Page 1 INTEGRATED SAFEGUARDS DATASHEET APPRAISAL STAGE I. Basic Information Date prepared/updated: 06/02/2005 Report No.: AC1580 1. Project Statistics Country: Madagascar Project ID: P090615 Project Name: Second Multisectoral STI/HIV/AIDS Prevention project Task Team Leader: Nadine T. Poupart Estimated Appraisal Date: April 1, 2005 Estimated Board Date: July 7, 2005 Managing Unit: AFTH3 Lending Instrument: Specific Investment Loan Sector: Other social services (65%);Health (35%) Theme: HIV/AIDS (P);Other communicable diseases (P);Participation and civic engagement (S);Gender (S);Other social protection and risk management (S) IBRD Amount (US$m.): 0.00 IDA Amount (US$m.): 30.00 GEF Amount (US$m.): 0.00 PCF Amount (US$m.): 0.00 Other financing amounts by source: BORROWER/RECIPIENT 0.00 0.00 Environmental Category: B - Partial Assessment Simplified Processing Simple [X] Repeater [X] Is this project processed under OP 8.50 (Emergency Recovery) Yes [ ] No [X] 2. Project Objectives The development objectives of the MSPP II are the same as the development objectives of the MSPP, that is to support the Government of Madagascar's efforts to promote a multisectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory. To do so, the project will build capacity and scale-up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread of HIV/AIDS. 3. Project Description PROJECT COMPONENT 1: Harmonization, Donor Coordination, and Strategies (US$1.5 million equivalent). Under MSPP I, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This component will be revised to include donor coordination, the updating of the national strategy, and a more selected support to sectors. This component will emphasize four activities: a) Harmonization and Donor Coordination: This activity will support practical mechanisms of coordination among donors to ensure better impact and cost-efficiency of HIV/AIDS interventions. Although Madagascar has achieved two of Three One Page 2 principles? (one national authority for HIV/AIDS, and one strategic framework) donor coordination needs to be intensified, particularly on the M&E system. b) Updating of the National Strategic Plan. The current Plan covers the period through the end of 2006, and will need to be updated and re-validated thereafter, based on recent knowledge about the disease and the evaluation of past activities. c) Implementing the HIV/AIDS/IST communications strategy and action plan. Though knowledge of HIV and information on prevention is now relatively widespread,actual sexual practices remain risky, and stigma strong. The project will maintain mass media campaigns, but will place more emphasis on activities that facilitate dialogue and action on prevention and stigma reduction at the grassroots level. This sub- component will also finance communication materials and toolkits for NGOs and CBOs that will implement grassroots communication sub-projects under the Fund (component 3). If needed, the existing communications strategy (October 2004) may be updated based on the evaluation of communication activities. d) Support for the development of a limited number of sector strategies and action plans (two to three). The sectors which focus on high risk groups (e.g. Education for the youth, Security for the solders, prisoners, police personnel etc.) will receive priority. If implementation progresses satisfactorily, the number or sectors may be expanded during the course of the project. PROJECT COMPONENT 2: Support for Health Sector Response (US$3.0 million equivalent). Under the MSPP I, the Ministry of Health was involved only in the implementation of a major STI program, and the implementation of the medical waste management plan. The involvement of the health sector in the fight against HIV/AIDS/IST will be strengthened under the MSPPII, which will complement general funding to the sector provided by the Second Health Support Project ($40 million for the original credit and $22 million for a supplemental credit that will be submitted to the Board in early FY06). This component will finance the revision of the health strategy for the prevention of HIV/AIDS, and will finance a range of activities of which examples are provided below. The UGP and the Health Ministry may decide together to sub- contract some of these activities to NGOs and the private sector. a) Support for STI control. MSPP I made a significant effort to control STIs by financing (a) training based on the Syndromic Approach, and (b) the sale of two STI treatment kits at subsidized prices in both the public and in private sectors . MSPP II will expand these activities in high risks places or groups. b) Support for care and treatment of PLWHA. Based on the preliminary experience of the IDA-financed Regional Treatment Acceleration Program (TAP), and on the Interim Review of the MAP Program in Africa, MSPP II will help the Ministry of Health establish a range of complementary ser?vices such as: (a) expansion of the VCT centers in all [figure] district hospitals and in health centers (CSB2) in high-risk areas ; These VCT will be staffed by one nurse/laborantin and one counseler. (b) psycho-social, nutritional, and other support for persons infected and affected by HIV/AIDS; and (c) Page 3 treatment of PLWHA (ARVs, CD4 count), Prevention of Mother To Child Transmission (PMTCT), and treatment of opportunistic infections (diagnosis tools and pharmaceutical products). c) Other health sector response activities. MSPPII will provide complementary funding for other activities as needed, such as laboratories (mainly supported by the Global Fund) or blood transfusion (mainly supported by the African Development Bank), training of health staff, and medical waste management. PROJECT COMPONENT 3: Fund for STI/HIV/AIDS prevention and care-taking activities (US$17 million equivalent). Under MSPP I, some 850 NGO, CBO, and association-sponsored sub-projects have contributed to a range of preventive interventions.These local response activities will be scaled- up with a stronger focus on places where the population is at greatest risk of being infected or of transmitting the infection. Seventy five (75) percent of the Fund resources will be allocated to these places, which will be identified using the PLACE methodology (already piloted) and the LQAS. This component will finance the following activities: a) Sub-projects. Sub-projects will include (i) condom distribution through social marketing and promotional distribution ; (ii) grassroots communication activities that shift the focus from general knowledge about the epidemic to Behavioral Communication for Change; (iii) home-base care and other support for PLWHA and associations of PLWHAs, (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for HIV/AIDS services,(vi) training of peer educators and community-based counselors, (vii) activities that aim at reducing stigma and discrimination against PLWA; (viii) workplace HIV/AIDS plans for the public sector. b) Fund management. This component will finance fund management by the Financial Management Agency (AGF), the Facilitation Organizations (OF) and the Technical Review Organism (ORT). The AGF reviews sub-project proposals for the strength of financial management arrangements, and transfers funds from the project to organizations who have received approval for the sub-project proposal. The OFs will i) support the CLLS in incorporating HIV/AIDS/IST activities into their Communal Development Plans (Plans Communaux de D?veloppement, PCDs) in the highest risk areas; and (ii) strengthen CBOs?capacity to develop and implement sub-projects. This sub-component will also finance the updating of the list of the standardized activities eligible under the Fund and developed under the MSPPI. Under the MSPPI, the list of the standardized activities was used to increase the effectiveness of Fund-financed activities and to avoid over-programming of geographic areas and/or target populations. The updating will refine this instrument and its mode d?emploi so that it can be used as effectively as possible in the MSPPII's high risk communes. PROJECT COMPONENT 4: Monitoring and evaluation system (US$3.0 million equivalent). In accordance with the "Three Ones" principle, the PMPSII project will support the national M&E plan and framework to which all HIV/AIDS partners in the country adhere. This component provides support to this single M&E system, and has three objectives: to develop a functional monitoring system (including MIS) to measure Page 4 and manage the performance of the PMPSII project; to track the evolving status of the HIV/AIDS epidemic in Madagascar; and to learn how government policy can slow the epidemic and mitigate its consequences, drawing from the Malagasy experience. The monitoring and evaluation component will have three parts: monitoring; epidemiological studies, impact studies and situation analysis. a) Monitoring: The project will support implementation of a five-part Monitoring Plan. The monitoring plan is designed to generate and/or collect key performance indicators, financial, input and operational data for the project; to consolidate this data in a fully functional management information system (MIS); and to use the data collected in project decision-making. Lot Quality Assurance Sampling will be used for quality data collection of a sub-set of key performance indicators. b) Epidemiological Surveys: The component will continue to finance a series of second generation surveillance surveys and other population based surveys. These include bi-annual behavioral surveys among high risk groups (sex workers, truck drivers, military and youth); annual sentinel surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers); The latter includes the cross-sectionnal sero?prevalence study (Enqu?te Nationale de Sero-prevalence Aupr?s des Femmes Enceintes) first conducted in 2003; the 2008/09 Demographic and Health Survey; and the annual ?PLACES? study of high risk sites and risk behaviors there. c) Impact Studies And Consolidated Annual Report: The MSPPII will support two project impact studies, one on the cost and effectiveness of a specific prevention intervention or intervention package in high risk zones, and the second on an intervention or intervention package in a low risk zone. Each impact study will use an intervention and a control group, and will collect data before and after the intervention group participates in the project. It will also develop a consolidated annual report, in close collaboration with the CNLS. The report will provide a summary analysis of data collected in the course of the year and recommendations on re-orientation of the national HIV/AIDS program, based on the data analysis. Component 5: Project Management (US$2.5 million). MSPP II will support the institutional arrangements and operational modalities established under MSPP I, at the central level (CNLS, the PMPS Council, and UGP), and the new structures established at the regional level (BCR), following the creation of regions mid-2004 . This component will finance part of each level?s staff, equipment and operating costs, vehicles, periodic technical assistance, and some training based on annual capacity building plans. 4. Project Location and salient physical characteristics relevant to the safeguard analysis The project will target high-risk zones, i.e. areas where the risk of HIV transmission is greatest. 5. Environmental and Social Specialists on the Team Ms Hope Neighbor (AFTH3) Page 5 6. Safeguard Policies Triggered Yes No Environmental Assessment (OP/BP 4.01) X Natural Habitats (OP/BP 4.04) X Forests (OP/BP 4.36) X Pest Management (OP 4.09) X Cultural Property (OPN 11.03) X Indigenous Peoples (OD 4.20) X Involuntary Resettlement (OP/BP 4.12) X Safety of Dams (OP/BP 4.37) X Projects on International Waterways (OP/BP 7.50) X Projects in Disputed Areas (OP/BP 7.60) X II. Key Safeguard Policy Issues and Their Management A. Summary of Key Safeguard Issues 1. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts: The only safeguard issue raised by the project realates to the management of medical waste in health facilities. dispoaneeded for this project is a Medical Waste Management Plan. 2. Describe any potential indirect and/or long term impacts due to anticipated future activities in the project area: N.A. 3. Describe any project alternatives (if relevant) considered to help avoid or minimize adverse impacts. N.A. 4. Describe measures taken by the borrower to address safeguard policy issues. Provide an assessment of borrower capacity to plan and implement the measures described. The Governemnet has prepared a Medical Waste Management Plan for the first Multisectoral STI/HIV/AIDS Prevention Project(MSPP). The Plan was updated during the preparation of the Secon MSPP. The MWMP includes proper disposal of hazardous bio-medical waste and a bio-safety training program for the staff of all hospital, health centers and community-based programs, including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and treatment. 5. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Under the MSPP I, three different agencies were responsible for, respectively: (i) ensuring development and implementation of the MWMP; (ii) implementing the plan; and (iii) supervising implementation of the plan at the provincial and district levels. ? Ensuring development and implementation of the plan: The Project Implementation Unit (Unit? de Gestion du Projet, UGP) has been responsible for Page 6 ensuring development and implementation of the MWMP. The UGP has satisfactorily fulfilled this role, supervising implementation of the MWMP according to the agreed- upon calendar and undertaking additional activities in support of implementation of the plan (national kick-off ceremony, annual evaluations of the plan). ? Implementing the plan: The Ministry of Health and Family Planning (MoH) has been responsible for implementation of the MWMP, and has demonstrated capacity to properly implement the plan. Since May 2004, the MoH has installed 200 small-scale burners to burn medical wastes in all 200 health centers rehabilitated under the Second Health Sector Support Project. Recent supervision found that burners are being used at the CHD of Ankazobe, Antanifotsy and Faratsiho. The construction of full incinerators at district level is underway, and some of them should be functional by June 2005. The Plan also includes specific medical waste disposal and management actions, to be carried out in Madagascar?s different types of health facilities. The MoH has demonstrated the ability to plan for and prepare these activities, as well. ? Supervising implementation of the plan: The Office for the Environment of the Ministry of the Environment (MINENV) has been responsible for supervising its implementation at the provincial and district level. It has performed this role satisfactorily. B. Disclosure Requirements Date Environmental Assessment/Audit/Management Plan/Other: Date of receipt by the Bank 05/01/2004 Date of "in-country" disclosure 03/07/2005 Date of submission to InfoShop 03/07/2005 For category A projects, date of distributing the Executive Summary of the EA to the Executive Directors * If the project triggers the Pest Management, Cultural Property and/or the Safety of Dams policies, the respective issues are to be addressed and disclosed as part of the Environmental Assessment/Audit/or EMP. If in-country disclosure of any of the above documents is not expected, please explain why: N.A. C. Compliance Monitoring Indicators at the Corporate Level (to be filled in when the ISDS is finalized by the project decision meeting) OP/BP/GP 4.01 - Environment Assessment Does the project require a stand-alone EA (including EMP) report? Yes If yes, then did the Regional Environment Unit review and approve the EA report? Yes Are the cost and the accountabilities for the EMP incorporated in the credit/loan? Yes BP 17.50 - Public Disclosure Page 7 Have relevant safeguard policies documents been sent to the World Bank's Infoshop? Yes Have relevant documents been disclosed in-country in a public place in a form and language that are understandable and accessible to project-affected groups and local NGOs? Yes All Safeguard Policies Have satisfactory calendar, budget and clear institutional responsibilities been prepared for the implementation of measures related to safeguard policies? Yes Have costs related to safeguard policy measures been included in the project cost? Yes Does the Monitoring and Evaluation system of the project include the monitoring of safeguard impacts and measures related to safeguard policies? No Have satisfactory implementation arrangements been agreed with the borrower and the same been adequately reflected in the project legal documents? Yes D. Approvals Signed and submitted by: Name Date Task Team Leader: Ms Nadine T. Poupart 05/12/2005 Environmental Specialist: Ms Hope Neighbor 05/12/2005 Social Development Specialist Additional Environmental and/or Social Development Specialist(s): Approved by: Regional Safeguards Coordinator: Mr Thomas E. Walton Comments: Sector Manager: Ms Laura Frigenti Comments: