDS Council chaired by the Prime Minister with representation from Government (one-third), civil society (one-third) and the private sector (one-third); The Government has agreed to implementation procedures that would help expedite project implementation and outsource project implementation. Given the post-conflict status o f Guinea-Bissau key implementation aspects cannot be outsourced to one or more private firms as such capacity does not exist in-country at this time and obtaining this from abroad would not be cost-effective. For other IDA projects this has meant establishing Project Management Units (PMUs) staffed with national consultants. This has worked and i s confirmed by positive financial management and procurement assessments by Bank supervision missions. Building a PMU takes, however, time and risks delays in project implementation. It has therefore been agreed that the project would initially use the financial management and procurement staff in place at the Private Sector Rehabilitation and DevelopmentProject (PSRDP) until N A S technical staff have beenhired and sufficiently trained. The PSRDP has satisfactory procurement and financial management procedures and trained staff. In addition, it has sufficient capacity to ensure the efficient management o f these activities during project preparation and take-off. It has also been agreed that all seven (national) technical staff o f the National AIDS Secretariat WAS) would be hired on a contractual basis through an open (internationally advertised), competitive and transparent process to manage implementation activities such as behavioral surveys, operational research, financial and program management, monitoring and evaluation, etc. All technical staff would receive compensation based on national expert standards to attract broad interest and would have annually renewable 2 contracts with clear performance criteria. These arrangements are aimed at ensuring efficiency, accountability and transparency o f project management and reducing implementation related and fiduciary risks. NAS staff selection would be done by a broad committee, including members o f the HIV/AIDS thematic group, as well as UNDP Agencies (including UNICEF), to ensure independence from Government. The World Bank no objection for each selected NAS staff will be requested before appointment. In addition, assurances were obtained during negotiations that the National AIDS Committee (NAC) and NAS would be autonomous from Government with an independent board comprised two-thirds o f non-public sector representatives. An independent institutional assessment would be carried out within twelve months o f grant effectiveness to ensure efficiency o f arrangements;' and d) The Government has agreed to use and fundmultipleimplementation agencies as reflected in its plans to channel funds directly to both public and private implementing agencies, civil society organizations, NGOs, associations o f PLWHA, andto communities. The proposed project will support the Government in mainstreaming program activities to all Ministries, Departments and Agencies (MDAs) and other non-health Government agencies at national and local levels, and making better use o f community and civil society organizations such as churches, trade unions and private businesses. The cost of the SNP has yet to be finalized, but it i s clear that Government resources and pledges by cooperating partners cannot adequately address the financing needs. To drastically scale up the current level o f activities and to reduce HIV/AIDS and its impact on socioeconomic development, technical and financial assistance from IDA i s required to fillpart ofthe fundinggap. Theprojectwillbea catalyst inhelping Government obtain resources from bilateral partners and the Global Fund to fight HIV/AIDS, Tuberculosis, andMalaria (GFATM). The focus will be to put inplace basic infrastructure and human resources for an expanded and multi-sectoral response, knowledge sharing, and systems strengthening. 3. Higher level objectives to which the project contributes This project is consistent with the objectives o f the Interim Support Strategy (ISS), currently planned for Board presentation in September 2004. The ISS supports the Government's goal to improve access to basic social services. The project will support the Government in implementing its SNP and will provide the necessary resources andtechnical skills to scale up and improve delivery mechanisms for HIV/AIDS control activities. The SNP was designedto take into account the following Government priorities: (i) build capacity at local and national level to ensure quality of services and expansion o f existing good practices; (ii)mitigate the negative socioeconomic impact of the HIV/AIDS epidemic; (iii)scale up advocacy measures to ensure full involvement o f policy makers, civil society and the private sector; (iv) reach all vulnerable groups to prevent new HIV infections; (v) promote positive socio-cultural ' Thesearrangements were confirmed during negotiations, behavioral changes; (vi) improve the institutional framework; and (vii) ensure sustainability o f the overall program. The project will focus on the following strategic choices to support SNP implementation: (a) intensify prevention, care and mitigation at the grass-roots level; (b) improve the health care system related to HIV/AIDS; (c) facilitate full public sector involvement; (d) support institutional strengthening; (e) ensure essential access to Anti Retroviral Treatment (ART) and treatment for Sexually Transmitted Infections (STI); and (f) mainstream gender issues. B. PROJECTDESCRIPTION 1. Lendinginstrument This project is a Sector Investment Loanunder IDA'SMulti-Country HIV/AIDS Program (MAP) for the Africa Region and i s in accordance with the Bank's regional HIV/AIDS strategy for "Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis." 2. Projectdevelopmentobjectiveand keyindicators The project will support the medium-term strategy of the Government to expand and accelerate the national response to HIVIAIDS by: (i) reducing the spread o f HIV/AIDS infection; (ii)increasing access to treatment for STIs and HIV/AIDS; and (iii) decreasing the socio-economic impacts of HIV/AIDS at the individual, household, and community levels. Specifically, the project will: - fund projects led by civil society, including the private sector, and carried out in urban and rural communities, which cover HIV/AIDS-related prevention, advocacy, public awareness creation and care for orphans and PLWHA, focusing - on the most vulnerable groups; strengthen delivery o f health services providing prevention, care and treatment services, giving priority to the five regions with highest HIV/AIDS prevalence rates. Such services would include voluntary testing and counseling services and - treatment o f STIs and opportunistic infections relatedto HIV/AIDS; enable Government at the national and regional levels to carry out programs advocating prevention and facilitating access to care for its own staff and - communities; and strengthen institutional capacity for planning, delivering and monitoring o f HIV/AIDS response interventions through all levels of Government and its line ministries, civil society andthe private sector, with a focus on vulnerable groups. The National Strategic Plan to Combat HIV/AIDS and STIs has established a series o f output, process, and outcome indicators. The project will support efforts to continuously improve the capture and assessment o f this information. Indicators for output and process will focus on the coverage and quality o f the various advocacy, prevention, and 4 care programs. Outcome and impact indicators will capture the long-term effect o f the national AIDS campaign, but are unlikelyto show dramatic changes during the three-year implementation cycle o f this project. There will be five surveillance centers operational by full development, one in each o f the five regions, permitting a broader and more reliable assessment of the epidemic status. This will also permit an assessment of the effectiveness o f fundedactivities. Key indicators to be monitored andtargets to be achieved by 2007 include: Input and Output Indicators Increase from 0% to 20 % of PLWA that receive medical assistance (01and/or ARV) by Y3 % of PLWHA and/or affected families receiving/benefiting in finding adapted sources of revenue Increase from 0% to 10%of OVC benefiting from improved access to education and/or food aid Funded line Ministries have achieved 75% of their annual HIV/AIDS outreach plan All public institutions distribute condoms, with 1million condoms distributed annually by Y3 All secondary and tertiary health facilities of pilot regions have the capacity to treat, diagnose and test for STDs by syndromic approach (trained staff and no drugs stock outs) At least 2 operators and 1 manager of each rural radio trained in HIVIAIDS IEC by end 2006 Number of men and women who are being counseled and tested for HIV Over 50000 clients reached annually by civil society initiatives on HIV/AIDS by 2007 At least US$1 million is channeled to communities for civil society initiatives by 2007 Outcome Indicators Condom use in sexual encounters outside of primary relationship in the last 12 months by persons 15-19, has increased by 10% over 2003 levels Percentage of men and women aged 15-49 reporting STI symptoms in the last 12 months, who sought care at a health facility, in the five pilot regions Process (and coverage) Indicators Seven VCT centers, equitably distributed geographically, are in place Percentage of men and women aged 15-49 that report having access to condoms 5 priority regions develop and implement their annual regional plans with stakeholder participation Impact Indicators By the end of the third year of the project, the rate of increase of seroprevalence of HIV among antenatal women aged 15-24 has declined (compared to the first year of the project) A full set of indicators is presented inAnnex 9. 3. Project components Total project costs amount to US$7.0 million. A detailed description o f the project i s attached in Annex 4. The project will be implemented through three components: (i) Community and Civil Society Initiatives and Capacity Building (US$2.5 million); (ii) Government Multi-Sector Response (US$2.2 million); and (iii) Institutional Development for Program Management (US$2.3 million). IDA funding would not be sufficient to support the national program without complementary funding from the GFATM. Hence 5 the IDA-supported project will focus on five pilot regions only. GFATM has already committed to provide US$2million to the Tuberculosis program. Component 1: Community and Civil Society Initiatives, and Capacity Building (US2.5 million) This component will focus on social mobilization and community level responses to HIVIAIDS. Funds will be set up to expand and strengthen HIV/AIDS activities of Community-Based Organizations (CBOs) and civil society associations themselves or in contracting Non-Government Organizations (NGOs) or private sector entities. Civil society associations include religious organizations, associations of persons living with HIV/AIDS (PLWHA) and orphan associations. There will be clearly defined eligibility criteria for organizations to be funded under this component, which will be elaborated in the ImplementationManual. Groups that receive funding will be encouragedto focus, but not necessary limit, their activities on the most vulnerable groups. These include: PLWHA, hospital workers, orphans, youth, commercial sex workers, and truck drivers. Fundswill be specifically set-asidefor two groups: Orphans. Project-provided support will not differentiate between orphans by cause, as this would be difficult and inhumane. UNICEF and WFP will be two of the main implementing partners. The project will set up a permanent regionalized system, managed by recipient CBOs, Faith-based Organizations and associations with involvement of representatives of service provider NGOs and private sector, to provide support to identifiedorphans andto identify and apply bestpractice approaches. PLWHA. The program will support efforts to create AIDS competent communities by improving skills and increasing implementation capacity for the implementation of targeted mitigation and prevention activities by supporters and target groups active under the Community and Civil Society Initiatives. Fundedactivities under component 1 will include: 0 Courses and activities to build HIV/AIDS awareness and leadership capacity in the public sector, civil society, andthe private sector; 0 Formulation of HIV/AIDS awareness training modules for use in public and private sector enterprises. Development and distribution of specialized packages of Information, Education and Communications (IEC) materials; 0 Rural radio equipmentrehabilitation and staff technical capacity strengthening. RCs will enter into contractual agreementsto include specific HIV/AIDS programs intheir broadcasts; and 0 Funding grant allocation for CBO empowerment and activities and NGO capacity strengtheningand activities. Component2: GovernmentMulti Sector Response(US$2.2M) This component will comprise a fund to scale up and strengthenprevention, care, support and mitigation of the social and economic impact of HIV/AIDS through programs/activities of the public sector. I t will support public sector institutions to 6 protect their own personnel from the impact o f HIV/AIDS and, where applicable, to integrate HIV/AIDS activities into their core business. Sub-contracting by MDAs, local authorities and parastatals will be encouraged in order to make the best use of the implementation capacity that may be available outside the public sector. This component will provide the following support: Subcomponent1: Support to Ministryof Health(US$1.3M) The largest share of funds under this component will be dedicated to supporting the Ministry of Health in its unique role in combating the epidemic. This support will partially finance the Ministry'sHIV/AIDS work plan. This subcomponentwill include: Strengthening the Integrated Health Network (IHN). The IHN provides voluntary counseling and testing and HIV/AIDS related services along the major transportation axes where prevalencerates are highest; Increasing the supply of drugs and materials, such as condoms, opportunistic infection drugs and anti-retroviral drugs for the reduction of Mother to Child Transmission (MTCT) andpost exposure prophylaxis; Strengthening clinical laboratory capacity to enable diagnosis and monitoring of HIV therapy, including those for CD4 monitoring and diagnosis of opportunistic infections; Support to epidemiological surveillance; Prevention, diagnosis, andtreatment of STIs; Prevention of MTCT; Improvingmanagement of opportunistic infections (OIs), focusing on prevention and treatment; and Improving management monitoring and evaluation of activities supported under the component and the overall progress of the epidemic. Subcomponent 2: Support to other Ministries and Government Agencies (US$0.9M) The range of activities to be consideredwithinwork plans of eachministry will include: Capacity building for mainstreaming HIV/AIDS-related activities into regular work plan: IEC campaigns, including promotion o f condom use, for staff and client awareness. The campaigns are to ensure a sustainable behavior change among its staff and clients; Promotion of staff access to condoms; Facilitation of HIV/AIDS social support network provisionfor all staff; Impact studies to investigate the qualitative and quantitative consequences o f the epidemicon specified sectors and analysis ofpossible andappropriate responses; and Policies regarding the posting and locationo f staff. 7 To reflect the highly decentralized nature o f Government, the component will be broken into national, regional, and local initiatives. Additionally, each ministry, key ministry or not, will conduct activities relevant to the areas o f its comparative advantage. Component3: InstitutionalDevelopmentfor ProgramManagement(US$2.3M) The project will support the NAC, whose broad responsibilities will evolve mainly around advocacy, and providing leadership for the multi-sectoral response to HIV/AIDS. The N A C is not envisioned to have implementation or funding responsibilities. The project design acknowledges the mandate o f the N A C and creates opportunities to support the N A C inthe implementationo f its mandate. Support will be given to the N A C for a semiannual one-day information workshop. The project will also support the NAS, including its regional components and focal points, to fulfill its national HIV/AIDS coordination mandate, technical support, financial management, and monitoring and evaluation. The N A S created by the Prime Minister inMarch 2004 will be the P M U and i s set-up as an autonomous entity attached to the Office o f the Prime Minister. Lessons learned from the satisfactory rated PMUs of the National Health Development Program and the PSRDP have been taken into account inprogram design. Supportwill be givento the NAS for: 0 Establishment and operation o f an effective secretariat and networks at national, regional, and district levels; 0 Provision o f high-leveltechnical references and establishment o f advisory capacity; 0 Establishment and operation and maintenance of performing financial management and procurement systems; 0 Resource mobilization; and 0 Establishment and operation and maintenance o f performing Monitoring & Evaluation Systems (M&ES). The PSRDP will initially provide project management support untilthe NAS P M U is in place and its staff has been sufficiently trained. It will receive incremental operating support for this activity from the Project PreparationFundadvance. 4. Lessonslearnedand reflectedinthe projectdesign International experience with HIV/AIDS, in particular experience from countries like Uganda, Senegal, and Brazil, and lessons from other ongoing Bank-supported HIV/AIDS projects inAfrica within the MAP, and country-specific efforts inGuinea-Bissau have all been reflected in project design. The Government has integrated many o f the lessons from the global response to HIV/AIDS and from the implementation o f other Bank- funded operations into the design o f its SNP. It has mobilized strong commitment at the highestlevels andestablished partnerships with key stakeholders. 8 Key lessons are outlined below. Their detailed descriptions canbe found inAnnex 4. -- political leadership and commitment i s imperative to confront the epidemic; vulnerability factors are key drivers o f the epidemic; focus on vulnerable groups - i s essential; external resources and capacity building will empower the response o f local - communities; there i s a need to address the multi-dimensional nature o f the epidemic with a - multi-sector approach; beneficiaries must initiate project orientation and evaluation to ensure their needs - are addressed; the project must focus on knowledge building and evidence-based interventions - where there i s lack o f consensus; the crucial role o f rural radios to efficiently educate large rural populations must --- be recognized; the use o findigenous knowledge andpractices are integralto HIV/AIDS efforts; the role o ftheNAC/NAS and implementingagencies mustbe clearly spelled out; complex supervision o f M A P projects requires more attention and resources than - average projects; sufficient resources and skills should be made available for robust monitoring and - evaluation; and effective coordination among development partners can significantly reduce transaction costs. 5. Alternativesconsideredand reasons for rejection Given the MAP context, no alternative project designs would be appropriate. C. IMPLEMENTATION 1. Partnershiparrangements The project will seek to enter into a partnership arrangement with UN agencies to assist in project implementation, particularly WHO for health, and UNICEF and WFP for orphans and PLWHA support. UNagencies and French cooperation have expressed their interest to support the project. A formal agreement at negotiations was not possible given the country context (elections in March 2004) and their ongoing review o f their country assistance programs. Given the important role to be played by UN partner agencies, especially in the first year o f project implementation, the project would finance their incrementaloperating costs ifno other funding sources are available. 2. Institutionalarrangements The project will support the SNP and will be under direct supervision o f the Prime Minister's Office (PMO). Policymaking will be the responsibility o f the NAC. The NAS, headedby a National Secretary, will carry out coordination, technical support, and financing at the national level. N A C and N A S would be autonomous from Government and two-thirds o f the N A C Board would be from civil society. NAS technical staff 9 would be recruited using open, transparent and competitive procedures internationally advertised and maintained on the basis o f annually renewable performance contracts. Continued financing from the Bank would be contingent on a satisfactory institutional assessment within one year o f grant effectiveness. Assurances to this effect were obtained during negotiations. The project preparation advance will provide funding for the hiringo ftechnical staff. The RCs will coordinate and provide technical support to project implementation at the local and regional levels. Implementation o f project-supported activities will be the responsibility o f CBOs, associations, and the public and private sector, which will contract NGOs and technical assistance when needed. Annex 6 provides detailed implementation arrangements. 