Report No. PID9648 Project Name Cameroon-Multi-sectoral HIV/AIDS (@) Project Region Africa Regional Office Sector HIV/AIDS Project ID CMPE73065 Borrower(s) REPUBLIC OF CAMEROON Implementing Agency Address MINISTRY OF PUBLIC HEALTH-NATIONAL HIV/AIDS COMMITTEE Comite National de Lutte contre le SIDA (CNLS) c/o Ministere de la Sante Publique Yaounde Cameroun Contact Person: Prof. Koulla Shiro Tel: 237 22 01 72 Fax: 237 22 02 33 Email: N/A Environment Category C Date PID Prepared November 23, 2000 Projected Appraisal Date November 6, 2000 Projected Board Date January 11, 2001 1. Country and Sector Background Epidemiological Situation of HIV/AIDSCameroon's first AIDS case was reported in 1986. By 1998, an estimated 600,000 people were infected with the virus. The latest HIV/AIDS surveillance results (September 2000) indicate a prevalence rate of 11 among the sexually active population, representing an estimated 937,000 infected people. Today, an estimated 500 people are newly infected with the HIV virus in Cameroon every day. By December 1994, the total number of full-blown AIDS cases registered was 5,375 and, in 1998, the cumulative AIDS cases had reached 20,419. By the year 2005, the government estimates 10,000-14,000 new AIDS cases. Subtype 0, a rare variant of HIV, has been detected in Cameroon. Approximately 90t of HIV transmission is by heterosexual contact, resulting in a roughly equal number of men and women being infected. However, among youth, the number of infected young women is twice as high as young men due to behavioral (age difference with sexual partner) and biological reasons (greater physiological vulnerability). The vast majority of reported cases - 75t - are found between 20-39 years of age.It is widely recognized that HIV/AIDS is a mayor threat to Cameroon's development. It affects all levels of society and is rapidly canceling the development gains made since the end of the depression in 1994. However, the precise macroeconomic impact of AIDS is difficult to assess. Most studies have found that estimates of the macroeconomic impacts are sensitive to assumptions about how HIV/AIDS affects savings and investment rates and whether AIDS affects the best-educated employees more than others. Studies in certain sub-Saharan African countries have found that the rate of economic growth could be reduced by as much as 25t over a 20-year period. A simulation model of the economy of Cameroon concluded that the annual growth rate of GDP could have been reduced by as much as 2 percentage points during the 1987-1991 period because of HIV/AIDS. Kambou, G., Shantayanan, D., and Mead, 0. 1992. "The Economic Impact of AIDS in an African Country: Simulations with a Computable General Equilibrium Model of Cameroon", Journal of African Economies, Volume 1, Number l.Up to very recently, HIV/AIDS has been addressed primarily as a health issue. However, it is increasingly becoming a national crisis that impacts negatively most sectors and exacerbates poverty. In the agriculture sector, several studies by FAO, WFP, and DFID have shown how poverty increases at the household when assets (e.g., livestock and/or land) are sold to cover the cost of medical expenses. In addition, subsistence agriculture is very sensitive to labor availability which is reduced by HIV/AIDS, both directly, by affecting productive members of the household and, indirectly through diverting labor to caring for the sick.The transport sector is another sector particularly vulnerable to HIV/AIDS and important to its prevention. A survey of bus and truck drivers in Cameroon found that they spent an average of 14 days away from home on each trip. 68t had sex during the most recent trip and 259 had sex every night they were away AIDS Analysis Africa, Vol. 4 (5), September/October 1994.Another study conducted in 1993-1994, found that 15t of truck drivers tested positive for HIV infection in Douala. A similar study carried out in the southwest and coastal areas found 17t of truck drivers positive for HIV infection.In the urban areas, considerable progress has been achieved in terms of sensitization to HIV/AIDS. Among urban youths, 89t are aware of the pandemic and 57T have already used condoms. Of pregnant women in urban settings, 73t are aware of mother-to-child transmission (MTCT) during birth and 84t of urban women know of the existence of condoms. The situation is somewhat different in the rural areas. Only 20t of men in rural areas have already used a condom (as compared to 73.5w in Yaounde /Douala where recent efforts start to pick up). The Ministry of Public Investments and Regional Developed along with 13 ministries has launched a pilot operation for community mobilization to control the spread of HIV/AIDS. The Ministry of Agriculture, in conjunction with local authorities and CBOs/NGOs, is providing technical assistance to this operation. By December 2000, close to 200 villages will be covered and the objective is to scale-up to achieve national coverage. In addition, with support from UNAIDS, the National Agricultural Extension and Research Program (NAERP) has trained 2,045 extension workers on HIV/AIDS and 560,000 rural families have been sensitized on HIV/AIDS.In spite of all these efforts and positive achievements, basic awareness remains minimal in the extreme northern areas. In addition, high-risk behavior is quite widespread. In 1998, 35t of single women infected with HIV in Yaounde did not use a condom during their most recent sexual contact; 13t of men had a relation with commercial sex workers; and 209 had extramarital affairs.The challenge facing Cameroon is now on two fronts. One is to translate the high level of awareness into behavioral change to prevent the spread of HIV/AIDS both in the rural and urban areas. The other is to identify the promising governmental and non-governmental HIV/AIDS prevention, mitigation, and care initiatives and rapidly replicate them to achieve national coverage. National Strategic PlanCameroon started addressing the HIV/AIDS epidemic in 1986 by establishing the Committee to Fight against HIV/AIDS. Since then, four short and medium term plans were designed and implemented: (1) the Short Term Plan of 1987, (2) the Medium Term Plan I (1988-1992), (3) the Medium Term Plan II (1993-1995), and (4) the -2 - Framework for the Fight against HIV/AIDS (1999-2000). However, these interventions had mixed results due to several factors, including insufficient coordination among the various stakeholders; ineffective integration and cooperation across sectors; and scarcity of human and financial resources.As a result, the HIV/AIDS situation worsened considerably: the HIV prevalence rate in Cameroon increased from 0.5% in 1987 to 11% in 2000. Faced with this pandemic, the government decided to "declare war" on HIV/AIDS and finalized the current emergency HIV/AIDS strategy in a record three months. In September 2000, the Prime Minister launched the highly-publicized National Strategic Plan for the Fight Against AIDS in Cameroon (2000-2005). The preparation of the Strategic Plan was coordinated by the Ministry of Public Health with technical support from UNAIDS. It is the outcome of a participatory process involving most line ministries, the private sector, non-governmental organizations, civil society, and the donor community. Its main objective is to improve the national response to the HIV/AIDS pandemic.The elaboration of the National Strategic Plan followed a five-step process which started in June 1999. First, a training workshop for representatives of the provincial governments and members of the Groupe Technique Central (GTC), the executive body of the National Committee for the Fight Against HIV/AIDS, on the process of developing the Strategic Plan. This was followed by a decentralized situation analysis of the HIV/AIDS epidemic at the provincial and district levels. Third, an analysis of the response to the epidemic, previously planned at the district level, was carried out at a national workshop in Yaounde to speed up the process. The fourth step, UNAIDS consultants drafted a preliminary strategic plan. And, in the last step, three meetings grouping all the stakeholders, representing line ministries, NGOs, the private sector, and religious organizations finalized the National Strategic Plan for the Fight Against HIV/AIDS in Cameroon.The National Strategic Plan comprises an operational plan covering six priority areas of intervention and an emergency plan for 2000-2003. It highlights the following priority areas for action:fn Prevention of HIV/AIDS and STI transmission through behavior modificationn Prevention of HIV transmission in hospital settings and through blood transfusion n Provision of clinical and home/community-based care for People Living with HIV/AIDS (PLWHA)n Establishment of an ethical, legal, and human rights framework for PLWHAn Increase in HIV/AIDS research and surveillancen Program management and coordinationThe emergency plan focuses on three aspects: (1) the use of condoms (masculine and feminine) - "100% condom strategy; (2) voluntary testing and counseling (VTC); and (3) the promotion of behavior change among young people 15-24. It will mostly target the "high-risk" population, namely the military, police, customs officials, penitentiary personnel, students, commercial sex workers, and truckers.In addition, the National Strategic Plan includes a major expansion of HIV/AIDS activities that will be implemented by the following line ministries: National Education, Higher Education, Agriculture, Defense, Labor, Social Affairs, Women's Affairs, Information, Public Health, Youth and Sports, and Local Administration. These activities cover the full spectrum of prevention, treatment, care, and support and target both the staff and the clients of the Government entities. In addition to the public sector, the Strategic Plan looks at the role of the private sector, non-governmental organizations, civil society, and the donor community in combating the spread of HIV/AIDS.To complement the new National Strategic Plan and reflect its multi-sectoriality, a government decision was issued to reorganize the -3 - Groupe Technique Central (GTC - executive body of the National HIV/AIDS Committee). The new GTC is managed by a Permanent Secretary and is composed of five sections: (i) a section for support to local responses; (ii) a section for support to sector responses; (iii) an operational section, responsible for monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) a section responsible for information, communication, and education (IEC); and (v) a financial management section. The Groupe Technique Provincial (GTP - executive body of the Provincial HIV/AIDS Commiittees) is managed by a provincial manager and comprises the same sections as the GTC. A second decision established the Commission Mixte de Suivi which will meet on a quarterly basis to oversee the National Committee for the Fight Against AIDS, review the quarterly progress reports, and ensure the proper use of funds. The Commission will be presided by the Secretary General of the Office of the President, and includes representatives of PLWHA, donor community, religious groups, professional organizations, Parliament, and the Ministries of Public Health, Economy and Finance, Public Investments, and Local Administration. 2. Objectives To curb the spread of the HIV/AIDS epidemic in Cameroon and to mitigate its impact for all those who are infected or affected by HIV/AIDS through the strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implementation of sector specific HIV/AIDS strategies. 3. Rationale for Bank's Involvement Through its involvement in various sectors in Cameroon and its experience with supporting large, decentralized and field oriented operations such as the National Extension and Research Program, the Bank is well placed to assist the Government to make the national effort to fight HIV/AIDS truly multi-sectoral and field-oriented. As an active member of the UNAIDS group, the Bank can contribute to galvanizing the support from various international agencies and donors. The Bank's involvement in the support to the HIV/AIDS program is leveraged by the focus given to HIV/AIDS in the public expenditure review exercises, the on-going Health, Fertility and Nutrition Project, the Poverty Reduction Strategy, the allocation of HIPC resources, and the possible retro-fitting of existing operations. Thanks to the availability of resources under the Multi Country HIV/AIDS Program (MAP), the Bank is able to quickly mobilize the financial resources needed to support the Government in the implementation of its emergency HIV/AIDS program. Finally, the Bank's support can also be instrumental to attract other donor's attention to complement the IDA Credit with additional grant money.In addition, the Bank has worked closely with the Government to develop specific HIV/AIDS prevention and mitigation measures prior to and during the construction of the Chad/Cameroon pipeline. This will benefit communities along the pipeline route which are currently relatively little affected by HIV/AIDS, and migratory workers who will be involved in the pipeline construction and who constitute one of the most vulnerable groups. Due to the Bank's work, the inclusion of HIV/AIDS prevention measures in the Chad/Cameroon Pipeline Project is a flagship example of galvanizing government, private sector and Bank partnerships for anticipating risks on HIV/AIDS and tackling the issue in the framework of a non-health operation. -4- 4. Description The project will support the implementation of the National HIV/AIDS Strategy. The strategy is based on two major pillars: local responses (support to rural and urban communities to develop and implement their own HIV/AIDS action plans) and sector responses (support to various sectors in the economy to develop and implement sector-specific strategies for HIV/AIDS). To strengthen the work on local responses and sector responses, three support functions are included in the Government's strategy: communication, planning/monitoring and evaluation, and coordination. The responses developed by local communities and in each of the sectors will deal with prevention as well as mitigation of the impact of HIV/AIDS. While the main focus of attention will go to prevention, special attention will be given to the monitoring of the treatment, care and support provided to people infected or affected by HIV/AIDS. To this effect, the Government has committed to the full inclusion of PLWHA in the design and implementation of local and sector responses, in the planning, monitoring, and evaluation of the programs, and in policy formulation and control.To meet the challenge of national coverage - starting with the rapid coverage of high risk areas and groups and moving on to gradually cover all groups and areas in the country - the Government has chosen to work through a multitude of implementing agencies. Not one organization or sector in the country has the capacity or resources to take on the HIV/AIDS challenge alone. However, by drawing upon all available capacity (in private and public sector, among NGOs, civil society, religious groups, traditional healers' associations, community based organizations, etc.) and resources (national budget, HIPC resources, donor-funded projects) the Government hopes to establish the institutions and mechanisms needed to sustain the effort to address HIV/AIDS over the next ten to fifteen years.Components: The project will have five components: (a) support to local responses; (b) support to the health sector response; (c) support to the design and implementation of sector strategies; (d) capacity building; and (e) coordination. (a) Support to local response: The project will support communities' efforts with regard to prevention and mitigation of the impact of the HIV/AIDS crisis. Under this component, communities - facilitated by local sub-contracting agencies and NGOs - elaborate their action plans, constitute their own HIV/AIDS committees, submit their action plans to the communal (county) HIV/AIDS committee, open an account, and receive financial resources directly from the project to assist with the implementation of their action plans and to match their own contributions (in cash and/or kind). Strong emphasis is given to the participatory nature of the development of community action plans, to the inclusion of all (especially vulnerable) groups in the planning and implementation of the activities, and to the involvement of PLWHA. As part of the component, the participatory methodologies - which are already under implementation in the National Extension and Research Program - will be adapted through action/research activities to accommodate specific work on HIV/AIDS in various social settings such as villages, urban neighborhoods, prisons, unions of truck drivers, commercial sex workers, orphans, street children, etc. (b) Support to health sector response: The implementation of specific targeted health sector interventions geared to HIV/AIDS will be supported through the program. These include the establishment of testing and counseling centers, the improvement of blood transfusion safety and the - 5 - management of blood banks, the increase in availability of drugs to treat opportunistic infections, the distribution of equipment and materials for home care of the sick, the support to private companies' efforts to fight against HIV/AIDS, the elaboration of a tool kit and the training of traditional healers and birth attendants on HIV/AIDS prevention and mitigation, etc. (c) Support to the design and implementation of sector strategies: Under this component, support will be provided to focal points in each sector to design (or continuously improve existing) specific HIV/AIDS strategies. Targeted sectors include health, communication, transport, defense, education, agriculture, public works, youth and sport, tourism, women affairs, etc. The sector focal points will be assisted to elaborate an action plan for the development of sector strategies. These action plans will spell out how private enterprises, semi-private organizations and public administrations will participate in the exercise. The sector strategies will have to address the challenges of prevention and mitigation both among the people working in the sector, and among the public which is being served by the sector. The strategies will also include sector-specific communication strategies with regard to HIV/AIDS. Part of the sector strategies will be the funding arrangements for implementation of the action plans. Funding will have to be sought through the reallocation of existing public budgets, budgets from private enterprises, HIPC resources, and retrofitting of existing and new donor-funded projects. (d) Capacity building: The project will provide resources to help address the challenge of rapid capacity building among those in the public sector, in the private sector, and in civil society who are involved in the fight against HIV/AIDS. This component will include: training of facilitators in implementing agencies on methodologies for community participation (in rural areas, urban neighborhoods, and among special vulnerable groups); training of HIV/AIDS committee members at communal, provincial and national level on strategy definition, supervision and budgeting mechanisms, and control; training of focal points in the various sectors on the development and implementation of HIV/AIDS strategies; training of staff in financial institutions on the mechanisms required to ensure adequate transfer of funds in support of communities' action plans; and training of managers, field staff, financial management staff, planners, and controllers on their roles, functions, and job descriptions. (e) Coordination: The establishment of a relatively small implementation and coordination unit at the national and provincial levels -Groupe Technique Central (GTC) and Groupe Technique Provincial (GTP) - will be supported through this component. This component will also support the operations of one staff in every commune. In addition, support will be provided to the operations of HIV/AIDS committees at national, provincial, and communal levels. The GTC and GTP will be responsible for (i) support to local responses; (ii) support to sector responses; (iii) monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) information, communication, and education (IEC); and (v) financial management. 5. Financing Total ( US$m) - 6- Total Project Cost 60 6. Implementation Project implementation:The project will support the existing national structures and institutions for the fight against HIV/AIDS and no new temporary implementation units will be created for the purpose of this project. The overall responsibility for the implementation of the national strategy for the fight against HIV/AIDS lays with the National HIV/AIDS Committee (NHAC) and its decentralized entities at provincial (PHAC), communal (CHAC), and local (LHAC) level. The HIV/AIDS Committees are 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.To ensure proper implementation, the HIV/AIDS Committees are supported by technical units. At the national level, the NHAC implements its strategy through the Groupe Technique Central (GTC). At the provincial level, the PHAC works through the Groupe Technique Provincial (GTP), and at the communal level, the CHAC is assisted by a Correspondant Communal (CC). The staff in the GTC, GTP, and CC work on a full time basis.The Groupe Technique Central (GTC) is managed by a Permanent Secretary and is composed of five sections: (i) a section for support to local responses; (ii) a section for support to sector responses; (iii) an operational section, responsible for monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) a section responsible for information, communication, and education (IEC); and (v) a financial management section. The Groupe Technique Provincial (GTP) is managed by a provincial manager and comprises the same sections as the GTC. Several aspects of the program implementation will be sub-contracted. These include:- Facilitation of community participation processes: At the beginning of program implementation, the PHAC/GTP will identify all organizations in the province who have capacity to facilitate participation processes at the community level. Annual contracts will be established between the PHAC/GTP and these organizations to specify which organization will be responsible for facilitation of participatory processes in which areas. The contract will also stipulate the financial and technical support the sub-contracting agencies will receive from the project to carry out their assignment. The sub-contracting agencies' field work will be supervised by the PHAC/GTP.- Communication strategy: The design and implementation of NHAC/GTC's communication strategies, which constitutes one of the key tools in the fight against HIV/AIDS, will be sub-contracted. Initially, the GTC will recruit a specialized agency to develop an appropriate communication strategy. Depending on the features of the strategy, one or more agencies will be contracted to implement (aspects of) the strategy. Within the GTC, the section responsible for IEC will ensure supervision of the sub-contractors.- Accounting and transfer of funds: The GTC will have the overall responsibility for the financial management of the program, but will execute this financial management through private firms. To maximize efficiency, the accounting of the program, the transfer of funds to communities, and the preparation of documentation to be submitted to the CAA for the replenishment of the special accounts will be contracted out. - Epidemiological and behavioral surveys: While the operational section of the GTC is responsible for the implementation of the epidemiological and behavioral surveys and for the timely production of reports, the actual surveys will be sub-contracted. By doing so, the GTC hopes to gain in efficiency, and to avoid having to - 7- recruit an important number of staff to carry out these surveys.The development of the sector specific HIV/AIDS strategies will be implemented by focal points in the respective sectors. To ensure ownership of the sector strategies by the various actors in each sector (private companies, public administrations, civil society, and the public at large), the focal points will remain employed by their respective sector organizations. The focal points will establish work plans in conjunction with representatives from all partners in the sector to elaborate the sector specific strategies. The relationship between the focal points and the GTC will not be hierarchical, but will be one of coaching and support: the GTC will provide technical guidance to ensure that the strategies are sound and to avoid duplication between the various sector strategies. The NHAC/GTC will also finance the activities that will be carried out to develop the sector strategies. However, the financing of the implementation of the sector strategies will be assured through HIPC, through reallocations in the existing sector budgets, and through reallocation within donor-funded projects.Project supervision, reporting, and audit requirements:The Program Implementation Manual (PIM) will delineate processes and responsibilities for general management, procurement activities, and financial management and control, including Terms of Reference for internal and external audits acceptable to IDA. The PIM, which will be submitted to IDA for its approval, will be finalized no later than April 16, 2001 (three months after the Credit has been approved by IDA's Board). The adoption of the PIM is a condition for Credit effectiveness. As the proposed implementation arrangements are partially based on experience in other countries, the adaptation of these will need to be seen as a continuous process responding to local circumstances. Consequently, the PIM will be reviewed and amended by mutual agreement with IDA as and when needed, with the first revised PIM being issued before January 31, 2002. In order for implementation to proceed without having to wait for the preparation of the PIM, Interim Program Implementation Procedures (IPIP) were developed during preparation. The IPIP will first be reviewed during the launching workshop which will take place before February 28, 2001. All parties involved in the implementation of the different components of the project as well as representatives from beneficiaries will participate in the workshop. The NHAC/GTC will submit to IDA an annual work program and on this basis will submit quarterly progress reports on achievements and problems. Similarly, it will obtain annual work programs and quarterly progress reports from all implementing agencies. The PIM will further elaborate on reporting requirements. Financial audits for all accounts and components will be carried out annually in accordance with Bank Guidelines. Financial audits will be submitted to the Commission Mixte de Suivi and to IDA not later than six months after the end of each fiscal year. Performance and impact audits as set out in the PIM will also be carried out to assess the project's contribution to Cameroon's HIV/AIDS program. In addition to the mandatory annual audit exercises, any of the members of the Commission Mixte de Suivi can order at any time an audit or examination of any complaint received by the Commission Mixte de Suivi about the implementation of the program or about the use of the resources.IDA's supervision of the project will need to be full-time and staff-intensive, given the "learning-by-doing" concept used for the project design. This will be especially important prior to Credit effectiveness as a host of activities must be undertaken to maximize implementation in the four years of the project. In the first project year, IDA staff will have to take active - 8 - part in the project launch and PIM review workshops, the workshop to review implementation progress toward the end of the year, and workshops on project implementation experience (preferably to take place at the provincial level). To be able to make effective contributions during the various workshops, IDA staff will have to focus on field visits to supervise the start-up of the program on the ground. The supervision needs for the following three years are unlikely to diminish, as the community-level program will see rapid expansion each year. On an annual basis, workshops will be organized to discuss experience and to scale up best practices. Supervision support from the Country Office will include close monitoring by the financial management specialist, the procurement specialist, and the disbursement specialist. Procurement procedures:The above implementation arrangements will be supported by procurement procedures that take into account the urgency of the project as well as the nature of the participating institutions. Procurement for all IDA-financed activities will be carried out in accordance with the Bank's Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995 and revised in January and August 1996, September 1997, and January 1999), in particular Section 3.15, Community Participation in Procurement. Consulting services by firms, organizations, or individuals financed by IDA will be contracted in accordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997, revised in September 1997 and January 1999). With respect to the support to local responses, the Bank's simplified Procurement and Disbursement Procedures for Community-Based Investments will be used. To facilitate speedy import of items valued at less than US$100,000 equivalent required urgently for diagnosis/treatment and institutional strengthening, contracts may be made based on international shopping and national shopping procedures, respectively, per IDA Procurement Guidelines (Clauses 3.5 and 3.6), provided contract awards are made within 12 months of the Credit effectiveness date. International procurement will also take place through procurement from the United Nations (i.e. IAPSO). Given the urgency of the project, a wide-ranging General Procurement Notice (GPN) for the first year of operations will be placed on the United Nations Development Business web site without a need for hard-copy publication. The Borrower will prepare a procurement plan for the first year of project operations to be included in the PIM. The plan will include relevant information on goods, works, and consulting services under the project as well as the timing of each milestone in the procurement process. The procurement schedule will be updated every quarter and reviewed by IDA. Procurement performance (including community based procurement activities) will be assessed on an annual basis (in the form of procurement/physical audits by an external agency). In addition to the formal annual audits, ad-hoc procurement reviews will be conducted periodically. Details of procurement arrangements are provided in Attachment 6. Financial management: The project will have an adequate financial management system in place by Credit effectiveness. Appropriate safeguards will be included in the design of the financial management system; these safeguards include the appointment of an internationally qualified Financial Manager, the sub-contracting of accounting to a specialized private company, the direct transfer of funds to communities, the direct payment from PHAC/GTP to sub-contracting agencies responsible for the support to local communities, and close links between and analysis of financial and physical progress reports.Not all executing entities (e.g., sectoral focal points, GTC, etc.) have established financial management systems adequate for the -9- project's demands. Before disbursing funds to these entities, the NHAC/GTC will need to confirm that appropriate financial management systems are in place, including the opening of project bank accounts and employment of qualified accounts staff.A detailed assessment of the financial management and internal control systems is presented in Attachment 6.Disbursement procedures:Timely procurement is only efficient if it is accompanied by timely disbursements. In the case of community-managed sub-projects, pre-financing of expenditures is essential as communities are unlikely to start contracting without the assurance of funds. Also at the national or central level, traditional methods of disbursement and the use of the Special Account pre-financing mechanism has to reckon with the need to open letters of credit (LC) for virtually all imports, which then leads to Special Account funds being deposited with the issuing bank as a substitute for IDA special commitments (which are not issued for sums below the procurement prior review threshold). These funds cannot be replenished until the LCs are cashed, which can take more than six months. In addition, when a significant amount of the Credit is used to pre-finance project activities through advances to the local currency project accounts of implementing agencies, the standard 90-day turnaround time for documentation of expenditures against advances can rarely be met. Therefore, the authorized allocation for the Special Account based on a standard four-month cash flow is in most cases not sufficient. Thus, under this Credit the estimated IDA financing for the first four months of project implementation will be disbursed into two Special Accounts in a commercial bank acceptable to IDA. Both Special Accounts will be operated by the Caisse Autonome d'Amortissement.All disbursements against expenditures originating from local currency project accounts will be made against statements of expenditure (SOEs). All procurement contracts not subject to IDA prior review will be disbursed against SOEs and documentation will be retained by the respective administrations and made available for review by IDA financial management and procurement specialists and project financial and procurement auditors. Expenditures by communities will be subject to simplified accounting procedures, review of interim reports, and random ex-post financial, physical, and technical audit to be carried out by financial and technical consultants employed by the NHAC/GTC and PHAC/GTP. 7. Sustainability Given the very low probability that an HIV/AIDS vaccine would be developed in the near future, and given the rampaging spread of the HIV/AIDS crisis in Cameroon, it is a near certainty that Cameroon will have to address the issue of prevention and mitigation of the HIV/AIDS crisis over at least the next ten to fifteen years. Apart from the humanitarian dimension - close to one million people in Cameroon are already infected with the virus and (even under the most optimistic program implementation scenario) several hundreds of thousands are likely to be added to this number - coping with HIV/AIDS is a prerequisite to safeguard any economic or social progress the country has made in the past and will make in the future.The design of the program is made in such a way that the efforts which are being deployed now can be sustained over a ten to fifteen year period. Specifically, this has implications for the allocation of budgetary resources and the remuneration of staff. With regard to budgetary resources, a conscious decision has been made to use the proposed program as a leverage tool to mobilize additional resources within the budgets of various sectors, and in donor-funded projects. Thus, the sustainability of - 10 - the effort is increased by spreading the budgetary burden over a larger number of sources of financing. With regard to the remuneration of staff, the Government has decided to provide only such compensation which can be sustained over a longer period of time. The litmus test for the sustainability of the program will lay with the quality of the field and sector work. To the extent that the various stakeholders and people in all different social groups take ownership of the fight against HIV/AIDS, Cameroon will be able to build up its capacity to deal with the crisis over an extended period of time. This is one of the reasons why special attention is being given during the preparation and launching period of the program to adapt the participatory methodologies which are known from ongoing community development efforts to the specific HIV/AIDS challenge. 8. Lessons learned from past operations in the country/sector Scaling up to reach national coverage: From experience in Cameroon and elsewhere, it became clear that the biggest challenge for HIV/AIDS programs was the scaling up. Like in other countries, several excellent initiatives on HIV/AIDS exist. However, these initiatives tend to be fairly small in size and work in an isolated fashion. As a result, only a small fraction of the needs with regard to supporting the fight against HIV/AIDS are covered. The strategies for scaling up have been derived from experience gained through large programs such as the agricultural services programs in several African countries.Sub-contracting: The experience with most projects in Cameroon (Health and Nutrition Project, Micro-credit, Extension and Research, etc.) indicates that the public service alone does not have the implementation capacity required for this type of operation. During the design of the Multi-Country HIV/AIDS Program, the preparation team reached agreement with government on the need to work through a multitude of implementing agencies, which is also one of the criteria to qualify for MAP eligibility.Community participation: From experience throughout Africa, it became clear that information, education and communication alone do not lead to behavior change in the fight against HIV/AIDS. However, when community participation methodologies are being used, a change in behavior can be seen. These findings were extensively discussed and documented by delegations from eighteen African countries during a workshop on community participation and HIV/AIDS which was organized in Mwanza, Tanzania in June 2000. Several experiences - among others TANESA (Tanzania), Gaoua (Burkina Faso), Abengourou (Ivory Coast) and others - have adequately demonstrated that behavior change can be reached through participatory approaches to the development of local responses. These findings have been at the basis of the design of the local response component of the proposed program.Transfer of resources to communities: The experience with social funds and community based operations illustrates clearly the gains in efficiency and effectiveness of micro-projects if communities are given direct access to the financial resources. The proposed design of this operation builds upon the lessons from the community based development operations and features the direct transfer of financial resources to communities. This seems especially appropriate in the Cameroonian context where the high degree of centralization of budget allocation decisions, and the tedious character of transfer of resources to the front line are specific constraints that need to be overcome. 9. Program of Targeted Intervention (PTI) N - 11 - 10. Environment Aspects (including any public consultation) Issues : The handling and disposal of HIV/AIDS infected materials is the most significant environmental issue in the context of this program. In many countries, the inappropriate handling of HIV/AIDS infected materials constitute a risk not only for the staff in hospitals and in municipalities who are involved in waste handling, but also for families and street children who scavenge on dump sites. Some aspects of project implementation (e.g. the establishment of testing clinics, the purchasing of equipment by communities for home care of the sick, etc.) can constitute an increase in the environmental risk with regard to the handling of HIV/AIDS infected waste.The examination on the current practices with regard to the handling of hospital waste will verify both the management of waste within the hospitals and the management of waste by municipal authorities once it has left the hospital. It will also look into the level of knowledge among staff (hospital orderlies, municipal managers and workers) about the practices to be adopted, and into the availability of equipment such as incinerators to deal with this type of waste. 11. Contact Point: Task Manager Jan Aime E. Weetjens The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: (202) 458 1683 Fax: (202) 477 0515 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. - 12 -