Updated Project Information Document (PID) Report No: AB692 Project Name GUINEA-BISSAU - HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT Region Africa Regional Office Sector Health (100%) Theme Other communicable diseases (P) Project P073442 Borrower(s) GOVERNMENT OF GUINEA-BISSAU Implementing Agency(ies) PNLS Address: Av. Unidade Africana C.P. 50 - Bissau Contact Person: Paulo Rabna Tel: 245 20 28 38 Fax: Email: Paulo6602@yahoo.co.uk Environment Category B (Partial Assessment) Date PID Prepared April 16, 2004 Auth Appr/Negs Date March 15, 2004 Bank Approval Date June 1, 2004 1. Country and Sector Background According to the most recent United Nations' Human Development Index, Guinea-Bissau is one of the world's poorest countries, and was ranked 156th out of 162 countries in 2001. The poverty rate in 2002 was estimated at 80 percent of the total population and the gross domestic product (GDP) per capita over the period 1997-2000 averaging US$195 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 in economic development in Guinea-Bissau in the early 90s. The conflict reduced real GDP by 28 percent and agricultural production by 17 percent. Much of the physical infrastructure was severely damaged. Subsequently, fiscal problems have hampered the implementation of all publicly financed programs, including HIV/AIDS activities. Access to modern healthcare is limited and the health system is very weak with one central hospital, nine dilapidated regional hospitals, and a patchwork of about 150 health centers and health posts of varying quality. Most of the rural population have no or limited access to modern health care and use the services of traditional healers. Availability of financial resources remains a serious problem. Health services, which are crucial for HIV/AIDS mitigation, are still in disarray and will take a long time to recover given the poor state of the physical infrastructure. The displacement of people only fuels transmission rates, which have increased following the civil war, especially among the under 30-age group. Besides increased poverty and dislocation of people after the war, additional determinants contributed to the increase in HIV infection rates: ignorance, low rate of condom use, denial and fear of AIDS, multiple partners as an accepted custom, prostitution, and stigma. There are no comprehensive and reliable HIV statistics. Available data from the Ministry of Health show that, between 1994 and 1996, there were between 600 to 900 new cases per year, 1101 in 1999. The disease is continuing to spread mostly along the main transportation axes from Bissau to Bafata, Gabu, and Cacheu. According to the 2001 WHO EPMODEL calculate, health centers were only capturing around 16 2 PID percent of estimated cases. It is projected that in the next years HIV-1 would infect 24 to 40 persons daily, while HIV-2 infection rates would continue to decline. 1.2. Government Strategy National Strategic Plan (NSP) for HIV/AIDS, with technical assistance and financial support from UN Agencies and the World Bank, was adopted at a national workshop chaired by the Prime Minister and the Health Minister in June 2002. The NSP reflectes the following Government priorities: (i) build capacity at local and national level to ensure quality of services and expansion of existing good practices, (ii) mitigate the negative socio-economic HIV/AIDS epidemic impact, (iii) scale up advocacy measures to ensure full involvement of policy makers, civil society and the private sector, (iv) reach all vulnerable groups to prevent new HIV infections, (v) promote positive socio-cultural behavioral change, (vi) improve the institutional framework, and (vii) guarantee program sustainability. Furthermore, during project preparation Government has agreed to use a decentralized participatory approach, a multi-sectoral strategy, and a reliable and fully transparent financing system for the project. 2. Objectives The specific project objective is to support the medium-term strategy of the Government to expand and accelerate the national response to HIV/AIDS by (i) reducing the spread of HIV/AIDS infection; (ii) increasing treatment access for STD and HIV/AIDS; and iii) decreasing the socioeconomic impacts of HIV/AIDS at the individual, household, and community levels. 3. Rationale for Bank's Involvement The Bank addresses HIV/AIDS as a developmental issue. The September 1999 launch of the Bank's regional AIDS strategy, Intensifying Action Against HIV/AIDS in Africa, 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 (ACTafrica), UNAIDS, and other partnerships, the Bank is well positioned to contribute its regional experience to the project. The existing HIV/AIDS Program has to be scaled up by mainstreaming program activities to all the MDAs and other non-health government agencies at all government levels, and by making better use of community and civil society organizations such as churches, trade unions and private businesses. To sustain the current progress and to reduce HIV/AIDS and its impact on socioeconomic development, technical and financial assistance from IDA is required to partially fill the funding gap. IDA support will also be an important factor for potential participation by bilateral partners and the Global Fund to fight HIV/AIDS, Tuberculosis, and Malaria (GFATM). 4. Description The project is designed within a multi-sector framework, under the Multi-Country AIDS Program (MAP) for Africa, which addresses HIV/AIDS in a broad context. It will support the Government in applying an expanded response to HIV/AIDS through: l community-based initiatives, which would include HIV/AIDS prevention programs through peer education, IEC activities, and Voluntary Counseling and Testing (VCT) services, care of orphans, widows and home-based care for Persons Living with HIV/AIDS (PLWHA) l mainstreaming HIV/AIDS into the programs of all MDAs and local government authorities l sensitize the private sector to the need for greater attention to the HIV/AIDS issue The project will be implemented through three components as follows: Part A. Community and Civil Society Initiatives, and Capacity Building. - social mobilization and community level responses to HIV/AIDS 3 PID - expanding and strengthening HIV/AIDS activities of communities NGOs, CBOs, private sector, religious sector, and PLWHA Funds will be specifically set aside for two groups: Orphans, whose numbers are increasing as the epidemic progresses. The program would target all orphans, as differentiating orphans by causes would be difficult and inhumane. PLWHAs, who have decreased productive capacity, which further reduces their resources. It is essential to help families avoid the poverty trap and adjust available technologies in the agricultural and private sectors to address this limitation and to create adapted sources of revenue. Part B. Government Multi-sector Response · strengthen prevention, care, support, and mitigation of the HIV/AIDS impact through public sector programs and activities · support public sector institutions to protect their own personnel from the impact of HIV/AIDS and integrate HIV/AIDS activities into their core business This component will support: The Ministry of Health ­ which will receive the largest share of funds under this component. The ministry has a unique role in combating the epidemic, as it is often the only source of health care in rural areas. This support will partially finance the Ministry's HIV/AIDS work plan. All other Ministries and Government Agencies ­ ministries with responsibility for the highest priority areas (education, health, agriculture, interior and army forces, youth and sport) will receive comprehensive support during the first year. Others will receive limited support. Part C. Institutional Development for Program Management The project will support the National AIDS Council (NAC) and its Executive Secretariat (NAS), including its regional components and focal points, to fulfill its national HIV/AIDS coordination mandate. The broad responsibilities assigned to the NAC evolve around advocacy, providing leadership for the multi-sector response, coordination, and monitoring and evaluation. 5. Financing Source (Total ( US$m)) BORROWER/RECIPIENT ($1.50) IDA GRANT FOR HIV/AIDS ($7.00) FRANCE: MINISTRY OF FOREIGN AFFAIRS (MOFA) ($0.50) Total Project Cost: $19.00 4 PID 6. Implementation Project Management The project will be under direct supervision of the Prime Minister's Office (PMO). The National AIDS Council (NAC) will lead policy making. Coordination, technical support, and financing on the national level will be carried out by the National AIDS Secretariat (NAS), which will have an autonomous PMU status. Its staff will be recruited on the open market and Bank financing will be subject to an annual institutional assessment. 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. Donor Coordination Donors are channeling support through NGOs, the UN System, or civil society organizations. Due to the diversity of channels and contracting mechanisms, it is difficult to track all activities and donor funds. The principal actors include The French Cooperation, WHO, and UNICEF. UNDP and WHO established a thematic group, which meets regularly to coordinate HIV/AIDS and health activities. This role would be gradually assumed by the NAC as it gains experience. Project Monitoring The system will inform program management, other stakeholders, and external parties. It will: · provide accessible, timely information on program inputs, process, outputs, and outcomes · identify intra-country variations to support the design of effective HIV/AIDS operations · inform about progress, lessons, and needed improvements through a participatory evaluation · provide best practice examples Once the M&E system for the national program is finalized, one of the first priorities of the NAS will be to determine whether the existing data provide a sufficient baseline for the program impact and outcome indicators. If not, new data will be collected from the onset of the project. Project Evaluation Existing data collected through the MES will be analyzed and program goals compared to achievements for annual reviews. It should thus be possible to evaluate whether the project is moving in the right direction during implementation and assess to which it will have achieved its objectives by the time the grant closes. Supervision The Regional Committees, assisted by the Regional Focal Points, will supervise project activities at district and sub-district levels. Staff from the NAS, cooperating partners, and the Bank's Task Team will make field visits to monitor performance. The NAS will monitor overall implementation, discuss progress with the various ministries, and organize annual project reviews to assess the performance of the program. The World Bank's Task Team will cooperate with all partners involved and will provide multi-sector expertise. Due to the weak implementing capacity and the scope of the project, an intensive supervision is proposed. Procurement Arrangements NAS and RCs will procure works, goods, and services in relation to the respective activities, in accordance with Bank Procurement. Consulting services by firms, organizations, or individuals financed by IDA will be contracted in accordance with Bank selection guidelines. Communities will use the simplified procedures for investments under the Community AIDS Response Fund. Most grants will be under US$ 10,000 and communities will use "local shopping". For urgently required items valued at less than US$100,000, contracts may be made based on international 5 PID shopping and national shopping procedures, per IDA Procurement Guidelines (Clauses 3.5 and 3.6) or through procurement from the United Nations provided contract awards are made within twelve months of the project effectiveness date. 