3. Monitoring and evaluation of outcomes/results There will be only one M&ES for both the Project and the National Program. The M&ES will be established at start-up and will include indicators to measure progress towards achieving project objectives. As such, it will provide valuable information for program management, other stakeholders, and external parties. The aim o fthe M&ES will beto: - provide accessible, timely information on program inputs, process, outputs and - outcomes; identify intra-country variations to support the design o f effective HIV/AIDS - operations; engage stakeholders by sharing information on progress made, lessons learned, and improvements needed through a participatory evaluation o f project activities at all levels; and - provide best practice examples. Once the M&ES for the national program i s finalized, one o f the first priorities o f the NAS will be to determine whether the existing data provide a sufficient baseline for the program impact and outcome indicators. If not, surveys would be carried out to collect the necessary data to allow for project monitoring and impact evaluation. Where possible, integration will be pursued between the financial management system and the M&ES as this makes implementationdata collection easier at marginal cost. The M&ES i s detailed inAnnex 9. 4. Sustainability The project is expected to be sustainable, as it is built on strong government ownership and broad partnerships. It will gradually expand interventions in line with capacities and progressively mainstream HIV/AIDS activities into major government sectors and civil society. The project emphasizes institutional capacity building at national, state, and local levels. At the community level, sustainability will be bolstered by participatory methodologies for identifying subprojects, end-user accountability, and tying replenishments to results. With regard to financial sustainability, it is unlikely that Government will be able to fully finance the program over the medium term given the 10 precarious position o f public finances. The country will therefore remain dependent on support from bilateral and multilateral agencies beyond the initial period o f implementation. 5. Critical risks and possible controversialaspects Risk Rating Risk Mitigation Measure 'rom Outputs to Objective 2uality and commitment of political leadership, S Major advocacy and awareness-building campaigns ncluding the National Council, would be will increase understanding and support among veaker than needed. policy makers and general public. Neak Health sector would hamper strategic The project will support improvement of health iIV/AIDS-related health care issues. sector services related to HIWAIDS. GFATM is already supporting the TB MOH program. However, complementary support from GFATM will be crucial for the MOH programs related to HIVIAIDS impact. lonor interest and financing would not Donors are currently willing to engage in support of ncrease. the program. Transparency and efficient M&E will provide evidence to the donors about the efficient use of their funds. 'rom Components to Outputs \IAS management and implementation H The NAS is implemented as an autonomous :apacity would be inadequate for task. structure with all national staff recruited on a competitive basis through a transparent and internationally advertised procurement process, with national expert level remuneration packages, and maintained on one-year renewable contracts with performance indicators. The project supports training, systems development, sharing of tasks, decentralization of responsibilities and activities, and contracting. Clear description of responsibilities and procedures in the Implementation Manual, which will be adopted as a condition of effectiveness. In addition, there would be an institutional assessment within 12 months 01 grant effectiveness to ensure that managemeni arrangements are appropriate and necessary adaptations can be made at that time. nsufficient data is available to measure project H An assessment of available data would be carriec mpact (some key data may not be easily out as part of the establishment of the M&E systen :ollectable or collected too late to be of use in and where necessary, data would be collected 01 xoject evaluation) systems put in place to collect such data. nsufficient CBOs and NGOs found in the Civil society institutions outside of main cities arc *egionsto carry out a broad program. weak. Project will build capacity by selecting NGC intermediaries and work with them to identify strengthen, register and invigorate institutions at thc community level. Substantial activity work being carried out by NGOs with local and foreign funding Civil society participation in steering committees wil also help maintain support. Overall Risk Rating !isk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk). ~ 11 The project has a "Substantial Risk" rating overall. Given the unreliable political situation, the limited implementation experience o f agencies, and the new mechanisms to channel funds to communities, IDA will need to take the following steps to minimize the risks: --- provide adequateresources for supervision; provide intensive support for financial, procurement andM&Emanagement; and collaborate closely with internal and external partners and stakeholders. 6. Grant effectiveness conditions and covenants - Adoption of: (i) accounting and financial management system for the project an which shall provide, inter alia, for the preparation o f FMRs; and (ii) the project implementation manual (including specific manuals for financial management and accounting, procurement and M&E); all in form and substance satisfactory to the - Association; Each Public Sector Organization (MDAs, in particular Ministry o f Health, MinistryofEducation, MinistryofDefense, MinistryofAgriculture, Forestryand Livestock, and the State Secretariat o f Youth Culture and Sports) have presented action plans to fight against HIV/AIDS for the first year o f project - implementation, inform and substance satisfactory to the Association; - The Government has appointed an independentauditor; and All technical staff o f NAS have been appointed, including the National Secretary to be responsible for overall project management, a financial manager, a procurement specialist, and a monitoring and evaluation specialist, all with experience and qualifications, and under terms o f reference satisfactory to the Association. A PPF is assisting Government inmeetingthese conditions ina timely manner. D. APPRAISAL SUMMARY 1. Economic and financial analyses Economic The economic analysis inthe PADfor the first phase M A P (Report# 20727 AFR) applies to this project. The analysis includes an overall assessment o f the impact o f HIV/AIDS on economic development and poverty and a cost-benefit analysis o f HIV/AIDS interventions. This section only highlights some o f the key points applicable to the project. The epidemic has become a serious socioeconomic development issue and it affects the economy through (a) reducing productivity, domestic savings and economic growth, and (b) increasing costs o f treatment and care for both affected households and society as a whole. AIDS strikes people in their most productive age, reducing both the size and growtho fthe nation's labor force. 12 Care and treatment for AIDS impose enormous costs on households and the society at large. Households with AIDS patients are likely to lose the income o f their members in addition to facing an increase in medical expenses. Some households are forced to withdraw their children from schools in order to save money as one o f their coping strategies. The economic benefits are multifold. First, since this project aims to expand interventions in HIVIAIDS control and mitigation, the majority o f the population will directly and indirectly benefit from increased access to HIV/AIDS prevention, treatment, care and mitigation activities. Secondly, new HIV infections will be reduced, due to an expansion in coverage o f the package o f HIV/AIDS prevention activities. Thirdly, people living with HIV/AIDS can lead longer and more productive lives by benefiting from better management o f opportunistic infections and access to nutritional supplements, resultinginless productivity andincome losses. Fourthly, orphans will have improved economic prospects with increased schooling. Financial The P A D for the first phase M A P states that, "for each o f the physical works components, the operation and maintenance costs will be calculated and commitment required from Government to finance and carry out effective O&M on an annual basis. An annual review of O&M for physical works will be carried out three months prior to the fiscal year." Where applicable, this process will be conducted for the project. 2. Technical The project will follow internationally accepted best practice for HIV/AIDS prevention, treatment, care and support services, and the training o f health care professionals, as validated by UNAIDS and WHO and other key technical partners. In addition, the technical design o f the project has been based on lessons learned from experience inother countries and inGuinea-Bissau. The epidemic behaves differently in every setting, so no single approach is universally valid. The program will emphasize learning-by-doing. Workshops will be heldregularly among communities andassociations and also at the regional and national levels. All key stakeholders will participate and share experiences from implementation and monitoring, as well as reviewing data emerging from the M&ES. Lessons from implementation experience will be usedto refine program design. 3. Fiduciary Procurement NAS and the Regional Committees will procure works and goods inaccordance with the Bank's Guidelines for Procurement under IBRD Loans and IDA Credits, and, in particular, Section 3.15, Community Participation in Procurement. Consulting services by firms, organizations, or individuals financed by IDA will be contracted inaccordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers. Communities and CBOs will use the Bank's simplified Procurement and Disbursement Procedures for Community-Based Investments to procure goods or 13 services needed to implement their initiatives under the Community AIDS Response Fund. Most grantsthat fall underthis category will beunderUS$lO,OOO. For urgentlyrequireditems valued at less than US$50,000, contracts may be made based on international shopping and national shopping procedures, per IDA Procurement Guidelines (Clauses 3.5 and 3.6). Pharmaceuticals, reagents and medical consumables maybe procured from the Inter-Agency Procurement Services Office o f the United Nations, UNICEF, the United Nations Fund for Population Activities (UNFPA) Proprietary agents maybe procured on a sole source basis. A wide-ranging General Procurement Notice (GPN) for the first year will be placed on the United Nations Development Business web site. The Government will include the procurement plan for the first year in the Procurement Manual. The procurement schedule will be updated quarterly and submitted to IDA by the NAS and its performance will be assessed on an annual basis and through ad-hoc reviews. Financial Management Given the lack of capacity to adequately manage project funds at the beginning o f the project at all levels, it was agreed, in keeping with the principles o f the umbrella MAP, that extraordinary arrangements were warranted to aid the community-level response. The arrangements for the NAS have been detailed above and aim at ensuring adherence to fiduciary requirements imposed by IDA and the Government while at the same time imposing efficiency in the provision o f funds for agreed upon purposes when needed. These two will be key criteria in assessing the performance o f NAS and its technical staff. According to terms o f the agreed action plans at the regional level, CBOs and NGOs will receive funds from NAS transferred through the Western Union system (no other formal banking system exists). Accounting and auditing procedures will apply to funds disbursed to public or private institutions, as detailed inthe Financial Reporting and Auditing of Projects Financed by The World Bank. Accounting requirements for project beneficiaries such as CBOs and NGOs will be simplified and detailed in the Project Implementation Manual. The N A S Financial and Administrative Director will ensure that financial management and reporting complies with international standards and acceptable to IDA. The Financial management system will be capable o f producing timely, clear, relevant, and reliable financial information for planning, implementing, and monitoring overall project progress. DisbursementProcedures All procurement contracts not subject to prior IDA reviewwill be disbursedagainst SOEs and documentation will be retained by NAS and made available for review. All disbursements will be subject to ex post financial and physical audits by the project's external auditor and Bank supervision missions. 14 Planningand Budgeting The work program planning and budgeting cycle has been designed to fit the National Budget cycle. Annual budget requests will be prepared at regional and central levels by mid-year. This process will be initiated and supported by the NAS. The planning process will be bottom-up, with work programs and budgets first agreed at the regional level before submission for consolidation at the national level. At this time, NAS will also invite MDAs, NGOs, etc., to present cross regionalhational level proposals that are eligible for project funding. 4. Social A social assessment was carried out duringproject preparation and it revealed two main issues. First, gender inequity i s a key issue inthe AIDS epidemic. Females will receive particular attention in project design and implementation by supporting efforts to reduce mother to child transmission, the risk o f infection o f adolescent girls, and specific programs targeting women who sell sex as a means o f survival. The NAS will have a specialist focusing on gender and human rights issues. 5. Environment The project is rated category B. The most important environmental issue identified relates to medical waste disposal. In February 2002, regulatory agencies, health care facilities, litter gatherers, and community organizations were consulted and identified issues include: lack o f appropriate selection o f health care waste, carelessness and lack of qualification of the medical staff, mingling o f health care waste with normal household litter, insufficient quantities of collection baskets and provisional litter containers, lack o f security equipment for cleaning staff, and no efficient waste treatment system. For detailed description o f the Medical Waste Management Plan, please review Annex 10. The project is allocating US$370,000 for MWMP implementation in the five pilot regions. 6. Safeguardpolicies Safeguard Policies Triggered by the Project Yes No Environmental Assessment [XI [ I Natural Habitats I1 [XI Pest Management [ I [XI Cultural Property [I [XI Involuntary Resettlement [ I [XI Indigenous Peoples [I [XI Forests 11 [XI Safety of Dams [I [XI Projects in Disputed Areas* [I [XI Projects on International Waterways [XI "By supportingthe proposedproject,the Bank does not intendto prejudicethe final determinationof the parties' claims on the disputed areas 7. Policy Exceptionsand Readiness Policy Exceptions Not applicable. 15 Readiness for Implementation 0 The first year's procurement plan has been submitted as a condition o f Board presentation; 0 The various implementation manuals are in an advanced stage o f preparation. Their completion will be a condition o f effectiveness; and 0 Recruitment o f key technical staff at NAS will be a condition o f effectiveness. 16 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 1: Country and Sector or Program Background For country and program introduction, please review SectionA 1 o f the main text. Below are explanations o f the fundamental determinants for the increase in infection rates: Awareness and BehavioralChange In 1998, a national survey showed that of all women in the 15 to 49 age group, 42 percent had never heard o f HIV/AIDS. Only 40 percent were informed about at least two ways to avoid infection. Sixty-five percent were unaware that a person living with AIDS could infect another persons through unprotected sex. Sixty-six percent of health workers were unaware of the risk posed by insufficient or no sterilization of medical equipment. In Bissau in 2001, 23 percent of men and 63 percent of women of all ages had no knowledge o f HIV/AIDS. Low rate of condom use In 1998, inthe Bissau area, only 27 percent ofmenand 2 percent ofwomen statedthat they had used a condom at least once. Amongst young sexually active people (15 to 19) only 11percent reportedhavingusedcondoms at least once. Denialand fear of AIDS The inability o f women to negotiate condom use limits their demand. Due to the absence of information on transmission and viable treatment options and a strong social stigma there is no incentive to get tested for HIV or change behavior. Multiple partnersis an acceptedcustom In 1998, 39 percent of menand 10 percent of women declared that they had more than one sexual partner. The development of multi-partner behavior has ledto an increased opportunity to transfer the diseaseand a decreasedincentiveto inform partners o fHIV status. Prostitution Commercial sex is accepted and the economic crisis is increasing the attractiveness to work as a sex worker. The prevalence amongst one group o f prostitutes was 25 percent in 1998. Stigma The problem o f stigma affected the momentum o f the past HIV/AIDS campaigns. Only a small number o f courageous individuals, living in urban areas, have revealed their HIV positive status. They are subject to discrimination andjob loss and are now slowly organizing themselves into an association, which can mobilize resources for care and advocacy. At higher levels of society the issue remains taboo. The national legislation is not taking into account the HIV/AIDS stigma. Government Strategy The importance of the HIV/AIDS epidemic is clear to the Government, which notes that "further evolution o f this epidemic would be disastrous for the country's development" and that "AIDS is more than a problem pertaining to the health sector alone, it i s a social problem of national and global proportions, which requires alerting society more 17 forcefully about the current infection situation inthe country and mobilizing support from all partners to intensify the fight againstthe disease." A first program to combat the spread of HIV/AIDS and treat STIs was launched with extensive donor support in 1990. The 1998/99 conflict stopped all efforts and donors financing. In the post-conflict situation, the waging of an effective campaign against HIV/AIDS is complicated by an economic situation where everyone is more concerned with daily survivalthanfocusing onthe long-term development impact ofHIV/AIDS. Ina difficult environment during the last two years the national team supportedby donors succeeded inthe following two steps: I.BuildinganationallyagreedStrategicNationalPlan In spite of the difficult post conflict conditions and with very scarce financial resources, the national team has succeeded in elaborating a SNP for HIV/AIDS, with technical assistance and financial support from UNAgencies and the World Bank. InJune 2002, the Planwas adoptedat a national consensus workshop chaired by the Prime Ministerand the Minister of Health. decentralized participatoryThe Government has confirmed their commitment to: i)a approach, ii)a multi-sector strategy, and iii)a reliable and fully transparent financing system. Each of these elements are crucial to building an efficient MAP. 11.Building a National Programfor SNP implementation During the 18 months of MAP preparation with the World Bank, UNDP, UNAIDS and other donors, the Government carried out several studies to analyze the national context and to prepare a reliable technical proposal. Studies and workshops developed the institutional framework clarifying the roles of NGOs and CBOs, the financing system, the M&E strategy and instruments, and the technical strengthening strategy for each sector. The GFATM comments for the first financing request of June 2003 have emphasizedthe lack of efficient management system, financial management, and M&E. The Government has completed the updatedNSP implementation program. NAC,which was created by the Prime Minister in March 2004, is comprised of the main ministers, civil society representatives including representation o f the three main religions, and the private sector, including NGO service providers (overall two-thirds non-government membership). Search for donors to fund the implementation of the National Strategy Plan. The Government is looking for support from the World Bank (May 2004), the GFATM (potentially June 2004), and other donors. In March 2004, a GFATM preparation team and the World Bank project appraisal team, worked together with the national team in preparing a comprehensive national plan, which would be eligible for support from both organizations. The Government expects to start a limitedimplementation planwith Bank support inJuly 2004 andan expandedplanwith bothBank and GFATMsupport in2005. 