Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB4686 Project Name Lesotho HIV and AIDS Capacity Building Project Region AFRICA Sector Health (40%); Other social services (30%); General public administration sector (20%); Central government administration (10%) Project ID P107375 Borrower(s) Government of Lesotho Implementing Agency Ministry of Finance and Development Planning; Ministry of Health and Social Welfare; Ministry of Local Government and Chieftainship; National AIDS Commission Environment Category [ ] A [] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared November 21, 2008 Estimated Date of Appraisal Authorization December 15, 2008 Estimated Date of Board Approval May 21, 2009 1. Key development issues and rationale for Bank involvement: HIV is an unprecedented challenge for Lesotho, a small country with a population of 1.8 million that is completely surrounded by South Africa. Lesotho has the third highest HIV adult prevalence rate in the world at 23.3 percent. There are an estimated 62 new infections and 50 deaths due to AIDS each day. 270,273 people live with AIDS as of the end of 2007, of which 11,801 are children. Life expectancy at birth has dropped to 36.8 years. AIDS related orphans reached 108,000 in 2007. The adverse impact of the HIV epidemic is devastating on all aspects of society. The demographic structure of the country is changing as large numbers of people die in their productive years, thus creating a high dependency ratio. Economically, the epidemic disrupts capital optimization by striking at a quarter of adult Basotho and diminishing labor inputs. Critical skill shortages are being felt in government services as well as in business. The social fabric is fraying due to the large burden of orphans and vulnerable children (OVCs) and others living with HIV/AIDS. Households are being reduced to asset stripping, if not outright penury. The inter-generational spillovers are immense, as the OVCs are often deprived of access to education, good nutrition and health care will be ill-equipped to deal with challenges in the future. With 80 percent of HIV positive patients co-infected with Tuberculosis (TB), the HIV epidemic has dramatically increased the TB threat to Basothos’ health. Lesotho has the fifth highest TB incidence in the world with 635 cases per 100,000 population. TB deaths have tripled since 1990 with it being the leading cause of death for those with HIV and AIDS. Multi-Drug resistant (MDR) and Extremely Drug Resistant (XDR) are on the rise, threatening the Southern Africa Page 2 Region as a whole. This “ two disease, one patient ” issue needs to be addressed in a carefully coordinated way. The country regards HIV as the one of its most important development issues, declaring it as a national emergency in 2000. Since then, several major policies have been adopted by the Government, including the National HIV and AIDS Policy , National Orphan and Vulnerable Children Policy, HIV Testing and Counseling Policy, and Blood Transfusion Policy . The Labour Code Act was amended to prohibit discrimination against people living with HIV, and a Legal Capacity of Married Person’s Act was passed to empower women to fight HIV and AIDS. The National AIDS Commission was established in 2005, to replace the Lesotho AIDS Programme Coordination Authority (LAPCA), to strengthen the coordination of the national response. A National HIV and AIDS Strategic Plan (2006-2011) and a corresponding HIV and AIDS Monitoring and Evaluation Framework (2006-2011) were approved in December 2006. In particular, the National Strategic Plan (2006-2011) identified the main drivers of the epidemic – multiple and concurrent sexual partnerships and cultural factors including gender inequality and women’s disempowerment - and is focused on achieving four main strategic objectives: (a) strengthening management and coordination mechanisms; (b) preventing transmission of HIV; (c) treatment and care; and (d) mitigating the impact of the epidemic in the population. The strong political commitment and increasing social mobilization plus increasing internal and external funding have contributed to improvement in several key HIV and AIDS related interventions in recent years. The coverage of Prevention of Mother to Child Transmission (PMTCT) increased fivefold from 5 percent in 2005 to 31 percent in 2007. The rolling out of Antiretroviral Therapy (ART) made significant progress, with 21,710 patients receiving treatment in 2007. The “Know Your Status” (KYS) campaign helped a total of 229,092 people to be tested for their HIV status by 2007, representing 12 percent of the population and about three times the number tested in 2005. Lesotho has maintained a TB case detection rate above 80% for the past 3 years, and currently has a treatment success rate of 73%. Despite this progress, the national response significantly falls behind in terms of the optimal coverage of key interventions required to address the epidemic effectively. The implementation of the National Strategic Plan (2006-2011) has been slow. The major challenge to expediting and expanding the response to the epidemic remains as weak implementing systems at both the national and local levels, which urgently require support on capacity building, organizational strengthening, and the creation of an enabling environment at all levels. Rationale for Bank involvement : The Bank is a strong supporter of the country’s efforts in fighting HIV and AIDS. The CAS (FY06-09) set fighting HIV and AIDS as a priority area and requires all Bank operations to include measures to address HIV and AIDS. In addition, a HIV and AIDS Capacity Building and Technical Assistance Project (HCTA) (Gr. H113-LSO), a US$ 5 million grant, is currently under implementation with satisfactory ratings throughout. It is scheduled to close on time on December 31, 2008. The HCTA is the only