Report No. PID9941 Project Name Benin-Multi-sectoral HIV/AIDS... Project Region Africa Regional Office Sector Multi-sector Project ID BJPE73118 Borrower(s) Republic of BENIN Implementing Agency Address Benin Technical Secretariat of the National AIDS Control Committee (CLNS) Contact Person: Dr. Alphonse Gbaguidi Tel: (229) 31 54 88 PO Box 04-0378 Fax: (229) 31 63 87 Environment Category B Date PID Updated August 22, 2001 Appraisal Date July 30, 2001 Projected Board Date October 18, 2001 1. Country and Sector Background National awareness of the spread of HIV/AIDS dates back to the mid-eighties. In 1987, the National AIDS Control Program (NACP- PNLS) was established within the MOH to coordinate the national response to the epidemic. While the national response to the HIV/AIDS epidemic has improved over time, the Government of Benin (GOB) recognizes that it is still inadequate. In August 2000, the council of Ministers have paved the way for further improvements noting the need for a multi-sectoral approach and a greater participation of the civil society and communities. With the support of external partners, a National HIV/AIDS Strategic Plan is being developed It is estimated that at least 2.5 percent (1999- UNAIDS figures) and possibly 4.1 percent (1999- NACP-PNLS) of the adult population of Benin is infected with HIV. According to these sources from 70,000 up to 160 000 Beninese are estimated to be living with HIV. 12 between 1990 and 1999 have multiplied prevalence. Surveys have shown wide variations in seroprevalence among regions (from 1.4w in Atacora to 7.9w in the Zou). Peak ages for reported AIDS cases are 20-29 for females and 30-39 for males. Although the primary mode of transmission of HIV is heterosexual (accounting for more than 90t of the cases), vertical transmission- from mother to child- is increasing. 2. Objectives The proposed project is part of the World Bank' s Multi-sectoral HIV/AIDS Program for the Africa Region (MAP). In accordance with the main goal of the MAP, the development objectives of the proposed project are: (i) to accelerate, intensify, diversify, and empower the response of civil society and the public sector to the HIV/AIDS epidemic; (ii) to build capacity in both civil society and the public sector to achieve and sustain this scaled up response. The main purpose of the project is to support the implementation of a diversified gender-responsive multi-sectoral response, engaging all relevant government sectors, private sector, nongovernmental and civil society organizations and grass-root initiatives in the fight against HIV/AIDS. In Benin, the scaling up of existing HIV/AIDS activities by definition involves the scaling up of both preventive and provision of care activities. The project focuses on reinforcing and extending the capacity needed by key actors in civil society and the public sector to stabilize and finally reduce the rate of HIV/AIDS transmission, and to minimize the impact of the epidemic. In collaboration with other partners in the International Partnership against Aids in Africa (IPAA) the project will mobilize and build capacity for Benin's multi-sectoral scaled -up response to the epidemic, by financing execution of HIVAIDS activities by the communities themselves, and by privileging the contracting out of capacity building, by both communities and line ministries, to competent NGOs, CBOs, indigenous associations, professional organizations, and private sector agencies. 3. Rationale for Bank's Involvement Availability of sufficient funding for HIV/AIDS: Although several donors are supporting Benin's efforts to step up the national response, resources currently allocated to HIV/AIDS related activities only represent a 0.20 US$ expenditure per capita/year. In 2001, the GOB has significantly increased its budgetary funding to HIV/AIDS related activities. However, this increase will not be sufficient to bring at the appropriate scale the efforts of non- governmental and community-based groups. Therefore, Bank's support would help GOB increase the expenditure on HIV/AIDS up to 0.75US$ per capita/year and be more effective in the fight against the HIV/AIDS. Cross-country experience: The Bank is the largest financier of HIV/AIDS and STD control projects and has ample experience in the design, implementation and evaluation of these programs in all continents the Bank works in. Moreover, the Bank has ample experience in the management of investment and community development funds all over the world in which implementing entities are largely organizations of civil society and local district governments. Analytical capacity: The Bank has authored numerous studies analyzing HIV/AIDS and its impact, drawing upon knowledge in epidemiology, public health, and economics in order to make recommendations on defining priorities, strategies to confront it, and the measurement of its impact. The Bank can provide added value in its technical assistance on monitoring and evaluation. 4. Description The project would finance a US$25.43 million, 4-year component of the Government's HIV/AIDS Strategic Plan. The project's objective is to support GOB efforts to promote and implement an appropriate, rapid, sustainable and efficient multi-sectoral response to the epidemic. To achieve its objective, the project includes support for the following activities: 1. Support to the response of Civil Society (US $13.3 million). The project will provide technical assistance and financial support for two broad - 2 - categories of activities: (A) the participatory community-based preparation and execution of community HIV/AIDS action plans by the communities and/or community-based groups themselves; (B) the execution of community-based HIV/AIDS preventive and provision of care activities by private sector organizations, NGOs and associations of civil society. The nationwide IEC campaign and training cycle will be repeated annually, following evaluation and feedback on the results and obstacles for the program to date from the community-based action plans via the decentralized Departmental level HIV/AIDS Committee's (CDLS) to the nationwide Committee for the National HIV/AIDS Strategy (CNLS.) 2. Support to the response of the public sector (including the health sector) (US $8.3 million). This component provides for follow-up support for two categories of public sector activities: (A) to non-health sector line ministries and public and private institutions at the national level, to build their capacity to elaborate and execute short and medium-term HIV/AIDS action plans; (B) to the Ministry of Health, (MOH) to contribute to the expansion of the coverage and improvement of the efficacy of 4 interventions in its program of activities to prevent the spread of HIV/AIDS. The project will mobilize 16/20 non-health sector line ministries, which have yet to launch their first HIV/AIDS initiatives; and will provide support to the Ministries of Rural Development, Defense, Education, and Youth and Tourism, to enable them to deepen and expand their current action plans. Of the 50 or so other public and private sector institutions, the National Assembly, both the Universities, the Port Authority and various associations of the judicial system are examples of key actors. The project provides for technical assistance and financial resources for the HIV/AIDS Unit (PNLS) of the MOH in 4 areas: (a) improved accessibility to HIV testing and counseling; (b) improved prevention of HIV transmission; (c) improved quality and scale of provision of health care to persons living with HIV/AIDS; (d) a program of collaboration with the national and decentralized associations of Traditional Practitioners. 3. Support to project management, monitoring and evaluation (US $3.8 million). The PMU will be responsible for facilitating project implementation within the framework of the National HIV/AIDS Strategy and the CNLS. The objectives and related responsibilities for the PMU fall into four categories: (A) Communications; (B) Capacity Building; (C) Monitoring and Evaluation; (D) Financial Management. This will essentially involve facilitation of (A) Communications: Launch and annual mass communications initiatives through the life of the project/ strengthening CNLS advocacy, and awareness raising capacity. (B) Capacity Building: technical assistance for the sectoral line ministries and the newly established multi-sectoral CNLS technical secretariat in their respective HIV/AIDS action planning, execution and coordination roles. (C) Monitoring and Evaluation. Technical assistance to ensure CNLS review of the HIV/AIDS M & E results and assessment of the strategic implications. (D) Financial Management. Timely and efficient disbursement and support for responsible management of funds by all subcontracted executing agencies 5. Financing Total (US$) GOVERNMENT 2.0 IDA 23.0 Community/NGOs 0.43 -3- Total Project Cost 25.43 6. Implementation The credit would be disbursed over a four-year period. The project will support the existing national structures and/or the new ones to be created under the new Strategic Planning. The overall responsibility for the implementation of the national strategy for the fight against HIV/AIDS lies with the National AIDS Committee, which would be in charge of the definition of broad priorities for action. The HIV/AIDS Committee is responsible for the strategy definition, the approval of annual work plans and budgets, and the supervision of the implementation of the strategies at their respective levels. Its technical secretariat will ensure proper implementation. The management unit would be responsible for the financial and administrative aspects of the project. It would contract the necessary technical support to guide executing entities in preparing proposals and implementing subprojects. It would prepare and administer contracts to selected executing entities and monitor their technical and financial performance. The PNLS would be for example in charge of the health support sub-component, while the support to civil society response component would be under the direct responsibility of an independent agency, i.e., AGeFIB which has five regional offices. The rule of thumb in the design of the institutional arrangement is the flexibility and ensuring that the money goes directly where it is needed. 7. Sustainability Sustainability is more likely to result from: selecting low-cost, preventive interventions and thus reducing the number of people who contract HIV/AIDS which would require more expensive treatment; and strengthening capacity to deliver cost-effective interventions, especially at the local level, and with major involvement community organizations. The project will help prevent substantial expenditures on treatment of AIDS cases in the public sector, by virtue of the number of HIV infections that are averted. Strengthening the capacity of the National AIDS Committee to oversee the program, and strengthening implementation capacity in the public, private and NGO sectors, especially at local level, would enhance managerial sustainability. The project would include capacity building. 8. Lessons learned from past operations in the country/sector The project design reflects key lessons learned from international experience with HIV/AIDS. Key lessons learned are: aggressive, preventive interventions are required to slow the spread of HIV; interventions targeted to high risk behaviors and groups, within a broader campaign, are the most cost-effective way to reduce transmission and the best way to protect lower risk groups from infection; information acquired through personal contacts is the most effective in promoting behavior change; targeted interventions need to be complemented by broader advocacy, awareness and information campaigns which inform and protect the general population, build support for the program, and reduce the stigmatization of those infected or members of marginalized groups; and advocacy and coordination across multiple sectors, including the NGO and - 4 - private sectors, is needed to stem the epidemic. The experience in Uganda, where an advanced epidemic has been brought under control, and in Senegal, where a generalized epidemic has been prevented, demonstrate that HIV can be controlled through aggressive action combining strong government commitment, energetic prevention programs targeted at high risk behaviors, and sufficient resources from multiple sectors and sources. 9. Program of Targeted Intervention (PTI): N 10. Environment Aspects (including any public consultation) Issues: Following the 8/2001 management decision that all MAP projects are to be considered as Category B, the following issues are raised: (i) to what extent hospital waste, such as syringes, gloves, bandages, human tissue, etc is being mixed with other waste and whether it is handled and disposed of in a way that may constitute an environmental hazard; (ii) current practices with regard to the handling of hospital waste by municipal authorities once the hospital waste has left the hospital; (iii) the level of knowledge among staff (hospital orderlies, municipal managers and workers) about safe hospital waste management practices and in specific HIV/AIDS waste management; (iv) the availability of hospital equipment such as incinerators to deal with this type of waste. Actions have been initiated to address these issues prior to project effectiveness. 11. Contact Point: Task Manager Nicolas Ahouissoussi The World Bank Zone Residential de la Radio BP 03-2112 Cotonou- Benin Telephone: (229) 31-12-24; Dama: 5390 321 Fax: (229) 31-58-39 12. For information on other project related documents contact: The InfoShop The World Bank 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. Processed by the Infoshop during the week ending August 31, 2001. - 5 -