18 The project will focus on the following strategic choices to support SNP implementation: a) intensify prevention, care and mitigation at thegrassroots level: - - engage broadly inrural areas; strengthen capacity building aimed at empowering CBOs and fund action plans - eligible under grant allocations; fund actionplans aimed at strengtheningNGOs so that they will become efficient - services providers; fund measures to mitigate the negative socio-economic impact of HIV/AIDS by supporting the design and promotion of social safety nets for those affected by - HIV/AIDS; and strengthenrural radios to ensure an efficient national cover as a key element of the preventionstrategy. PLWHA and orphans will be the mainbeneficiaries o fthe above activities. By late 2000 it was estimated that there were some 35,000 people living with HIV/AIDS in Guinea- Bissau. About 6,000 children inthe country are without parents due to the conflict and/or HIV/AIDS. This burdenhas been, to a limitedextent, absorbed by the extended family, but there are limits to how much support is available. The burden is expected to grow exponentially, as the number o f adult deaths from AIDS will increase in the coming years. The creation o f the first NGO-supported PLWHA association last year has beena positive step forward. The association i s very active and will be supported by the project to scale up its activities at the regional level. The project recognizes that support for community-based responses targeting orphans i s a desirable and economically feasible intervention and it will address the education, health, economic and social needs o f orphans (see Annex 12). b) improveHIV7AIDS-related health care system: The health system in Guinea-Bissau consists o f a network o f one national hospital, four regional hospitals (plus one new under construction), and about 135 rural health centers and health posts. It is estimated that about sixty percent o f the population have access to basic public health services and live within ten kilometers o f a facility. Most o f the doctors in the country are concentrated inthe Bissau region with the health centers being administered by midwivesand nurses. People living on the regional outskirts can be thirty kilometers (almost a day o f walking) away from a doctor. Health posts with nurses are on average five kilometers away. The closest medical service available to most o f the population is the traditional healer, located usually less than two kilometers (thirty minutes o f walking) from the rural household. The traditional healer i s normally the first stop for the rural population with health concerns. Health care i s officially free of charge in Guinea-Bissau. However, in reality patients are required to contribute about ten percent of the health care cost, which i s often too expensive. Prevention without care for people living with HIV/AIDS i s not an appropriate strategy. The Ministryo fHealthwill be one o fthe pillars supported by the project inthe following 19 areas: availability o f VCT facilities, prevention, diagnosis and treatment of STIs, epidemiological surveillance, mother to child transmission, access to drugs, improvement o f laboratory capacities, monitoring and evaluation o f activities. Equipment and a large training program will help improve the response to the epidemic. c) facilitate full public sector involvement: - encourage involvement o f key ministries: Education, Agriculture, Youth and Sport and Army . Other ministries will also provide IEC programs, training, - facilitation to access to care and monitoring for all of their staffs; and ensure respect o f human rights o f those affected by HIV. The project will focus particularly on reducing the social stigma associated with HIV/AIDS by helping improve the legal environment. d) support institutional strengthening: - buildcapacity o fthe National AIDS Secretariat (NAS) andthe National AIDS - Council (NAC) bothnationally and regionally; build coordination and coherence among stakeholders by putting in place -- M&Esystems andby sharing informationandbest practices; improve quality o f financial management and flow o f resources; and seek increased financial support from donors. e) ensure essential access toART and treatmentsfor STI: Access to HIV/AIDS-related care and treatment i s critical for a population that cannot afford current drug prices. The Bank will assist Government in developing partnerships to make HIV/AIDS and STI treatments more accessible, while ensuring that improved health services are in place to support improved access to ART. The project will also support the development o f procurement and financing policies and methods, M&E systems and analytical work to provide the basis for better decision-making by the Government on this issue. The Government will take advantage o f the new WHO regulations allowing poor countries to import low cost HIV/AIDS medication. Funding support from the Global Fundwould be needed to complement the M A P resources. fi mainstreamgender issues: Young girls tend to engage insexual activities earlier than their male counterparts. They also enter into relations with older, more experienced men who are more likely to have beeninfected. Females withmultiplepartners are also less likely to perceive risk and less likely to report sexual activity with non-regular partners when compared with their male counterparts. After the death of their male partners, females are more likely to lose control over the properties o f the deceased thereby becoming even poorer. When parents are illor have died, girls are more likely to drop out o f school to care for sick parents or younger siblings. When placed infoster homes, girls are much more likely to be sexually abused. Physical violence, the threat o f violence, and/or fear o f abandonment can act as substantial barriers to women in negotiating condom use, discussing fidelity with partners, or in leaving relationships perceived to place them at increased risk o f HIV infection. Boys and young men are still brought up in an environment in which social values, education and peer pressure encourage multiple and casual sexual relationships. 20 To address the HIV/AIDS epidemic successfully, it will be essential to consider the role o f gender inincreasingthe vulnerability and impactof HIV/AIDS. Gender specific community activities that focus on the prevention of HIV will be encouraged. Reducing the HIV prevalence in the teenage girls population will receive highpriority, and a concertedeffort will bemadeto involveactivitiestargetingolder men to facilitate this change. The project will support community-drivenactivities that focus on the care of women, girls andwidowers affectedby HIV/AIDS. 21 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT Annex 2: Major RelatedProjectsFinancedby the Bankand/or other Agencies Sector Issue Project Latest Supervision (PSR) Ratings* Implementation Development Bank-financed Progress (IP) Objective (DO) National Health Development Program S S Private Sector Rehabilitation and S S Development Project IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory). *Bank-financed projects only 22 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATION SUPPORTPROJECT Annex 3: ResultsFrameworkandMonitoring ResultsFramework OutcomeIndicators Use of OutcomeInformation By the end of Y3 of the project, the rate letermine overall effectivenessofthis Guinea-Bissau o f increaseof seroprevalenceo f HIV ipproachand progress on stemming amongst antenatalwomen aged 15-24 -IIV/AIDS inGuinea-Bissau. has declined in the population (comparedto Y1). IntermediateResults ResultsIndicatorsfor Each Use of ResultsMonitoring One per Component Component ComponentOne: Community and Component One: Component One: Civil Society initiatives and Capacity Building Civil society and the private sectorare 50 priest, predicatorsor marabous in 4nalysis of communities' commitment carryingout HIV/AIDS related each regionhave receivedHIV/AIDS :o the HIV/AIDS fight prevention, advocacy andpublic IEC formal training by the end of PY2 awareness creation \/lassmediaexposureto HIVIAIDS At least 2 operators and 1managerof Drevention Relevant community groups are being each rural radio have receivedformal trained training in HIV/AIDS IEC by the end of Monitoringof geographicalcoverage PY2 Inthe five pilot regions, PMTCT Analysis o f condomdistributionand of servicesare available Number of programsthat are levelof declaredutilization by the disseminatedon HIV/AIDS in local population Condomspromotionand distributionis languages widely practiced Vulnerable groups aretargetedwith Number of regions that have at least 1 preventiontraining The mostvulnerable groupsprotect PMTC center inplace themselvesagainst HIV/AIDS Analysis of the relationbetween Numberof women who are HIV+ who knowledge and practices do full preventioncourse by the nationalguidelines % of men and women 15-49 that reporthavingaccessto condoms % of sex workers, military, truckers and market female traders aged 15-49 that reporthavingaccessto condoms Use of condoms in sexual encounters outside of primaryrelationshipinthe last 12monthsby persons 15-19, has increasedby 10%over 2003 levels by PY5 Number of sexual partnersoutside of primaryunion in last twelve months amongst the 15-49age grouphas declinedby 10%from the 2003 level hv PY5 23 IntermediateResults ResultsIndicators for Each Use of ResultsMonitoring One per Component Component Component Three: Institutional ComponentThree: ComponentThree: Developmentfor Program Management Project facilitation, coordination, Reliable and decentralizedmonitoring Project managementefficiency and monitoring and evaluation systems are dataare available and usedto improve transparency. fully operational. project management 50 regional and 50 national association membershave received formal training on the Project's proceduresby end PY1 5 priority regions develop and implement annual regional planswith stakeholder participation PDO OutcomeIndicators Use of OutcomeInformation Increase access to STIJ HIVJAIDS Increase from 0% to 20% o f PLWHA Determine effectiveness and coverage treatment that receive medical assistance(01 o f care services andlor ART) by PY3 20% increase in men and women aged 15-49reporting STI symptoms inthe last 12 months, who sought care at a health facility, in the five pilot regions by PY3 IntermediateResults ResultsIndicatorsfor Each Use of ResultsMonitoring One per Component Component ComponentOne: ComponentOne: ComponentOne: Community and Civil Society initiatives and Capacity Building The community care responseis 50 traditional healersin each region Analysis of communities' commitment available have received formal training STI / and attitudesto AIDS andPLWA HIV/AIDS counseling by PY2 50 traditional "sage femmes" and 20 traditional healersin each region received training in STI / HIV/AIDS counseling by PY2 ComponentTwo: Government multi- ComponentTwo : Component Two: sector response Structures for STI J HIVJAIDS Care are All secondaryand tertiary health The Government is committed and efficient, available and affordable for facilities of pilot regions have capacity capableof investing to prevent people living in the five pilot regions to treat STIs by syndromic approach HIV/AIDS. (trained staff and no drugs stock out) as o f PY3 ComponentThree: Institutional ComponentThree: ComponentThree: Developmentfor Program Mgmt Efficient management and Percentageo f health centerswhere Donors are informed and sufficiently implementation arrangements funding STI / HIV/AIDS prevention and funding the needs treatment is available as needed 24 PDO OutcomeIndicators Use of OutcomeInformation Reduce socio-economic impacts of Percentageof orphans receiving Assess national capacity and solutions HIV/AIDS, at the individual, support increased from 3% to 20% by to mitigate the socio-economicalimpact household, and community levels and PY3 ofthe epidemic andmonitoring of strengthen national capacity to respond equity to the epidemic Increasefrom 0 % to 20 % of PLWHA that receivemedical assistance (01and/or ART) by PY4 IntermediateResults ResultsIndicatorsfor Each Use of ResultsMonitoring One per Component Component Component One: Community and ComponentOne: ComponentOne: Civil Society initiativesand Capacity Building Civil society andthe private sector are Number of community-basedprojects Analysis o f communities' commitment carrying out HIV/AIDS mitigation and attitudesto HIV/AIDS and initiatives that supportOVC or PLWA and their families PLWHA Inthe five pilot regions, civil society At least 12HIV/AIDS civil society Evaluate the empowermentand strength and private sector capacity is built to initiatives funded by region per year of civil society and the private sector implement HIV/AIDS prevention care from PY2 through PY5 and support By 2007, at leastUS$1million is channeledto communities for civil society initiatives Over 30 private sector clients funded by PY4 ComponentTwo: Governmentmulti- ComponentTwo : Component Two: sector response Eachministry has included HIV/AIDS Percentage of ministries including Monitoring information are regularly mitigation into its national strategy and HIV/AIDS mitigation in their work disseminatedto the council o f ministers work plan plans Percentage of agricultural advisers trained to support rural PLWHA and their families Percentage ofjudges and community leaders trained about the rights o f PLWHA Component Three: Institutional ComponentThree: ComponentThree: Development for Program Management TheNAS is issuingreliable, updated, and Semi-annualregionalizedimpact analysis Reportdisseminationto all partners(civil regionalizeddata analysis about reportsare availableandreliableas of society, public andprivate sector donors) HIViAIDS impact development project start 25 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROSECT Annex 4: DetailedProjectDescription Component 1: Community and Civil Society Initiatives and Capacity Building (US$2.5M) This component will focus on social mobilization and community level responses to HIV/AIDS. Funds will be set up to expand and strengthen HIV/AIDS activities of Community Based Organizations (CBOs) and civil society associations themselves or in contracting Non-Govemment Organizations (NGOs) or private sector entities. Civil society associations include religious organization, associations o f persons living with HIV/AIDS (PLWHA) and orphans associations. Funded activities will include prevention, care, and mitigation support to decrease negative socio-economic impacts. There will be clearly defined eligibility criteria for organizations to be funded under this component, which have been elaborated in the Implementation Manual. Groups that receive funding will be encouraged to focus, but not necessary limit, their activities on the most vulnerable groups. These include: people living with HIV/AIDS (PLWHA), hospital workers, orphans, youth, commercial sex workers, andtruck drivers. Financial assistance i s especially important for the support o f youth, as it i s one o f the most vulnerable and spread facilitating groups. Due to inaccessibility o f television programming, rural radios will serve as key instruments in the public awareness campaign. Project funding would be limited to five pilot regions. Once complementary funding from the GFATM has been acquired, coverage would become national. Funds will be specifically set aside for two groups: Orphans, whose numbers are increasing as the epidemic progresses. The program will not differentiate support to orphans on the basis o f cause as this would be difficult and inhumane. UNICEF and WFP will be two o f the main implementing partners. The project will set up a permanent regionalized system, managed by recipient CBOs, faith- based Organizations and associations with involvement o f representatives o f NGOs and the private sector, to provide support to identified orphans and to identify and apply best practice approaches. PLWHA, who have decreased productive capacity, which further reduces their resources. It i s essential to help families avoid the poverty trap and adjust available technologies in the agricultural and private sectors. It is also important to create alternative sources o f revenue. Based on the outcome o f a study on how the disease affects economic capital formation for PLWHA (rural and urban), appropriate responses will be formulated and tested for roll out duringthe thirdyear. The conceptual basis for this component is that the factors that determine the spread o f the HIV virus can only, to a limited extent, be influenced by Government. Where traditional and cultural values and practices are of critical importance, Civil Society has to play an important role as a vital partner inthe response to the epidemic. Civil Society organizations are sometimes better able to understandthe needs and problems o f people, 26 and therefore are in a better position to effect behavioral change, empowerment and ownership. They can also be innovative and flexible and therefore fast reacting. For the purposes o f this project, Civil Society Organizations are self-defined community groups that share a common interest for a specific purpose. They can be organized by age, gender, profession, etc., and include groups like village workers' associations, community-based organizations, and faith-based organizations. This component will support efforts to create HIV/AIDS competent communities by improving skills and increasing implementation capacity for the implementers, supporters, and target groups active under the Community and Civil Society Initiatives. Funded activities will include: Training and activities to build HIV/AIDS awareness and leadership capacity in the public sector, civil society, and the private sector; Formulation of HIV/AIDS awareness training modules for use in public and private sector enterprises. Development and distribution o f specialized packages o f Information, Education and Communications (IEC) materials; Rural radio equipment rehabilitation and staff technical capacity strengthening. RCs will enter into contractualagreements to include specific HIV/AIDS programs intheir broadcasts; and Funding grant allocation for CBO empowerment and activities and NGO strengtheningand activities. There will be a cap on the number o f grants for sub-projects costing more than US$5,000, to ensure a community-level focus. Larger NGOs or national organizations will access these funds only as service providers to individual communities. They could be contracted directly by the NAS with prior Bank review o f their action plan. Private sector organizations will also be eligible to access the funds. The maximum sub-project size will be US$50,000 equivalent. The funds will be managed ina decentralized fashion through the RCs, who will have approval authority up to US$20,000 equivalent per subproject. They will receive training and adequate resources to be able to carry out this task. The subproject selection process will be open and participatory, with representation of beneficiaries. Duringthe first phase, subprojects will have a maximum duration o f one year. The regional commissions will meet a minimum o f three times per year to review project proposals. Selection procedures will be detailed in the implementation manual and monitored by the regional adviser to avoid conflicts o f interest. All projects over US$20,000 equivalent will be forwarded to the NAS for approval after an initial RC review. At the beginningo f the program major cities will be dividedinto districts, which will be considered as villages in rural areas. Bissau city will be included in the Bissau region program. The project will support neighborhood association buildinginthese districts. Project preparation and approval criteria and procedures will be specified in the Implementation Manual, and will cover: (i) principles o f operation; (ii)eligible the 27 applicants; (iii) institutional arrangements and facilitating agents; (iv) eligible activities; (v) process o f allocation of resources by province; and (vi) the features of the project identification, preparation, approval and supervision cycle. Monitoring and evaluation will involve active participationof CBOs and associations, contracted NGOs, and private and public sector. They will participate in defining or reviewing what will be monitored, andhow results can be shared. This will improve implementation. Component2: GovernmentMulti Sector Response(US$2.2M) This component will comprise a fund to scale up and strengthenprevention, care, support and mitigation of the social economic impact of HIV/AIDS through programs/activities of the public sector. It will support public sector institutions to protect their own personnel from the impact of HIV/AIDS and, where applicable, to integrate HIV/AIDS activities into their core business. Sub-contracting by ministries, local authorities and parastatals will be encouraged in order to make the best use o f the implementation capacity that may be available outside the public sector. Each public sector agency will define a work program that will address issues regarding HIV/AIDS among its employees. Public agencies will also be expected to extend HIV/AIDS services to their clients and neighboring communities. The component has two sub-components. Subcomponent1: Supportto Ministry of Health (US$1.3M) The largest share of funds under this sub-component will be dedicated to supporting the Ministry o fHealth inits unique role incombating the epidemic. Inrural areas, the public sector i s the primary source o f modern