Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB1466 Project Name Eritrea HIV/AIDS/STI, TB, Malaria and Reproductive Health Project (HAMSET II) Region AFRICA Sector Health (70%); Other social services (15%);Sub-national government administration (10%);Central government administration (5%) Project ID P094694 Borrower(s) GOVERNMENT OF ERITREA Implementing Agency Ministry of Health Hiwet Street # 5 Asmara Eritrea Tel: 291-1-124199 Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared March 21, 2005 Estimated Date of Appraisal Authorization April 26, 2005 Estimated Date of Board Approval June 23, 2005 1. Key development issues and rationale for Bank involvement Eritrea is one of the poorest countries in the world (annual GDP per capita US$ 150) with a low Human Development Index (ranking 156 th among 177 countries). Since independence in 1991, the country has made great efforts to improve health outcomes. Some achievements are remarkable for a low-income Sub-Saharan African (SSA) country. HIV/AIDS prevalence rate remains low at 2.4% of pregnant women in 2003 (compared to 2.8% in 2000). Over the same period, the number of reported sexually transmitted infections fell by a quarter. Malaria mortality and morbidity were reduced by more than 80% in the last four years, by far the best performance in SSA. These achievements can largely be attributed to the IDA-financed HIV/AIDS/STI, Malaria and TB (HAMSET) control project (US$ 40 million, planned closing date March 2006 but likely to disburse fully in the fall of 2005). These successes notwithstanding, addressing HAMSET diseases remains an unfinished agenda in Eritrea. Eritrea still faces a high burden of communicable and preventable diseases. Certain population sub-groups exhibit very high rates of HIV infection (e.g. commercial sex workers or certain urban “hotspots”). TB control faces various challenges – coverage of DOTS 1 , case detection and treatment outcomes all need improving. Without continued vigorous control efforts, there is always the risk of malaria outbreaks, especially as Eritrea’s neighboring 1 Direct Observed Treatment Strategy, the internationally recommended strategy for TB control. Page 2 countries have weak malaria control programs. In addition, reproductive health (RH), which has strong links to HAMSET diseases (especially malaria), remains a great challenge. In 2002, only 28% of women gave birth in a health facility and a very low 5% used modern contraceptives. The harmful practice of female genital mutilation is widespread. Accessibility, availability and quality of emergency obstetric care (EmOC) is limited. As a result, maternal mortality remains very high, at 998 per 100,000 live births. Eritrea’s RH indicators are among the worst in SSA and RH is an important outlier among an otherwise encouraging set of health indicators. As a very poor country, Eritrea is in dire need of more investment in health in order to achieve the Millennium Development Goals. Although Eritrea was allocated modest amounts of US$ 8.1 million for HIV/AIDS and US$ 2.6 million for malaria by the Global Fund (GFATM), the country receives very little external support for the health sector and the GoE remains strongly interested in Bank support. There is no significant external funding for reproductive health in the country. The HAMSET credit is expected to be fully utilized soon. Significant progress in many health outcomes is solid evidence that Eritrea could, with continued investment and support, be one of a very few SSA countries which can achieve most of the health-related MDGs. Thus, further efforts to address HAMSET diseases and reproductive health represent an important opportunity for IDA to reinforce and build on the recent substantial gains. Key development partners in the country (especially USAID, Italian Cooperation, UNICEF and UNAIDS) advocate strongly that IDA support should continue. IDA’s contribution to health sector development in Eritrea has been significant and its role has evolved over recent years. The recently closed Health project and the nearly fully disbursed HAMSET project both supported the implementation of key priority aspects of the sector. Policy dialogue within the context of the implementation of these projects has continued. Another pivotal development was the preparation of the Health Sector Note (Report No. 28267- ER, 2001) which formed a major input for the government’s health sector policy preparation. IDA is now the largest external financier of the health sector and the few other donors typically provide supporting technical assistance. Apart from its technical and operational expertise in the health sector, IDA also brings its experience of many HIV/AIDS projects to the table and of working multi-sectorally to address better HIV and other communicable diseases. IDA has been able to support high priority communicable disease interventions and ensure their impact. We are now proposing also to address one of the major outstanding health challenges in Eritrea -- maternal and reproductive health. 2. Proposed objective(s) The proposed project's development objectives are to: (i) reduce the spread of HIV/AIDS/STI in high-risk groups as well as the general population through a multi-sector approach which aims at scaling up prevention, diagnosis, care, and support services for HIV/AIDS, with a renewed focus on the most high-risk populations, (ii) expand DOTS coverage, improve case detection and treatment outcomes for TB; (iii) prevent any increase in malaria mortality and morbidity from the current low level, and (iv) improve RH interventions coverage and RH outcomes. During project preparation, the task team and the GOE will agree on proxy indicators for each area and determine specific overall targets. Page 3 3. Preliminary description The proposed HAMSET II (IDA grant US$ 24 million) would support key priorities in the national strategic plans for HIV/AIDS/STI, TB, malaria and RH. It would have four components: (1) Multi-sectoral response (US$ 3 million) : this component supports key (non-health) line ministries, local governments and civil society organizations to scale up prevention (including behavior change communication or BCC), care and support interventions for HIV/AIDS/STIs, malaria, TB and RH. (2) Health sector response (US$ 12 million): this has four sub-components – HIV/AIDS/STI (US$ 3 million), TB (US$ 2 million), malaria (US$ 2 million) and RH (US$ 5 million). Each sub-component would include the following activities: a. Improve the information base for decision making (including disease surveillance, surveys, operational research, etc.) b. Scale up prevention interventions (especially technical support in behavior change communication for the multi-sectoral response and community initiatives) c. Scale up diagnostic, treatment, care and support services (3) Community response (US$ 5 million) : this component aims to scale up and consolidate community-managed response initiatives to address HAMSET diseases and RH. (4) Project coordination, capacity building and M&E (US$ 4 million) : In particular, capacity building would include support for pre-service and in-service training. The proposed HAMSET II project would be built on the successful on-going HAMSET project, making use of the existing HAMSET institutional framework as well as arrangements which are in place for safeguards, procurement, financial management, etc. Various HAMSET institutional arrangements (Project Management Unit, HAMSET Steering Committees and Technical Committees at the national and local levels, etc.) are working effectively and will be utilized for HAMSET II. 4. Safeguard policies that might apply Environmental assessment (medical waste management plan): The proposed project involves risks associated with the handling and disposal of medical wastes. However, a Health Care Waste Management Plan has been developed by the country and evaluated by IDA under HAMSET I. That plan is currently being implemented. Pest management: The proposed project will finance insecticides for malaria control activities. The overall use of insecticides is relatively small (e.g. for the impregnation of bed nets), and only safe compounds approved by the World Health Organization Pesticide Evaluation Scheme (WHOPES) will be used, namely temphos (a larvicide) and pyrethroid. DDT will not be procured under the project. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 5.1 INTERNATIONAL DEVELOPMENT ASSOCIATION 24.0 Page 4 LOCAL COMMUNITIES 0.9 Total 30.0 6. Contact point Contact: Christopher D. Walker Title: Lead Health Specialist Tel: (202) 458-0729 Fax: (202) 473-8299 Email: Cwalker@worldbank.org Location: Washington DC, USA