Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB2552 Project Name HIV/AIDS Multi-sectoral AIDS Project Region AFRICA Sector Other social services (40%);Health (30%);General information and communications sector (20%);General education sector (10%) Project ID P098031 Borrower(s) GOVERNMENT OF ETHIOPIA Implementing Agency National HIVAIDS Prevention and Control Office (HAPCO) Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared December 19, 2006 Date of Appraisal Authorization January 10, 2007 Date of Board Approval March 8, 2007 A. Country and Sector Background 1. Country Background: Ethiopia is among the poorest countries in the world with per capita income of about US$100 in 2005. Its population, the second largest in Africa, was estimated at 71.3 million in 2005, and is growing at an estimated annual rate of 2.7 percent. The economy is predominantly agriculturally-based, accounting for 80 percent of total employment and serving as an important source of inputs for the manufacturing sector. Around 44 percent of the population lives below the “basic needs” poverty line (estimated at US$139 (Birr 1053) based on annual market exchange of 2000) and improvements during the last decade have only been marginal. Poverty is particularly prevalent in rural areas where 85 percent of the population lives and where health facilities are sparsely distributed. 2. HIV/AIDS: Ethiopia is one of the countries hard hit by the HIV/AIDS pandemic. The first AIDS cases in Ethiopia were reported in 1986. From that year onwards, the epidemic has spread all over the country, beginning with the urban areas. As of 2005, HIV prevalence was estimated at around 3.5 percent according to Antenatal care (ANC)-based sentinel surveillance data, and 1.4 percent based on DHS-Plus data. Although overall HIV prevalence in Ethiopia is low, because of the large population, the absolute numbers of people infected and affected by HIV are significant. An estimated 1.32 million people live with HIV/AIDS, and there were around 128,900 new HIV infections in 2005 (i.e. 353 a day). Life expectancy in Ethiopia is falling as a result of the epidemic and is expected to drop to 50 years by 2010 from a previous estimate of 59 years. The country also has one of the largest populations of children orphaned by AIDS in Sub-Saharan Africa, currently estimated at 744,100. B. Objectives 3. The main objectives of the second Ethiopia Multi-sectoral AIDS Project are to: a) increase access to prevention services for youth, in particular females aged 15-24, and other most-at- Page 2 2 risk populations; and b) sustain access to care and support for PLWHA and orphans undertaken in EMSAP I. C. Rationale for Bank Involvement 4. While the World Bank is no longer the major funding agency in the fight against HIV/AIDS, its continued involvement is still believed to be critical by government, communities and partner agencies, particularly in the areas of prevention and support to civil society. EMSAP II will allow for scaling-up of HIV/AIDS prevention activities to target those communities not already reached as well as well as most at risk groups. Finally, the Bank’s financial support also provides the Government flexibility in the allocation of resources, as the donor of last resort, and complements the resources of GFATM, PEPFAR, DFID, Irish AID, UN agencies and other bilateral and multi-lateral organizations. D. Description 5. The World Bank will utilize a Specific Investment Loan (SIL) instrument to provide an IDA Grant of US$30 million equivalent for three years. Many current HIV/AIDS support programs in Ethiopia have a short timeframe for their financial commitments (i.e. annual basis). The risk of abrupt changes in the resource envelope is expected to be mitigated to some extent through the flexible design of the project and the longer project period. 6. The proposed project would finance three main components and would support the Government to move towards a programmatic approach. A fourth unallocated category (around $9 million) would be used to finance new activities as a result of changing priorities and sudden reductions in donor funding. Indicative allocations by component for the three years have been made; however, the actual allocations will be made annually in line with the agreed annual action plan with major donors. The detailed project description by component is in Annex 4. Component 1: National Program Coordination and Institutional Strengthening (US$2.5 million): The objective of this component is to further strengthen HAPCO at Federal, regional, woreda and community levels to ensure effective coordination and management capacity, and develop a sound M&E system. Expected outcomes include the establishment of a fully functional HAPCO structure and M&E system at all levels to facilitate coordination of all donors and key stakeholders. Success will be measured in terms of the percentage of woredas submitting program monitoring forms to HAPCO that are consistent with the national strategic plan for HIV/AIDS. Component 2: Multi-Sectoral Prevention Fund (US$3.5 million): This component is aimed at supporting a broad range of interventions in the public sector to prevent the spread of HIV. The main activities to be supported will include behavioral change targeted activities, peer and community conversations, condom distribution, and mechanisms for reduction of harmful traditional practices. The support will be targeted towards most important high-risk and vulnerable groups. Scaling up of interventions in public