health care, with only in few areas additional services being provided by national or international NGOs. The project will partially finance the Ministry's HIV/AIDS work plan and will include prevention activities, medical treatments, and the procurement o f HIV/AIDS commodities and services. It will also include Ministry assistance to other partners inthe multi-sector campaign. Giventhe special nature o fthis subcomponent, the funds will be for a broad range o f purposes. Project support will not be sufficient to respond to the Ministry's needs for a national HIV/AIDS program. Other sources of funding such as from GFATM will be essential to complement project funding and ensure national coverage. GFATM has already committed about US$2 million for support to the Ministry's tuberculosis program. The IDA financed project will only provide funding at the regional level for activities inthe pilot regions. With the objective of scaling up the response of the health sector to the epidemic and to provide technical leadership on the treatment and care for PLWHA, this sub-component will include: 0 Strengthening the Integrated Health Network (IHN). The IHN provides voluntary counseling and testing and HIV/AIDS related services along the major transportation axes where prevalence rates are highest; 28 Increasing the supply o f drugs and materials, such as condoms, drugs to treat opportunistic infections, and anti-retroviral drugs for the reduction o f M T C T and post exposure prophylaxis; Strengthening clinical laboratory capacity to enable diagnosis and monitoring o f ART, including those for CD4 monitoring and diagnosis of opportunistic infections; Support to epidemiological surveillance; Prevention, diagnosis, andtreatment of STIs; Mother to child transmission prevention; Improving management o f opportunistic infections, focusing on prevention and treatment; and Improving monitoring and evaluation o f activities supported under the component and measuring the impact o fthe project onthe epidemic. Subcomponent 2: Support to other Ministries, Departments and Government Agencies (US$0.9M) All other MDAs will be supported in the implementation o f their comprehensive HIV/AIDS work plans. Ministerial work plans must be presented indecentralized shape clearly defining regional responsibilities, which will be reviewedand agreed upon by the RCs. Some ministries with advanced work plans and responsibility for the highest priority areas (education, health, agriculture, interior and army forces, youth and sport) will receive comprehensive work plansupport duringthe first year. Other ministrieswill receive limitedsupport duringthe first year focused mainly on workplace interventions to protect their own personnel and to support them in building their own comprehensive further strategy . Additional technical assistance will be providedinthe first year to support ministries and their focal points to strengthentheir work plans inaccordance with the national strategy. The focal points will be part of the NAS, participating in all coordination and review meetings. Comprehensive support i s expected to address the following two broad areas: The external impact of the HIV/AIDS epidemic on the specijk ministry/agency: The extent to which HIV/AIDS has affected (i) quality, quantity and substance of the services; (ii) ability to supply the required services; (iii) organization o f the the the sector; (iv) the role of service providers; (v) human resources policy and management practices; (vi) the planning and management o f sector resources; and (vii) the availability o f resources to the sector; and The internal impact of the epidemic relative to the work of the spec@ ministry/department/agency: Support will focus on the prevention o f further spread among ministerial staff and facilitation of access to care and support for affected and infected employees andtheir families. 29 The range o f activities to be considered withinwork plans o feach ministrywill include: 0 Capacity building for the mainstreaming o f HIV/AIDS-related activities into regular work programs; a IEC campaigns, including promotion o f condom use, for staff and client awareness. The campaigns are to ensure a sustainable behavior change among its staff and clients; e Promotion o f staff access to condoms; 0 Facilitation o fHIV/AIDS social support network provision for all staff; 0 Impact studies to investigate the qualitative and quantitative consequences o f the epidemic on specified sectors and analysis o f possible and appropriate responses; and 0 Policies regarding the posting and location o f staff. Ministries and subordinate institutions will be supported under this component in the development and implementation o f HIV/AIDS related programs directed at their own personnel and their families (particularly high risk staff such as soldiers, police, agriculture agents, teachers, health workers). Public servants and their families will be provided with HIV/AIDS education, training, condoms, and support for caring for those who are infected or affected. The activities will also focus on encouraging behavioral change and not stigmatizing the illness at the work place. To combat stigmatization, funds will be provided to address its legal aspects and improve the rights o f PLWHA, orphans and widow(er)s. Activities will include technical assistance, studies, training, and study tours to facilitate the improvement o f the legal framework and will target lawyers, deputies in the National Assembly, journalists, communities, associations andNGO leaders. Support will be provided to facilitate outreach programs o f ministries. In each o f the 5 key ministries (Education, Health, Agriculture, Army, Youth and Sport), a Focal Point has been appointed and i s supported by ministerial and/or departmental management committees designated to oversee the design and implementation o f HIV/AIDS related policies and action plans. The Focal Points, appointed full time for the program, will receive training and day-to-day guidance on their roles and responsibilities from the NAS, of which they will be an active part. The project will fund their basic office equipment and operating costs. To reflect the highly decentralized nature o f Government, the component will be broken into national, regional, and local initiatives. Additionally, each ministry, key ministry or not, will conduct activities relevant to the areas of its comparative advantage, for example: Ministry of Education e Development and application o f lessons which seek behavioral change through a teaching approach which targets both skills and knowledge and includes negotiation, resistingpeer pressure, self-esteem, communication and assertion; 30 0 Promotion of school and student association-led HIV/AIDS initiatives in primary, secondary andtertiary educationinstitutions; 0 Monitoring and evaluation of the HIV/AIDS impact in the education sector in collaboration with other relevant ministries; 0 Integration of HIV/AIDS IECs in curricula at all levels of the formal education system including teacher training colleges. Best practices from other countries, particularly from Brazil, will be usedto improve the dissemination process; and 0 Promotion of safe sex practices, includingthe use of condoms, among sexually active youth. Ministry of Financeand Planning 0 Provisiono f cost models to determine the cost o f HIV/AIDSrelated interventions; 0 Provision of national and sector HIV/AIDS-related projection models for national humanresource and economic development planning; and 0 Appropriate budgetsto support national HIV/AIDS activities. Ministry of Defense 0 Promotionof safe sex practices, includingthe use of condoms, among its employees; and 0 Creation of HIV/AIDS social support networksfor its employees. Ministry ofJustice 0 National legislation review to identify and promote laws that protect people living with or affected by HIV/AIDS, in particular regarding the property rights of widow(er)s and orphans; 0 Provisionof HIV/AIDS IEC to prisoners and people indetention; and 0 Training of National Assembly members, judges, CBO and NGO leaders as agents for defending PLWHA and orphanrights. Ministry of Agriculture and Fisheries 0 Research and test specific services support to those families affected by HIV/AIDS; and 0 Facilitate general training andinformationo fproducer organizations. Ministry of Transportation 0 Provision of HIV/AIDS IEC to its employees and water and other transport workers; 0 Promotion of safe sex practices, including the use of condoms, among its employees and commercial vehicle/maritime drivers; and 0 Creation of HIV/AIDS social support networks for its employees and commercial vehicle/maritime drivers. 31 Component3: InstitutionalDevelopmentfor ProgramManagement(US$2.3M) This component will provide support to NAC, whose broad responsibilities will evolve mainly around advocacy, and providing leadership for the multi-sectoral response to HIV/AIDS. NAC is not envisioned to have implementationor funding responsibilities. The project designacknowledges the mandate o f the NAC and creates opportunities to support N A C inthe implementation o f its mandate. Additional support will be givento N A C for a semi-annual one-day information workshop. The project will also support the National AIDS Secretariat (NAS), including its regional components and focal points, to fulfill its national HIV/AIDS coordination mandate, technical support, financial management, and monitoring and evaluation. Support will be givento the N A S for: 0 Establishment o f an effective secretariat and networks at national, regional, and district levels; 0 Guarantee a highlevel technical references and advisory capacity; 0 Establishment o f financial management and procurement systems; 0 Resource mobilization; and 0 Monitoring& evaluation. Below are the detailed descriptions o f lessons learned as listed inthe maintext: Politicalleadershipandcommitment The successive Governments o f Guinea-Bissau have indicated their firm commitment to the fight against HIV/AIDS. The successful examples o f HIV epidemic control in countries like Senegal and Uganda were facilitated by political leadership drivenby good epidemiological data, effective programs, and vibrant activist civil society participation. The project will support decision makers at national and regional levels. They will be informed, invited to participate in semiannual workshops and supervision missions, and asked for recommendation. Vulnerabilityfactors are key drivers of the epidemic Underlyingvulnerability factors among populations drives the HIV/AIDS epidemic. The combination o f poverty, gender disparities, .and information asymmetry provide very fertile soil for HIV infection rates to rapidly grow. Any attempt at controlling the epidemic will have to address the vulnerability factors. This project focuses on the vulnerable groups. Civilsociety organizationsas a processof empowerment The affected communities find themselves facing multifaceted challenges, but have limitedresources to respond. Inaddition, short term focused strategies may not meet the need for long term rehabilitation and healing in those communities. Community participation engages the people to fight the epidemic. With external resources and local capacity building, communities and civil society association will be more empowered in 32 their response, which is more likely to be sustainable. This project will have a specific component on civil society-led initiatives. Multi-sector approach It has been widely recognized that the HIV/AIDS epidemic extends far and beyond the health sector. The multi-dimensional nature o f the epidemic and its impact warrant a change in paradigm from a biomedical to a development one. Inthis context, the multi- sector approach in HIV prevention, care and mitigation offer best chances of success. This project will involve the active participationof all sectors at all levels. Beneficiariesmust take the leadto defineorientationand project evaluation The risk is that funds would be usurped by public sector agencies and well-connected and/or large NGOs. One o f the main objectives o f the project i s to improve the life quality o f the victims: PLWHA and orphans. One o f the priorities o f the project will therefore be to support capacity buildingo f associations by and for PLWHA and orphans so they will be able to orient project activities to addressing their real needs. Focuson knowledgebuilding and evidence-basedinterventions There i s a huge deficit o f knowledge, best practices, and resources to build strong evidence based prevention and care interventions. There i s lack o f knowledge on areas such as preventing Mother-To-Child Transmission, ART, use of vaginal microbicides, and treatment o f STIs, prophylaxis, and opportunistic infections. This project will adopt a progressive approach initially supporting well-designed socio-cultural research activities and pilot operations for larger intervention. The project will benefit from tested approaches in other countries such as Senegal and Brazil. Such research findings could provide firmer bases for specific interventions. Ruralradios are crucial They can efficiently deliver updated messages to the largely rural population. The project will support the completion o f national coverage by rural radios, managed by community-based associations and broadcasting in national languages. It will also provide technical and management skills strengthening. The use of indigenousknowledgeand practices Indigenous knowledge and practices could be complementary in the efforts to fight HIV/AIDS, InMozambique, the involvement o f traditional healers had a higher impact at a lower cost. Along similar lines, the Bank i s currently piloting the use o f traditional channels o f communication to deliver culturally congruent messages in prevention o f HIV/AIDS inWest Africa. Local practices o f community orphan support have beenused successfully in many countries. Inthis regard, this project will encourage access to and use o f appropriate indigenous knowledge and practices that have been shown to work in the fight against HIV/AIDS. Role clarity betweenNACLNASand implementingagencies Channeling significant resources to institutions that were set up to coordinate and monitor project activities introduces a temptation for those institutions to venture into 33 implementation. The N A C would therefore be from the beginning limitedin its activities to policymaking and project implementation oversight, and not involved in project implementation. The NAS will be supportedunder the project to coordinate and monitor the technical activities, whereas a wide spectrum of civil society organizations, CBOs, faith-based organizations, associations, and public and private institutions will be supported to implement the project activities with contracted support from public and private sector including NGOs. Complexity of supervision of MAP projects Given the innovative M A P approach andmultitude o f stakeholders and partners which all lead to the relative complexity o f the projects, supervision o f M A P projects requires more attention and resources than average projects. The experience suggests that supervision teams for MAP projects should draw on the resources o f partners, particularly bilateral and other stakeholders. The composition o f the supervision teams should also be multi- sector and multi-donor. Robust Monitoring and Evaluation The key features o f MAP require that robust M&E systems and plans need to be developed through a participatory involving stakeholders who will be involved in implementing M&E activities according to their expertise areas. Sufficient financial resources with a specific budget line and consequent skills strengthening support are made available for M&E under the Project. Good Donor Co-ordination Effective coordination among development partners can significantly reduce the transaction costs. Common arrangements for program reviews, M&E, planning o f financial and technical assistance, support missions, funding o f programs or program components are all areas that will be pursued in close cooperation with the NAC/NAS, UNAIDS, Global Fundand other partners. 34 GUINEA-BISSAU: HIV/AIDS GLOBALMITIGATION SUPPORTPROJECT Annex 5: ProjectCosts ProjectCost By Componentand/or Activity Local Foreign Total US$M US$M US$M Community and Civil Society Initiatives and 1 .o 1.3 2.3 Capacity Building Government Multi-sector Response 0.8 1.4 2.2 Institutional Development for Program 1.2 0.8 2.0 Management Total Baseline Cost 0.0 Physical Contingencies 0.2 Price Contingencies 0.3 TotalProjectCosts' 7.0 Interest during construction 0.0 Front-end Fee 0.0 TotalFinancingRequired 7.0 'Identifiable taxes and duties are US$O.O, and the total project cost, net o ftaxes, is US$O.O million. Therefore, the share of project cos! net o ftaxes is 100%. 35 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 6: ImplementationArrangements The project will support the National AIDS Program and will be under direct supervision o f the Prime Minister's Office (PMO). Policy making will be the responsibility o f the National AIDS Council (NAC). Coordination, technical support, and financing on the national level will be carried out by the National AIDS Secretariat (NAS) directed by a National Secretary. The Regional Committees (RCs) will lead regional policy and activity implementation on local and regional level. Implementation will be performed by Community Based Organizations (CBOs), associations, public and private sector, which will contract NGOs and technical assistance when needed. Institutionalarrangements. The NationalAIDS Council(NAC) The N A C is housed inthe Prime Minister's Office and responsible for providing strategic direction and policy leadership. It i s headed by the N A C President (Prime Minister), and includes 1/3 representation from Government, 1/3 from civil society and 1/3 from private sector including NGOs. The N A C was formally established by Prime ministerial decree inMarch2004. The NationalAIDS SecretariatPAS) The Government has agreed to implementation procedures that would help expedite project implementation and outsource project implementation. Given the post-conflict status o f Guinea-Bissau, key implementationaspects cannot be outsourced to one or more private firms as such capacity does not exist in-country at this time and obtaining this from abroad would not be cost-effective. For other IDA projects this has meant establishing Project Management Units (PMUs) staffed with national consultants. This has worked and i s confirmed by positive financial management and procurement assessments by Bank supervision missions. Building a P M U takes, however, time and risks delays in project implementation. It has therefore been agreed that the project would initially use the financial management and procurement staff inplace at the Private Sector Rehabilitation and Development Project (PSRDP) until N A S technical staff have been hired and sufficiently trained. The PSRDP has satisfactory procurement and financial managementprocedures and trained staff. Inaddition, it has sufficient capacity to ensure the efficient management o f these activities during project preparation and take- off. It has also been agreed that all seven (national) technical staff o f the National AIDS Secretariat (NAS) would be hired on a contractual basis through an open (internationally advertised), competitive and transparent process to manage implementation activities such as behavioral surveys, operational research, financial and program management, monitoring and evaluation, etc. All technical staff would receive compensation based on national expert standards to attract broad interest and would have annually renewable contracts with clear performance criteria. These arrangements are aimed at ensuring efficiency, accountability and transparency o f project management and reducing 36 implementation related and fiduciary risks. NAS staff selection would be done by a broad committee, including members of the HIV/AIDS thematic group, as well as UNDP Agencies (including UNICEF), to ensure independence from Government. The World Bank no objection for each selected NAS staffwill be requested before appointment. An independent institutional assessment would be carried out within twelve months of grant effectiveness to ensure efficiency of arrangements2 The NAS will include a President, one national secretary, seven national technical staff, five focal points inkey ministries,and two staff per region: one regional adviser andone regional accountant who would support the RC. National and regional staff will be recruited through a transparent and competitive process and receive annually renewable contracts. These would only be renewed upon satisfactory rating by an independent evaluator two months prior to the end of the contract. Representatives of orphans, PLWHA, NGOs, CBOs, and ministries will participate in the evaluation process. Given the difficult post-conflict financial situation the project will provide contractual salaries, equipment,training, technical assistance, andoperating costs ofthe NAS. The regionalcommittees (RCs) At the regional level SNP implementation will be the responsibility of the RC, which would include representatives from regional ministries (regional focal points), civil society and private sector representatives (one third o f representatives for each). The RC will be presided by the Regional Governor's nominee and will be coordinated by a Regional Coordinator, who will be elected by CBOs, including PLWHA associations, orphans associations, associations of youth and women, and regional focal points representingtheir ministries. The Mandates: NAC NAC will be the national HIV/AIDSpolicy maker. Itwill overseethe national HIV/AIDS program and related projects. It will have an advocacy role to improve fund raising and set policy and strategy. It will organize two semi-annual workshops where all stakeholders can meet to discuss progress inimplementing the SNP. NAS NAS is an autonomous structure mandatedby the Government. Under the responsibility o f its Head (the National Secretary) it will perform day-to-day management ofthe SNP, it will be responsible for ensuring consistency of all aspects of the national response including the national strategy, day-to-day coordination of the program, mobilization of resources, and M&E. The project will support the NAS to manage the SNP at the national level and in five pilot regions. The NAS will present annual work plans and regular progress reports of the program and the proposed project and will provide These arrangementswere confirmedduringnegotiations. 37 information on the use o f project funds, procurement progress, and findings from M&E. It will also organize annual reviews for all partners and stakeholders, including annual financial and technical audits as detailed inthe project implementationmanual. NAS will coordinate and facilitate activities implemented by civil society. Once RCs have approved sub-projects for funding, NAS will transfer the funds using the Western Union system to the organization responsible for implementing the sub-project, informing the regional adviser and accountant. Regional accountants under the oversight o f the NAS will follow-up to fulfill fiduciary responsibilities. Modalities for disbursementswill be clearly spelled out inthe ImplementationManual. The Ministryo f Economy and Finance would be informed monthly on disbursement status. The NAS will also contract out capacity building o f the RCs, NGOs, CBOs, faith-based organizations, and other groups. NAS including regional advisers, regional accountants and the five key focal points will hold bi-monthly meetings to review national program and project implementation progress. These two or three-day meetingswill be located inone o f the regions (selected on a rotating basis). Travel and subsistence cost will be supported by the project. An analysis o f the project's technical and financial performance over the preceding two months and an action plan for the following two months will be the core part o f that meeting. NAS will convene two annual National Forums to review the status o f the HIV/AIDS Campaign. The first will be timed to coincide with the international HIV/AIDS Day (December first) while the second will be approximately six months later (May/June). The second will coincide with the preparation o f the National Finance Law for the next year. The events will bring together all key actors active in the HIV/AIDS campaign, from both Government and civil society, for two days o f review, reflection, guidance and training. ?'he second meeting will be preceded by a number o f workshops at the regional level. In order to ensure transparency, the regional events will also be used to publicly display information on planned and completed activities, financial accounting and audits (financial and technical). Each Ministry will ensure that project activities are aimed at mitigating the impact o f HIV/AIDS in their sectors and that prevention activities are integrated into sector work programs. They will also ensure that grant resources will be used for intendedpurposes and towards eligible expenditures according to their contract. The Focal Point in each ministry will coordinate project implementation at the ministry level, regularly update work plans, and be the primary interlocutor with the NAS. Focal points representingthe different ministries will submit their regional and local administration plans to the RC, which will contract them upon agreement. The RegionalCommittees RCs will have the responsibility to define the regional policy in accordance with the national strategy. The RC will review the proposals from civil society, and the public and 38 private sectors at the regional level. Its approval authority i s limited, however to US$20,000. With the help o f the regional adviser it will monitor the contracted regional action plans and collect the related data. The Regional Committees will meet at least three times per year. The project would support a full time regional adviser and a regional accountant under the umbrella o f each RC. Partners Response Organization The Civil Society HIV/AIDSresponse: The civil society includes CBOs and associations. The civil society responses will be coordinated through the RCs as outlined above. This component will be community driven, and the projects to be funded will be identified and proposed by the civil society organizations. The RC will select projects from a menu o f broadly-proposed activities. The process starts when a civil society organization preparesa proposal for funding of an HIV/AIDS activity to the RC. A facilitating agency such as anNGO canbe contracted by a civil society organization to provide assistance inthe proposal preparation if requested. The proposal i s channeled to the RCs for review and approval during its regular sessions. The Private SectorHIV/AIDS response: The private sector can prepare action plansto be involved inthe campaign. To prepare a proposal, enterprises can contract NGOs, hire private technical assistance, or request support from regional advisers and the national NAS staff. Trade and industry chambers can also prepare national or regional programs related to HIV/AIDS mitigation and solicit support for its members. All proposed activities must be reviewed and agreed upon by the RCs. Expertise o f the ILO with private sector HIV/AIDS mitigation support programs will be examined. The Public Sector HIV/AIDS response: Each Ministry, at the regional level, will prepare an annual action plan. The focal point at the regional levelresponsible for the preparationcanrequest technical assistance from the regional adviser, central NAS staff, or central focal points. The RC will review the action plan and ifagreed, the RC will contract and monitor it. For all proposed activities by public, private, or civil society, the regional level will be the first point o f entry. The national level will decide only activities that exceed US$20,000, cannot be handled at the regional level or activities, or where significant economies o f scale exist. 39 InstitutionalArrangements for the NationalStrategic PlanImplementation: The National Council (NAC) (1/3 Administration - 1/3 Civil Society - 1/3 Private Sector) The Prime Minister: President of NAC Policy Making Oversight The National Secretariat (NAS) The President of NAS The National Secretary 5 Focal points in the key ministries 7 technical staff (contractual) 5 Regional advisers 5 Regional accountants Technical Coordination - Financing - Monitoring Regional Committee (RC) The President of RC (Nominated by the Regional Governor) Regional Coordinator (elected) Civil Society - Private Sector - NGOs - Ministries Representatives of: Implementation OperationalArrangements ImplementationManual An implementation manual is being prepared by the Government in close collaboration with representatives from civil society and donors. The manual will detail the Project's institutional and implementation arrangements, the respective responsibilities and mandates o f each participating identity, and the functional relationships between participants. It will define procedures and eligibility criteria for review and approval o f projects proposals. It will include the contractual arrangements between the N A S and implementing agencies and standard contracts for a broad range o f activities. It will detail procurement arrangements and financial management requirements, including accounting and reporting norms at national, regional, and local levels. Completion o f the manual with all its annexes i s a condition o f Grant effectiveness. 40 The manual will also specify the approval authority for the differentlevels: Approving entity Size of project proposals (US$ equivalent) NAS All proposals from Central Ministries, Ce'ntral Government Agencies, National Associations, National NGOs. Also regional proposals in excess of US$20,000. RC Approval of proposals from civil society: CBOs, NGOs, regional and local associations, regional private sector, and public services: up to US$20,000. Disbursement of funds civil, private, or public entities will be in accordance with the eligibility criteria and terms specified inthe operational manual. Eachproposal from any entity will include an action plan. ImplementingAgencies Project fundedactivities will be implementedby public and private sectors including civil society groups, and both non and for profit organizations. The project will be implemented incrementally, starting with entities, which already have HIV/AIDS work plans and experience. Coverage will be extended as implementation capacity is strengthened and work plans prepared. All funded activities will be contracted by the CRs or the NAS. (a) PublicEntities At local and regional levels, the public entities (ministries and parastatals) will prepare project proposals and submit them directly to the RCs. At the national level, public entities will support the preparation and implementation of their regional teams. The NAS will fund directly to the local and regional level after RC approval and contract signature. The ministries will implement their respective plans through their existing regional offices. National public entities can also submit financing requests directly to,the NAS for national (cross-regional) activities inorder to decrease the cost. The NAS points will also provide administrative and technical support for SNP implementation, including relevant guidelines, training, and M&E. A formal contract including a six-month action plan and budget with agreed input and output indicators would guide the relationships betweenthe ministries, the NAS, and the CRs. The Ministry o f Finance will be informed about project funding for each of the ministriesat boththe national andregional levels. (b) Civil Society Organizations CBOs and associations operating inonly one regionand with a proposal costing not more than US$20,000, will present their project proposals to the respective RC. The RC according to the budget allocated to the region and after technical and financial review by 41 the regional adviser, the regional accountant, and, if necessary technical support by the NAS, will review and where appropriate approve the proposal. Both the related RC and the NAS must approve regional level proposals for more than US$20,000. Once the RC approves proposals of less than US$20,000, the NAS Financing Service will automatically fund them. Implementing agencies operating nationally or inmore than one region will submit their proposals directly to the NAS. The NAS review will be required only for tasks that are technically complicated, involve more than one region or exceed us$20,000. (c) NGOs In general, NGOs are service providers. As service providers they will need to be contracted by the project beneficiary organizations (civil society organizations, and public or private entities). Exceptionally, NGOs willing to be consideredas civil society organizations will have to demonstrate the appropriateness of their mandate, representative membership, transparent management procedures, and account for their funding. At the beginning ofthe project the role o fNGOs will be defined andthey will be eligible to receive support to help them reinforce their technical capacity, management ability, and accountability. (d) Private Sector Private sector enterprises, such as the Chamber o f Industry and Trade, can submit action plans with budgets to RCs or NAS according to the location and type of envisaged actions. Donor Coordination To date, the donors are channeling most of their small support through NGOs, the UN System, or civil society organizations. Due to the diversity of implementation channels and contracting mechanisms, it is difficult to track all activities, or account for all donor funds. The principal bilateral and multilateral actors include: the French cooperation, WHO, and UNICEF. A UNDP thematic group meets regularly to coordinate UNDP support to HIV/AIDS and health activities. This group will continue its crucial role in support coordination and it will progressively bestow that role on the NAC and the NAS during the first year of the project. The NAC/ NAS will use the semiannual meetings to report to Government and donors on the status of implementation of the National Action Plans. The meetings will also serve as a venue for raising additional funds as donors gain confidence inthe ability of the NAC andthe NAS to account for funds. Project Monitoring There will be only one M&ES for both the Project and the National Program. The GFATM appraisal team has agreed to this. The project will support the national M&E system. A specific line will be includedinthe NAS budget to charge M&E expenses on national andregional levels. PleasereviewAnnex 9 for detailed M&E information. 42 The aim o fthe M&E system will be to: Identify intra-country variations inHIV/AIDS epidemiology to support the design o f effective HIV/AIDSprevention, care, and impact mitigation operations; Identify trends in behavioral attitudes and knowledge, to inform project design and track obtained results; 0 Provide best practice examples; and 0 Provide information on HIV/AIDS prevention, care, and impact mitigation services undertaken by implementingagencies of the public sector and civil society, as well as their coverage, quality, cost-effectiveness and access. This will provide information to the management and services providers at every level operations improvement. Program and project M&E will be based on a broad range o f measures, including specified indicators and process and output measures to capture project performance in the intermediate term. An M&E manual, o f which an advanced draft will be included in the Project Implementation Manual as a condition o f Grant effectiveness, will be finalized within five months o f Grant effectiveness and inform and substance satisfactory to IDA. Project outcomes will be measured employing data from the HIV sentinel surveillance, baseline, and end-point population-based surveys on knowledge, attitudes, practices, and behavior. Service utilization and special studies commissioned to assess outcome in specific areas not easily addressed by population-based surveys will also be used. Monitoring o f the project will be carried out usingproject-based data, beneficiary inputs, andprogram reviews. The NAS through direct contracting and the RCs will monitor overall project implementation, assessing the performance o f project implementation as well as the effectiveness and efficiency o f implementation at national, regional and local levels. Ministries will also monitor their respective mandates. The activities o f civil society and private organizations will be monitored based on their contract performance. Central NAS staff, focal points, and regional advisers will supervise overall project implementation and will meet every two months to discuss progress under each implementingagency. They will have mandatory field visit included into their monthly budgeted action plan. The N A C and the N A S will organize semiannual project development reviews, and, together with the donors, a joint project launch workshop within a month o f project effectiveness. Its main purpose will be to strengthen project monitoringandreporting requirements. To simplify the system, it will include a single goveming flowchart and database to ensure a single structured form. It will also have a single unitary system, based on nationally agreed data collection forms and pathways, leading to a single database. External technical assistance from the World Bank and other donors will be required for system refinement and startup assistance. Periodic assessments o f key aspects of the 43 program will be organized and contracted by the NAS. These will provide the background and material for annual Learning Events and Progress Reviews by all stakeholders, starting at the regional level and leading to a National Assessment. Other learning events and study tours will be built into the program. ProjectEvaluation(PerformanceAssessment) Once the M&E system for the national program i s finalized, one o f the first priorities o f the NAS will be to determinewhether the existing data provide a sufficient baseline for the program impact and outcome indicators. If not, new data will be collected from the onset o f the project and the feasibility o f the indicators may need to be reviewed. The program evaluation process will evolve around the annual reviews, when the existing data collected through the M&E system will be collated and analyzed specifically relative to the achievements o f the goals set by the project and program. During the project preparation process, an attempt was made to set realistic and achievable targets. While project progress will be monitored regularly, it should be possible to evaluate definitively whether the project is moving in the right direction or not and, and at the end o f the project, assess its impact. In the event that significant weaknesses appear, the annual reviews will provide a timely opportunity to address these. It is expected that these reviews, as well as the final evaluation o f the project, will be participatory and will include beneficiary assessments. Supervision The RCs, assisted by the RegionalFocalPoints, will supervise project activities at district and sub-district levels. Staff from the NAS, cooperating partners, and the Bank's Task Team will make visits to the field to monitor the performance o f implementing agencies at the regional levels. The N A S will monitor and review overall program implementation and meet regularly with HIV/AIDS focal points o f the various ministries to discuss progress under each ministry. The NAS will organize semiannual project reviews to assess the performance o f the National Program, including this project, its components and its contribution to the national effort to reduce the spread and impact of HIV/AIDS. Semi-annual supervision missions, preferably jointly with other donors, will be planned. In addition, timely mission will be scheduled to provide specific technical implementation support. Specific areas o f the review will include technical and operational aspects o f implementation. The reviews will draw on the information generated from routine monitoring, conducted studies, and any other relevant information. Project reviews will culminate in stakeholder meetings, which will be held in May or June and will form a planning basis for the next year. These meetings will be usedto share information on trends, best practices, and to provide general technical and financial information. The World Bank's Task Team charged with the supervision will cooperate closely with all partners involved in project financing to achieve multi-sectoral expertise based on each partner's relative technical strengths. In 44 view of the new institutional structures being put in place, the multiplicity o f implementing agencies, and the consequent need for broad consultations, participation and coordination, an intensive supervision strategy i s proposed as essential to the success of the project. 