INTEGRATED SAFEGUARDS DATA SHEET CONCEPT STAGE Public Disclosure Copy Report No.: ISDSC396 Date ISDS Prepared/Updated: 21-Dec-2011 I. BASIC INFORMATION A. Basic Project Data Country: Malawi Project ID: P125237 Project Name: Malawi Nutrition and HIV/AIDS Project (P125237) Task Team John Paul Clark Leader: Estimated 23-Jan-2012 Estimated 27-Mar-2012 Appraisal Date: Board Date: Managing Unit: AFTHE Lending Specific Investment Loan Instrument: Sector: Other social services (35%), Central government administration (25%), Health (20%), Sub-national government administration (20%) Theme: HIV/AIDS (35%), Nutrition and food security (30%), Participation and civic engagement (15%), Population and reproductive health (10% ), Child health (10%) Financing (In USD Million) Financing Source Amount Public Disclosure Copy BORROWER/RECIPIENT 10.00 International Development Association (IDA) 32.00 IDA Grant 48.00 CANADA Canadian International Development Agency 13.10 (CIDA) Total 103.10 Environmental B - Partial Assessment Category: Is this a No Repeater project? B. Project Objectives Proposed PDO The proposed project development objectives are to expand access to and increase use of essential services for nutrition and HIV and AIDS. The PDO is aligned to the goals and objectives of the: (i) the National Action Framework (NAF; 2005-2010), the Extended NAF (2010-2012) and the draft National Strategic Plan (2011-2016); and (ii) the National Nutrition Policy and Strategic Plan (NNPSP) 2007 – 2012, which is currently being updated. Public Disclosure Copy Key Results This project will contribute to reduced incidence of stunting, anemia and HIV infections while mitigating the impact of HIV/AIDS on the Malawian people. For nutrition, the focus is on interventions and services that contribute to the reduction of stunting and anemia as the two most widespread and programmatically most neglected nutritional disorders while maintaining achievements and piloting approaches for other nutritional concerns. The proposed performance indicators are: Percentage of pregnant women who take a 90 days’ supply of iron supplements during pregnancy; Proportion of mothers practicing exclusive breastfeeding for the first six months; Number of pregnant and lactating women being reached regularly (month or quarterly) by a minimum package of community nutrition services For HIV/AIDS, the proposed performance indicators are: Proportion of sexually active males and females who report having had sex with a non regular partner within the last 12 months [by gender and age cohort]; Percentage of HIV+ pregnant women receiving a complete course of ARV prophylaxis to reduce the risk of mother to child transmission. C. Project Description Proposed components are organized according to institutional arrangements for project implementation as well as the flow of funds. Component A will provide support for National Public Disclosure Copy Nutrition Policy and Strategic Plan (NNPSP) 2007 - 2012, and the updated version that is currently under elaboration, to contribute to the reduction of stunting and anemia in women and children by scaling up service delivery and strengthening multisectoral program governance. Component B will build on the experience from the current project and provide support for the NSP (2011-2016) to contribute to the reduced incidence of HIV infections particularly among the drivers of the epidemic through geographic and risk group targeting, while mitigating the impact of HIV/AIDS on the Malawian people. Program activities will be executed through performance contracts with line ministries, Local Governments, health districts, NGOs, the private sector, and communities. PROJECT DESCRIPTION Component A - Support for Nutrition Improvement (IDA $30 million): This component will support the scaling up of nutrition services by: (i) enhancing and expanding the implementation framework for nutrition service delivery at community level; (ii) strengthening multisectoral program development, coordination and monitoring. Nutrition service delivery at community level: The activities will focus on community mobilization for direct nutrition interventions with a strong emphasis on community-based behavior change communication, education and counseling on infant and young child feeding practices, home-based care and treatment of common infectious illnesses such as diarrhea, ARI and malaria, and family and health care for pregnant and lactating women. UNICEF has worked with the DNHA to develop the Public Disclosure Copy Nutrition Education and Communication Strategy (NECS) which has just been finalized and presented as part of the Scaling Up Nutrition launch in July 2011. The NECS is essentially a community behavior change communication strategy centered on community growth monitoring and promotion. Other activities include screening and management of acute malnutrition as well nutrition sensitive interventions such as the promotion of food hygiene and transformation, community hygiene and sanitation, and household food security. Implementation will involve NGOs for community mobilization as well as public service providers at district level. Generally, NGOs have a comparative advantage when it comes to community mobilization and service delivery in large part because: (i) they work closer with communities and are therefore better equipped to represent community interests than most government structures; (ii) they are not constrained by sectoral boundaries; and (iii) they have less bureaucracy than government structures, hence are more flexible and innovative in accommodating strategies around community needs and characteristics. The proposed project support will build on the (i) successful roll out of community management of acute malnutrition through partnership arrangements between NGOs and health districts; and (ii) experience with the Grants Facility by the NAC for the implementation of HIV/AIDS activities in a decentralized and multi-sectoral manner through Grant Recipient Organizations. In coordination with other donors a harmonized strategy for contracting out to NGOs will be developed as part of the project. The harmonization will focus on a common set of indicators and a basic package of interventions, and tendering criteria such as a minimum area of coverage, contract duration, and characteristics of the NGO. The focus for the Bank project will be on developing a cost-effective implementation platform for nutrition service delivery at community level, starting in approximately 10 worst affected districts, and in coordination with USAID and UNICEF which are Public Disclosure Copy in the process of piloting the implementation of the NECS in 2-3 Districts. CIDA is also interested to support the roll-out of NECS in a number of districts. In addition to the health districts, this component will foster effective partnership arrangements with agricultural extension workers and Local Governments to support community mobilization and service delivery for nutrition development. Multisectoral program coordination and management: The expansion of the implementation framework needs to be backed up by an effective program management structure. The component will finance activities in support of (i) program management, capacity building at the local, district and central level; (ii) multisectoral planning and implementation of sector-specific interventions including therapeutic management of acute malnutrition, food fortification, micronutrient supplementation and dietary diversification; (iii) the development and implementation of the monitoring and evaluation framework; (iv) strengthening of the coordination structures and mechanisms; (v) operational research and surveys; and (vi) technical assistance on policy development and program coordination. CIDA and the Bank are conducting an organizational assessment of the DNHA to better understand the capacities and capacity challenges of the organization as the entry point for sector policy and coordination matters. This will inform the design of the project as to what areas require strengthening for the DNHA to mobilize and maintain a nutrition constituency able to keep nutrition on the development agenda as a public sector priority. Component B - Support for the National HIV/AIDS Strategic Plan 2011-2016 (IDA $50 million; pooled fund $XX million ): Building on experience from the current project, and in line with the national response, including the anticipated National Strategic Plan (2011-2016), the proposed Public Disclosure Copy project will contribute to the reduced incidence of HIV infections, while mitigating the impact of HIV/AIDS on the Malawian people. As with the currently active project, the proposed project will contribute to the national response through the multi-donor HIV/AIDS pool. The annual work plans and budgets for the implementation of activities with pooled funding will be based on the anticipated NSP currently under development. The World Bank is making a significant contribution to development of the NSP through direct technical assistance and policy dialogue. In that dialogue, the Bank is emphasizing prioritization of activities and interventions based on the epidemiological characteristics of the epidemic, the evidence base for interventions and best practices identified in the Malawi context under previous financing. At this stage, the draft NSP is an evolving document and the structure and number of components is in flux. Therefore, for the purposes of this concept note, three (3) broad sub- components have been identified: i) prevention and behavior change; ii) treatment, care and support; and iii) impact mitigation. This represents a reduction in complexity from the ongoing project which has seven (7) separate components. This component will also finance activities in support of program management, capacity building at the local, district and central level; multisectoral planning a nd implementation of sector-specific interventions; the implementation of the mo nitoring and evaluation framework which includes routine information collection, special surveys and operational research; strengthening of the coordination structures and mechanisms; and technical assistance on policy development, program coordination and mainstreaming. Component B1 - Prevention and behavior change: Given the overarching goal of reducing the incidence of HIV infections, this sub-component is assigned a very high priority both within component B and the overall project. Interventions in this priority area have been aimed at reducing the number of new infections through reduction in sexual transmission of HIV; PMTCT; blood and transfusion safety; and, by creating a supportive environment for HIV prevention. Over the past few Public Disclosure Copy years there has been a significant increase in the supply of most services, such as counseling and testing sites, the number and frequency of messages in the media, condom availability, treatment of STIs, post-exposure prophylaxis and PMTC T. Unfortunately, some services are not yet broadly available, such as male cir cumcision. Services such as condoms and STI treatments are occasionally subject to stock-outs, while others have low uptake, such as with HIV counseling and testing services #particularly by men and couples, and PMTCT. There are also some potential concerns about prioritization and targeting of interventions. Much of this is being addressed in the context of the NSP drafting process and the Task Team will work with the client, HIV/AIDS pool donors and other stakeholders to ensure that the project addresses these weaknesses and increases overall program efficiency. For example, the Task Team plans to advocate for a significant in crease in effort and resources directed toward reducing incidence of HIV in the southern part of the county, which is home to the vast majority of new infections; and programmatic and analytical activities that will facilitate the scale up of male circumcision, which together with PMTCT is one of two prevention priorities identified by the HIV and AIDs Department of the National Ministry of health. . Voluntary medical male circumcision (VMMC) has been shown in both randomized control trials and observational studies to reduce a man#s risk of contracting HIV disease by 50-60%. When the proportion of circumcised men in the general population reaches a critical mass (about 60-80%), such preventative benefits begin to accrue to women as well, making VMMC one of the most effective tools available to reduce the incidence of HIV, especially in countries with high levels of the disease. If widespread adoption of MC occurs, scaling up safe MC programs to reach 80 percent of all adult and newborn males by 2015 would reduce the number of new adult HIV infections Public Disclosure Copy dramatically. By 2025, under such circumstances, the total number of annual new infections should decline by 55 percent (i.e. from 70,000 to about 31,000), even in the absence of other evidence-based prevention interventions. Scaling up MC programs is expected to result in a further decline in new adult HIV infections to a level of about 15,000 in 2025. Based upon an observed antenatal prevalence of 9.6 percent and an estimated 527,000 deliveries per year, 50,592 HIV-exposed infants are expected to be born in Malawi this year, out of which about 30 percent (or 15,177 infants) would be infected with HIV in the absence of PMTCT interventions. While only 54 percent of pregnant women deliver in health facilities, 92 percent of pregnant women make at least one antenatal care (ANC) visit. A strong national PMTCT program in Malawi has the potential to: (i) dramatically reduce new HIV infections in children; (ii) enroll many HIV-positive women and family members into care and treatment at an early stage of disease; and (iii) reduce maternal and child mortality by strengthening MCH service-delivery platforms. Component B2 - Treatment, care and support: The two key interventions of this sub-component are anti-retroviral therapy (ART) and PMTCT. These interventions not only prolong the lives of PLWHAs, but also contribute significantly to the prevention of new infections by reducing viral loads in PLWHAs and decreasing vertical transmission of HIV from mother to child (25% of new infections are among children born to HIV+ women). There still exist significant challenges with the integration of PMTCT and ART services into services provided by health facilities and community- based programs, low uptake of PMTCT packages by HIV+ pregnant women attending antenatal clinics and increasing the supply and demand for PMTCT services. Treatment activities will therefore focus on the facilitation of change in national ART policy to conform to new WHO guidelines (although it is not anticipated that the project will support the procurement of drugs, which are provided by other development partners) and PMTCT by making available pre-ART packages and nutrition support services in the context of ANC (See Component A). HIV+mothers will also be Public Disclosure Copy encouraged and/or monitored to return for follow-up treatment postpartum as well as postnatal for their newborns. Mitigation: Mitigation services will include nutrition services for PLWHAs and possibly other forms of social support. D. Project location and salient physical characteristics relevant to the safeguard analysis (if known) The project will be based in Malawi and will support services throughout the country with an emphasis on districts in the southern region for HIV and AIDS interventions. E. Borrowers Institutional Capacity for Safeguard Policies Under the Multi-sectoral AIDS Project, the Government of Malawi developed a Health Care Waste Management Plan and has several years of experience in its satisfactory implementation. However, safeguards capacity is generally low in the country and with numerous and diverse implementing agencies, attention will be given during preparation to the ongoing suitability of the Plan and the capacity to implement it under the new project. F. Environmental and Social Safeguards Specialists on the Team Stephen Ling (AFTN1) II. SAFEGUARD POLICIES THAT MIGHT APPLY Safeguard Policies Triggered? Explanation (Optional) Public Disclosure Copy Environmental Assessment OP/ Yes Safe disposal of medical waste is expected to be BP 4.01 the key environmental issue in the project. A Health Care Waste Management Plan has been developed and satisfa ctorily implemented under the existing Multi- sectoral AIDS Project. The potenti al for small-scale civil works (e.g. refurbishment or minor construction of offi ces, health posts, storage facilities, etc.) to be included in the project or di rectly-related investments will be assessed early during preparation, although s ignificant activities or impacts are not expected. The project is Category B and triggers OP 4.01. At a minimum, the project will require the preparation of a medical waste plan before appraisal. A short ESMF m ay also need to be prepared to take account of environmental impacts of civil wo rks. Natural Habitats OP/BP 4.04 No Forests OP/BP 4.36 No Public Disclosure Copy Pest Management OP 4.09 No Physical Cultural Resources OP/ No BP 4.11 Indigenous Peoples OP/BP 4.10 No Involuntary Resettlement OP/BP No 4.12 Safety of Dams OP/BP 4.37 No Projects on International No Waterways OP/BP 7.50 Projects in Disputed Areas OP/BP No 7.60 III. SAFEGUARD PREPARATION PLAN A. Tentative target date for preparing the PAD Stage ISDS: 15-Dec-2011 B. Time frame for launching and completing the safeguard-related studies that may be needed. The specific studies and their timing1 should be specified in the PAD-stage ISDS: 1 Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the InfoShop and (ii) in country, at publicly accessible locations and in a form and language that are accessible to potentially affected persons. The Malawi Waste Management Plan (MWMP) will be disclosed in the Country as well as in the Bank InfoShop before Appraisal. IV. APPROVALS Public Disclosure Copy Task Team Leader: Name: John Paul Clark Approved By: Regional Safeguards Name: Cary Anne Cadman (RSA) Date: 22-Dec-2011 Coordinator: Sector Manager: Name: Jean J. De St Antoine (SM) Date: 06-Jun-2012 Public Disclosure Copy