Authorized Documentof The WorldBank Disclosure FOROFFICIAL USEONLY Public ReportNo: 42867-BI Authorized Disclosure PROJECT APPRAISAL DOCUMENT ON A Public PROPOSED GRANT INTHE AMOUNT OF SDR9.4 MILLION (US$ 15 MILLIONEQUIVALENT) Authorized TO THE THE REPUBLIC OF BURUNDI Disclosure FOR A Public BURUNDISECOND MULTISECTORAL HIV/AIDS PROJECT April 18, 2008 Authorized Human Development I11 Country DepartmentEastern Africa 1 Africa Regional Office Disclosure Public This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange RateEffectiveas of February29,2008) CurrencyUnit = FBu 1163FBu = US$1 US$1.6 = SDRl FISCALYEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS ASAP AIDS Strategy andAction Plan Service ARV Antiretroviral CAMEBU Burundi Drugs Supply Center CNLS ConseilNationalede Lutte Contre le SIDA (NationalHIV/AIDS Council) DFID Departmentof InternationalDevelopment DGR DirectionGeneralede Ressources(GeneralDirectionof Resources) EU EuropeanUnion GAMET GlobalMonitoring and EvaluationTeam GF GlobalFund for TB, Malaria& HIV/AIDS HIPC Heavily IndebtedPoor Countries IDA InternationalDevelopmentAssociation MAP Multi-sectoralHIV/AIDS Project MDGs Millennium DevelopmentGoals M&E Monitoring & Evaluation MoF Ministeredes FinancesEconomieet Dkveloppement(Ministry of Finances, Economy and Development) MSPLS Ministerede la Sante Publique et Lutte Contre le SIDA (Ministry ofHealthand HIV/AIDS) MedicalWaste ManagementPlan MWMP NGO Non-GovernmentalOrganization NHAS NationalHIV/AIDS Strategy and Plan NSPSBS NationalSero-Prevalenceand Socio BehavioralSurvey PMTCT PreventionMother-to-ChildTransmission of HIV/AIDS PSMLO ProjetMultisectorielde Lutte contre le SIDA (Multi-sectoral HIV/AIDS Project) Preparation PPF Facility PRSP Poverty Reduction StrategyPaper SEP/CNLS Secre'tariat Exe'cutive du Conseil Nationale de Lutte contre le SIDA (Executive Secretariat for the NationalHIV/AIDS Council) SWAP Sector Wide Approach UNAIDS Joint UnitedNations Program on HIV/AIDS USLS Unite Sectorielle de Lutte Contre le SIDA (Sectoral Unit for HIV/AIDS Control) VCT Voluntary Counselingand Testing Vice President : Obiageli Katryn Ezekwesili CountryDirector : John McIntire CountryManager : Alassane Sow Acting Sector Manager : John A. Elder Task Team Leader : MontserratMeiro-Lorenzo FOROFFICIAL USE ONLY BURUNDI BurundiSecond MultisectoralHIV/AIDS Project CONTENTS Page I STRATEGICCONTEXTANDRATIONALE . .................................................................. 8 A. Country and sector issues .................................................................................................... 8 B. Rationale for Bank involvement....................................................................................... -12 C. Higher level objectives to which the project contributes .................................................. 13 I1. PROJECT DESCRIPTION ............................................................................................ 13 A. Lendinginstrument............................................................................................................ 13 B. Program objective and Phases........................................................................................... 14 C. Project development objective and key indicators ............................................................ 14 D Project components............................................................................................................ . 15 E. Lessons learned and reflectedinthe project design.......................................................... 16 F. Alternatives considered and reasons for rejection............................................................. 17 I11. IMPLEMENTATION ..................................................................................................... 18 A. Partnership arrangements(ifapplicable) ........................................................................... 18 B. Institutional and implementation arrangements ................................................................ 19 C. Monitoring and evaluation o f outcomes/results ................................................................ 20 D Sustainability..................................................................................................................... . 20 E. Critical risks and possible controversial aspects ............................................................... 21 F. Grantconditions and covenants ......................................................................................... 21 I V. APPRAISAL SUMMARY .............................................................................................. 22 A . Economic and financial analyses....................................................................................... 22 B. Technical ........................................................................................................................... 22 C. Fiduciary............................................................................................................................ 23 D. Social ................................................................................................................................. 24 E. Environment ...................................................................................................................... 25 F. Safeguard policies.............................................................................................................. . . 25 G. Policy Exceptions and Readiness ...................................................................................... 26 This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not be otherwise disclosed without World Bank authorization. Annex 1: Country and Sector or ProgramBackground .......................................................... 27 Annex 2: Major RelatedProjectsFinancedby the Bankand/or other Agencies ..................37 Annex 3: Results Frameworkand Monitoring ......................................................................... 39 Annex 4: DetailedProjectDescription ...................................................................................... 48 Annex 5: Project Costs................................................................................................................ 52 Annex 6: ImplementationArrangements .................................................................................. 53 Annex 7: FinancialManagementand DisbursementArrangements ..................................... 57 Annex 8: ProcurementArrangements ....................................................................................... 66 Annex 9: Economic and FinancialAnalysis .............................................................................. 71 Annex 10: SafeguardPolicyIssues ............................................................................................. 76 Annex 11:ProjectPreparationand Supervision ...................................................................... 77 Annex 12: Documents in the ProjectFile .................................................................................. 78 Annex 13: Statementof Loansand Credits ............................................................................... 79 Annex 14: Countryat a Glance .................................................................................................. 80 Annex 15: Map IBRD No 33380 . ................................................................................................ 82 4 BURUNDI BURUNDISECOND MULTISECTORALHIV/AIDS PROJECT PROJECTAPPRAISAL DOCUMENT AFRICA AFTH3 Date: April 18,2008 Team Leader: MontserratMeiro-Lorenzo Country Director:John McIntire Sectors:Other social services (65%);Health Sector Managermirector:JohnA. Elder (25%);General informationand communications sector (10%) Themes: HN/AIDS(P) Project ID:P109964 Environmentalscreeningcategory: Partial Assessment LendingInstrument: Specific InvestmentLoan [ 3 Loan [ ] Credit [XI Grant [ ] Guarantee [ 3 Other: For Loans/Credits/Others: TotalBank financing(US$m.): 15.00 Borrower: Ministryof Finance Bujumbura Burundi ResponsibleAgency: SecretariatExecutive duConseilNationalede LutteContre le SIDA. (SEPKNLS) ChausseePrinceLouisRwagasore ImmeubleBanquede la ZEP Bujumbura Burundi Tel: 257 22 24 53 00/+257 22 24 53 Fax:257 22 24 53 01 SEP-CNLS@USAN-BU.NET 5 Projectimplementationperiod: Start September 30,2008 End:January 30,2011 Expectedeffectiveness date: September 1 2008 Expectedclosingdate: June 30, 2011 Does the project depart from the CAS in content or other significant respects?Ref: PAD I.C. [ ]Yes [XI No Does the projectrequireany exceptions from Bank policies? [ ]Yes [XI No Re$ FAD IV.G. Havethese beenapproved by Bankmanagement? ]Yes [INo I s approval for any policy exception sought from the Board? [ ]Yes [XI No Does the project includeany critical risks rated "substantial" or "high"? Re$ FAD III,E. [XIYes [INo Does the projectmeet the Regionalcriteria for readinessfor implementation?Re$ PAD IV.G. [XIYes [ 3 No Projectdevelopment objectiveRef: FAD ILC., TechnicalAnnex 3 Increase the utilization of a selectedset of preventiveservices, among groups highly vulnerable to, or affected by HIV/AIDS. ProjectdescriptionRef; FAD II.D., TechnicalAnnex 4 Component 1:Preventive ServicesTargetedto HighRisk Groups. The component aims at reducingHIVtransmission amonghighrisk groups throughbehavior change and increased access to preventativeservices. 0 Component 2: Performance-BasedCurativeServices.This component will support the geographic extensionof ARV treatment and opportunistic infectionprophylaxisandtreatment to HIV+ people inthe whole country. Component 3: DecentralizeFinancingof SmallGrants to Familieslivingwith HIV/AIDS and HighRisksGroups. This component aims at providinglimited economic and legalsupport to the most vulnerablefamilies affected by HIV/AIDS. 0 Component 4: Capacity Buildingfor Local Authorities andKey Ministriesto Implement HIV/AIDS Activities, andNationalProgramManagement.The objectives ofthis component are to build capacity to implement and monitor HIV/AIDS activities in key ministriesand local governments; contributeto ensureadequate operation of the SEPKNLS; increasethe SEP/CNLS capacity to managethe M&E system; and implementthat nationalwaste managementplan. 6 Which safeguard policies are triggered, ifany? Re$ PAD IV.F., TechnicalAnnex 10 Environmental safeguard policy is triggered in relation to medical waste management. The waste management assessment and action plan carried out under the previous operation has been updated to reflect the changing country situation. The results o f the updated assessment and the plan to mitigate potential negative effects have been approved by ASPEN and will be made public prior to appraisal. The Project environmental category is B and safeguards responsibilityhas been transferred to the Sector Unit. Significant, non-standard conditions, if any, for: Re$ PAD ZII,F. Board presentation: Not applicable. Grant effectiveness: 0 The Recipient has revised, in a manner satisfactory to the Association, the Project ImplementationManual, for purposes o f Project implementation. The Recipient has adopted the Ministryo f Public Health and AIDS Control (MSPLS) Administrative and Financial Procedures Manual, in form and substance satisfactory to the Association. 0 The Recipienthas appointed, to the accounting unitso f the entities involved in Project implementation, staff with qualifications, experience, and terms o f reference satisfactory to the Association, for purposes o f Project implementation. Covenants applicable to project implementation: 0 The Government will allocate the equivalent o f $3 million US$ annually to the SEPKNLS in the general Budget Law to carry out activities under the agreed annual plan for the duration o f the Project. 0 An agreement, acceptable to IDA, describing the results to be achieved directly or indirectly by the MSPLS, and the fiduciary arrangements and responsibilities will be received by the Bank no later that a month after Grant effectiveness. 0 N o later than one month after the Effective Date, the Government will clarify, in a manner satisfactory to the Association, particularly for purposes o f Project implementation, the responsibilities o f the SEPKNLS and the MSPLS, respectively, and the arrangements for coordination between said two entities. 7 I. STRATEGICCONTEXTANDRATIONALE A. Country issues 1. At an income levelof around US$ 100 per capita, Burundi is one of the poorest countries in the world. For the last 13 years civil conflict has claimed more than 300,000 lives, displaced a good part o f the population, damaged infrastructure and institutions and reduced overall capacity in all sectors by encouraging brain drain. The socio-political and macroeconomic situation is frail and governance is poor. Government budget constitutes about 50 percent o f GDP, a good part o f which i s allocated to security and the demobilization o f soldiers. 2. The consolidation of the peace process has helped start reconstructionand created positive prospectsfor the country. Since 2000, the country has progressively recovered from a decade o fpolitical and economic turbulence and negative growth (average -1.8 percent), to a positive growth rate o f 5.0 percent in 2006. Economic growth is, however, largely determined by the widely fluctuating agricultural sector. Therefore, despite increased donor-financed capital expenditure, a decline in real economic growth to 3.6 percent is projected for 2007, reflecting a poor agricultural season. 3. However, the politicalsituation remainsfragile and the limited growth and relative stability haveyet to translateinto improvementsin Burundi's basic social indicators,which remain among the poorest inAfrica. Maternal and child mortality rates are about 900/100,000 and 179/1,000, respectively, which compare unfavorably with Sub-Saharan Africa averages. Primary school enrollment, which tripled in 2005 after the President abolished primary school fees, has surpassed the pre-crisis long-term level, reaching a gross enrollment close to 100 percent in school year 2005/06 (compared to 80 percent in 2003/04). Data from a 2005 survey suggestthat two out o fthree Burundian children under five are chronically malnourished, which ranks Burundiat first or second place interms o fmalnutrition rates on the continent. 4. I n September 2006, the Governmentapprovedits first full Poverty Reduction StrategyPaper (PRSP) which was presented to IDA and IMF Boards in March 2007. The PRSP aims to strengthen political stability, consolidate peace, and reduce poverty through accelerated, sustainable, and equitable growth. The principal strategic axes o f the PRSP are: (i)improving governance and security; (ii)promoting sustainable and equitable economic growth; (iii) developing human capital; and (iv) combatingHIV/AIDS. Progress has been made inall four areas. The implementationo fthe PRSP is being supported by several donors through budget support, investment operations, and technical assistance. Even with this support, it is not likely that Burundiwill achieve its MDGs. However ifthe donor assistance is well targeted and invested, it may allow Burundito initiate recovery and to ensure that its population reaps some o f the peace dividends equitably. B. Sector issues 5. In 2005 HIV prevalence among the adult populationwas estimated to be around 4.6 percent,but there are signs that it may have been underestimated.Preliminary data from the October 2007 National Sero-Prevalence and Socio-Behavioural Survey (NSPSBS) show an increase o f prevalence rate in the general population from an estimated 3.5 percent in 2005 to 4.8 percent in 2007. Most worrisome, inrural areas prevalence has exploded from 0.7 percent in 1989 to around 5 percent in 2007. Prevalence in border provinces varies between 7.5 percent and 9 percent. Surveillance data from sentinel sites suggested that in 2007 prevalence among pregnant women hovered around 12 percent, and rising, which is substantially higher than other countries 8 inthe regionwhichhavehigher prevalencerates' amongthe general population.Furthermore, about 120,000 childrenare considered HIV/AIDS orphans. 6. The data suggest that Burundiis one of the very few countriesinthe regioninwhich incidenceratesare stillincreasing, probablydue to the longconflict.Inmost countries in Africa HIV incidence has stabilizedinrecent years. The hypothesis is that Burundihas beenuntil recently somewhat "protected" from HIV by the longterm conflic?. As in other countries, the freedom of movement and generalpopulationredistributionsubstantiallyincreasethe transmission ofthe virus. This seems to be corroborated by the fact that this prevalence is much higher in border Provinceswhere access to treatment is not widespread yet. The introductionof Preventionof Mother-to-ChildTransmission (PMTCT) services in sentinel clinics in late 2003, which increasedthe share of high-riskpregnant women who are willing to be tested goingto those clinics, may have also increasedthe reported prevalence of HIV+pregnant women at sentinel sites above that of other countries inthe region. 