45 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 7: FinancialManagementand DisbursementArrangements ExecutiveSummary and Conclusions The Government has agreed to implementation procedures that would help expedite project implementation and outsource project implementation. Given the post-conflict status of Guinea-Bissau key implementation aspects cannot be outsourced to one or more private firms as such capacity does not exist in-country at this time and obtaining this from abroad would not be cost-effective. For other IDA projects this has meant establishing Project Management Units (PMUs) staffed with national consultants. This has worked and is confirmed by positive financial management and procurement assessments by Bank supervision missions. Building a P M U takes, however, time and risks delays in project implementation. It has therefore been agreed that the project would initially use the financial management and procurement staff inplace at the Private Sector Rehabilitation and Development Project (PSRDP) until NAS technical staff have been hired and sufficiently trained. The PSRDP has satisfactory procurement and financial management procedures and trained staff. Inaddition, it has sufficient capacity to ensure the efficient management o f these activities duringproject preparation andtake- off. The objective of the financial assessment was to determine the necessary action plan to get the Project quickly offthe ground. The following issues were identified: Staffing, Administrative, Accounting and financial manual, m Accounting software, External audit, Flow o f funds. The action plan is detailed below and has been agreed with the Government and the President o fthe NAS during negotiations. Staffing The NAS Financial Manager will report to the NAS' Secretary and be responsible for ensuring that financial management and reporting procedures will be implemented as agreed with Government, the World Bank and, ifapplicable, other cooperating partners. Given the complexity o f fund flow arrangements, which include many and widely dispersedbeneficiaries, many small transactions, andmultiplelayers o f accountability, 46 NAS will have two accountants at the central level, working under the responsibility of the financial manager: .. the first will be in charge of the Community and Civil Society Initiatives (Part A o f the project) andthe Government Multi-sector Responses (Part B) at the central level. the second will be at the level of chief accountant and in charge of the regional disbursementsandsupervision of the five regional accountants. At the regional level, a regional accountant will be appointed to support each RC. The project will be implemented in five regions namely Bissau, Gabou, Bafata, Ohio and Cacheu. The recruitment of the financial manager will be an effectiveness condition. At the regional level, the recruitment of regional accountants will be done progressively following the setting up ofthe RCs. Ithas also beenagreedthat all seven (national) technical staff ofthe NAS would be hired on a contractual basis through an open (internationally advertised), competitive and transparent process to manage implementation activities such as behavioral surveys, operational research, financial and program management, monitoring and evaluation, etc. All technical staff would receive compensation based on national expert standards to attract broad interest and would have annually renewable contracts with clear performance criteria. These arrangements are aimed at ensuring efficiency, accountability and transparency of project management and reducing implementation related and fiduciary risks. NAS staff selection would be done by a broad committee, including members o f the HIV/AIDS thematic group, as well as UNDP Agencies (including UNICEF), to ensure independence from Government. The World Bank no objection for each selectedNAS staff will be requested before appointment. Inaddition, assurances were obtained during negotiations that NAC and NAS would be autonomous from Government with an independent board comprised two-thirds of non-public sector representatives. An independent institutional assessment would be carried out within twelve months of grant effectivenessto ensure efficiency of arrangement^.^ Accounting Policiesand Procedures,Reportingand Monitoring The Financial Management System (FMS) objective will be to help management effectively and efficiently provide project resources to intended beneficiaries and thus achieving the objectives. Specifically, the FMS must be capable of producing quarterly, understandable, relevant and reliable financial information that will allow management to plan, implement, monitor and appraise the Project's overall progress or lack thereof. The FMS will allow for the proper recording of all project-related transactions as well as timely monitoringof expendituresper category, implementing agency, and component. These arrangementswere confirmed duringnegotiations. 47 Given the lack o f capacity at the beginning o f the project at all levels, to adequately manage project funds, it was decided, in keeping with the principles o f the umbrella MAP, that extraordinary implementation arrangements were warranted to facilitate the decentralized civil society-level response. Moreover, the project i s expected to conduct training on basic bookkeeping for the civil society organizations including at community level. As part o f the Project Implementation Manual, a manual detailing administrative, accounting and financial procedures will be prepared and submitted for Bank no objection. This manual will include accounting policies and procedures, definition o f respective duties with a good segregation, budgeting system and all relevant administrative and financial procedures, and relations between the components o f the project. It will also cover the decentralized levels o f the project and a specific section will cover civil society initiatives. The Bank standard procedures related to financial management, accounting and auditing will apply to the funds disbursed to either public or private institutions, as set out in Annual Financial Reporting andAuditingfor WorldBank-Jinanced activities. To ensure consistent financial reporting, detailed procedures will be developed for project accounting based on IDA'S experience with other decentralized projects. Internal accounting controls for the project will be set out in detail in the financial procedures of the manual and will be satisfactory for providing reasonable assurances that accounts will be properly recorded and resources safeguarded. NAS will prepare quarterly Financial Management Reports (FMR). The quarterly reports will cover financial management, procurement and physical progress monitoring, and cover all activities financed underthe project regardless o fthe source o f funding. The first FMRshall beprovidedto IDA no later than 45 days after the end o fthe calendar year after the effectiveness o f the Grant. Thereafter, each FMR shall be provided to IDA not later than 45 days after each subsequent calendar quarter. A financial management review o f the Project's progress will be made by a the Bank within 18 months o f Grant effectiveness to assess the FMS and decide whether or not the project can be qualified for FMRbased disbursement. The annual financial statements o fthe project will be prepared be preparedinaccordance with the new guidelines o f IDA : Annual Financial Reporting and Auditing for World Bank-Financed Activities. FinancialManagementSystem The project FMS will be computerized with software acceptable to IDA. The chart o f accounts for the national and regional program will be clearly designedto allow reporting to requirements o f each o f the donors. It will be installed at the NAS and each of the RCs. The FMS will be managed at the central level by the financial manager supported 48 by the two accountants. The FMS mustbe inplace, satisfactory to IDA, as a condition of effectiveness. Audit The NAS will be responsible for the preparation and production o f the annual financial statements in accordance with IDA new guidelines: Annual Financial Reporting and Auditingfor World Bank-Financed Activities. The project consolidated annual financial statements will be audited by independent external auditors acceptable to IDA according to detailed terms o f reference approved by IDA. The auditors' report should be submitted to IDA no later than six months after the end o f a fiscal year. The auditors' report should include a management letter. The auditor will be recruited as a condition o f effectiveness. Flow of funds Giventhe weaknesses o f the formal banking system, the project will use Western Union (WU) for the disbursement o f funds to implement regional level activities. Western Union i s expected to be represented in all the pilot regions by grant effectiveness. NAS will use similar arrangements as already in effect in for other Bank projects and reflect these inthe manual. The normal fees o f WU are five percent o f the amount sent. It was agreed that the consultant in charge o f the implementation manual would prepare a Memorandum o f Understanding (MOU) with WU to reflect these arrangements. The fee would also be negotiated. Summary of ProjectDescription See SectionB o fthe maintext. Summaryof CountryFinancialManagementissues The IntegratedFiduciary Assessment for Guinea-Bissau is scheduled for FY06.There are a number o f concerns about public financial management. The recent Public ExpendituresReviewhighlighted some o f them. However, those concerns will not impact this project because o f the specific arrangements for the flow o f funds, outside o f Government. Impact of ProcurementArrangements At the time o f the financial management capacity assessment, the Project's procurement assessment was under preparation. It was therefore not possible to assess the impact o f the procurement assessment findings on the Project's financial management arrangements. However, the procurement arrangements described in Annex 8 are not expected to have an impact on the financial management o f the project. 49 DisbursementArrangements See section D.3 o f the main text o f the PAD relatedto the disbursementarrangements. RiskAssessment At the country level: The FY04 public expenditure review assessed the procedures in place for budget preparation, execution and control. The report identifieda number o f shortcomings at the level o f budget executon. One potential strength o f the system i s the strong centralization o f the expenditure control, which in a situation o f loose managementand cash shortage could be an effective alternative to ensure at least some budgetary discipline. The many weaknesses, however, lie in the fact that the government has been unable to adjust to a deteriorating macroeconomic environment in a transparent way and there i s an almost complete absence o f effective reporting on budget execution. This may be pervasive at all levels o f Government in Guinea-Bissau due to the existence o f multiple rents that key figures are extracting from the system. The final accounts o f each fiscal year are not consolidated in time thus creating disruptions in the flow o f information on the budget execution. The Treasury lacks a modern accounting system and i s therefore unable to produce meaningful information on the budget and the use o f public funds. The General Audit Office does not operate well, especially for the ex-post control o f the public accounts and these have not been audited since 1987. Based on the main findings o f the review, the mission concluded that the risk at the country level i s high. At the project level: Because o f the highfiduciary risk at the country level, IDA has taken special measures to ensure adequate financial management o f its portfolio. PMUs are often established to manage IDA-financed projects and Bank funding i s following special mechanisms to mitigate fiduciary risk. Accounting staff is hired on contractual basis, typically on salaries higher than civil servants, to work on projects, even when a Ministry implements these projects. In addition, IDA projects are invariably audited by independent and competent audit firms. The N A S i s therefore established as an autonomous PMU. As mentioned elsewhere in the text, the P M U o f the PSRDP will ensure financial management o f the Project untilNAS financial management staff (financial manager and two accountants) have been sufficiently trained and the FMS has been satisfactorily installed. This will help avoid implementation delays and minimize fiduciary risks. The table below identifies the key risks at the project level and provides a basis for determininghow management should address these risks. 50 Rating iskAs, 'ssmen H S M N / Comments InherentRisk 1. Corruption X The proposedfinancial 2. Poor governance X management(FM) action 3. Weak Judiciary X planbelow will help solve 4. Weak Managementcapacity X this issueby hiringon Overall Inherent Risk X qualifiedaccountingstaff. Moreover,there will be regularsupervision by IDA andat the endofthe year, the Projectand Programfinancial statementswill be auditedby an indenendentauditfirm. ControlRisk 1. ImplementingEntity X PSRDP. 2. FundsFlow (fromthe central to the X A MemorandumOf regions) Understandingwill be signed with WesternUnionto ensure the availability o f funds inthe regions anda correct flow recording. 3. Counterpartfunds X No counterpart funds will be requiredunder this project 4. Staffing X Ideminherent risk 5. AccountingPolicies and Procedures X Ideminherent risk (i) 6. InternalAudit X Ideminherent risk 7. ExternalAudit X 8. ReportingandMonitoring X 9. InformationSystems X Overall Control Risk X I Idem inherent risk (i) spec@ risk such as Delay on the Civil Society and the line Ministries component due to lack of capacity accountant and regional advisers . in budget formulation and execution will be solved by the assistance to those two component by the NAS 51 ACTION PLAN Action Tasks Target CompletionDate . 1. Recruitment o f . Entity Preparation of the TOR for the staff . NAS ..........June2,2004 the staff (i) . 9 Review of TOR and approval 9 IDA June 10 Advertisement IDA June 16 Selection process m NAS June 30 Non Objection IDA July 6 2. Development o f TOR for the consultant . m NAS June 10 ... the project's manual Selection process m NAS June 16 o f procedures ... ... Draft manual Consultant June 16 Review ofthe draft manual NAS June20 Final version NAS June25 3. Installation of the Development of a chart of NASI August 30 financial accounts reflecting the activities1 consultant management system . sources of financing of the project (regional and central level), August 30 . Customizing the agreedformat . NASI for the quarterly Financial consultant . MonitoringReports (FMR) September 30 Completingthe testing of the transactions recording and the NASI financial statementproduction consultant and printing 4. Selection of an Preparation o f the request for proposal NAS . July 30 auditor package including the terms of reference and the standard bidding documents World Bank's no objection on the IDA August 6 request for proposals package Requestsfor proposals sent out NAS .. August 15 Proposals received, Technical and NAS August 29 financial evaluation completed and transmitted to IDA non objection IDA no objection IDA September 11 52 FLOW OF FUNDS \ \ \ \ \ \ \ \ / \ Accounts o f Suppliers, Consultants, or all other WESTE,RNUNION contractor (REGION) i REGIONAL ACCOUNTANT Paymentof suppliers, consultant or NGOs and other operating costs 53 FINANCIAL CHART OF NAS 1 NATIONAL SECRETARY CHIEF ACCOUNTANT ACCOUNTANT ---------_____ Responsiblefor ---._ Responsible for ------______ REGIONAL componentsA et B component C -----____ACCOUNTANTS (5) Liens hikrarchiques ____________--_ Liens fonctionnels 54 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORTPROJECT Annex 8: Procurement 1. Generalprocurementenvironmentin Guinea-Bissau A new national procurementpolicy has beenapproved and tested in five line Ministries but it is not yet beengeneralized. All procurementactivitiesunder Bank-financedprojectsare subject to World Bank guidelinesanduse of standarddocuments. The general procurement environment in the country is acceptable as most Bank-financed projectsmake use ofPMUs that includea procurementspecialistwho is trained inthe guidelines andthe use ofstandarddocuments. 2. Use of World Bank guidelines IDA will finance goods, civil works, consultancies, training, and other local activities necessary to implement the project according to the World Bank's procurement and disbursement guidelines 3. Procurementofworks and goods (a) Procurement of works and goods for all IDA-financed activities will be carried out in accordance with the Bank's Guidelines for Procurement under IBRD Loans and IDA Credits (January I995 and revised in January andAugust 1996,September 1997,and January 1999); (b) The Bank's standardbiddingdocuments for works and goods, the standardpre-qualification document (when applicable) andthe standardevaluationform will be usedinthe process; (c) National standard biddingdocuments do not exist inthe country. It will be ensuredthat the proceduresare acceptable to the World Bank, ifthe country intends to elaboratenational bidding documents.The principlesof economy, transparency, efficiency and fair participationwill have to be respected. Such biddingdocumentswill ensure that: (i) bids will be advertised in national newspapers and rural radio network with wide circulation; (ii) the documentclearly explainsthe bidevaluationandaward criteria; (iii) bidders are given adequate response time (minimum four weeks) to prepareand submit bids; (iv) bids will be awardedto the lowestevaluatedbidder; (v) eligible bidders, including foreign bidders will not be precluded from participating;and (vi) no domestic preference margins are applicable to domestic manufacturers or suppliers or contractors. Requirementsfor large-ticketitems such as medicalsupplies (drugs and equipment) andvehicles will be consolidatedand preparation of procurement documents will be carried out by the NAS using the ICB method. Thus, to the extent possible, procurement for goods will be grouped where feasible into packages valued at US$150,000 equivalent or more. Delivery of these goods 55 to the end users will either be done directly by the suppliers or through separate distribution contracts that will ensure timely delivery o f the goods. It will be necessary to ensure that adequate procurement capacity i s available at the center to organize the procurement and distribution. 4. Selection of consultants The selection o f consultants necessary for the execution o f the project will take place in accordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997,revised in September 1997,January 1999andMay 2002). The Bank standard request for proposals will be used and forms o f contracts as needed (lump- sum, time-based and/or simplified contracts for short term assignments and individual consultants) as well as the sample form o f evaluation report for the selection o f consultants. 5. Advertising (a) A General Procurement Notice (GPN) has been prepared and finalized and will be issued in the United Nations Development Business before the end o f May; the finalized GPN lists all goods and works contracts above US$200,000 and large contracts for selection o f consultants estimated to cost the equivalent value o f US$lOO,OOO or more; (b) The related pre-qualification (ifany) or bidding documents will not be released and the short list for consultant services will not be prepared before the eighth week following GPN publication; (c) The GPN will be updated annually for those contracts still to be let; (d) Incase o f expressions of interest, a minimumo f 14 days will be allowed before preparing the short list; the period will be 30 days incase international firms might be interested; (e) Specific procurement Notice (SPN) for goods and works will be advertised in the national press of wide circulation, and internationally for large contracts; (f) Large contracts to be advertised internationally will put inUNDNand DgMarket web sites; and (8) Sufficient time will be allowed to obtain the biddocuments. 6. Procurement capacity (a) General features. Since the NAS procurement specialist has not yet been recruited, no assessment could be carried out. As soon as all technical staff have been recruited, NAS will be evaluated to determine whether all conditions are in place to procure in compliance with World Bank procedures. These conditions will be an important part o f the terms o f reference and the contracts. The core staff at the N A S will include a Procurement Specialist who should be familiar with World Bank's procurement procedures and will work closer with each o f the RCs and the NAS RegionalAccountants andAdvisers under the project to ensure efficient andtimely project implementation through compliance with the procurement schedules agreed with the Bank. The Procurement Specialist will: (a) prepare and update the procurement plan for the project; (b) monitor the progress o f procurement; (c) assist the implementing agencies in the preparation o f biddingdocuments and advertisements for goods and works contracts and request for proposals for consulting assignments; and (d) be responsible for bid opening and evaluation. The Procurement Specialist will also advise the implementingagencies onprocedural matters. 56 To avoid delays inproject launch, it was agreed after the mission o fthe procurement specialist to have the PMU o f the PSRDP, which has procurement staff on-board with satisfactory qualifications, manage procurement for the Project o f all non-medical supplies and equipment. It will manage the selection process o f the seven contractual staff o f the NAS and initial studies andtraining, procure basic equipment, and organize office rehabilitation. These activities will be financed from the Project Preparation Fundadvance. Once the NAS procurement specialist has beensufficiently trained, PSRDPwill transfer procurement responsibilities back. (b) Capacity of CECOME ( Centralede Commandedes MCdicamentsEssentiels) Drugs and equipments for drugs may also be purchased through CECOME, which is administratively and financially autonomous since November 2003, CECOME will be responsible for purchasing drugs and medical equipment for public hospitals and small health centers under the control o fthe central Government and the municipalities. (i)Organizationand operationalmechanisms Regardingprocurement activities, CECOME will make an arrangement with PNDS (theNational Health Development Project) for assistance from their specialist; technical specifications for goods and works and terms o f reference for consultants will be issued by CECOME and the process conducted under the control o f the procurement specialist o f the Health Sector Development Program. However, the evaluation committee will be mainly composed o f CECOME members. (ii)Procurementprocedures CECOME has no procurement system inplace yet; during the period they will be assisted by the procurement specialist o f PNDS. There will be a need for them to: 0 Establish a proper procurement system to ensure sustainability and reduce delays for procuring drugs andequipment; 0 Provide for capacity building o f the procurement team to be recruited; 0 Elaborate appropriate standard biddingdocuments for drugs and equipment inconformity with requirements o f a World Bank-financed project and ensure that procedures will remain flexible untilthe Bank has evaluated them as satisfactory; and 0 Elaborate an implementation manual that institutes a tender board commission and evaluation commission, so as to enhance the transparency ofthe process. Where feasible, bid packages will be of such size to attract interest from larger manufacturers and distributors (this i s however contingent on availability o f adequate storage facilities) and lengthof procedures. 7. Procurementplan A global procurement plan for the whole project and a detailed procurement plan for the first year o f the project have been completed following the appraisal mission and finalized as a 57 condition o f Board presentation. The procurement plan includes relevant information on all goods, works and services contracts under the project as well as the timing o f each milestone in the procurement process. The procurement schedule will be updated every six months and submitted to IDA. The Procurement Specialist will monitor the progress of procurement and implementation o f each contract under the project and will ensure effective and timely project execution. 8. Implementationmanual The implementation manual is under preparation and its adoption is a condition o f effectiveness. The section o f this manual related to procurement will be in compliance with the procurement arrangements described inthis annex. Specifically, subprojects identified and executed by NGOs or CBOs will be carried out inaccordance with private sector procedures acceptable to the Bank. 9. Procurementimplementationarrangements (i)Centrallevel : The NAS procurement specialist. This specialist will handle all procurement activities for vehicles, office rehabilitation and equipment, and all large items that can be grouped in big packages for all project public or private executives agencies. The specialist will also participate inbuildingcapacities for the other actors andassist/control their procurementactivities Since there i s lack of capacity in the country, line Ministries will refer to NAS for their procurement activities. CECOME will be responsible for drugs andmedical equipment procurement. (ii)Regionallevel The RCs will be allowed to procure their own goods and works except drugs and medical equipment; if needed they will be assisted by the national level at the beginning o f project implementation. (iii)Locallevel At the community level NGOs and CBOs will be fully responsible for procuremento f goods and services under the project and will be provided with training inproject procurement procedures; international and national NGOs will be selected on the basis o f their qualification but local NGOs and CBOs will be awarded funding for subprojects only when they have demonstrated capacity to manage funds in accordance with Project requirements. Public procurement at the local level will be under the control o fthe regional level. 58 10. Procurement Methods (a) Procurementmethods for goods and works. The methods to be usedfor procurement are describedbelow. The estimated amounts for eachmethod are summarized intable A below. The threshold contract values for the use of each method and the total amount of contracts above prior reviewthresholds are shown intable B below. Goods. Given the urgency of the program, items required urgently during the first 12 months could be obtained on a fast-track basis using appropriate procurement methods directly from UnitedNations agencies (UNFPA, WHO, UNICEF=, etc). Immediate requirementsof vehicles and office equipment specifically for the program could be acquired from IAPSO or by local shopping (preferably ex-bonded warehouses on a competitive basis) or international shopping. Furniture for coordinating offices could be procured through local shopping. Where feasible, procurement agents could be used, including UNFPA for procurement and distribution of condoms, andpossibly other UnitedNations agencies for procurement and distribution of drugs. All procurement actions will follow standard IDA procurement guidelines and annual general procurement notices (GPN) will be preparedfor the project and publishedinthe UnitedNations' Development Business and DgMurket. The distribution to the final users can be done through the municipalities, the NGOs, or the CBOs. Inorder to facilitate the procurement process the thresholds will be established as stated below for essential goods: (i) ICB: equal or above US$150,000 equivalent for goods including drugs; (ii) NCB: Less than US$150,000 up to a total amount not exceeding US$ 800,000; (iii) National or international shopping: US$50,000 up to a total amount of US$500,000; (iv) Drugs and medical equipment purchased from CECOME will follow sole source system with IDA prior review; however CECOME must follow adequate procurement methods; and (v) Goods up to an aggregate amount of US$l.O million may also be procured through various UNprocurement agencies. Regarding civil works, for example rehabilitation of facilities, the procurement procedures will be as follows: (i)ICB:equalormorethanUS$200,000equivalent; (ii)NCB: Less than US$200,000 up to a total amount not exceeding US$800,000; and (iii)Procurement of small works: US$50,000 up to a total amount not exceeding US$500,000. (b) Selection of consultants. Selection and appointment of consultants for studies, technical assistance, promotion of the project activities, and support of project execution will be carried 59 out in accordance with the Guidelines: Use of Consultants by World Bank Borrowers, January 1997, revised in September 1997, January 1999 and May 2002 (Consultant Guidelines). As a rule, consultant services will be procured through Quality and cost-based selection (QCBS) methodology. All consultancy assignments estimated to cost the equivalent of US$200,000 or more will be advertised in a national newspaper and in Development Business (UNDB) and DgMarket. In addition, the contracts may be advertised in an international newspaper or a technical magazine seeking "expressions o f interest." All consulting assignments exceeding US$200,000 will be procured through QCBS. In the case of assignments estimated at US$lOO,OOO or less, the assignment may be advertised nationally and the shortlist may be made up entirely o f national consultants provided that at least three qualified national firms are available in the country and foreign consultants who wish to participate are not excluded from consideration. Consultant services estimated to cost less than the equivalent of US$50,000 may be contracted by comparing the qualifications o f consultants who have expressed an interest in the job or who have been identified. Auditors will be selected using least-cost selection procedures. 11. Prior review thresholds (i)Goodsandworks All goods and works contracts estimated to cost the equivalent value o f US$150,000 and US$200,000 respectively or more will be subject to IDA review o f bidding documents including draft contracts and technical specifications prior to inviting bids and IDA review o f bid evaluation report prior to contract award and signature. (ii)Consulting services The TOR and the short list for all consulting assignments irrespective o f value will be subject to IDA prior review. For consultancy contracts with firms with an estimated value of US$lOO,OOO or more, and US$50,000 or more inthe case of individuals, the draft request for proposals (RFP) or letter of invitation for individuals and the shortlist o f consultants must be cleared by IDA prior to inviting proposals from consultants. Inaddition, the evaluation o f technical proposals must be cleared with IDA before financial proposals o f the qualifying firms are opened. The draft contract accompanied by the final evaluation report (combining technical and financial criteria), and the negotiation session report will be submitted to IDA for no-objection before contract signature. This means that with respect to each contract for the employment o f the consulting firms estimated to cost the equivalent o f US$lOO,OOO or more and each contract for the employment o f individualconsultants estimated to cost the equivalent of US$50,000 or more, the procedures set forth inparagraphs 1, 2 (other than the third subparagraph o f paragraph 2(a)) and 5 of Appendix ItotheConsultantGuidelinesshallapply. 60 12. Post review Contracts that are not subject to prior review will be selectively reviewed by the Bank during project implementation and will be governed by the procedures set forth in paragraph 4 of Appendix Ito the guidelines 13. Readiness for implementation Drafts o f the documents required for effectiveness: (a) an implementation manual i s under preparation; and (b) A draft o f the general procurement plan for the whole project and the detailed procurement plan for the first year have been prepared and reviewed during appraisal and completed as a condition o f Boardpresentation. Table A: Project Costs by Procurement methods (US$ `000 equivalent) Expenditures categories Procurement methods Total ICB NCB Consulting Other NBF Total services Civil works 44.9 44.9 Equipments I 273.6 I107.7 II i429.4 810.7 Consultant services ( technical 3,148.9 3,148.9 assistance and training) I Operating costs and 1,950.5 maintenance 1y950.5 I Salaries 868.5 Total 1 273.6 1152.6 I 3.148.9 3,248.4 1 6.823.5 61 Table B: Thresholds for Procurement Methods and Prior Review (US$) Expenditures categories Contract value Procurementmethod Contractssubject threshold to prior review 1. Civil works -200,000 > ICB 0 <200,000 NCB - 50,000 < Proc. of small works 2. Goods -150,000 > ICB 791,000 <150,000 NCB 0 - 50,000 < Nat. or intern. shopping 0 3. Consultant services and training : Firms 2 100,000 QCBS andother 2,5 13,200 Individual <50,000 Individual consultants selection method Total amount of contracts 3,304,200 subject to mior review Overall ProcurementRisk Assessment: Medium Frequencyofprocurementsupervisionmissionsproposed : One every four months including procurementsupervision for post review during the first year and one every six monthsafter that Table C: Allocation of Grant Proceeds Expenditure Category SDR equivalent Financing Percentage 1. Civil Works 10,000 100% 2a. Goods: vehicles and office 450,000 100% equipment 2b. Goods: drugs, tests and 280,000 100% medical supplies 3. Consultantservices, training 1,890,000 100% and audits 5. OperatingCosts 1,460,000 100% 6. Refunding of PPF 5 10,000 7. Unallocated 100,000 Total 4.700.000 62 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 9: Monitoringand Evaluation Introduction The MAP is based on the assumption that rapid project preparation without extensive ex ante technical analysis i s possible if effective M&E systems (M&ES) are urgently established as a management tool to guide project adjustments. M&ESComponents M&E comprises (a) surveillance; (b) epidemiological research; (c) financial management; and (d) Program activities. Surveillance This encompasses both biological and behavioral surveillance. In Guinea-Bissau there is an urgent need to implement regular, annual, comprehensive HIV surveillance. Antenatal surveillance i s the bedrock o f biological surveillance. The N A S and the ministry o f health will implement antenatal surveillance among up to 2000 antenatal patients, 400 each d r a k from one o f the 5 priority regions o f Bissau, Bafata, Gabu, Cacheu, and Ohio, taking into account both rural and semi-rural (or urban) antenatal sites. Further surveillance i s required to track STI/HIV trends among priority groups. In particular, surveillance will examine STLrHIV prevalence among a key sentinel or "tripwire" population, up to 400 female sex workers, sampled from Bissau and Gabu. The uniformed forces will also be monitored, with up to 600 samples, drawn from Bissau, Gabu and Catchungo. Intensive interventions and continuing STI and HIV surveillance will also be conducted among these cohorts to assess intervention impact. STI prevalence, aetiology, and sensitivity studies among sex workers and other groups are also urgentpriorities. Technical assistancewill be provided by international agencies such as WHO. Behavioral surveillance will be managed by the NAS, using FHI's manual and materials and undertaken by a competitively identified researchkonsulting agency or NGO. FHI have established comprehensive manuals and rigorous procedures for questionnaire adaptation and translation, interviewer training and supervision, sampling, data management, and quality assurance. Guinea Bissau will initiate regular behavioral surveillance at 18-24 month intervals, among up to 1000 female sex workers, 1000 uniformed service members, and 1200 young people aged 12-19 (300 male in-school, 300 female in-school, 300 male out-of-school, 300 female out-of-school). Epidemiologicalresearch The focus will be on two major areas: (a) STI prevalence, aetiology and sensitivity studies and (b) evaluation o f HIV interventions among priority groups, including sex workers and uniformed service members. 63 Financial and projectmonitoring This will focus on the NAS contracting and coordinating capacity and the relevance, quantity, quality, and economy o f public sector, municipal, and civil society services. Project monitoring will be combined with financial monitoring and managed by NAS staff recruited from a competitive international manpower market (restricted to Guinean nationality) with annual contract according to specific related TOR. Contract renewal will be submitted to external evaluation every year. Each technical NAS staff and each contracted partner will collect and verify primary monitoring data from each operation. Through the project, NAS will assume a major grant-making role, supporting numerous AIDS projects nationally. NAS will develop established systems and procedures for budget transfers and grant-making, including systems for identifying epidemiological priorities and soliciting compliant applications, publicizing grants, developing and publicizing structured, transparent selection procedures, publicizing recipients, monitoring program performance o f recipients and communicating achievements. An M&E manual will be developed as a condition o f Grant effectiveness. All Program staff at the national and regional levels, as well as those NGOs, MDAs and civil society leaders, will be trained on M&E procedures. During project implementation, the manual will be reviewed, adapted, simplified, and translated to ensure that it meets the Program's needs. M&EStructure Biological surveillance will be undertaken by the Department o f Hygiene and Epidemiology with support from the National Public Health Laboratory, with specialized staff at national and regional level. External technical assistance will be provided by WHO, UNAIDS, CDC and/or FHI. Behavioralsurveillancewill be contracted to a researcWconsulting agency or anNGO. It i s suggested that FHI provide technical assistance, to ensure surveillance, fully incorporates international good practice. Epidemiological research will be conducted jointly by the Department o f Hygiene and Epidemiology, with external technical assistance from FHI. The NAS M&E specialist and financial manager will be responsible for Financial and program activity monitoring. There are several reasons why it i s preferable to combine financial and program activities monitoring into the NAS. Since the M&E specialist and the M&E financial staff are working together at the NAS, such a set-up is more efficient. Project monitoring may be added to financial monitoring at marginal cost. Moreover, combining financial and physical project implementation monitoring provides a basis to corroborate financial and activity data and to ensure sounddata cross-verification. This improves both financial and project accountability. 64 Component I Contracted to SurveilIance I Biological: Departmentof Epidemiology,with support from Behavioral: Directed by NAS and contracted to research/consultingagency or NGO Epidemiological research Departmentof Epidemiologyof the Ministry of Health Public sector and civil society Directed by NAS financial staff (annual contract) financial monitoring Public sector and civil society Directed by NAS M&E staff (annual contract) technical project monitoring NASActions The NAS will undertake the following actions to effectively coordinate project monitoring: e Clarify its coordination role and increase its capacity to coordinate, not implement, M&E; e The NAS M&E specialist will coordinate M&E activities and will be responsible for training partners andverifying, collating, analyzing and reporting data; e The NAS and stakeholders will undertake a participatory process, to prepare a nationally owned M&E plan and manual and to build commitment and ownership for M&E. Each partner will agree on key targets with NAS M&E unit, usinga structured targets form; 0 Eachpartner will report results monthly using a simple, structured reporting form. Results will be verified semi-annually bythe Program activities unit; e The NAS M&E will support partners to introduce M&E into all contracted activities to assess progress by usingsimple standardized forms; 0 The NAS M&E will collate, analyze and prepare semi-annual summary reports o f aggregate activities, usinga standard format; e The NAS and key stakeholders will meet semi-annually to review monitoring reports and to identifykey lessons; and 0 The NAS M&E unit and key stakeholders will update their operational and M&E manuals and procedures based on lessons learned. Monitoringand EvaluationBudget Component Y1 Y2 Y3 Total Biological Surveillance 30,000 30,000 30,000 90,000 Behavioral Surveillance 0 40,000 0 40,000 Epidemiological Research 10,000 0 10,000 20,000 Financial and program monitoring 5,000 5,000 5,000 15,000 Total 45,000 75,000 45,000 165,000 65 Action Completed Guinea Bissau project M&E plan and M&E manual producedthrough September 2004 national stakeholder consultativemeeting Training of key staff October-November2004 M&E included into the project launchingworkshop December 2004 Key Indicators Input and Output Indicators Increase from 0% to 20 % of PLWA that receivemedical assistance (01and/orARV) by Y3 Increasefrom 0% to 10% of OVC benefitingfrom improved access to education and/or food aid % of PLWHA and/or affected families receiving/benefitingin finding adaptedsources of revenue 50 priest, predicators or marabous in each region have received HIV/AIDS IEC formal training 50 regional, 50 national associationmemberstrained on project proceduresby end 2004 50 traditional healers in each region have receivedformal training in STI/ HIV/AIDScounseling 50 traditional "sage femmes" in each regiontrained in STI/ HIV/AIDScounseling Funded line Ministries have achieved75% of their annual HIV/AIDSoutreach plan 75% of all civil servants have been reached by HIV/AIDS related IEC by 2007 All public institutions distributecondoms,with 1 million condoms distributedannually by Y3 All secondary and tertiary healthfacilities of pilot regions have the capacity to treat, diagnose and test for STDs by syndromic approach (trained staff and no drugs stock outs) At least 12 HIV/AIDScivil society initiativesfunded by region per year, at full project development At least 2 operators and 1 managerof each rural radio trained in HIV/AIDSIEC by end 2006 Number of men and women who are being counseled and tested for HIV Number of programsthat are disseminatedon HIV/AIDS in local languages Number of regions that have at least 1VTC center in place (at least 2 for Bissau) Number of community based projects that support OVC or PLWA and their families Over 30 private sector clients funded by 2007 Over 50000 clients reached annually by civil society initiatives on HlVlAlDS by 2007 At least US$1 million is channeledto communities for civil society initiatives by 2007 66 Outcome Indicators Condom use in sexual encounters outside of primary relationship in the last 12 months by persons 15-19, has increased by 10% over 2003 levels Percentage of men and women aged 15-49 reporting STI symptoms in the last 12 months, who sought care at a health facility, in the five pilot regions Number of sexual partners outside of primary union in last twelve months amongst the population aged 15-49 has declined by 10 % from 2003 levels Percentage of orphans receiving support increased from 3% to 20% by Y3 Process (and coverage) Indicators Seven VCT centers, equitably distributed geographically, are in place Percentage of men and women aged 15-49 that report having access to condoms Percentage of sex workers, military, truckers, and female market traders aged 15-49 that report having access to condoms 5 priority regions develop and implement their annual regional plans with stakeholder participation Impact Indicators By the end of the third year of the project, the rate of increase of seroprevalence of HIV among antenatal women aged 15-24 has declined (compared to the first year of the project) 67 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORTPROJECT Annex 10: SafeguardPolicyIssues MEDICAL WASTE MANAGEMENT PLAN : LOGICAL FRAMEWORK* 0bjective I Performance Indicator OBJECTIVE 1: To strengthen the legal and institutional framework of the MWM Result: Policy document, law, rules, and procedures for sound MWM completed. Monitoring Set up a coordinationand monitoringteam. MonitoringCommittee Prepare MWM policy. Documentof Policy Activities Prepare and enact legaltext for MWM. Law and rules Prepare and enact technical guidelines for MWM. Guidelines Prepare a training plan and to executethe training. Training documents Activities Train all people involvedwith the manipulationof medical waste. # of peopletrained Assess the implemented plan. Evaluation report OBJECTIVE 4: To increase population awareness about MWM risks Result: Population is well informed about MWM risks. Activities To inform population about MWM risks. % of population informed OBJECTIVE 5: To support the implementation of the MWM plan Result: Plan is agreed, coordination system, M&E in place. MWM directors at national, regional, Organization of regionalworkshops for sanitary chiefs Number of workshop Survey, evaluation, and planning of activities. Reports Activities Monthly and annual MWM plan implementation monitoring. monitoring reports. Mid term review report and final assessment report. *Operations and costs bellow are referring to the five pilot regions in which the medical waste management plan will be piloted. 68 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATION SUPPORTPROJECT Annex 11:ProjectPreparationand Supervision Planned Actual PCN review December4,2003 December4,2003 Initial PID to PIC February 13,2004 Initial ISDS to PIC 02/20/2004 February 20,2004 Appraisal March 2004 March6,2004 Negotiations April 2004 March 19,2004 Board/RVP approval May 26,2004 Planneddate o f effectiveness September 30,2004 Planned date o f mid-termreview Before December 31, 2005 Plannedclosing date December 31,2007 Key institutions responsible for preparation of the project: PNLS inGuinea-Bissau (Paolo Rabna) Bank staff and consultantswho worked onthe project included: Name Title Unit Christian Fauliau TTL AFTS4 Marie-JeanneN'Diaye LanguageProgram Assistant AFTS4 Rohan Selvaratnam Sr. Program Assistant AFTS4 Virginie Vaselopulos Language Program Assistant AFTS4 Demba Balde Social Development Specialist AFTS4 Fily Sissoko Financial Management AFTFM Specialist Bourouma Diaite Procurement Specialist AFTPC Kees Kosterman LeadPublic HealthSpecialist AFTH2 Laura Rose Sr. Public HealthSpecialist AFTH2 FernandoVasco HealthSpecialist Consultant DirkPrevoo Operations Officer AFTS4 Inacio Alvarenga Implementation Aspects AFTS4 (consultant) Alioune BadaraDiouf Audit Specialist (consultant) AFTS4 Clara Barros M&ESpecialist (consultant) HDNGA Pave1Trcala Consultant AFTS4 69 Bank funds expendedto date on project preparation: 1. Bank resources: US$240,000 2. Trust funds: US$267,000 3. Total: US$507,000 EstimatedApproval and Supervision costs: 1. Remaining costs to approval: US$O 2. Estimated annual supervision cost:US$120,000.00 70 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT Annex 12: Orphan Support It is estimated that there are currently some 6,000 orphans in Guinea Bissau. However, the orphan identification system is not reliable and data collection is not covering every part of the country. The situation is also not sufficiently analyzed. The few NGOs supporting orphans (SOS Villages, Casa Emanuella) have recently started to collect data and monitor development. There is no information on the conditions and needs of families already integrating orphans. Orphan support i s not planned and it largely depends on the good will of people deciding to help them with very limitedresources. The orphan question cannot be approached in standardized manner, as orphans in different communities will require a different kind of support. Their vulnerability to HIV/AIDS is not based only on their material needs, but it also concerns their health, social environment, legal situation, and, last but not least, their emotional status. The support package will be definedby evaluating the different aspects of vulnerability according to the situation of each individual orphan. The objective will not be to solve all problems o f all orphans, as i s not possible during the three-year project, butitwill aim to improve the lives of orphans. The nationalorphan strategywill aimto: e Build a small and efficient national core team. It will include a NAS staff at the central level with TOR to support PLWHA and orphans, an NGO representative already working in supporting orphans (SOS, Caritas, Casa Emanuella), representatives of the mainreligions, and arepresentativeofministryof social support. The national team will be supportedby regional teams; Train the national and regional leaders about orphans situation, needs, and support; Informthe civil society leaders andNGOs about the potential project support; Launch community lead identification survey with counts, localization, and short needs descriptions; Launchpotential adoptive families identificationbasedon their proximity to orphans; Define priority criteria for eligibility o f orphans support; Set up various mechanismsfor orphans support; Set up the monitoring system at national, regional, and community levels; Support orphans association building at regional and national levels; and Support adoptive family associationbuildingat regional andnational levels. The approachwill be very pragmatic, learning by doing. However, rigorous monitoringwill be a key element of success and particularly to find better ways to extend a reliable support to other orphans. 71 GUINEA-BISSAU: HIVIAIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 13: Project SupervisionStrategy Objectives Project implementation i s expected to take o f f inthe second half o f calendar year 2004 (end first quarter FY2005). Although project preparation has beenextensive, it i s still anticipated that there will be considerable need for close supervision during the initial years o f project implementation. The main objectives o f the supervision inthe first year are to (a) ensure that there is adequate implementation capacity at the regional levels and all the participating line ministries; (b) ensure that the contractual staff o f NAS has sufficient adequate capacity and support to begin carrying out their mandate o f coordination and M&E; (c) ensure that implementation arrangements are efficient and responsive to program and project requirements, and where necessary make changes; and (d) ensure adherence to appropriate safeguards and fiduciary responsibilities. Strategic focus The supervision strategy will focus on the following critical areas inthe first year. However, as i s the case with the overall project design, flexibility in focus for support supervision will be requiredinorder to be responsive to evolving priorities or emergingproblems. Institutionalarrangementsfor implementation The supervision will focus on the essential institutional arrangements inorder for the project to carry out the planned project activities. The role o f the Facilitating Agencies and the committees at the regional level for coordination of project activities under the first component will be evaluated during the first year of implementation. At the national level, the evolution o f the mechanisms for Monitoring and Evaluation, Planning and Financing under NAS will be closely monitored. During the initial stages o f the project there will be a strategic focus on the strengthening and creation of partnerships - with civil society organizations, private sector organizations and within the public sector - for the implementation o f the national program. Such partnerships are seen as the main vehicle to address concerns about the absorptive capacity to intensify the national response to HIV/AIDS as significant as foreseen underthe project. Monitoringand Evaluation Ina multi-sector projectwithdiverseimplementing agencies suchas this, itwill be important to have a sound M&E system in place early during project implementation. At the core o f the mandate o f the N A C is the M&E function for the overall national program. The project will strengthen the M&E capacity within NAS. During the first year, the supervision activities will focus on: - Achieving an adequate level o f functioning for the M&E. It i s anticipated that participatory stakeholder meetings will form part o f the annual project reviews. 72 Participatory M&E systems, such as being developed for community-based projects will be used to give the NAS the advantage o f sample tools and lessons learned - elsewhere; and Reviewing the appropriateness o f indicators as well as quality and quantity o f available data. Where needed the supervision mission will also provide additional support to the establishment o f terms o f reference for base studies and continuous data collection. Coordination The core function o f NAS is the coordination of a large range o f activities and initiatives implemented by a host o f agencies from the public sector, the private sector and civil society organizations, from national level to decentralized level. The supervision strategy will concentrate on supporting NAS inthis formidable task. Key targets inthe initial year will be the development o f a Joint M&E Framework for the national program, the development o f a model for Joint HIV/AIDS Program Reviews, the elaboration o f a joint financing framework for HIV/AIDS, and the functioning of NAS as the institution for joint administrative functions. Procurement Supervision will provide problem-solving support on procurement and evaluate whether capacity and procedures for procurement at the national and regional levels are satisfactory. It will also do ex-post reviews to ensure compliance with guidelines and evaluate the need for additional training. Financialmanagement Duringthe first year the project, supervisionwill focus onthe establishment andmanagement o f the Special Account and facilitate timely flow of funds directly to implementation entities. The argument for the fast tracking o fthis project hinges on an efficient and fast-disbursement channel to support the community and multi-sector responses to HIV/AIDS. The financial management specialist will also regularly evaluate the appropriateness o f the financial management set-up. Partnerships Many UN and bilateral agencies such as UNAIDS, WHO, UNICEF, and the French Cooperation have made useful contributions during project preparation. The Global Fund also expressed interest inparticipating on the basis o f the Government's strategy and the IDA prepared project document. A joint implementation mechanism will be established to ensure efficient allocation of scarce donor resources. The supervision o f the project will continue to build such partnership and collaboration. Three methods are identified to further develop the partnership and collaboration: 73 (i) Joint-missions. The IDA team will participate in the annual joint review o f the national HIV/AIDS program as organized by N A S together with other program partners. For all other regular supervision mission, the IDA team will invite other partners to participate. As each other partner can contribute a particular expertise this would leverage supervision resources and provide a more effective support to the program than individual missions can support; (ii) Sharinginternationalexperiencesandbestpracticesthroughsupervisionandbuilding o f regional alliances (exchanges and visits in sub-regional countries where more implementation experience exists), and by inviting resource persons with experiences inimplementingsimilar programs; and (iii) Periodicevaluationofthepartnershipswithaview(a) tostrengthenoftherelations; (b) improvecoordination. Duringthe project launch workshop, the IDA team will discuss the options described above with various partners to confirm possible arrangements and support. Supervision The project will need intensive supervision given the large span o f activities, its blend of public and private sector interventions, and its multi-sectoral as well as its multi-agency nature. In addition, concerns about severely constrained capacity will require intensive support. The project will be implemented by many entities with limitedto no experience in the area and whose capacity will therefore need substantial strengthening. A budget o f US$120,000 and a Junior Professional Associate based inthe Senegal Country Office will be needed to supervise the project during the first 12 months o f project implementation. The project task team will closely collaborate with the Bank's Global HIV-AIDS Office to obtain additional support to strengthen and review the project's M&E system as described above. Some o fthe skills required for the supervision o f the project will be needed on a regular basis while others will be required on an ad hoc basis. A core project team will be established after Board presentation, consisting o f staff involved in project preparation, emphasizing financial, procurement, monitoring and evaluation and general implementation skills, complemented by technical specialists as needed, in particular those covering M&E, community participation, training o f health staff in ART and STI diagnosis and treatments, maternal and child needs, specific health treatment issues, etc. A much more intensive than normal supervision program should be carried out during the first year o f the project to put in place a sound institutional base that will ensure efficient implementation o f a complex operation. Clearly there will be a learning process for N A C and NAS staff, who will have just come on board (developing a management culture, preparing terms o f reference, and with limited World Bank procuremedfinancial management experience). The Bank team will needto assess--on the ground--whether the indicators levels chosen are realistic, given the paucity o f data and the difficulties in data collection in a post-conflict country and evaluate their conformity to program and project needs. This is made more difficult in the absence of a permanent in-country presence o f Bank operational staff. The involvement o f 74 the Senegal Country Office staff in the project preparation would facilitate close supervision through their continued involvement. It i s expected that the Bank's country office will fully ensure supervision o f fiduciary aspects. Concerning the health sector, which i s crucial for related HIV/AIDS care, a specific supervision plan and budget will be established at the beginning o f each fiscal year. The project team will include the following members: (i) Task Team Leader with experience inHIV/AIDS operations; (ii) specialist, (iii) specialist, (iv) IEC specialist, (v) health M&E implementation specialist, to help in the critical first half year o f project's implementation; (vi) financial management specialist who will review adherence to Bank procedures with regard to fiduciary responsibilities; and (vii) procurement specialist, responsible for the procurement related issues. Sectoral specialists in the areas o f education, gender, maternal and child needs, and community participation will participate on an ad hoc basis. 75 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT Annex 14: Documents inthe Project File L i s t of studies financed by the PHRD Grant (TF026788) Identification of best practices: NationalAcces Systemto ARV: Anne Marie BodoBlizabeth MoreiraDos Santos Community and Traditional practitioners' involvement: ENDA Tiers Monde Creation o f an Association of PLHVIH: ENDA Tiers Monde Religious Involvement: ENDA Tiers Monde Strategical Plan and Instruments for the creation oftesting and counselling centers: Sonia MariaBatista Da Silva Making o f a kit for informal sexual education: Simone Souza Monteiro HIV/AIDS HumanRights andLaw inGuineaBissau: Ousmane Sane Designof a decentralized funding mechanism: OMS Consulting/Julio Injucam Designof an IEC strategy: Jacques DaMathdJose Rodrigues Santy Design of a nationalparticipatory strategy to fight against HIV/AIDS: AbdessalamFarzd Inacio Alvarenga Preparation of a strategy for orphan and PLWHA: Marie France AdrienKheikh Sagna Diagnostic of existing health care facilities: Fernando Vasco Da Silva Marques Preparation of Health Service Delivery Component: Fernando Vasco Da Silva Marques MAP Restructuring Proposal: AbdessalamFarza. Other Studies or documents: -- The HIV/AIDSNational Strategic Plan (2002) The first proposal for the GlobalFundfinancing (2003) 76 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 15: Statementof Loansand Credits (data as of February 2004) ~~ Difference between expected and Original Amount in US$ actual million disbursements Project FY Purpose IBRD IDA SF GEF Canc Undisb. Orig. Frm. ID el. Rev'd PO01001 2002 Private Sector 0.00 26.00 0.00 0.00 0.00 24.19 2.61 0.00 Rehabilitation and Development Support Project PO65725 2000 Economic 0.00 25.00 0.00 0.00 0.00 13.79 14.32 4.77 Rehabilitation and Recovery Credit PO35688 1998 National Health 0.00 11.70 0.00 0.00 0.00 4.46 4.13 4.30 Development Program. PO01015 1997 Basic Education 0.00 14.30 0.00 0.00 0.00 5.67 "5.21 4.59 ~~ ~~ Total: 0.00 77.00 0.00 0.00 0.00 48.11 26.27 13.66 77 STATEMENT OF IFC's Held and DisbursedPortfolio In Millions of US Dollars (Data as of February2004) Committed Disbursed IFC IFC FYApproval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1998 Banco da Africa 0.00 0.28 0.00 0.00 0.00 0.28 0.00 0.00 Total portfilio: 0.00 0.28 0.00 0.00 0.00 0.28 0.00 0.00 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic. Total pending commitment: 0.00 0.00 0.00 0.00 78 GUINEA-BISSAU: HIV/AIDS GLOBAL MITIGATIONSUPPORT PROJECT Annex 16: Country at a Glance Sub- P O V E R T Y and S O C I A L Guinea- Saharan L O w- Bissau Africa income Development diamond* 2002 Population mid-year (millio ns) I 1.3 688 2,495 Life expectancy GNipercapita (Atlas method, US$) 150 450 430 GNI (Atlas method, US$ billions) 0.19 306 1,012 Average annual growth, 1996-02 T Population (%) 2.1 2.4 1.9 Laborforce (%) 2.1 2.5 2.3 GNI Gross per primary M o s t racent estimate (latest year available, 1996-02) capita enrollment Poverly (% o f population belo wnationalpo vertyline) Urban population (%oftotalpopulation) 33 33 30 Life expectancy at birth (years) 45 46 59 1 Infant mortality (per 1000 live births) 122 105 61 Child malnutrition (%of children under5) 25 Access to improvedwater source Access to an improved water source (%ofpopulatlon) 56 58 76 Illiteracy (% of population age 59 59 31 31 Gross primaryenrollment (% o f school-agepopulation) 63 86 95 -Guinea-Bissau M ale 99 92 m3 low-incomegroup Female 66 60 87 KEY ECONOMIC R A T I O S and LONG-TERM TRENDS 1962 1992 2001 2002 E c o n o m i c ratios. GDP (US$ billions) 0.V 0.23 0.20 0.22 Gross domestic InvestmentlGDP 26.3 48.4 21.7 6.3 Exports of goods and serviceslGDP 1.8 4.9 40.1 Trade Gross domestic savingsiGDP -5.2 3.2 -11.2 Gross nationalsavings/GDP .. 10.6 -3.2 Current account balancelGDP .. -31.6 -22.1 Interest payments/GDP 0.6 1.3 5.6 3.6 Total debt/GDP 102.6 336.4 335.7 Total debt service/exports .. 59.5 59.8 Present value of debt/GDP 213.0 Present value of debtlexports 792.1 Indebtedness 1982-92 1992-02 2001 2002 2002-06 (average annualgro wth) GDP 3.6 0.1 0.2 -4.2 -Guinea-Bissau GDP percapita 1.4 -2.0 -2.0 -6.3 Low-income group STRUCTURE o f the E C O N O M Y Igg2zoo1 / G r o w t h o f investment and GDP (%) h (%ofGDP) Agriculture 46.8 49.4 56.2 58.1 Industry 14.4 m.7 12.7 12.2 50 M anufacturing 2.5 10.1 9.4 Services 38.6 39.9 31.1 29.7 0 Private consumption 15.1 81.8 98.9 -50 General government consumption 29.4 9.o 12.3 Imports of goods and services 41.3 50.1 13.6 I -GDI -GDP 1982-92 1992-02 2o01 2o02 Growth o f exports and imports (%) (average annualgro wth) Agriculture 3.5 3.2 1.2 8.1 '50 Industry 2.8 -4.6 6.5 " 100 M anufacturing 6.3 -3.7 5.9 Services 4.2 -0.1 9.2 50 - Private consumption -3.3 0.5 -16.0 0 General government cOnSUmPtiOn 4.6 4.6 -14.2 .. - -50 Gross domestic investment 14.6 -9.9 86.2 -1.9 -Exports -Imports Imports of goods and services -1.4 2.2 -5.8 9.9 79 Guinea-Bissau ~~ P R I C E S a n d G O V E R N M E N T F I N A N C E 1982 1992 2 0 0 1 2002 D o m e s t i c p r i c e s I n f l a t i o n (%) I (%change) 50 Consumer prices 69.4 5 0 3.5 40 Implicit GDP deflator 16.5 65.0 -5 1 7.9 20 G o v e r n m e n t finance (%of GDP, includes current grants) 0 Current revenue 0.0 13.9 22 5 -20 Current budget balance 0.0 -2.1 -0 7 I Overall surDlus/deficit 0.0 -34.3 -16 4 ---GDPdeflator -CPI I T R A D E 1982 1992 2001 2002 (US$ millions) E x p o r t a n d i m p o r t l e v e l s (US$ mill.) Totalexports (fob) 6 50 IO0 T Cashew nuts 3 46 Fish and shrimp 1 1 75 M anufactures Total imports (cif) 95 81 50 Food 32 30 Fuel and energy 5 9 25 Capital goods 24 7 0 Export price index(1995=WO) 86 69 95 97 98 99 00 01 02 Import price index(895=WO) 87 1% Exports Imports Terms o f trade (S95=WO) 98 60 B A L A N C E o f P A Y M E N T S 1982 1992 2 0 0 1 2 0 0 2 C u r r e n t a c c o u n t b a l a n c e t o G D P (%) (US$ millions) Exports of goods and SeNiCeS TI 11 55 0 Imports of goods and Services 80 113 116 Resource balance -62 -la2 -61 -5 Net income -14 -16 -15 .10 Net current transfers 30 32 .I5 20 Current account balance -86 -45 Financing items (net) 91 41 Changes in net reserves 16 -5 4 -7 M e m o : Reserves including goid (US$ millions) 18 51 55 Conversion rate (DEC, local/US$) 0.7 x36.7 733 0 699.3 E X T E R N A L D E B T a n d R E S O U R C E FLOWS 1982 1992 2 0 0 1 2 0 0 2 (US$ millions) C o m p o s i t i o n o f 2 0 0 1 debt (US$ mill.) Total debt outstanding and disbursed l70 761 668 IBRD 0 0 0 IDA 13 165 220 G: 18 Total debt service 6 7 32 IERD 0 0 0 IDA 0 1 7 Composition o f net resource flows Official grants 33 28 42 Official creditors TI 38 -14 Private creditors 1 0 0 Foreigndirect investment 0 6 30 Portfolio equity 0 0 0 D: 145 World Bank program Commitments 0 lo 0 4 IBRD E - Bilateral Disbursements 3 11 4 3 -- IDA D -Other multilateral F Private Principal repayments 0 0 5 3 - I M F G Short-ter -- 80