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 by ad-hoc reviews. Financial Management There is no qualified financial management firm in the country to carry out the project financial management. Cost of a foreign contractor is very high relative to the size of the grant. It has therefore been agreed with Government to hire a financial expert for the NAS instead of a firm. This approach has been successfully used in two other projects in Guinea-Bissau. Standard accounting and auditing procedures will apply to the funds disbursed to public or private institutions. Under the supervision of the PMO, the NAS Finance and Administration Director will ensure that financial management and reporting is in compliance with requirements of Government, IDA, and other partners. The Financial Management System (FMS) objective will be to assist management in providing project resources to beneficiaries. The FMS must be capable of producing timely, clear, relevant, and reliable financial information for planning, implementing, monitoring overall progress. Disbursement Procedures All procurement contracts not subject to prior IDA review will be disbursed against SOEs and documentation will be retained by NAS and made available for review. All disbursements will be subject to sample ex post financial and physical audits by financial and technical consultants employed by the NAS. Planning and Budgeting The planning and budgeting cycle will be designed to fit the National Budget cycle. Annual budget requests will be prepared and reviewed at regional and central levels by mid-year and submitted to the NAS for compilation into the aggregate program and budget. 7. 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. The country remains serious in its HIV/AIDS response, but support from bilateral and multilateral agencies beyond the initial period of implementation will be needed. 8. Lessons learned from past operations in the country/sector International experience with HIV/AIDS, experience from countries like Brazil, lessons-learnt from ongoing Bank supported HIV/AIDS projects in Africa within the MAP and country specific efforts in Guinea-Bissau have all been reflected in the project design. Key lessons learned from all this experience are outlined below: 6 PID · political leadership and commitment is imperative to confront the epidemic · vulnerability factors are key drivers of the epidemic; focus on vulnerable groups is essential · external resources and capacity building will empower the response of local communities · need to address the multi-dimensional nature of the epidemic with a multi-sector approach · beneficiaries must initiate project orientation and evaluation to address their needs · focus on knowledge building and evidence-based interventions where there is lack of consensus · rural radios have crucial role to efficiently educate large rural populations must be recognized · use of indigenous knowledge and practices may be complementary in the HIV/AIDS efforts · the role of the NAC/NAS and implementing agencies must be clearly spelled out · complex control of MAP projects requires more attention and resources than average projects · sufficient resources and skills should be made available for robust monitoring and evaluation · effective coordination among development partners can significantly reduce transaction costs 9. Environment Aspects (including any public consultation) Issues : The most important environmental issue relates to medical waste. In February 2002, regulatory agencies, health care facilities, litter gatherers, and community organizations were consulted and identified issues include: lack of appropriate selection of health care waste, carelessness and lack of qualification of the medical staff, mingling of health care waste with normal household litter, insufficient quantities of collection baskets and provisional litter containers, lack of security equipment for cleaning staff, and no efficient waste treatment system. The project is allocating US$370,000.00 for the medical waste management program in the five pilot regions. 10. List of factual technical documents: Several studies have been carried out as part of project preparation in the following areas: l Orphans l PLWHA l Rural radios l Implementation arrangements l Financial management arrangements In addition, the following documents are available from the Infoshop and the implementing agency: l Environmental Assessment l Social Assessment l Medical Waste Management Plan 11. Contact Point: Task Manager Christian Fauliau The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: 202 458 9870 Fax: 202 473 8229 12. For information on other project related documents contact: The InfoShop The World Bank 7 PID 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project.