7. The mainfactors contributingto vulnerabilityto HIV in Burundiappear to include low levelof male circumcision(particularlyamongthe young), low condom use, displacedand returningpopulations, low educational attainment ofwomen and girls, socio-politicalinsecurity, conflict, and limited access to HIV/AIDS services. Conflict has confoundedattemptsto determine the specificweight of each these factors inBurundi's epidemic. Results from the IDA-funded NSPSBSwill helpdetermine how andto what extent each ofthose factors affectHIV transmission, andwhich groups are at highest risk. Finalresults are expectedat the end of June 2008. 8. Burundi's responseto the HIV/AIDSepidemic has beenembodied intwo successive nationalHIV/AIDS strategies and plans (NHAS), developed with support from IDA and UNAIDS. The first strategy coveredthe period2002 to 2006 and includedactivitiescostingan estimated US$240million, andwas the basisfor the first "Multi-sectoral HIV/AIDS Controland Orphans Project" (Cr. 3684). The Projectwas financed througha US$36 million IDA Grant in the context ofthe first roundof Multi-sectoralHN/AIDS (MAP). At the time ofthe previous project's approval(June 2002), IDA was the first and only donor supportingthe country in its fight againstthe epidemic. In2005, the GlobalFund allocated US$32million to support NHAS, and a further US$3 million came throughother UNagencies.The total resourcesallocated to cover activities underthe 2002-2006NHAS financed only about 30 percent ofthe estimated needs.Despite beingone ofthe poorestnations inthe world with an unstablepolitical and security situation, Burundi's Government put in place a set of institutionsand staffed them with adequatepersonnel. 9. The first NHASwas very broad and ambitious. Ittargetedthe generalpopulation insteadoftargetingspecificgroups, andfocused on interventionsconsidered at the time to be effectiveandefficient by the internationalcommunity, but which have since beenprovento be less so. Examples of this includecondompromotionandtreatment of sexually transmitted diseases amongthe generalpopulation,versus focusingthose measuresamong highrisk populationsas is advocatedtoday. Furthermore, the institutionalsetup was new, and capacity for implementation, coordination,monitoringand evaluationwasjust beginningto be built. Finally, unpredictableand insufficient external aid and poor executionofthe nationalbudget have also Prevalence rates amongpregnant women in Ugandaand Tanzania are estimated at 8.5 percent and 7.5 percent respectively. Relativeisolation and low populationmovementsduring open conflict seem to haveslowedthe transmissionof HIV in several countries. 9 impairedthe ability ofthe Governmentto plan for and implementlongterm measuresof HIV/AIDS control. 10. Eveninthis constrainedenvironment, the first IDA MAP has been implemented successfully.Activities financed under the first Grant are beingcarriedout with minimal delays andthe Projectis likely to achieve its development objectives.Results attributableto the IDA MAP are promising(seeAnnex 1A).A few results worth highlighting include:(i)voluntary counseling andtesting(VCT) has increasedthroughthe establishment of 161sites, where as of mid-2007about 450,000 persons hadbeentested; (ii)over 5,000 pregnant women andtheir babies benefitedfrom PMCT services between2002 and 2006, probablypreventingabout 1,500 new HIV infectionsamongthose newborns, andreducingthe likelihood of a new unwanted pregnancy amongHIV+women; (iii) the number ofpatientsunder antiretroviraltherapy has increasedfrom 600 in2002 to about 10,000 in2006; (iv) according to population-based studies, the percentageofyouthwho correctlyidentify ways ofpreventingsexualtransmission of HIV/AIDS has doubled since 2003; (v) in a 2004 survey, condom use duringthe last sexual encounter amongyoung menandwomen was 48 percentand42 percent, respectively-up from about 20 percent for all groups in 2001;(vi) the use of condoms increasedto 54 percent and45 percent respectivelyinthese same groups in intercoursewith a commercialsex partner; and (vii) all Government agencies and parastatalshave defined and are implementingHN/AIDS preventionplans. 11. The first Projectensuredan effective implementation of the "Three Ones3".By supportingthe development of a unifiedM&E system and by workingwith other donors as they initiatedactivities inthe country, the first MAP has ensuredan unprecedented levelof harmonizationinthe sector. Coordinationwith other partnerswill continue andbe strengthened duringthe proposedoperation. 12. As encouragingas those resultsare, they remaininsufficient to stop transmissionof the diseaseor reduceits impacton affected families. This was to be expected since only 30 percent ofthe activitiesinthe 2002-2006 NHASwere financed, andthere were many institutional,technical, financial, andcapacity-relatedissuesconstrainingthe implementationof the 2002-2006 NHAS.A relativelysmall IDA-financedprojectcannot single-handedly reverse the courseof the epidemic. Public institutionshave provento beweak anddo not havethe personnel or resourcesto adequately mainstream HIVIAIDS activitiesintheir programs and NGOs havebeen limitedintheir capacity by the shortageof qualifiedpersonnel. 13. Although the SEP/CNLS has been an effective implementingagency, the current institutionalarrangements are deemedinstitutionallyunsustainablein the medium and long term. As a resultof perceivedlack of capacity inthe public sector until 2006, the SEP/CNLS became a public executing agency, taking over mandatesfrom severalministries.As the public sector capacity increases, the SEP/CNLS is seen as a "super ministry" and as underminingsome technicalministries.Hencethe Government's efforts to progressively mainstream HIV/AIDS control activitiesin key ministriesand to further decentralize implementation. 14. Lessonslearned from the implementationof the first strategy and international experiencesare included inthe updatedNHAS 2007-2011 and inthis second IDA-financed MAP, and are listedin SectionEand inAnnex 1A ofthis PAD. 3The UNAIDS-recommended"Three Ones" includea unified coordinatingbody, a commonnational HIV/AIDS strategy and a single monitoringand evaluationsystem. 10 15. Interventionsin the new 2007-2011NHAS remainsomewhat scattered but the Government has takensteps to further improvethe strategy.Lack of country-widereliable epidemiologicaldata has resulted in a limited understandingofthe dynamics of Burundi's epidemiologicalprofile and of risky behaviorswhich favor the spread of HIV. Results from the NSPSBS shouldhelp further refinethe NHAS, andby extension the IDA Projectinterventions. Concomitantly,ongoingtechnicalassistance financed by the AIDS Strategy and Action Plan service (ASAP) will help refinethe newNHAS actionplan, andwill providethe foundationto target IDA resourcestowards the most effectiveapproaches Support from the GlobalMonitoring andEvaluationTeam (GAMET), duringProjectpreparation and supervision, will further strengthenthe existingnationalM&E system and operational planparticularlyinthe areas of impact evaluationof specific interventionsand data use for decision making. 16. In order to leveragethe country's limitedfinancialand humanresources,the 2007- 2011NHAS introducedchangesin the focus and scope of operationsfor HIV/AIDS preventionand treatment.The basic features that differentiatethe new NHAS 2007-2011 from the previous one includethe smaller scope (the current strategy amounts to about halfofthe previousone), clearer focus, and efforts to mainstreamand further decentralize activities in key ministriesand localauthoritiesto leveragehuman and financial capacity from other sectors. The new NHAS also intendsto further use already existingperformancecontracts andagreements with serviceproviders. 17. The 2007-2011NHAS has four strategic axes includingactivitiesin severalsectors. The overarching objectives ofthe 2007-2011NHAS remain those ofthe overallNational Plan, which are to reducethe transmission of HIV/AIDS and minimizethe effects amongpersons livingwith HIV/AIDS and their families.To achievethese goals the new NHAS divides its action into four axes: (i) extensionof preventiveactivities; (ii)improvement of living conditionsof persons livingwith HIV/AIDS; (iii) reductionof povertyand other determinant factors of HIV/AIDS vulnerability; and(iv) improvement ofthe nationalresponse managementand coordination. 18. The proposedIDA-financedProjectwill finance a transversalslice of the currently underfinanced 2007-2011NHAS.The estimatedamount neededto implementthe NHASis US$145million4,ofwhich only about 33percent is coveredby the current MAP, the Government, andthe 5~ roundofthe GlobalFund for TB, Malaria& HIV/AIDS (GF) (US$3.5, US$15 andUS$29million, respectively).Burundihas not been selectedas arecipientof resourcesfrom round 7 ofthe GF.Therefore, since no other donors have expressed an intentionto contributein a substantialway to finance the NationalStrategy and Plan, the country is facinga substantial shortage of resourcesto continue its effortsto curb the epidemic.The IDA Grant (US$15 million) will help cover part of the gap andwill givethe countrythe breathingspace until Round 8 ofthe GF in mid- to late 2008. Even inthe best case scenario, total availablefinancing will probably be insufficientto achieve Burundi'sMDGHIV/AIDS targets. IDA resourcesare thus fundamentalto even a moderately successfulcurbingofthe epidemic, will initiate the process of streamliningHIV/AIDS activitiesin key ministriesthus levera ing additional resourcesfrom other sectors, andwill support the preparationofthe GF 8` roundproposal. The 8 proposedProjectfinances activitiestargeted only to HIV/AIDS orphans, rather than to all orphans. 4 It is possiblethat the financial needs are underestimated given that important strategies likemale circumcision services are not included.The Governmenthas requestedtechnical assistance to ASAP to helpcalculate the real costs andprioritize the activities before the endofthe year. 11 19. Activitiesunder the proposedProjectwill be complementaryto an IDA-financed HealthProjectcurrentlyunder developmentand will aim at strengtheningthe health system. Inthe late 1990the then Ministryo fHealth' launched a series o f public consultations that have culminated inthe adoption o f the National Health Plan in January 2006. The plan is very ambitious, and the Government and the donors through the sector coordination group are currently prioritizing its activities. The coordinating group aims at defining an operational plan for the development o f the sector to be supported progressively by different donors inthe context o f a Sector-Wide Approach (SWAP). The dialogue is being informed by two IDA-financed studies, the "Health Sector Note" (2006), and the "Health Sector Financing Study" (2008). Interventions related to health included inthe 2007-20 11 NHAS are in line with the corresponding sections o fthe National HealthPlan. Health activities in the proposed Project will be implemented by or through the "Ministhe de la Sante Publique et de la Lutte Contre le SIDA" (MSPLS), ina manner that will strengthen the health system. Details can be found inAnnex 4. C. Rationalefor Bankinvolvement 20. The rationalefor the Bank's continuedinvolvementin HIV/AIDS in generaland in Burundiin particular, has been reflectedin the Bank's recently approved sector strategies. Strategic guidance and lesson learned reflected inthe 2006 "AIDSProgramof Action ",and the HealthNutrition and Population Strategy published under the name o f "HealthyDevelopment", (2007), were central to the Project's design. Specifically, the Bank provided technical assistance to strengthen the 2007-20 11NHAS, and to ensure the synergy between health system strengthening and HIV/AIDS interventions. The Project's focus on results and accountability also stems directly from the referred strategies. 21. Consolidationand scaling-up of effective interventions under the first MAP is essentialto progresstowards achievingthe country's MDGs.The financial support provided by the first M A P has been fully disbursed. The Government, some UNagencies and the GF also finance the National HIV/AIDS Plan. Those resources are however quite low in the first two cases, volatile in the last case, and in both cases fairly inflexible once allocated. Recently, DFID and the EUhave indicated their interest in financing HIV/AIDS through their health-sector support operations. 22. Current and pledgeddonor contributionsto HIV/AIDS are generally limitedto health-servicesbasedactivities and do not finance multi-sectoral, mitigationand certain prevention activities.Most donors consider HIV/AIDS exclusively as a health sector issue and thus they do not include intheir financing preventive activities that fall outside the health sector. Inthe foreseeable future, IDA is the only substantial source o ffinancing for certain prevention and multi-sectoral activities. 23. These multi-sectoralactivities are centralto control HIV/AIDS. Preventive activities are often the most cost-effective and lessons from international experience have shown them to be the most effective way to control the epidemic. Sector ministries, professional and labor organizations, and civil society groups are generally better placed than the ministries o f health to deal with behavior change and regulations to reduce stigma intheir respective groups o f influence such as fishermen (inthe case o f Burundi), commercial sex workers, truckers, work crews in big civil works, prisoners, policemen etc. Social protection for highlyvulnerable or HIV/AIDS- affected individuals and families is considered a central part o f any comprehensive preventive strategy as it tries to lessen vulnerability, which is one o f the underlying determinants o f the RenamedinNovember2007 `MinistBre de la Santk Publiqueet de la Lutte Contre le SIDA'. 12 spreadofthe epidemic. Socialprotectionactivitiesfall squarely outside Burundi's MSPLS competences. 24. Besidesthe much-needed financial resources,IDA bringsadded value to the National Program in a number of different ways as reflectedin the HNPand HIV/AIDS Bank strategies mentioned above, including: Convening power for Government, civil society, and development partners arounda commonvision of effectiveHN/AIDS preventionand improvedaccountability, which has helpedthe Government implementthe internationallyrecognized"three ones" (one nationalplan, one coordinatingbody one M&E system). Intensetechnicalguidance andM&E support throughcareful supervision; Ability to foster a sustainable, multi-sectoralresponse, through its work with multiple sectorsreceivingBank support. Potentialof helpingthe Government in its effortsto ensure synergy between health system strengtheningand priority-diseaseinterventionsto increase convergencewith other health programsand strategiesthroughupcominghealth operations; Uniquecapacity to finance system development and capacity building; and Flexibility to cover unforeseenfinancial gaps in key activities. Innationalandinternationalfora, the Government, communities andpartner agencieshave indicatedthat they consider IDA's continuinginvolvementin Burundi'sNationalProgramas critical, particularlyregarding it multi-sectoralcapacity and inthe areas ofpreventionand support to civil society through subprojects and capacity buildingactivities. D. Higher levelobjectives to which the Project contributes 25. The Government's higher-levelobjectivesas enunciated inthe previous and current NHAS strategies are to: a) slow the spread ofHIV/AIDS inthe general population;and, b) mitigatethe impactofHN/AIDS on individualsand families. 26. The Project is fully aligned with the first pillar of the 2006-2007 Interim Strategy Note "Improving security, social stabilityand service delivery," which includes curbingthe spreadofthe HIV epidemic as its first goal. Burundi's CountryAssistance Strategy (under preparation) is basedon Burundi's PRSPand HIV/AIDS controlwill be a strategic priority. The proposedprojectis therefore fully consistent will the Bank's current and expected future strategic prioritiesfor Burundi. 11. PROJECT DESCRIPTION A. Lending instrument 27. The proposed lendinginstrumentis a Specific InvestmentLoan(SIL) supportinga National Program.Programmatic lendinginstrumentsincludingan APL were considered but discarded for the following reasons:(i) the difficulties ingeneralbudget management encounteredinthis and other sectors; (ii) poor implementationcapacity of ministriesin general versus the provencompetence to implement, coordinate, and supervise ofthe SEP/CNLS which is independent of any ministry; (iii) country i s still relativelyunstableand IDA's country the strategy for the next four years has yet to be defined, therefore committingfunds for the longtern was deemedby managementandthe team as too risky; and(iv) IDA's resourcesfor Burundiare relativelylimited. Inview ofthe competing needsthe Bank intends to move away from financing 13 HIV/AIDS activitiesthrougha self-standingprojectandtowards mainstreamingactivitiesthrough projectsinthe key sectors.To ensure a coherent approachto health-relatedneeds, the upcoming Health Sector Projectsupportinga sector-wide approachwill includefinancing for HIV/AIDS medicalactivities. B. Programobjective and Phases 28. The implementationof the 2007-2011 NHASwould contributeto achieving the long term objectives of the National Program.These objectives are to be attainedby building on and improvingexistinginterventionsthat involvemultiplesectors and engage all line ministries, civil society (includingreligiousorganizations), privateenterprises, laborunions, farmers, women, youth and student associations, peoplelivingwith HN/AIDS and other NGOs.Detailsofthe current institutionalstructure to overseethe National Programand implementthe successive NHAS can be found inAnnex 6. 29. The specific objectivesof the new 2007-2011NHAS are to: (a) Reduce HNtransmission throughreinforcement and extension of effectivepreventive activities, intense technicalguidance, and M&E support throughcareful supervision; (b) Improvethe living conditions of persons living with HIV/AIDS; (c) Reducepoverty and other determinant factors of HIV/AIDS vulnerability; (d) Improvethe quality of HIVIAIDS nationalresponsemanagementand coordination. C. Projectdevelopment objectiveand key indicators 30. The Projectdevelopment objective is to increasethe utilization of a selectedset of preventiveservices, amonggroups highly vulnerable to, or affectedby HIV/AIDS. 3 1. To achieve this objectivethe proposed Projectwill finance a transversal slice of the 2007-2011NHAS, and its componentscorrespondto the four axes of said strategy.The Projectwill achievethose goals by contributingto : (i)capacity-buildingand service deliveryfor service providerswith a focus on preventionactivitiesin high risk groups; (ii)existingandnew treatment services onthe basis of performance; (iii)small grants for highly vulnerablegroups and HIV-affectedfamilies; and, (iv) capacity building for localauthoritiesandkeyministriesto implement and monitor HIV/AIDS controlactivities, and operational costs for managingthe NationalProgramincludingimprovingthe M&E system. 32. A few key performanceindicatorsincludedin the results framework ofthe NHAS have been selectedto measurethe achievement ofthe development objective andare detailed in Annex 3. Those indicatorsinclude: Percentageof female sex workers who report usinga condomwith their most recent client. Percentageof women and menaged 15-49 who report havingsex with more than one partner inthe last 12months which report havinguseda condom in the last sexual act. Number andvalue of subprojects targetingvulnerable populations and highrisk groups. Percentageandnumber of adults andchildrenwith advancedHIV infectionreceiving antiretroviralcombinationtherapy. Numberof HIV+pregnant women who receivedantiretroviraltherapy to reducethe risk of MTCTversusthe expectednumber of HN+pregnantwomen. Numberof persons livingwith HIV/AIDS reachedthrough small grant activities. 14 (g) Number o f public sector organizations that have HIV control-related activities inthe annual plans or sector strategies. D. Projectcomponents.(see Annex 4 for a detailed description). 33. The proposed Grant will facilitate the consolidationof recent gains on the ground and allow for the scaling-up of the localintegrated responseto HIV/AIDS. It would also promote strengthening o f the quality o f current interventions as well as capacity o f key public agencies, in particular MSPLS. 34. The IDA Grant will financeselected interventionsthat fall under four components which follow the four axes of the NHAS. The proposed four components are as follows: 35. Component I:Preventive Services Targetedto High Risk Groups (IDA financing: US$7 million). Interventions supported by this component fall under the first axis (or operational Program) o f NHAS 2007-2011, and aim at reducing HIV transmission among high risk groups through behavior change and increased access to preventative services. The component will finance: (i)activities carried-out by NGOs, community groups, social groups, professional associations and sector ministries (except the MSPLS) to promote behavioral change in high risk groups; (ii)communication campaigns to promote male circumcision; (iii)voluntary counseling and testing; (iv) transfers to General Direction o f Resources o f the MSPLS to finance performance-based contracts between the MSPLS and public and private service providers for PTME and male circumcision activities; (v) the goods and technical assistance to carry out the National Medical Waste Management Plan (NWMP) in relation of HIV/AIDS medical waste; and (vi) technical assistance to design, pilot and ifsuccessful scale up performance-basedcontracts/ agreements for the provision o f behavior change services. 36. Further the component would: (i) provide technical assistance to improve existing performance-based contracts/agreements between the MSPLS and service providers for offering male circumcision and prevention o f mother to child transmission services; and (ii)transfer o f resources to the MSPLS to carry out the supervision o f performance based contracts and accreditation service providers o f PTME, male circumcision and HIV/AIDS medicaltreatment and implement the National Waste Management Plan (NWMP). Details on the existing experience on performance-based contracts for service provision in HIV/AIDS are to be found in Annex 4. 37. Component 2: Performance-Based Curative Services (IDAfinancing: US$2million). This component will support the geographic extension o f antiretroviral (ARV) treatment and opportunistic infection prophylaxis and treatment to HIV+ people inthe whole country. To achieve this objective, IDA resources will finance technical assistance to improve existing performance-based service contractdagreements between the MSPLS and public and private health facilities to provide clinical care for HIV/AIDS patients. Currently such contracts / agreements are between the SEPKNLS, the MSPLS and the service providers. 38. Improving those agreements will increase the possibility that the GF, other donors and the Bank, under a potential health operation, would eventually finance those activities as part o f the performance-base financing schemes beingproposed for the health sector. To demonstrate the value o f those arrangements the component will initially (untilother sources o f financing come on board) transfer resources to the General Direction o f Resources (DGR) o fthe MSPLS to finance those agreements. 15 39. Finally, resources under this component will also help further develop community-based home care services ina limited set of communities.Interventionsunder this component fall within the subprograms of the second axis ofthe 2007-2011NHAS, "Improving the living conditionsof persons livingwith HIV/AIDS". 40. Component 3: Decentralized Financing of Small Grants to Families Living with HIVIAIDSand High Risk Groups (IDA-financing: US$3millionLThis component aims at providinglimited economic and legal support to the most vulnerablefamilies affected by HN/AIDS andthereby falls under the NHAS2007-2011third axis "Reduction ofpovertyand other determinant factors of HIV/AIDS vulnerability". IDA Grant resourceswill use the mechanisms set-up under the first MAPto finance subprojects managedby NGOs, commune developmentalcouncilsandcommunity-groups,that provide small grants to vulnerable families, and families livingwith HIV/AIDS to increasetreatment compliance; increase their capacity to nourishthemselves inorder to improvethe impactof drugs; and support to HN/AIDS orphans andwidowed women with their rights.The subproject scope and procedureswill be the same as in the prior Project. 41. Component 4: CapaciQ Building-for Local Authorities and Kev Ministries to Implement HIV/AIDSActivities. and National Propam Management (IDA financing: US$3 million). Component activitiesfall within Axis 4 of the NHAS 2007-2011which aims at "improving HIV/AIDS nationalresponsemanagementand coordination." The objectives of this component are to buildcapacity to implementandmonitor HN/AIDS activities inkey ministriesand local governments, contributeto ensure adequate operation ofthe SEP/CNLS; increase the SEPICNLS capacity to managethe M&E system, inparticularcarry-outimpact assessmentof interventions. This componentwill finance: (i)SEP/CNLS operational costs to carry out its coordination, monitoringandevaluation, andfiduciary responsibilities;(ii)technical assistance and surveysto improvethe capacity of the nationalM&E systemto carry out impact evaluations and epidemiologicalstudies; (iii) technicalassistance andrecurrent costs for ministriesother than the MSPLSto coordinate andsuperviseHN/AIDS activities intheir respectivesectors, and(iv) quarterlytransfers to pilot provincialauthoritieson the basis of annual actionplans approved by the SEP/CNLS, so that they can carry out their supervision and data collectionactivities inthe communesandvillages. Detailscan be found inAnnex 4. E. Lessonslearnedand reflectedinthe project design 42. Midterm reviews, supervision reports and external evaluationssuggest that the ongoing MAPand GF projectshave been performingwell and are likely to achieve their objectives. However, those same resourcesas well as internationalbest practiceshighlight the following lessons learnedthat have beentaken into consideration inthe design ofthe new Project: Technical:(i)every country, and zone within a country, has a unique epidemic profile and success is directly correlatedto tailoring interventionsto that specificity; (ii)in a concentratedepidemic, targeted interventionsin high-riskareas andhigh-riskgroups are the most effectiveway to reducetransmission becauseof the multiplier effect of preventionto the generalpopulation;(iii)previouslywell-accepted interventions, substantiallyfinanced under the first 2002-2006 NHAS and first MAP, are proving difficult to substantiateunder stricter empiricalscrutiny:mass VCT, sexually transmitted infectionstreatment (inthe generalpopulation), mass condom distribution,massmedia campaigns, etc; (iv) interventionsnot previouslyfinanced have come to the forefront of preventionsuch as male circumcision,reductionof partner concurrency, peer-based 16 communication for behavior change, and condom distribution in high-risk settings; (v) surveillance, epidemiological and analytical work, to correctly direct policies and interventions i s generally under-funded; and, (vi) impact assessment o f interventions is a must to redirect policies and ensure results. (b) Institutional:(i) concentration o f resources and capacity by a coordinating body at the highest political level has positive effects; but it also tends to create "supra-ministries," that take on functions beyond their coordinating mandate and thereby create friction with other public agencies and local authorities, further undermining the generally low capacity o fthe public sector; (ii)streamlining activities in other sectors is crucial for institutional and financial sustainability in the fight against H N / A I D S and to increase the impact o f the activities; (iii) transitioning towards integrating HIV/AIDS prevention and treatment interventions within existing health services is needed to increase institutional sustainability and rationalize the use o f scarce resources; (iv) sharing M&E results with stakeholders and decision-makers helps get support for the strategy changes that may be necessary; (v) persons livingwith HIV/AIDS are best reachedthrough community mobilization; and (vi) communication activities have to be regularly and rigorously assessed and adapted consequently, in order to ensure their usefulness in H N / A I D S control. (c) Other lessons include the need to: (i)increase the coverage o f prevention and treatment services outside Bujumbura; (ii) tailor interventions to the different realities o f highrisks groups; (iii)increase efforts to mainstream activities related to H N / A I D S in key ministriesand local authorities; (iv) move to performance-based contracts or agreements to finance service provision and civil society activities, so as to increase transparency o f resultsand create incentives for efficiency F. Alternativesconsidered and reasonsfor rejection 43. The first decisionwas to completelyharmonizethe Project to the existing2007-2011 NHAS both in terms of context and format. The experience with the first MAP suggests that having IDA components" that were not directly aligned with the axes and subprograms, as " defined inthe NHAS, added unnecessary bureaucratic burden to the National Coordinating authority (SEPKNLS) as they had to keep track o f expenditures and produce reports on different formats. 44. Secondly, giventhe limited resourcesof the IDA Grant and the need to show results, itwas decided that the Projectwould finance a limited set of the interventionsof the NHAS2007-2011, as opposedto the moregeneralfinancingof the first Project. The specific interventions were prioritized through a participatory process, on the basis o ftheir relevance to Burundi's epidemic, proven cost-effectiveness, experience with their implementation incountry or abroad, and complementarily to activities funded by other donors, mainly the GF. It was agreed to finance activities across axes rather than focus on one or two axes to allow flexibility to respond to changing country circumstances. 45. I n terms of modalitieschosento implementspecific project activities,the team and the Government chose to: (i)further institutional and financial decentralization to provincial governments; (ii)mainstream financing and activities to key ministries; (iii)improve existing performance-basedcontracts/ agreements with treatment, PMTCT and male circumcision services providers; and (iv) pilot performance-based contracts for providers o f behavior change services. A few ofthose choices are highlighted below and details for all o fthem can be found inAnnex 4. 17 46. Linked to mainstreamingactivitieswithin the MSPLSthe choicewas made to move funds through the General Direction of the Resourcesof the MSPLSratherthan throughthe MSPLS HIV/AIDS Program.Inthat way the capacity of managingresources ofthe MSPLS would be strengthenedandthe resourceswould be usedto strengthenthe health systems, particularly inthe areas of pre-natal, pediatricand postnatalcare and family planninginthe context of providersofPTMCT services, and strengthenminor surgery capabilities inthe context of male circumcision. 47. Although the mentionedchoices representa certain level of innovationwith respect to the prior Project, they are all based on ongoingexperienceand follow-up national policy. The exceptionto this rule is the design and implementationof performance based-contractsfor behavior change service providers.Since there is no experience inthis area, the Projectwill first pilot this type of contract with a few providers.Supervision and final evaluationwill indicate whether these types of arrangementscan be generalized. 48. The final strategicchoicewas whether to proceedwith a stand-aloneoperation versus either provide additional financingto the existing MAPor integrate HIV/AIDS control activitieswithin the healthsector operationcurrently under preparation. The PCN meetingrejectedthose alternatives, andthe QER panel concurred onthe following basis: (a) Many ifnot most of the activitiesinthe proposedoperation are multi-sectoralin nature andwill be carriedout by institutionsnot linkedto the MSPLSor to health services; (b) Institutionallythe SEP/CNLS is under the Presidency andhence not linkedto the MSPLS; (c). The non approvalof the GF Round 7 for Burundi has created a financial gap that needsto be urgentlyclosed. Since preparationofthe health project will take more time than the HIV/AIDS project, combiningthe two projects would delay our responseto the urgent needsinthe HIV/AIDS sector; (d) The existingHIV/AIDS coordinatingand executing agency (SEP/CNLS) has a very good implementation,coordinationand monitoringand evaluationrecord, while the MSPLS implementationcapacity is limitedand shouldnot be dispersedon issuesoutside its direct mandate. (e) Combiningthe issueswould addto the complexityofthe operation; (f) Additional financingshouldnotbe consideredbecausenew activitiesshouldbe completedwithin three years of the current closingdate; and (g) Experiencewith combinedoperations suggests that ministriesofhealth are generally not well placedto coordinate and overseemulti-sectoralissues andto cooperate with other ministriesor institutions. 