sectors will help register better Page 3 3 outcomes in terms of increasing prevention knowledge and fostering behavior change. Specific attention will be paid to integration of HIV/AIDS in reproductive health. Component 3: Local Response Fund (US$15 million): This component would support community and woreda-based initiatives focused on HIV/AIDS prevention, care and support activities targeting specific key at-risk groups. Evidence-based interventions for HIV prevention would be undertaken using an ABC methodology where A, B or C do not compete with each other but are applied to segmented risk groups. Expected outcomes would include a higher level of HIV/AIDS awareness at community level; behavioral change (reduction of traditional harmful practices; safer sexual behavior by both CSWs and their clients; delayed first sexual intercourse; reduction in early marriage; reduced sex with non- regular partners); increased condom use; increased VCT, and in particular increased number of young couples testing for HIV/AIDS before marriage. E. Financing Source: ($m.) BORROWER/RECIPIENT 3 IDA Grant 30 Total 33 F. Implementation 7. The National AIDS Council (NAC) will have the overall responsibility for overseeing the implementation of the national response. The NAC will be supported by the Secretariat, HAPCO, which has the facilitation and coordination role of all HIV/AIDS activities in Ethiopia. HAPCO at the Federal level is directly accountable to a Management Board, chaired by the Minister of Health on behalf of the Prime Minister. The regional HAPCOs are accountable to their respective regional health bureaus. Zonal and woreda health departments and offices are also responsible for coordinating HIV/AIDS activities in their respective areas. 8. A business restructuring process (BRP) of HAPCO has recently been carried out by the Government with the objective of re-structuring the agency to ensure more efficient coordination of HIV/AIDS activities and partners. A detailed capacity assessment is under way as part of this process. EMSAP II resources will support the strengthening of HAPCO based on recommendations from the BRP. One major improvement is the integration of the EMSAP I Project Coordination Unit (PCU) into the overall HAPCO structure in order to ensure ownership, sustainability, and to avoid fragmentation of responsibilities (in particular financial management, procurement and M&E). G. Sustainability 9. The sustainability of services over the longer term, especially with respect to ART, is of major concern, as the Government may not have the resources to continue financing such a huge – and growing – expense with the present level of local revenue generation. The donor organizations are actively seeking solutions to this question, focusing on finding a Page 4 4 mechanism to ensure external support until the country is able to pickup the cost of ART. The cost of maintaining prevention activities is relatively low, and Government is willing to gradually increase its share, so that by the end of the project, it will be fully covering related costs. Capacity building efforts will have been fully implemented by the end of the project, and it is expected that the strengthened institutions will be able to maintain the established implementation capacity for HIV/AIDS interventions. HIV/AIDS is a key pillar of PASDEP and will continue to benefit from donor support. H. Lessons Learned from Past Operations in the Country/Sector: a) focus in concentrated epidemics must be on high-risk areas and most-at-risk groups b) the focus on prevention activities must be renewed c) a strong national coordination unit must be in place d) partner coordination is critical e) a well-functioning, national M&E system for HIV/AIDS is of paramount importance f) the data collected by the M&E system must be used for informed decision-making g) communities, woredas, and civil society groups need ample capacity building to ensure results on the ground I. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assessment ( OP / BP 4.01) [X ] [ ] Natural Habitats ( OP / BP 4.04) [ ] [X ] Pest Management ( OP 4.09 ) [ ] [X] Physical Cultural Resources ( OP/BP 4.11 ) [ ] [X ] Involuntary Resettlement ( OP / BP 4.12) [ ] [X ] Indigenous Peoples ( OP / BP 4.10) [ ] [ X] Forests ( OP / BP 4.36) [ ] [X ] Safety of Dams ( OP / BP 4.37) [ ] [ X] Projects in Disputed Areas ( OP / BP 7.60) * [ ] [ X] Projects on International Waterways ( OP / BP 7.50) [ ] [ X] J. List of Factual Technical Documents * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas Page 5 5 · National Monitoring and Evaluation Framework for the Multi-Sectoral Response to HIV/AIDS in Ethiopia - HAPCO - December 2003. · Federal HAPCO - The Status of Mainstreaming HIV and AIDS in Major Implementing Agencies - January 2005. · Ethiopian HIV/AIDS National Response 2001-2005 - Consolidated National Report of the Terminal Evaluation of IDA Support for EMSAP - HAPCO - June 2005. · Analysis of the Community Response to HIV/AIDS in Ethiopia - AIDS Emergency Fund (EAF) Component of the Ethiopia Multi-sectoral AIDS Program (EMSAP) - 2001-2005 (June 2005). · Ethiopian Strategic Plan for Intensifying Multi-Sectoral HIV/AIDS Response 2004-2008, National HIV/AIDS Prevention and Control Office (HAPCO), Federal Ministry of Health (FMOH), December 2004 K. Contact point Contact: Gebre S. Okubagzhi Title: Sr Health Spec. Tel: 5358+352 Fax: Email: Gokubagzhi1@worldbank.org Location: Addis Ababa, Ethiopia (IBRD) L. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop