Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: 39862 Project Name HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT Region AFRICA Sector Other social services (40%);Sub-national government administration (40%);Health (20%) Project ID P073442 Borrower(s) GOVERNMENT OF GUINEA-BISSAU Implementing Agency NAS Prime Minister's Office Bissau Guinea-Bissau Tel: (245) 20-0000 Fax: N.A. gabrielca@eguitel.com and coopmadrugada@eguitel.co Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared May 1, 2007 Date of Appraisal Authorization March 15, 2004 Date of Board Approval June 2, 2004 1. Country and Sector Background A. STRATEGIC CONTEXT AND RATIONALE 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 156 th out of 162 countries in 2001. The poverty rate in 2002 was estimated at 80 percent of the total population and the growth domestic product (GDP) at around US$250 million with 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. Fiscal problems have hampered the implementation of all publicly financed programs, including activities to fight HIV/AIDS. Access to modern healthcare is limited and the health system is weak with one central hospital, four regional hospitals, and a patchwork of about 135 health centers and health posts of varying quality. Much of the rural population have no or limited access to modern health care and use the services of traditional healers. Page 2 Availability of financial resources remains a serious problem. Health services, which are crucial for HIV/AIDS mitigation, are in disarray and will take a long time to recover given the poor state of the physical infrastructure. The displacement of people fuels transmission rates, which have increased following the civil war, especially among the under 30 age group. Some limited actions to prevent HIV/AIDS and mitigate its impact are being carried out by a few NGOs. However, these NGOs are motivated only by goodwill and donor support has been weak. There are no comprehensive and reliable HIV statistics. Available data from the Ministry of Health show that from 1994 to 1996, there were between 600 to 900 new cases per year, and 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 calculations, health centers were only capturing around 16 percent of estimated cases. It is projected that in the next years HIV-1 would infect 24 to 40 persons daily, while HIV-2 rates would continue to decline. The Government’s response : The importance of the HIV/AIDS epidemic is clear to the Government, which notes that “further evolution of this epidemic would be disastrous for the country’s development” and that “AIDS is not a problem pertaining to the health sector alone, it is also a social problem of national and global proportions, which requires alerting society more forcefully about the current epidemic in the country and mobilizing support from all partners to intensify the fight against the disease”. In a difficult environment during the last two years, the national team supported by donors has completed a Strategic National Plan (SNP) and a National Program for SNP implementation. The Government has also confirmed its commitment to a decentralized participatory approach, a multi-sectoral strategy, and a reliable and fully transparent financing system. Each of these elements are crucial to building an efficient MAP. 2. 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 (ACT africa ), UNAIDS, and other partnerships, the Bank is well positioned to contribute its regional experience to the project. The Government has requested access to IDA resources within the framework of the second phase of the Multi-Country HIV/AIDS Program (MAP II) for the Africa Region. Guinea-Bissau is eligible for MAP II funding and has satisfied the four eligibility criteria as follows: a) Guinea-Bissau already has a coherent national strategy and has developed a comprehensive medium-term, multi-sectoral plan in a participatory manner with all concerned stakeholders; b) It has created a National HIV/AIDS Council chaired by the Prime Minister with representation from government (one-third), civil society (one-third) and the private sector (one-third); c) The Government has agreed to implementation procedures that would help expedite project implementation and outsource project implementation. Page 3 d) The Government has agreed to use and fund multiple implementation agencies as reflected in its plans to channel funds directly to both public and private implementing agencies, civil society organizations, NGOs, associations of PLWHA, and to communities. 3. Original Objectives The project will 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 access to treatment for STIs and HIV/AIDS; and iii) decreasing the socio-economic impacts of HIV/AIDS at the individual, household, and community levels. The project is consistent with the objectives of the Transitional Support Strategy, which will be presented to the Board before the end of 2004. The TSS supports the Government’s goal to improve access to basic social services. The project will support the Government in implementing its SNP and will provide the necessary resources and technical skills to scale up and improve delivery mechanisms for HIV/AIDS control activities. The SNP was designed to take into account 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 socioeconomic impact of the HIV/AIDS epidemic; (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 changes; (vi) improve the institutional framework; and (vii) ensure sustainability of the overall program. The project will focus on the following strategic choices to support SNP implementation: (a) intensify prevention, care and mitigation at the grass-roots level; (b) improve the health care system related to HIV/AIDS; (c) facilitate full public sector involvement; (d) support institutional strengthening; (e) ensure essential access to Anti Retroviral Treatment (ART) and treatment for Sexually Transmitted Infections (STI); and (f) mainstream gender issues. 4. Original Project Description Total project costs amount to US$7.0 million. The project will be implemented through three components: (i) Community and Civil Society Initiatives and Capacity Building (US$2.5 million); (ii) Government Multi-Sector Response (US$2.2 million); and (iii) Institutional Development for Program Management (US$2.3 million). IDA funding would not be sufficient to support the national program without complementary funding from the GFATM. Hence the IDA supported project will focus on five pilot regions only. GFATM has already committed to provide US$2 million to the Tuberculosis program. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0 IDA GRANT FOR HIV/AIDS 7 FRANCE: Ministry of Foreing Affairs (MOFA) 0 Total 7 Page 4 6. Implementation The project will support the updated SNP and will be under direct supervision of the Prime Minister's Office (PMO). Policymaking will be the responsibility of the NAC. The NAS, headed by a National Secretary, will carry out coordination, technical support, and financing at the national level. NAC and NAS would be autonomous from Government and two-thirds of the NAC Board would be from civil society. NAS technical staff would be recruited using open, transparent and competitive procedures internationally advertised and maintained on the basis of annually renewable performance contracts. Continued financing from the Bank would be contingent on a satisfactory institutional assessment within one year of grant effectiveness. Assurances to this effect were obtained during negotiations. The project preparation advance will provide funding for the hiring of technical staff. The RCs will coordinate and provide technical support to project implementation at the local and regional levels. Implementation of project supported activities will be the responsibility of CBOs, associations, and the public and private sector, which will contract NGOs and technical assistance when needed. Annex 6 provides detailed implementation arrangements. 7. Sustainability The project is expected to be sustainable institutionally, 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 finance even a part of the program over the medium term given the precarious position of public finances. The country will therefore remain dependent on support from bilateral and multilateral agencies beyond the initial period of implementation. B. Rationale for restructuring Since the grant supporting the Project became effective in January 2005, some progress has been made by the country. . Prevention activities have gradually expanded and now include all key ministries and there is an increased access to condoms to all sexually active age groups. A national communications strategy was launched with the help of rural radios and Non- Governmental Organizations (NGOs) to focus on reducing the spread of HIV/AIDS infection; its effectiveness is presently being assessed. Access to treatment for sexually transmitted diseases and HIV/AIDS has been expanded and it is planned to continue to do so in the five priority regions as part of a multi-donor collaborative effort (250 persons receiving anti-viral treatment, expanded support for prevention of mother to child transmission). Finally, NGOs have continued to provide education, health and nutrition support to those affected by HIV/AIDS. A scheme to increase access to micro-credit for this group is presently under preparation in collaboration with the United Nations Development Program. The project has a number of specific challenges which will have significant negative impact on the outcomes of the Project if not addressed through this restructuring: (i) overall M&E and Page 5 specifically, data collection and reporting, remains the critical bottleneck in the national M&E system. This will require the revision and realignment of key performance indicators and their targets to the reality and the capacity of the country to collect and report progress; (ii) the current PDO needs to be revised to acknowledge that the country does not have the capacity and adequate resources to reduce the spread of HIV infection (as defined in the current PDO) especially within the project timeframe; (iii) increased support to Ministry of Health is needed to develop and roll out the ART strategy to strengthen the integrated health network. Support to development of health sector infrastructure to improve access to treatment was planned to be included in the National Health Sector Development Project – this did not materialize. Since improving access to ART is not a possibility without support from the current Project, reallocations are needed in some expenditure categories; (iv) the roles of the National AIDS Council and its Secretariat need to be strengthened for better integration of the Bank financed and the Global Fund financed interventions. This will support the country in meeting the principles of the Three Ones; (v) social marketing of condoms has been stopped by PSI and given the limited capacity in-country for sustainable social marketing, the emphasis will be shifted to distribution through pubic sector agencies as well as one or two national NGOs; and (vi) skills building to support income generation activities for PLWHA and commercial sex workers needs to be targeted and prioritized to reflect limited resources and capacity. In addition, it would be difficult to attain the current DO within the project implementation period given the precarious state of national infrastructure and the level of international support. Therefore the project needs to be extended by 12 months. The proposed restructuring also takes into account the nature of the epidemic in Bissau. Based on limited date, the epidemic is primarily concentrated among those 25 years and older, and in particular in the age group 45 years and older. No overall prevalence data are available and Guinea-Bissau has only formally reported on sub-groups such as the military or from donors to the national blood bank. Early sexual activity (10% by age 11), multiple partners coupled with lack of knowledge of methods of transmission and low condom use require that prevention activities are focused in particular on the younger age groups, while a mixture of prevention, care and mitigation activities will be focused on older groups. In addition stigma to HIV positive people is very strong, which is why the project has provided support to strengthen the National Association of People Living with HIV/AIDS and anti-discrimination legislation. Revised PDO. The proposed amendments will refine the DO as follows: The Project will support i ncreased access to HIV prevention, care, treatment and mitigation services Key performance indicators will be redefined in line with the existing capacity and resources, target resources to the vulnerable groups, strengthen institutional and coordination mechanisms with other donors; strengthen national monitoring and evaluation capacity, and integrate the ART strategy of Ministry of Health and provide support to improved infrastructure. C. Safeguard Policies (including public consultation) Safeguard Policies Triggered by the Project Yes No Environmental Assesment [X] [ ] Natural Habitats [ ] [X] Pest Management [ ] [X] Cultural Property [ ] [X] Involuntary Resettlement [ ] [X] Page 6 Indigenous Peoples [ ] [X] Forests [ ] [X] Safety of Dams [ ] [X] Projects in Disputed Areas* [ ] [X] Projects on International Waterways [ ] [X] * By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas D. List of Factual Technical Documents Identification of best practices: - National Acces System to ARV: Anne Marie Bodo/Elizabeth Moreira Dos Santos - Community and Traditional practitioners’ involvement: ENDA Tiers Monde - Creation of an Association of PLHVIH: ENDA Tiers Monde - Religious Involvement: ENDA Tiers Monde - Strategical Plan and Instruments for the creation of testing and counselling centers: Sonia Maria Batista Da Silva - Making of a kit for informal sexual education: Simone Souza Monteiro - HIV/AIDS Human Rights and Law in Guinea Bissau: Ousmane Sane Design of a decentralized funding mechanism : OMS Consulting/Julio Injucam Design of an IEC strategy: Jacques Da Matha/Jose Rodrigues Santy Design of a national participatory strategy to fight against HIV/AIDS: Abdessalam Farza/ Inacio Alvarenga Preparation of a strategy for orphan and PLWHA: Marie France Adrien/Cheikh Sagna Diagnostic of existing health care facilities: Fernando Vasco Da Silva Marques Preparation of Health Service Delivery Component: Fernando Vasco Da Silva Marques MAP Restructuring Proposal: Abdessalam Farza. Other Studies or documents: - The HIV/AIDS National Strategic Plan (2007) - Second Phase Global Fund financing proposal (2006) E. Contact point Contact: Dirk Nicolaas Prevoo Title: Operations Officer Tel: (202) 473-3358 Fax: Email: Dprevoo@worldbank.org Page 7 F. 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