collaboration between the government and development partners exclusively focusing on strengthening the implementing system. The project was explicitly designed to strengthen the implementing systems to help the disbursement of the large GFATM grants (Round 2). Based on the mid-term evaluation and feedback from partners, the HCTA, although small in dollar terms compared to the size of the GF grants, has helped fill in critical gaps in the implementation systems Page 3 (particularly in financial and grant management, procurement, M&E, development of strategies and operational plans) and contributed to the recent improvement in the national response. As a result, the ratings of the implementation of the GFA TM grants has improved from an almost “no go” (cancellation of the grants) three years ago to a fully satisfactory rating now, which is one of the best ratings in the region. The Bank’s efforts are much appreciated and welcomed by the Government and GFATM as well as other partners. The proposed project, which was explicitly included in the CAS as a key instrument of the Bank’s continued support, will utilize the Bank’s comparative advantages and provide follow-up support to the capacity building area of the national response. Lesotho is at a crossroads in the fight against HIV and AIDS. The country and its partners have a rare opportunity to make a difference now. First, although there is no significant decline in adult HIV prevalence rate (which could partly be the result of the rolling out of the ART program), adult HIV incidence rate decreased from 2.9 percent in 2005 to 2.3 percent in 2007 and new infections dropped from 26,000 to 21,558 in the same period. This is the first time the HIV epidemic has shown signs of declining. Second, following several major analytical studies (sponsored by the Government, Bank and UNAIDS), we have a better understanding of the drivers of the epidemic, which include multiple concurrent partners, unsafe sexual behaviors, the low condom use, limited male circumcision as well as social-economic factors. This provides the intellectual underpinning for tackling the epidemic effectively. Third, we have increasing knowledge on what works on the ground. For example, the UNGASS report has listed the PMTCT and the KYS campaign as best practice. Fourth, increasing resources for HIV programs, both internal and external, are available. If used effectively and efficiently, there is a real possibility of making a dent in the epidemic. 2. Proposed objective(s): The project aims at building capacity of government agencies and civil society organizations at both the national and local level to support the implementation of the National HIV and AIDS Strategic Plan in general and the scaling up of the coverage of effective interventions in particular in an effort to contain and reverse the epidemic. 3. Preliminary description : Component 1: Improved institutional capacity and organizational efficiency to implement the multisectoral response . This component aims at supporting NAC, MOHSW, MOFDP, other line ministries, and civil society organizations in their roles in implementing the NSP with a focus on effective preventive and behavior interventions. Specifically, the component will: (i) provide financial and technical support to the HIV mainstreaming in line ministries and relevant sectors; (ii) strengthen NAC’s management and coordination capacity to coordinate the implementation of the NSP; (iii) develop financial management skills in the CSOs so that they can mobilize and use resources efficiently; (iv) strengthen the country’s HIV and AIDS research capacity to generate timely and accurate evidence to guide the national response; and (v) support the development of the HIV resource tracking system and assist HIV expenditure analysis. Page 4 Component 2 : Improved capacity to scale up the health sector response . This component mainly support implementers in the health sector (both MOHSW and NGOs) to build capacity for delivering essential and effective HIV/AIDS and TB services. Specifically, it will: (i) support the scaling up of the existing programs proven to be effective, such as PMTCT, KYS, HIV testing and counseling, etc.; (ii) strengthen the health information system and research capacity; (iii) assist in updating the outdated Public Health Order (1972) to provide an over-arching legal framework for the provision of health services; and (iv) strengthen the national TB programs and support the integration of TB and HIV programs. Component 3 : Strengthened systems and coordinated efforts to implement the decentralized local response . This component intends to build capacity and provide technical assistance to implementers (including both governmental and civil society implementers) at the district and community levels to implement HIV/AIDS activities. As the current local response is vertically- organized and fragmented, this component will be the most challenging component among the three components. Specifically, it will (i) build the skills and capacity of district and community council structures to implement the essential HIV and AIDS Service Package (ESP); (ii) strengthen the operational capacity of the local civil society organizations to provide HIV and TB services at the community level; and (iii) enhance the management capacity of the District AIDS Committee and the proposed Community AIDS Committee and use them as the gateway to harmonize HIV and TB activities at the local level. 4. Safeguard policies that might apply: The proposed project will provide technical assistance and capacity building and will not directly support implementation. 5. Tentative financing Source: ($m.) Borrower International Bank for Reconstruction and Development 5 Total 5 6. Contact point Contact: Feng Zhao Title: Sr. Health Specialist Tel: (202) 458-7772 Fax: (202_ 473-8299 Email: fzhao@worldbank.org