111. IMPLEMENTATION A. Partnership arrangements 49. No other agency is financing the proposedProject. However, the GFthroughremnant Round5 resources and some UNagenciesdo finance a selected set of activitiesfrom the 2007- 2011 NHAS.Harmonizationof activitiesand financingare providedby the Government through the SEP/CNLS leadership, the approvedNHASandthe unifiedM&E systemfor HIVIAIDS. Overall, the current gap for the NHAS, includingthe proposedProjectIDA ofUS$ 15 million, is estimated at 54 percent. 18 B. Institutionaland implementationarrangements 50. From the Bank's point ofview, the new Projectwill use the same implementation arrangementsas the prior Project as reflected in the existing "Projet Multisectoriel de lutte contre le SIDA" (PSMLO) ProceduresManual approvedby the Bank. Fromthe point of view of the Government, there will be some changes on the flow of funds to the localauthoritiesand key ministries.Detailsofthese changesare to be found belowand inAnnex 7. 5 1. The key reasonfor Government and IDA efforts to mainstreamHIV/AIDS control activities in key sectors and in localauthoritiesis the needto increasethe institutional capacity and sustainabilityofHIV/AIDS control.Boththe Governmentand IDA evaluations of the MAPhave identifiedthe strengths andweaknesses ofthe prevailinginstitutionalmodelin the fight against HIVIAIDS (see lessons learned in section E). 52. The current institutionalset-up and flow of funds reflectthe multi-sectoralnatureof the fight againstHIV/AIDS, and the needto havestrongcoordination and a unifiedM&E systemto facilitatethe establishment of partnership betweenall sectors and civil society for a concerted responseto the epidemic. However, as funds from the internationalcommunityhave flowed exclusivelythroughthe executing branchofthe nationalcoordinatingbodies, inthe case of Burundithe SEP/CNLS, those agencies have gone beyondtheir originalmandateto become the mainimplementersof HIV/AIDS control activities.InBurundithis situationis further compoundedby the acute lack of capacity of local authoritiesandministriesafter 13 years of conflict. 53. The recommended"cure" for the centralized implementation "ailments" affecting mostHIV/AIDS nationalprogramsis to mainstream activitiesso as to devolve responsibility to and strengthenthe capacity of institutionswith specializedmandatesinHIV/AIDS control. Following the mentionedrecommendations,this secondProjectbuildsonthe strengthof the existingmodelwhile addressing some of its weaknesses.Therefore the SEP/CNLS will continue to be the institutionresponsiblefor overallprojectimplementation, but some funds will be decentralized at the provincialleveland some key ministries, specificallythe MSPLS, will have increasedresponsibilityto managefunds. 54. The prior projectdecentralizeddecision-making for subprojects to community- basedHIV/AIDS committeesat the provincial,communeand village level. The new Project will build onthis experienceandfurther decentralize funds to the provinciallevelon the basis of agreed targets. Likewise, funds will be transferred in quarterlytranches to a few key ministries, startingwith the MSPLS, on the basis of annualplans and targets, so that they can implement their activitiesin a timely manner.The MSPLS will enter into performance-basedcontracts or agreements with public andprivateprovidersof HIV/AIDS treatment, PMTCTandmale circumcisionservices.The MSPLS will supervisethe contracts andthe SEP/CNLS will monitor achievements. Successivetranchesto the MSPLS will reflect how well the targets have been reached. A summary ofthe additionalimplementationarrangementson the Government side can be found inAnnexes 4 and7. Those changes have beenreflectedinthe existingPSMLO ProceduresManual. 55. As inthe first MAP project,the CNLS under its ExecutiveSecretary(SEPICNLS) will be responsiblefor the overallimplementationof the Project.The SEPICNLS has proven its capacity to manageresourcesfollowing IDA procedures.However, inthis second Project,the SEP/CNLS will transfer funds to some key public implementingagencies onthe basisof agreed work plans andresults. The implementingagencies identified so far are the MSPLS and local 19 authorities. Decentralization o f financing to local authorities will be carried out in a phased manner. Inthose casesthe project financial management could be weakened by the following: (a) Inability to find qualified staff to strengthen the accounting functions o f the additional implementingunits. (b) The increase on the number o f implementingunitsmay impact negatively or reduce the quality, time and accountability o fthe financial reporting. 56. The Projectdesign includesthe steps to reducethe potentialimpact of the proposed changes,namely, technical assistance and hiringo f qualified personnel. 57. The Grant will have only one disbursement category, so that reallocationcan be easily done in case potential financing for some critical activity fails to materialize (see risks), thus increasingthe predictability o f sector resources. C. Monitoring and evaluationof outcomes/results 58. Data on Projectoutcomesand resultswill come from the established M&E system, managed by the SEP/CNLS which has provided the data for the Project Development Indicators (Annex 3). The monitoring capacity is quite comprehensive but there is a need to simplify and refine the reports produced. Decentralization to local authorities and devolution o f activities to key line ministries can potentially increase the difficulty of collecting data to monitor activities from those institutions. To avoid this issue, the decentralized agreements with local authorities and line ministries will include data collection as one o f the key performance indicators. 59. The capacity to evaluate the impactof interventionsand to carry-out country-wide surveillance is somewhat limited.Additionally, the information generated by the M&E system i s not sufficiently used for day-to-day management and policy making. Under component four, the proposed Project will finance technical assistance to improve the capacity to carry out impact evaluations o f interventions, develop simple tools for presenting data to decision makers and help them use the data. It will also support technical assistance to: (i)provide evidence for effective targeting o f interventions; (ii)support and improve HIV biological and behavioral surveillance among general population and high risk groups, sentinel surveillance and monitoring behavior, and (iii)build capacity o f the SEP/CNLS and other NHAS implementers on data analysis and use o f strategic informationfor activity and program improvement. The Project will also finance part o f the cost o f operation o f the M&Esystem and GF will finance the rest o fthe costs. D. Sustainability 60. The Government of Burundi has repeatedlyshown its commitmentto HIV/AIDS controland has taken several steps in this regard.These include: (i)making HIVIAIDS one o f the four central themes o f the PRSP; (ii)regularly allocating government budget and HIPC resources to HIV/AIDS; (iii)creating and maintaining a competent team to manage HIVIAIDS activities; (iv) preparing the new 2007-201 1NHAS through a participatory process and including lessons learned from 2002-2006 NHAS; and (v) approving the 2007-2011 NHAS, preparing its operational plan and presenting both to the donor community at the June 2007 roundtable for financing. 61. Given the currentcentralized implementationarrangements, one of the key issues is the institutionalsustainabilityof HIV/AIDS. The proposedProject intendsto tackle this issue through focusing on mainstreaming key activities inthe agencies that have the governmental 20 mandate to carry out those activities, notably the MSPLS and the local authorities. As the responsibility to implement activities is progressively taken back by those institutions, it is expected that the financial burden o fthese activities will also progressively be shared, thereby increasing somewhat the financial sustainability o f individual interventions. E. Critical risks 62. Politicalinstability, restarting of conflict and non-approval of the tithround of the GF for Burundiare the key risksfor the Project.The first MAP demonstratedthe practicality o f working under a certain level o f conflict, particularly when some activities are decentralized and can be implemented without constant inputs from the central level. IfBurundiwere not to benefit from resources from Round 8 o f the GF the National Programwould confront an insurmountable financial gap. 63. Both scenarios, conflict and sudden lack of financing, would requireProject reappraisal in order to: (i)assess the likelihood o f Project objectives being achieved, and make changes as needed, and (ii)adapt activities and strategies to the new situation. Another risk is the potential substitution o f the current Government team by a weaker one. Finally, it is recognized that the capacity o f local authorities and key ministriesto implement their activities is still somewhat weak. The Project includes a substantial amount o f resources to strengthen the existing institutions through a process o f learning-by-doing plus technical assistance. This should create a broader and more capable constituency and will distribute responsibilities among different actors, thereby increasingthe likelihood o f institutional sustainability. 64. The current financial gap (50 percent) may create friction amonginterestgroups (HIV+associations, pregnant women, NGOs dealingwith prevention or social support etc). In order to address the complexities surrounding this issue, Project priorities were selected in consultation with all the mentioned groups, and a stakeholder analysis will be carried out under the ProjectPreparation Facility (PPF). 65. To ensure that resourcestransferred to the MSPLS or other implementingagencies are adequately used and tracked, a PPF finances capacity building on fiduciary functions. IDA experts carried-out an assessment. Recommendations from the assessmentwill be implemented under the PPF prior to transferring resources to the MSPLS. The table below shows the critical financial management riskProject management may face inachieving Project objectives and provides a basis for determining how management should address these risks. 66. Progress on environmentalissues realizedunder the first MAPwas limited by civil conflictand low country capacity.The environmental rating for the project is B.The assessment and action plan carried out underthe previous operation has been updated to reflect the changing country situation. The results o fthe updated assessment and the plan to mitigate potential negative effects were made public on February 11,2008. F. Grant conditionsand covenants 67. The following Grant effectivenessconditionswere agreed upon negotiations: (a) The SEP/CNLS will revise, in a manner satisfactory to the Association, the PSMLO Procedures Manual. 21 (b) The Government will adopt the Ministry of Public Health and AIDS Control Administrative and Financial Procedures Manual, in form and substance satisfactory to the Association. (c) The Government will appoint, to the accounting units of the entities involved in Project implementation, staff with qualifications, experience, and terms of reference satisfactory to the Association for purposes of Project implementation. 68. The following covenants were agreed upon at negotiations: (a) The Government will allocate the equivalent of at least $3 million US$ annually to the SEP/CNLS in the general Budget Law to carry out activities under the agreed annual plan for the duration of the Project. (b) An agreement between the SEP/CNLS and the MSPLS acceptable to IDA, describing the results to be achieved directly or indirectly by the MSPLS, and the fiduciary arrangements and responsibilities will be received by the Bank no later than a month after Grant effectiveness. (c) A message clarifying the Institutional Arrangements, particularly the role of the recently constituted MSPLS versus the CNLS and will be received by the Bank no later than a month after Grant effectiveness. IV. APPRAISAL SUMMARY A. Economic and financial analyses 69. Detailed economic HIV/AIDS analysis has been carried out by different sources, including the Multi-country HIV/AIDS Program for Africa Region. The analysis demonstrates the impact of the epidemic on economic development and poverty as well as the cost-benefit of HIV/AIDS interventions. 70. The fiscal impact of the Project is expected to be very modest. Ongoing Government contributions that are part of the HIPC commitments will be considered as counterpart funds thus no additional burden will be imposed on the Government. Since the activities of this Project represent a sub- set of those carried out under the first MAP there will be no supplemental operational costs associated with the new operation. Given Burundi's macroeconomic situation, it is expected that in the foreseeable future, the HIV/AIDS response will be primarily funded by external aid and thus all the incremental costs incurred by the Government as a result of implementing Project activities are not expected to place any additional fiscal burden on the Government. B. Technical 71. Project design represents the general consensus among stakeholders of the priorities that Burundi faces in its effort to control the epidemic and the complementarities with resources from other donors. The M&E activities were designed in collaboration with UNAIDS and GAMET. The 2007-2011 National Strategy has benefited from support from ASAP to prioritize its activities on the bases of cost-effectiveness and expected impact of activities. 72. The Project relies on a learning-by-doing approach to certain innovative ideas, and follows national health policy regarding health service provision. The Project also builds on that which worked adequately in the first MAP, such as contracts with service providers, while discarding what has been 22 proven less effective. The Project also incorporates new knowledge of the local epidemic generated by the 2007 national epidemiological and socio-behavioral survey. Finally, the Project deepens Government efforts to mainstream HTV/AIDS strategic activities within the different sectors attempting to create synergies and increase institutional sustainability. C. Fiduciary 73. Burundi has made progress in all areas of weaknesses in its Financial Management environment which were documented in the Country Financial Accountability Assessment (CFAA) concluded in 2004. These included budget formulation and execution, financial reporting, oversight systems as well as weak linkages between agreed policies budgeting planning and execution. 74. Notable improvements include: (i) the introduction and implementation of an interim Financial Management Information System which generates standard quarterly budget execution reports and reports on poverty-reducing expenditure and/or HPC expenditure execution; (ii) the adoption and implementation of a new unified functional and economic budget classification system; and (iii) a double- entry accounting system which has served to improve budget monitoring while weakened treasury controls are being addressed. The closing of Government's extra-budgetary accounts is successfully on track. The Audit Court (Cour des Comptes) established in 2004 has been an important step towards the strengthening of jurisdictional control over public finance management. 75. The Project's transactions will be managed by the SEPKNLS Financial Management Department. The Director of Finance will be responsible for approving payments to contracted service providers, suppliers of equipment and goods, and implementing agencies and for submitting consolidated financial monitoring and audited financial statements to IDA. The Internal Auditor will review the financial monitoring reports and will carry out regular internal audit controls. These controls will include ex-post verification of expenditure eligibility, as well as physical inspection of goods and any works acquired during the implementation of the Project. The findings and recommendations of the Internal Auditor will be used by the SEP/CNLS to improve project implementation in areas related to financial management and procurement. 76. Mainstreaming of Project funds into the MSPLS will be done through the DGR within said ministry. As a Government department in charge of government resources within the MSPLS, its financial management is currently under the Ministry of Economy, Finance and Development Cooperation (MOF). The DGR will be autonomous in relation to procurement and public tenders as per the new law to this effect. The DGR is equipped to handle public expenditure as it has, within its structure, a budget unit. The budget unit does not currently manage funds but reviews and approves invoices and other bills and clears them for payment. Through IDA support the DGR will have power and capacity to manage funds which will enable it to pay invoices submitted by service providers duly approved by the General Direction of Health of the MSPLS and its sub national entities. In line with ongoing public expenditure reforms, the DGR will be suited to serve as a pilot for the Government and IDA will provide support. However the current financial management team of the MPLS does not have the capacity to manage the Project hence an unsatisfactory FM arrangement rating. The DGR risk rating is also high given the decentralized nature of its activities. 77. The DGR has undertaken measures to improve its financial management capacity such as the preparation of terms of reference to contract technical assistance for an approximate 23 periodof one year. The consultantwill, amongst other things, prepare an implementationmanual, put inplace and organizationalstructure ofthe directorate, define key staff profilesand fiduciary responsibilitiesandto helpthe DGRput in placethe new procedures.The DGRwill recruit inthe near future an accountant and assistant accountant. The above envisagedtechnical assistanceis beingfinancedby the PPF. 78. Actions requiredbeforeeffectiveness of the Grant includestrengtheningthe capacity of the accountingunitsof the new targeted implementingagenciesand an updated PSMLO manualreviewedand approved by IDA.Projectaccounts will be audited andthe audit reports submitted to IDA as stipulatedinthe financialcovenants ofthe Grant Agreement. 79. The conclusionof the assessmentis that the financial managementarrangements have an overallriskratingof low which satisfies the Bank's requirements under OPh3P10.02 andthereforeis adequateto provide, with reasonableassurance, accurate andtimely information on the status ofthe projectrequiredby IDA. With the implementationof the actionplan, the financialmanagement arrangementswill be strengthened. 80. With regards to procurement, the key difference in this new Projectis the transfer of responsibilityfor some activities from the SEP/CNLSto MSPLS. This i s in line with the new procurement code adoptedby the country on February4,2008 which states that each procuringagency shall handle its procurement activities.Itwill ensure better sustainabilityand institutionalmemory regardingProjectachievementsafter its completion. 81. The MSPLS haslimitedexperiencewith procurement. Since October 1993, the resources allocatedto investment in healthsector throughthe nationalbudget were very limited. Whenthe Government was in a positionto carry out constructionor rehabilitationof health infrastructureor to supply drugs and medicalequipment it was oftenprocuredeither througha project implementationunit supervised by a donor or directly by the donor.The MSPLShas however procuredits own drugs with the support of CAMEBU. Forthis reason it was agreedto transfer procurement responsibilityfrom the SEP/ CNLS to the MSPLS ina somewhat progressive fashion. Specifically, for 2008, any internationalcompetitivebidding, complex procurement contract and requestfor proposals estimatedto cost morethan the equivalentof US $100,000 would be handled by the MSPLSwith continuous support and oversightofthe SEP/ CNLS. Inparallel,the MSPLS is gettingsupport from the MoFto strengthenits procurement capacity.This support is part of the nationalprogramto decentralize procurement by creating procurement units in all line ministries.The MoF initiative includespersonneltraining and development of a nationalproceduresmanual.Additional technical assistance to the DGRofthe MSPLSto strengthen its procurement capacity is eligibleto be financedunder the approved PPF. D. Social 82. The Projectinterventionswill mitigate the economic and socialimpactof HIV/AIDS in the population, by targetingactivitiesto orphans, women and the rural poor.National productivity and earnings are likely to rise as mortality and morbidity among people intheir most productiveyears is decreased.The lives of people living with AIDS will be improvedand extendedas preventionand treatment of opportunistic infectionsimprove.Finally, the national mobilizationagainst AIDS, includingstrengtheningof localcapacity, may resultin pooling energy, creativity, and resources from all segmentsof society.The development of local partnerships and coalitionsagainst HNmay contributeto unite individualsand householdsacross ethnic and other boundaries. 24 E. Environment 83. In an effort to protect the public's health in general and the health of health care personnel in particular, the SEP/CNLS has carried out a study of current medical waste management practices in Burundi which made general recommendations for improvements. 84. The study noted that health care professionals have a very limited understanding of the dangers of medical waste, and the public information campaigns via radio and other channels do not highlight the risks of poor medical waste management. The most serious risk is the potential spread of HIV/AIDS due to improperly handled and disposed medical waste (blood, urine, syringes, sharps, bandages, laboratory waste etc.). The main report's recommendations center on the importance of training health center personnel in safe medical waste management and to ensure the safe disposal of medical waste. 85. The appraisal mission discussed the recommendations of the above report with representatives of the SEP/CNLS; USLS/Santé; Département de la Promotion de la Santé; and the Ministry of Environment. It was determined that the proposed project would fund the following activities under component 4 (total cost estimate: $105,500): (a) Update of the norms and standards for health centers providing HIV/AIDS services to include safe medical waste management practices (consultant); (b) Identification, quantification and description of materials needed for safe medical waste management in the health centers (consultant); (c) Preparation of a training module on safe medical waste management (consultant); (d) Multiplication and dissemination of the training module to about 500 health centers; (e) Training of health center personnel; and (f) Acquisition of protective gear and equipment for health care personnel for safe medical waste management. 86. The SEP/CNLS will be responsible for supervising and the MSPLS for implementing the above measures. There is a very low probability that the project will include some minor rehabilitation of health facilities, youth centers, and communal meeting facilities under subprojects. F. Safeguard policies 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 4.1 1) [ ] [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)1 [ ] [X] Projects on International Waterways (OP/BP 7.50) [ ] [X] 1By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas 25 87. The Project has triggered OP 4.01 Environmental Assessment due to the potential adverse environmental impacts of poor medical waste management. The environmental category is B, and the safeguards category is S2. 88. In an effort to mitigate potential adverse environmental and social impacts effectively, the project has prepared a study: "Study on implementation of the Medical Waste Management Plans", November 2007. This study was disclosed in Burundi on February 6, 2008, and at the Bank's Infoshop on February 11, 2008. 89. The study was prepared in consultation with health care personnel, hygiene and sanitation personnel, representatives of the Institut National pour 1'Environnement et la Conservation de la Nature, Bureau Burundais de Normalisation et de Controle de Qualite, Ministry of Public Health, provincial sanitation facilities, and environmental health specialists, and involved site visits to several representative health care facilities. Their views have been reflected in the study. 90. Project was related to medical waste management. Progress on medical waste management realized under the first Project was limited by civil conflict and low country capacity. The MWMP plan carried out under the previous Project has been updated to reflect the changing country situation. The results of the updated MWMP and the plan to mitigate potential negative effects have been approved by the Africa Safeguard Policies Enhancement team and have been made public. There is a very low probability that the Project will include some minor rehabilitation of health facilities, youth centers, and communal meeting facilities under subprojects (Components 1 (a), 2 (c), and 3 of the Project), which in no case will involve land acquisition or involuntary resettlement. Should such rehabilitation be undertaken civil works contracts will include clauses for the adequate provision of waste materials, use of non-toxic construction materials and respect for cultural property, and any such activity will be subject to review by an environmental and social specialist who will determine whether an environmental or social assessment is needed. Those clauses will be submitted to the Africa Safeguards Policies Enhancement team for review and approval. G. Policy Exceptions and Readiness 91. There are no policy exceptions in this operation. 26 Annex 1: Country and Sector or Program Background BURUNDI: Burundi Second MultisectoralHIV/AIDS Project A. Country Background 1. At an income levelof around US$ 100 per capita, Burundi is one of the poorest countries inthe world. For the last 13 years civil conflict has claimed more than 300,000 lives, displaced a good part o f the population, damaged infrastructure and institutions and reduced overall capacity inall sectors by encouraging brain drain. In 1996, external aid came virtually to a halt due to an international embargo. Only humanitarian activities and existing World Bank Projects were able to occur in such environment. 2. The consolidationof the peace process has helped start reconstruction,and created positive prospectsfor the country. Since 2000, the country has progressively recovered from the negative growth (average -1.8 percent) o fthe decade o f political and economic turbulence to a positive growth rate with 5 percent in 2006. However, economic growth i s largely determined by the widely fluctuating agricultural sector. Therefore, despite increased donor-financed capital expenditure a decline in real economic growth to 3.6 percent is projected for 2007, reflecting a poor agricultural season. 3. However the socio-political and macroeconomic situation is frail and governance is poor. Government budget constitutes about 50 percent o fthe GDP, a good part o fwhich is allocated to security and soldier's demobilization. Legislative and executive activity virtually came to a halt duringall o f 2007 due to divergent opinions among the political parties. Governance issues have reducedthe population confidence inthe Government. 4. The limitedgrowth and relativestability haveyet to translateinto improvementsin basic social indicators,which remain among the poorest inAfrica. Maternal and child mortality rates are about 900/100,000 1.b and 179/1000 respectively which compares unfavorably with Sub- Saharan Africa averages. Primary school enrollment which tripled in 2005, after the President abolished primary school fees, has surpassed the pre-crisis long-term level, reaching a gross enrollment close to 100 percent in school year 2005/06 (compared to 80 percent in 2003/04). Nonetheless, completion rates for primary school are still very low at around 60 percent. Finally, data from a 2005 survey suggest that two out o f three Burundian children under five are chronically malnourished which ranks Burundiat first or second in malnutrition inthe continent. 5. The resolutionof the 2007 politicalcrisis and consequent Government reshuffling has broughta measure of stabilitywhich is expectedto be maintaineduntil the end of the legislature(2010). This can be particularlybeneficial for the social sectors as the current Government has committed to increase transparency on budget management and implementation. 6. In September 2006, the Governmentapproved itsfirst full PovertyReduction StrategyPaper (PRSP) which was presentedto IDA and IMFBoards in March 2007. The PRSP aims to strengthen political stability, consolidate peace, and reduce poverty through accelerated, sustainable, and equitable growth. The principal strategic axes o f the PRSP are: (i)improving governance and security; (ii)promoting sustainable and equitable economic growth; (iii) developinghuman capital; and (iv) combating HIV/AIDS. Progress has been made in all four areas. The implementation o f the PRSP is being supported by several donors through budget support, investment operations, and technical assistance. However, even with this support, it is 27 not likely that Burundiwill achieve its MDGs,though ifwell invested it may allow the country to initiate recovery and to ensure that its populationreaps some o f the peace dividends equitably. B. Sector background and issues 7. HIV/AIDS representsa difficult healthand development problem inBurundi. As seen in Table 1the 2002 national sero-prevalence survey found an overall adult prevalence o f 3.2 percent, and preliminary results o f the 2007 National Epidemiological and Socio-Behavioral Survey (NSPSBS) show current prevalence at around 4.8 percent. AIDS is a large health problem, constituting the second cause o f mortality for adults and the fourth cause for children 6- 14 registered in hospitals. Additionally, UNAIDS (2006) estimates that there are about 150,000 people living with the disease and about 120,000 orphans in the country due to the epidemic. Table 1: Estimatesof HIV/AIDS prevalence in Burundi Semi- Source Urban urban Rural National 1989-90 National survey (15-49 years) 11.3 14.7 0.7 1.5 2002 National survey (12-49 years) 9.4 10.5 2.5 3.2 2007 National Survey (preliminary results) 3.7 5.1 4.8 4.8 8. Although urban areas have higherincidence ofHIV/AIDS than rural areas, the incidencein rural areas has increased over the years. Data from the last two national sero- prevalence surveys show that the epidemic seems to have stabilized in Bujumbura; however, it has tripled in rural areas, where the prevalence increased from less than 1 percent in 1989-90 to about 3 percent in 2002 and 4.8 percent in2007. 9. The data suggest that Burundi is one of the very few countries in the regionin which incidence rates are still increasing, probablydue to the longconflict.Inmost countries in Africa HIV incidence has stabilized in recent years. The hypothesis is that Burundihas been until recently somewhat "protected" from HIV by the long term conflict6. As in other countries, the freedom o f movement and general population redistributionsubstantially increase the transmission o f the virus. This seems to be corroborated by the fact that this prevalence is much higher in border Provinces where access to treatment is not widespread yet. The introductiono f Prevention o f Mother-to-Child Transmission (PMTCT) services in sentinel clinics in late 2003, which increasedthe share o f high-riskpregnant women who are willing to be tested going to those clinics, may have also increased the reported prevalence o f HIV+pregnant women at sentinel sites above that o f other countries inthe region. Table 2: Sero-prevalencerate among adult men and women Women Men Urban 13 5.5 Semi-urban 13.7 6.8 Rural 2.9 2.1 6 Relative isolation and low population movements during open conflict seem to have slowed the transmission of HIV inseveral countries. 28 10. In 2005 HIV prevalenceamongthe adult populationwas estimatedto be around 4.6 percent, butthere are signs that it may havebeenunderestimated. Preliminarydata from the October 2007NationalSero-Prevalenceand Socio-BehaviouralSurvey (NSPSBS) show an increaseof prevalence rate in the general populationfrom an estimated 3.5% in 2005 to 4.8% in 2007. Most worrisome, inrural areas prevalencehas exploded fiom 0.7% in 1989to around 5% in 2007. Prevalence in border provincesvaries between 7.5 % and 9%. Surveillancedata from sentinel sites suggestedthat in 2007 prevalenceamongpregnantwomen hoveredaround 12 percent, andrising, which is substantiallyhigher than other countries inthe regionwhich have higherprevalencerates' amongthe generalpopulation.Furthermore, about 120,000 childrenare consideredHIV/AIDSorphans. 11. The mainfactors contributingto vulnerabilityto HIV/AIDS inBurundiappearto includelow levelsof male circumcision(particularlyamongthe young), low condomuse, displaced and returningpopulations,poverty, low educational attainment ofwomen and girls, socio-politicalinsecurity,conflict, and limited access to HIV/AIDSservices. Conflict has confounded attempts to determine the specific weight of eachthese factors in Burundi's epidemic.But over the past few months, with IDA funding, the Government has launchedan epidemiologicaland socio-behavioralsurvey to determine how and to what extent each ofthose factors affect HIV transmission, and which groups are at highest risk 12. Burundi's responseto the HIV/AIDS epidemic has beenembodied in two successive nationalHIV/AIDS strategiesand plans W A S ) , developedwith support from IDA and UNAIDS ). The first strategy coveredthe period2002 to 2006 and includedactivities for an estimatedUS$400million, such as: (a) Preventivemeasuresfor the generalpopulationas well as at-risk groups; (b) Universalaccess to services for treatment and preventionof mother to child transmission; (c) Socialprotectionfor individualsand families affectedby HIV/AIDS, and for orphans and other groups consideredvulnerableto contract HIV/AIDS; and (d) Settingup institutionsto coordinate and manageNHAS and its correspondingmonitoring and evaluationsystem. 13. The 2002-2006NHASwas the basis for a first IDA Multi-SectoralGrant (MAP) of about US$36million, approved inJune 2002. At the time IDA was the first and only donor supporting the country inits fight againstthe epidemic. 14. As it becameclear that the requiredresources for the definedNHASwere not goingto be availablethe strategy was reviseddownto US$240 million. In2005, the GlobalFundallocated US$32 million to support the nationalresponse, and a further US$3 million camethrough other UNagencies.The totalresourcesallocatedto cover activitiesunderthe revised2002-2006NHAS covered only about 30 percent of the estimatedneeds.Despitethe unstable political and security situation, and the fact that Burundiis one ofthe poorestnations inthe world, the Government put inplace a set of institutionsand staffedthem with adequatepersonnel. 15. The first NHASwas very broadand ambitious inthat it targetedthe general populationand focused on interventionsconsideredat the time to be effectiveand efficient by the internationalcommunity,but which have since beenprovento be less so. Examplesofthis includecondompromotionand treatment of sexuallytransmitteddiseasesamongthe general 7Prevalencerates amongpregnantwomen inUganda and Tanzania are estimatedat 8.5 percentand 7.5 percent respectively. 29 population, versus focusingthose measuresamonghighrisk populationsas it is today advocated. Furthermore,the institutionalset up was new, and capacity for implementation,coordination, monitoringandevaluationwasjust beginningto be built. Finally, unpredictableand insufficient external aid and poor executionofthe nationalbudgethave also impairedthe ability ofthe Government to planfor and implementlongterm measuresof HIV/AIDS control 16. Evenin this constrainedenvironment, the first MAP has beenimplemented successfully.Activities financed under the prior Grant are beingcarriedout with minimal delays andthe ongoingProjectis likely to achieve its development objectives.Results attributableto the first IDA MAP are listedin part A ofthis annex (below). 17. The first MAPensured an effectiveimplementationof the "Three Ones'". By supporting the development of a unifiedM&E system and by working with other donors as they initiatedits activitiesinthe country,the first MAP has ensured a levelof harmonizationinthe sector which is so far unparalleledinthe country.Coordination,with other partners will continue andbe strengthenedduringthe proposedoperation. 18. As encouragingas the prior MAP and 2002-2006 NHAS results are they remain insufficientto stop transmission of the disease or reduce its impacton affectedfamilies. This was to be expectedsince only 30 percentofthe activitiesinthe 2002-2006NHAS were financed, andthe many institutional,technical, financial, and capacity-relatedissuesconstrainingits implementation.A relatively small IDA project cannot single handedly reversethe course ofthe epidemic. Public institutionshave provento be weak and do not havethe personnelor resources to adequately mainstream HN/AIDS activities intheir programs andNGOshavebeen limited in their capacity by the shortage of qualifiedpersonnel. 19. Lessons learnedfrom the implementationof the first strategy and international experiences have beenincludedin the updatedNHAS 2007-2011, and the requesteda follow-up IDA-financedMAP. A summary of those lessons is listedbelow. Technicallessons learned: Everycountry, and zone within a country, has a unique epidemic profile and success is directlycorrelated to tailoring interventionsto that specificity; In a relativelyconcentratedepidemic, targeted interventionsin high-riskareas and groups are the most effectiveway to reducetransmissionbecause ofthe multiplier effect of preventionto the general population; Behaviorchange activitiesfor highrisk groups needto betailored carefully and monitoredand evaluatedregularlyto ensurethat they are havingan impact; Previouslywell-acceptedinterventions, substantially financed under the 2002-2006 NHASandMAP, are provingdifficult to substantiate under stricter empiricalscrutiny: massVCT, STItreatment (in the general population),mass condom distribution,mass mediacampaigns, etc; Interventionsnot previouslyfinanced have come to the forefront ofprevention:male circumcision, reductionof partner concurrency, peer-basedcommunicationfor behavior change, and condom distribution inhigh-risksettings; Surveillance, and epidemiologicalandanalyticalwork, to correctlydirect policiesand interventionsare generally under-funded; * The UNAIDS-recommendedthree ones includea unifiedCoordinatingBody, a commonNational HIVIAIDS Strategy,a singleMonitoringandEvaluationSystem. 30 Impact assessment o f interventions i s a mustto redirect policies and ensure results; and, Linkingfinancing o f services to performance increases transparency on the management o f public resources, creates incentives for efficiency and helps share the risks inherent in any interventionbetween the provider and the financer. Institutionallessonslearned: Concentration o f resources and capacity by a coordinating body at the highest political level has positive effects; but it also tends to create "supra-ministries" that take on functions beyond their coordinating mandate, create friction with other public agencies and local authorities underminingthe generally low capacity o f the public sector; Streamliningactivities in other sectors is crucial for institutional and financial sustainability o f the fight against HIV/AIDS and to increase the impact o f the activities; IntegratingHIV/AIDS prevention and treatment interventions within the existing health system i s needed to increase institutional sustainability, rationalize the use o f scarce resources, and strengthen rather than debilitating the normally weak health system; Insituations with a moderate level of conflict, decentralization ofactivities and resources can help ensure implementation even as the security situation does not Grant free circulation o f persons; Sharing M&E results with stakeholders and decision-makers helps get support for the strategy changes that may be necessary; Persons living with HIV/AIDS are best reachedthrough community mobilization; and, Communication activities have to be regularly and rigorously assessedand adapted to ensure their usefulness in HIV/AIDS control. Interventionsin the new 2007-2011NHAS remain somewhat scattered but the Governmenthas taken steps to further improvethe strategy.Lack o f country-wide reliable epidemiological data has resulted in a limited understanding o f the dynamics o f Burundi's epidemiologicalprofile and o f risky behaviors which favor the spread o f HIV.As part of the M&E system the country launchedthe NSPSBSwhich should help further refinethe NHAS and by extension the proposed Project interventions. Concomitantly, ongoingtechnical assistance financed by the AIDS Strategy and Action Plan service (ASAP) will help refine the new NHAS action plan, and will provide the foundation to target IDA resources towards the most effective approaches. Support from the Global Monitoring and Evaluation Team (GAMET), duringProject preparation and supervision, will further strengthen the existing national M&E system and operational plan particularly inthe areas o f impact evaluation o f specific interventions and data use for decision making. Specificallythe new 2006-2011NHAS calls for: Continued commitment o f the Head o f State, Government, political and religious leaders, and communities to fight the HIV/AIDS epidemics; Protection o f the rights o f HIV+and vulnerable groups; A continuation o fthe multi-sector response to guarantee comprehensive response; Further decentralization o f financingto provinces, reinforcement o f partnerships and stronger involvemento f all strata o f the community; Emphasis o f prevention and VCT on highrisk groups, geographic expansion o f preventive MTCT and treatment services. Improvement o f existing performance-based contracts and agreements with service providers (public and NGOs) to increase the accountability and efficiency and assess the impact o f interventions. 31 (g) Further responsibility o f key public institutions according to their respective mandates; (h) Coherence of HIV/AIDS and Heath strategies inthe relevant actions; 24. The 2006-2011NHAS hasfour strategic axes includingactivitiesin several sectors. The overarching objectives o f the strategy remain those o f the overall National Plan, that is, to reduce the transmission o f HIV/AIDS and minimize the effects among persons livingwith HIVIAIDS and their families. To achieve those goals the new NHAS divides its action in four axes: (a) Extensionof preventiveactivities.This axis has three interventionareas namely: (i)ReductionofsexualtransmissionofHIV/AIDS; (ii)ReductionoftransmissionofHIV/AIDSthroughblood; (iii)ReductionoftransmissionofHIV/AIDSfrommothertochild. (b) Improvement of life conditionsof persons livingwith HIV/AIDS.Three intervention areas or programs under this axis: (i) Prophylaxisdiagnosisandtreatmentofopportunistic infections; (ii)Universalaccesstoretroviraltreatmentforchildrenandadults; (iii)PsychologicalandnutritionalsupporttoHN+toincreasetreatmentcompliance. (c) Support reductionof povertyand other determinant factors of HIVIAIDS vulnerability. The three additional programthat fall under this axis are: (i) Improvementofthesocio-economic situationofpersonslivingwithandaffectedby HIV/AIDS; (ii)SupporttoorphansandvulnerablechildrenduetoHIV/AIDS; (iii) PromotionoftherightsofpeoplelivingwithHIV/AIDSandotherhighly vulnerable groups and people. (d) Improvement of the national responsemanagement and coordination.Finally the fourth axis also has three programs which are: (i)ImprovementoftheinformationsystemforthemanagementoftheNational HIV/AIDS response; (ii)Coordinationandimplementationofthemulti-sectoraldecentralizedresponseto HIV/AIDS; (iii) Mobilizationoffinancialresources. C. Rationale for Bank involvement 25. The rationalefor the Bank's continued involvementin HIV/AIDS in generaland in Burundi in particular, has been reflectedin the Bank's recentlyapprovedsector strategies. Strategic guidance and lesson learned reflected in the 2006 "AIDSProgram ofAction ",and the Health Nutrition and Population Strategy published under the name o f "HealthyDevelopment", (2007), were central to the Project's design. Specifically, the Bank providedtechnical assistance to strengthen the 2007-2011NHAS, and to ensure the synergy between health system strengthening and HIV/AIDS interventions. The Project's focus on results and accountability also stems directly from the referred strategies. 32 26. Consolidationand scaling-up of effective interventions under the first MAP is essential to progress towards achievingthe country's MDGs. Resources from the first M A P have been fully disbursed. The Government, some UNagencies and the GF also finance the NHAS.Those resources are however quite low inthe first two cases, volatile inthe last case, and inboth cases fairly inflexible once allocated. 27. Moreover, donor-financed current and pledgedcontributions to HIV/AIDS are generally limited to health-servicesbased activities. Recently DFIDand the EUhave indicated their support to HIV/AIDS in the future by strengthening the health system. Most donors consider HIVIAIDS exclusively as a health sector issue and thus they do not include in their financing preventive activities that fall outside the direct scope o fthe health sector such as behavior change activities among sex workers, professional groups and associations in risk groups (transport workers, education workers and students, fisherman, prisoners, military, police, etc). Likewise, social protection for people very vulnerable to HIV/AIDS such as widows (in the case o f Burundi)and HIV+patients and their families; and regulatory and other activities to reduce discrimination inthe population (such as discrimination laws etc.) are also not generally financed by other donors, with the exception in some cases o fthe GF. Inthe foreseeable future, IDA is thus the only substantial source o f financing for certain prevention and multi-sectoral activities. 28. Multi-sectoral activities are central to control HIV/AIDS. Preventive activities are often the most cost-effective to control the epidemic. In general, sector ministries, labor organizations, and civil society groups are better placed that ministrieso f health to deal with behavior change and regulationto reduce discrimination intheir respective groups o f influence such as fishermen (in the case o f Burundi), commercial sex workers, truckers, displaced workers inbigcivil works, prisoners, policemenetc. Social protection for highlyvulnerable or HIV/AIDS affected individuals and families are considered a central part o f any comprehensive preventive strategy as they try to lessen vulnerability which is one o fthe underlying determinants o f the spread o fthe epidemic. Social protectionactivities fall squarely outside Burundi's MSPLS competences. 29. Besides the much-needed financial resources, IDA brings added value to the Program in a number of ways, including: (a) Conveningpower for Government, civil society, and development partners around a common vision o f effective HIV/AIDS prevention and improved accountability, which has helped the Government implement the internationally recognized "three ones" (one national plan, one coordinatingbody, and one M&E system); (b) Intense technical guidance and M&Esupport through careful supervision; (c) Ability to foster a sustainable, multi-sectoral response, through its work with the different sectors receiving Bank's support. (d) Potential o f helping the Government in its efforts to ensure synergy between health system strengthening and priority-disease interventions to increase convergence with other health programs and strategies through upcoming health operations; (e) Unique capacity to finance system development, capacity building; and (f) Flexibility to cover unforeseen financial gaps in key activities. 30. The Government, communities and partner agencies have indicated in national and international fora that they consider IDA'Scontinuing involvement inthe National Program critical to its success thanks to its capacity to work across sectors, its focus on prevention and its support to civil society. 33 Annex 1A: Summary of results from the FirstMAP Project 1. Institutional and capacity building results: (a) The NationalHIV/AIDS Council (CNLS) was createdandhas beenplayingits steering role.It has meet regularlyand approvedHIV/AIDS budget and providedgeneralpolicy guidanceto its executive arm (the SEP/CNLS); (b) The Permanent Secretariatofthe CNLS, the SEP/CNLS, was createdto coordinateand monitor HIV/AIDS activitiesandhasbeenfully operational; (c) All public andpara-publicinstitutionshave created internalHIV/AIDS unitswhich have implemented/institutedHIV/AIDS education programs for their personnel; (d) A unified nationalHIV/AIDS M&E system was developed. This system is usedby all stakeholders (donors, NGOs civil society etc.) The monitoringsub-system is quite comprehensive and reliable. Although the evaluationsub-system system needsto be improved(seeAnnex 3); (e) About 15 localexperiencedNGOs constitutedthemselves in an umbrellaNGO and have beenprovidingsupport to small NGOs andcommunity groups with the preparationof subprojects to access IDA funds andwith the implementationofthe activities; (f) The 2002-2006 NHAS has beenreviewedthrough a highly participatoryprocess(over 100representatives of all stakeholders); and (g) A nationalM&E planhas beendevelopedto accompany the NationalNHAS 2006-2011. 2. Resultsof preventiveactivities:Dueto limited capacity to carry out impact evaluations andthe lack of a base line, most of the resultsfrom these activitiescan be measuredof only either throughproxy outcomes or as progress over time rather than througha randomizedimpact evaluation.The proposedProjectintends to increase capacity at carryingout impactevaluationof interventionsthrough its fourth component. Although it is therefore difficult to attributedirectly the results to specific interventions, supervision missions, anecdotal evidence andnon- randomizedevaluationreportscarriedout by other donors suggestthat the overallimpact is positive.Only about 50 percent ofthe activitiesinthe area oftreatment, bloodsafety, and PMTCT havebeenfinanced by the first MAP Project. 3. Specific quantifiable program results include: (a) Voluntary counseling andtesting, consideredthe key entry point for behavior change and access to treatment, has increasedthrough the establishment of 161sites, at which as of mid 2007, about 450,000 persons had beentested. Since 2002 the annual numbers of people undergoingVCT has increasedfive fold; (b) Materials for IECregardingPMTCTtransmissionhave beendeveloped and450 health stafftrained; (c) The number of provinces havinga PMTCT service has increasedfrom 4 to 10; (d) Over 5000 pregnant women andtheir babies benefited from PMTCT services between 2002 and2006. That meansthat about 3000 new HIV infectionsamongthose newborns were prevented.HIV+women were given access to free family planningcounseling and commoditiesthus reducingthe likelihoodof new pregnancy amongthose women; (e) Accordingto populationbasedstudies, the percentageofyouthwho correctly identify ways of preventingsexualtransmissionhas doubled since 2003; (0 Over 30 million condomshavebeendistributedfrom 2002to 2007; 34 (g) Ina 2004 survey, condomuse duringthe last sexual encounter amongyoung men and women was 48 percent and 42 percent, respectively-up from about 30 percent for all groups in 2001; (h) The use of condoms increasedto 54 percent and 45 percent respectivelyin intercourse with a commercialsex partner; (i)Accesstoanduseofcondomsamongtheyoungandthemilitaryincreased.School enrollment rates and grade completionamong orphans reachedlevelscomparableto non- orphans, and over 400 community-basedsubprojectsprovidedsome form of economic supportto vulnerablefamilies; The NationalBloodBanktests bloodfrom all the nationaland regionalhospitalsfor HIV/AIDS, and syphilis; Guidelinesfor the preventionof transmissionof HIV/AIDSthrough bloodare available inall health facilities inthe country. 30 percent of formal healthpractitionershave beentrained on protectionmeasures and are distributedinmost of the health facilities in the country; Health facilities have beenprovidedwith protectivematerialsto avoidblood transmission; Self-screeningofblooddonors was introducedand currentprevalenceamongblood donors is estimatedat 0.4 percent; Traditionalpractitionersand midwifeswere also trained on bloodsafety measures; and 972 STOP/HIV/AIDSclubs have beenset up and are functional coveringthe practical totality of Burundi's secondary schools and 111youth communitycenters(or 70 percent of the communes ofthe country). Results of mitigation activities. 32,000 families havebeenprovidedeconomic supportthroughGrants and participationin income generatingactivities (agricultural, sowing, etc); Community-based committeesto protectand support HIV+people, orphans and the most vulnerablefamilies have beenset up in all provincesand communes of the country and about 505 ofthe villages; Over 40,000 personslivingwith HIV have received socialsupportthroughNGOsand communities; 240,000 orphans received support with their school fees and materials; Over 32,000 familiesthat have accepted an orphan have received financialsupport; A nationalpolicy to protectorphans and vulnerablechildrenhas been adoptedand it is beingimplementedthroughthe Ministry of SocialProtection; Orphans supported by the Projectenrolledinprimary schools and passedgrade at the same levels as their non-orphancolleaguesup from previouslylower levels; The 1/081Law, indicatingthe rights of HIV+peopleand outlawingdiscriminationon the basis of sero-statuswas promulgatedinMay 2005. An observatory for the rights of HIV+people has beencreated; The InternationalTrade Organizationdirectives on HIV inthe work place have been distributedto all the key labor collectivitiesand bigbusinesses.Trainingand follow up has beencarriedout; and HIV+ support committeeshave been created in all the communesof the nationalterritory. Results of treatment activities: Duringthe Projectthe number of patientsunder HN/AIDS treatment increased from 600 in2002to 10,000 today; 35 (b) The number o f people having received treatment for opportunistic infections increased by 10 fold; (c) 40 treatment sites are functional which cover the whole territory except one province. (d) 175 doctors, 220 nurses and 90 laboratory technicians have been trained on ARV treatment; (e) About 90 community health workers and 238 social workers have been trained and follow-up the patients intheir homes; and (f) Nine CD4 counters and one device to determine viral-charge have been installed inkey hospitals in the nationalterritory. 36 Annex 2: Major RelatedProjectsFinancedby the Bank and/or other Agencies BURUNDI: BurundiSecond MultisectoralHIV/AIDS Project 1. OngoingBank-financedprojects:The GovernmentofBurundi is currentlyimplementing nineoperations funded by IDA, totalingaboutUS$347 millionof commitments. Ofthese, the following two are relevantto the proposedproject are: (a) A US$36 millionMulti-sectoralHIV/AIDS & Orphans Project(approved in June 2002 and closinginNovember 2008). This is the first MAP approvedto support the implementationof Burundi's Multi Sectoral HIV/AIDS Program, through :(i)Slowingdown the spreadof HIV/AIDS inthe general population;and (ii)mitigatingthe damage of HIV/AIDS on individualsandfamilies. Latest IPRating: Satisfactory -Latest DO Rating: Satisfactory; (b) A US$26million Economic ManagementSupport Project(approved inJanuary 2004, effective inApril 2004) to increasethe efficiency of Burundi's macroeconomic, financial, and administrativemanagementby strengtheningaccountabilityandtransparency through Satisfactory. improvedprocedures andcontrols.Latest IP Rating: Satisfactory-Latest DO Rating: 2. Bank-financedprojectscompleted in the lastfive years: The following Projects were completed inthe last five years (a) A US$27.4million SecondHealth& PopulationPro-iect(approved in May 1995 and closed inJune 2006). The initial ProjectDevelopmentObjectives(PDO) under IDA Creditwere to support the: (a) Ministry ofHealthto supplement sectoral reforms inthe areas of human resourcemanagementandreducethe current shortage of healthpersonnel; (b) public hospitalmanagementto improvethe quality ofhealth services; (c) health financingfor pre- payment schemes; (d) equippingandrehabilitationof 9 hospitals; (e) MCWFP; and (0IEC progressto complement public healthprograms. PDO were refinedinMay 2000, to accord highpriority to the following: (a) supporting the implementionof key sector reforms (institutionof in-countrytrainingat the new INSP, decentralizationof sector management, improvement in cost-recovery) ;and (b) strengtheningdelivery ofpriority health services, targetingmajor diseases(diarrhea, nutritiondisorders, malaria, traumas, reproductivehealth problems, acute respiratoryinfections,HIV/AIDS, andtuberculosis). ICR for this operation was completed inDecember 2007 with PDOratingof ModeratelySatisfactory. IEGrating: Moderately Satisfactory; (b) A US$26.2million SecondSocial Action Pro-iect(approved in October 1999andclosed in June 2006). Its PDO were: (i)Diverse communitygroups work together to select, partly finance, monitor and evaluate, use and maintaintheir priority community investments; and (ii)thepoorestandmostvulnerablegroupsbenefitfromimprovedsocialandeconomic services and improvedsocial protectionthrough social services that limit risks ofpoverty andthroughtransitory wages. ICR for this operationwas completed inJanuary 2007 with PDOratingof Satisfactory. IEGrating:ModeratelySatisfactory. 3. Ongoing projectsfinanced by other donors:Resourcesfrom the Round 5 ofthe GF are beingusedto support HIV/AIDS controlactivities.Moreover several donors are supporting projectsin the healthsector but in generalthey do not includeany support for HIV/ AIDS preventiveor curative services. However many ofthem aim at strengtheningthe service delivery capacity ofthe public health sector. This should help with the treatment ofAIDS patients, and 37 PMTCT andmale circumcisionservices. The following are the key Projects and organizations supportingthe health sector and inthe case ofthe GF HIV/AIDS activities: About U S 1 9 millions remainingfrom the round5 ofthe Global Fundto finance HIV/AIDS treatment and preventiveactivities amongthe general populationfor the next three years; An ongoing EuropeanUnion US$18 million Proiect, supportingservice delivery of basic services andfirst referral infour provincesas well as the development of districtteams and systems, andreconstructionof facilities until 2009; About US$9 million from the GlobalAlliance for Vaccines and Immunization(GAVI) to set up districtteams and systems inthree healthdistricts between2007-2009; An ongoingUS$ 8.5 million Projectfrom the Japanese Governmentto rehabilitatehealth infrastructureand management capacity of health services inthree provinces, due to be completedby the endof 2008. About US$6 million per year from the British cooperation (DFID) for the nest two years to finance general drugs for basic mother and child services and strengthen the country's capacity to procure anddistribute drugs; A Proiectfromthe Swish cooperation of about US$ 6 million that aims to develop district teams and systems, and reconstruct health facilitiesin one districtbetween2006-2008. An ongoingUS$5 million fromthe BelgiumCooperation. About halfofthe resources are supporting the rehabilitationand developmentalthe districtteams and systems in one district inKirundo Province.The other half is supporting capacity building activities, mostlytechnicalassistanceto the general Directionof Healthofthe MSLPL to manage the healthreformprocess; and About 1.7 million per year fromthe World HealthOrganization(WHO) to strengthenthe capacity ofthe health system. Some ofthose resourceswill support HIV/AIDS capacity buildingactivities; 38 Annex 3: ResultsFrameworkandMonitoring BURUNDI: BurundiSecondMultisectoralHIV/AIDS Project NationalMonitoring and Evaluation System 1. The 2007-2011National HIV/AIDS Strategy and Plan (NHAS) outlinesthe various interventionsrequiredfor the realizationofthe NationalHIV/AIDS response in Burundi.The NHASresults frameworkprovidesthe overarchingframeworkfor achievingthe third principleof the "Three Ones" (one agreednationalmonitoringand evaluationsystem for HIVIAIDS). The framework capturesthe elements of a results chain linking inputs, outputs, resources and outcomes. Italso provides the foundations for donors, partners and all projects and processes supportingthe program includingstrategic planningby outliningthe objectivesand intended results of all projects within the nationalresponseto HN/AIDS inBurundi. 2. Duringthe implementationof the NHAS2002- 2006, andthe implementationof the first MAP Project, significantprogresswas made inmany components ofthe M&E systemnamely:(i) the establishment of a monitoringand evaluation unit at the SEP/CNLS (ii) the development of a costedNationalM&E Plan for HIV/AIDS; (iii) development of a nationaloperationalmanual the for monitoringandevaluation, (iv) the development of a system for managementof HIV data thereby leadingto increasedavailabilityof data for program managementand accountability. 3. However, some challenges and constraints still remainwhich needto be addressedduringthe implementationofthis Project, to the extent that the focus is muchaccentuatedon results tracking anddata utilizationfor program improvement rather than on the processesofmonitoring& evaluation.Inaddition, the NHAS results framework needsto be streamlinedto reduce its complexity inorder to enhance its utilizationandcompliance by all stakeholders.The SEP/CNLS, with technicalassistancefinanced throughthe AIDS Strategy andAction Plan service at the World Bank, is currently streamliningthe 2007-2011NHASnationalresults framework. 4. Other areas needingimprovement, which will be supportedby the Projectincludethe following: (i) buildingthe capacity of implementingagencies in M&E; (ii)providinga better evidence base for effectivetargetingof interventionsbasedon vulnerability mapping andperiodic triangulationof datato identifyhigh-risk factors; (iii)supporting an improvedHIV biologicaland behavioralsurveillance amonggeneralpopulationandhighrisk groups; (iv) buildingcapacity of the SEP/CNLS and other N H A S implementerson data analysis anduse of strategic information for activity andprogram improvement; and (v) improvingquality assuranceof interventions through strengthened project supervision. Additionally, the M&E systemwill maintainits capacity to producethe internationallyagreed indicators(including UNGASS indicators), in order to attract fundingand allow for internationalcomparisons, thereby cooperatingwith the internationalstandards ofmonitoringofthe HIV epidemic. Monitoringand Evaluation of Outcomes/Results 5. The premise o fthe resultsframework is that achievingthe NationalProgramobjectivesof reducingthe transmission of HIV/AIDS andminimizingthe effects amongpersons living with HIV/ALDSandtheir families dependson numerous factors, includingculturalmores, public healthinterventions, economic and social environment, capacity, and resourceavailability.The World Bank support throughthis Projectwill contributeto increasingthe coverageand utilization of selectedservices and interventions, however, since IDA financing is less than 10 percent of 39 2007-2011NHAS, it will not be sufficient inand of itselfto achieve the NationalProgram objectives statedabove or the county's HIV/AIDS MDG objective. 6. The Project's resultsframeworktakes into account areas of contribution of World Bank support and is fully compliantwith Burundi's NHAS results framework.This approachcomplies with the Bank's andcountry commitmentto the internationallyagreed"Three Onesg"principles. Itwill ensurecongruencebetweenBank support andcountry goals, further strengthenexisting country capacity and ownership, andminimizethe costs to the country by reducingredundantor competingM&E systems.As with most support to nationalprograms,the Bankwill not seek to attribute precise results to specific IDA investments.Onthe basis ofthe nationally agreed frameworkandthe nationalreports producedby the M&Esystem the SEP/CNLSwill develop periodic quarterlyM&E reports, andan aggregatedannualM&E report.Those reports will enable the Bank task team to identify the share ofthe programoutputs and activitiesthat have been financed with IDA. 7. Burundi has many of the elements of an effective monitoringand evaluationsystem.These elements needto be integrated intoa cohesive andcoherent nationalmonitoringand evaluation systemto assist with progress measurement,accountability,learningand planning.To that effect, the proposedIDA support will strengthen: (a) The overallHIV/AIDS M&E. (b) ProgramMonitoring,which will be basedon informationfrom the existingdata sources of the nationalM&E system for HIV/ AIDS, in additionto new proposedstudies which will facilitatetrackingof coverage and utilizationof services. (i).Healthservices will be tracked usingdata from the HealthManagement InformationSystem(HMIS) andepisodic health facility surveys; (ii).coverage Interventioncoverage, particularly of high risk groups will be assessedusing modules in behavioralsurveys; (iii).Servicedeliveryformsfromactivityimplementerswillbeusedtotrackservices providedoutsidethe healthsector (c) Programmaticevaluation, includingsurveillance, which will be strengthenedthroughthe following ways: (i).Existingsurveillance data from numerous sources, includingantenatal care sentinel sites, Prevention of Mother to ChildTransmission(PMTCT), blooddonors, population-basedsurveys andtargeted surveys, will be rigorouslyanalyzed and synthesized (ii).Periodicbiologicaland socio-behavioralnational householdbasedsurvey(s); and (iii). Biologic and behavioralsurveillance (BBS) of HRG, which will be undertaken twice duringthe life of the project; (d) Dataanalysis andtriangulationto improve policiesandprograms. Data from each ofthe sources described above will be analyzedin an integratedmanner, to producea holistic understandingof Burundi's HIV epidemic andresponses.Importantfindingswill be 9 One National HIV/AIDS coordinatingauthority, one national HIV/AIDS strategy, One National HIV/AIDSM&Esystem 40 shared widely through various dissemination fora and usedto strengthen national and sub-national HIV planning and program implementation; Existingfinancial monitoring and expendituretracking will be usedto monitor resource use and needs; Procurement tracking for the physical and financial progress o f the contracts issued; Program Evaluation research. Inaddition to surveillance, evaluation researchwill be commissioned to better understand HIV transmission factors, HIV transmission dynamics and interventioneffectiveness. 8. The intention of the proposed results framework is to move from a traditional "monitoring and evaluation" systemto a strategic informationmanagementapproach. The system will produce a clearly definedset of products on a quarterly, annual or periodic basis to allow information to be usedstrategically. It is expectedthat progress could be tracked usingan approachthat recognizes the implementation plans of the project both interms of its ability to cover sufficiently large sections of identified high risk groups, as well as the ability of the project to influence outcome indicators over time. NationalProgram ResultsFramework NationalProgram Objectives I NationalProgram OuteomeDmpactIndicators I Percentage of women and men aged 15-49who bothcorrectly Slow the spread of HIV/AIDS in identify ways ofpreventingthe sexualtransmissionof HIV and the generalpopulation; and who reject majormisconceptionsabout HIV transmission [disaggregatedby sex and age (15-19,20-24)] (UNGASS, IDA 14) Percentageof women and men aged 15-49who have hadmore than one sexualpartner inthe last 12 monthsreportingthe use of a condom duringtheir last sexual intercourse [disaggregatedby Mitigatethe impact of HIV/AIDS sex and age (15-19,20-24,25-49)] (UNGASS, AAP) on individualsand families Percentageof female sex workers reportingthe use ofa condom with their most recent client disaggregatedby age (<25,25+>) (UNGASS, AAP) Percentageand number of adults and childrenwith advanced HIV infectionreceivingantiretroviraltherapy [disaggregatedby sex I and age (<15, 15+)] (UNGASS, UA, AAP) 41 I m L-r - e3Ya,E B I 5 Ya, Y8x - e4a,YE;m 5 Ya, Y8 B 3EU 8-2 8 E - 200k I-C a,YEF I 5 Ya, Y8 B 3 L e 0E mY2 e - e e d m Arrawements for resultsmonitoring 9. As indicatedinthe Projectdescription, detailed descriptionofthe monitoringandevaluation system is includedinthe ProjectImplementationManual(PIM). Indevelopingthe results frameworkfor the project,available baselinevalues have been includedandtargets have been set, basedon expected fundinglevelfor each component. 10. For indicatorsonwhich current baselinevalues are non existent such as the male circumcision rates, base line data for will be obtainedprior to project implementation, through the ongoingNational Epidemiologicaland Socio-Behavioralsurvey, andother local surveys, which are expected to conclude in May 2008. 11. Through the life ofthe Project, special surveyswill be conducted to ensure availabilityof outcome leveldata for Projectresults trackingand measurementof success. Prior to the mid-termreview follow up biologic andbehavioralsurveys will be conductedto facilitate concrete review of Project results. These surveys will be repeated priorto the end ofthe Projectto yield final indicatorvalues against which final Project outcomes will be measured.As described in the PIM, the M&E function for HIV/AIDS activitiesand Projectresults is the responsibilityofthe CNLS/SEP. SEP/CNLS will utilize external consultants/firmsto carry out baselineand other surveys as needed.Support will be providedby GAMET on a periodic basis, especially for development of surveys and mid-termreview. 12. Representation ofthe CNLS and Government agencies at the provincial andcommunal levels makes it possibleto supervisethe details of Projectimplementation, follow up activitiesand cross- sectoral coordinationat all administrativelevels.Evaluationwill be undertakenthroughannual Project reviews, a mid-termProjectreview anda Projectcompletionreportto assess performanceand its contributionto the nationaleffort to reducethe spreadand impact of HN/AIDS. All the reviews mentionedabove are the subject of datedcovenants. Short-term consultantswill be contractedwhen needed, andexternal technicaland financial audits ofthe project will be carriedout annually by the Government in order to ensure financial andtechnicalcompliance andquality control. 44 22 $$ w t N x 6 l- 0 s b cpn0 M O e .-E M x m 0 0 0 W 0 0 0 N I-s m 0 s 0 s Wm x d E a Y VI 3c Be B I 3 c) c)8 P 3 3 E N Annex 4: Detailed Project Description BURUNDI:Burundi Second Multisectoral HIV/AIDS Project 1. To achieve the Project PDO, IDA resources will finance a transversal slice o f the national HIV/AID control program operationalized inthe 2007-2011NHAS. Given the very limited resources o f the IDA Grant and the needto show results, it was decided that the Project would finance a limited set of the interventions o fthe 2007-201lNHAS, as opposed to the more general financing o fthe first Project. The specific interventions have been prioritized through a participatory process, on the basis o f their relevance to Burundi's epidemic, proven cost-effectiveness, experience with their implementation in country or abroad, and complementarily to activities funded by other donors, mainly the Global Fund. It was agreed to finance activities across axes rather than focus in one or two axes as to allow flexibility to respond to changing country situations. 2. Interms o fmodalities chosen to implement specific project activities, the team and the Government chose to further institutionaland financial decentralization to provincial governments; mainstream financing and activities to key ministries; improve existing performance-based contracts/ agreements with treatment, PMTCT, and male circumcision services providers; and pilot performance- based contract for providers o f behavior change services. 3. Linkedto mainstreaming activities within the MSPLS, the choice was made to move funds through the General Direction o fthe Resources o fthe MSPLS rather than through the MSPLS program. Inthat way the capacity o fmanaging resources o fthe MSPLS would be strengthened and the resources would be usedto strengthen the health systems particularly in the areas o f pre-natal, pediatric and postnatal care and family planning in the context o f providers o f services, and strengthen VCT and minor surgery capabilities in the context o f male circumcision. All those interventions are in line with the corresponding sections o f the National Health Plan. 4. Although the mentioned choices represent a certain level o f innovationwith respect to the previous Project, they are all based on ongoingexperience, and national policy.The exception to this rule is the design and implementation o f performance based-contracts for behaviorchange service providers.Since there is no experience inthis area the Project will first pilot this type o f contract in with a few providers. Supervision and final evaluation will indicate whether these types o f arrangements can be generalized. 5. All the mentionedchoices are reflected inthe contents and implementation modalities o fthe proposed four components. Those components follow the four axes o f the NHASdescribed in Annex 1. The proposed four components are as follows. 6. Component 1:Preventiveservices targeted to high risk groups (IDA financing: US$7 million). Interventions supported by this component fall under the first axis (or operational Program) o f 2007-201 INHAS, and aim at reducing HIV transmission among high risk groups through behavior change and increased access to preventative services. 48 This component will finance: Subprojects carried-out by NGOs, community groups, social groups, professional associations and sector ministries (except the MSPLS) to promote behavioral change inhigh risk groups and communication campaigns to promote male circumcision. These activities' will be implemented and financed following the same mechanisms as inthe previous Project for the selection o f proposals to be funded. However, inthis new operation subprojects selection will be carried out with support from behavior-change staff from the SEP/CNLS. Sub-project selection criteria will favor activities targetedto high risk groups to activities in underserved "hot spots" as well as to promote male circumcision. Through Component 4 (discussed below), SEP/CNLS capacity will be strengthened with behavior-change experts, who will review and improve/approve the proposals presented. SEP/CNLS experts will closely supervise the implementation o f the activities and will provide technical support as needed. Voluntary counseling and testing services offered by public and private providers. Currently the SEP/CNLS has established performance-based contract and agreements with some o f the providers o f VCT, PMTCT and treatment services. Component 4 will finance technical assistance to help the SEP/CNLS to evaluate the experience, improve the existing contracts/ agreements and extendedto all providers o fthose services. Technical assistance to the SEP/CNLS to design and pilot performance-based contracts/ agreements for the provision o f behavior change activities. Training o f health personnel and medical supplies for public and private health facilities to deliver the PMTCT service package and provide safe male circumcisions. A socio-behavioral study on attitudes, practices, costs etc o fmale circumcision is beingfinanced under the PPF. The results o f such study will inform these activities. Provision o f PMTCT and male circumcision services, through performance-based contracts/ agreements between MSPLS and health service providers. The contracts/ agreements will be improved versions o f the existing ones. Those contracts will be based on agreed set o f services to be provided to the patients at a set per-capita price. As per presidential decision HIV+pregnant women will not get charged for those services. MSPLS will be responsible to supervise the quality and pertinence o fthe services to patients and provide data to the SEP/CNLS on the execution o f the activities. Capacity to carry-out adequate prenatal and basic pediatric care and family planning is needed to screen pregnant women for HIV/AIDS and provide PMTCT services. Therefore, financing under this component will contribute to improve the capacity o f the national heath system. Capacity building and other costs to enable the MSPLSs to carry out its activities o f accreditation o f the service providers and the supervision o fthe service contracts. Selected commodities, such as PMTCT drugs and contraceptives to service providers, only if needed. Goods such as gloves and other protectionmeans and technical assistance for the MSPLS to support the implement the National Waste Management plan with regards to HIV/AIDS. 49 7. Component 2: Performance-basedcurativeservices (IDA financing: US$2 million). Followingthe second axis ofthe NHAS, "Improving the life conditions of persons livingwith HIV/AIDS", this component will support the geographic extension ofARV treatment and opportunistic infectionprophylaxisandtreatment to underservedareas ofthe country.To achieve this objective, the Componentwill finance: Transfers to the MSPLS to: (a) Financeperformance-basedservice contracts/ agreementswith public and privatehealthfacilities at local levelto provide clinical care for HIV/AIDS patients. As inthe previouscomponentthose contracts will be improvedversions ofthe existingones. (b) Trainpersonnelin selectedhealthservice providersto accreditedthese facilities and declaring them ready to deliver treatment for HIV/AIDS patients. The Component will also finance: (c) Subprojects betweenSEP/CNLS and civil society organizations to providehome care services in a limited set of communities. 8. Component 3: Decentralizedfinancing of Grants to families of people livingwith HIV/AIDS and high riskgroups (IDA financing: US%3million). The objectiveofthis component is to provide economic and legal support to the most vulnerable families affected by HIV/AIDS, andthereby falls under the NHAS 2007-2011third axis "Reduction of povertyand other determinant factors of HIV/AIDS vulnerability'. 9. Inthe previous IDA Project, provincialandcommunityHIV/AIDS committees havethe mandate to select and finance community based subprojects until certain amounts (see Annex 6).The subprojects are implementedbyNGOs, developmentalcommune councilsand community-groupsandprovide small grants to vulnerable families, andfamilies livingwith HIV/AIDS to: (a) Increasetreatment compliance; increase their capacity to nourishthemselves in order to improve the impact ofdrugs; and (b) Support to HIV/AIDS orphans andwidowedwomen with special focus on socialand legalrights and on stigmatization. 10. Resourcesare then directlytransferred fromthe central SEP/CNLS to existingprovincial accounts.Thereby the Provincialcommitteesfinance the implementation, by the localassociationsor NGOs ofthe approved subprojects.Usingthe same mechanismas inthe first Projectthe SEP/CNLS will transfer IDA resourcesto the provincialcommittees for the financingof subprojects. Insame pilot provinces the transfers would includealso resourcesto finance the contracts ofthe two support staff. 11. Component4: Capacity buildingfor localauthoritiesand key ministriesto implement HIV/AIDSactivities, and NationalProgram management (US$ IDA financing: US$3 million). This component activitiesfall within Axe 4 ofthe 2007-2011NHAS which aims at "improving the HIV/AIDS nationalresponsemanagement and coordination." The objectives of this component are to: (i) build capacity to implementandmonitor HIV/AIDS activitiesin key ministriesand localgovernments; (ii) contributeto ensureadequateoperation ofthe SEP/CNLS; and (iii) increasethe SEP/CNLS capacity to managethe M&E system, in particularcarry-outimpact assessment of interventions.To achieve these objectives the component will finance: 50 (a) A part ofthe operationalcosts for the SEP/CNLS to carry out its ProgramandProject Managementresponsibilities(coordination, monitoringand evaluation, and fiduciary). (b) Technical assistance and surveys to improvethe capacity ofthe nationalM&E system to: (i)carry out impact evaluations andepidemiologicalstudies; (ii)provideevidence for effectivetargeting of interventionsbasedon vulnerability mappingand periodictriangulationof datato identify high-riskfactors; (iii)support HIV biologicalandbehavioralsurveillanceamong general populationandhighrisk groups, sentinel surveillance and monitoringbehavior; and (iv) build capacity ofthe SEPICNLS andNHAS implementerson data analysis and use of strategic informationfor activity andprogram improvement. (c) Transfers to provincialauthoritiesinthe decentralizationpilots on the bases of annual action plans approved by the SEP/CNLS, so that they can carry out their supervisionanddata collection activitiesinthe communes and communities (colines). Currently, provincialandcommunal HIV/AIDS committees are supportedby two SEP/CNLS staff at provinciallevel.The role of these two staffis to accompany, mobilizeand increase the capacity ofthe localcommittees, collect implementationdata from the associations/ NGOS implementingthe subprojects, and community-based data from the committees. The proposed Projectwill pilot decentralizationof these two positionsto the provinciallevel. The purpose ofthis decentralizationis to increase capacity at peripherallevelas well as ownership andresponsibility.To that endthe SEP/CNLS would finance those salaries on decliningbases (10 percent less every year). (d) Technicalassistance and operational costs for ministriesother thanthe MSPLSand selected public entitiesto implement, andor coordinate and supervise HIV/AIDS activitiesintheir respective sectors. 12. Financingof activitiesunder this component will increasethe financial and institutional sustainabilityof HIV/AIDS control interventionsand also help to progressively limit the SEPICNLS functionto its original coordinationmandateand away from its currentexecution role. 13. Other areas needingimprovement, which will be supported by the project includethe following: (i)buildingthecapacityofimplementingagenciesinM&E; (ii) providinga better evidence base for effectivetargetingof interventionsbasedon vulnerability mappingandperiodictriangulationof datato identify high-riskfactors; (iii)strengtheningharmonizationofthe M&E Systemwhile ensuring traceabilityof interventionsby the Projectto avoidduplicationof data; (iv) supportingan improvedHIV biologicalandbehavioralsurveillance among generalpopulationandhighrisk groups, sentinel surveillanceandmonitoringbehavior, (v) buildingcapacity ofthe SEP/CNLS and other NHAS implementers on data analysis and use of strategic informationfor activity and program improvement; and (vi) improvingquality assuranceof interventions through strengthenedprojectsupervision. Additionally, the M&E system also needsto be ableto producethe internationallyagreed indicators (includingUNGASSindicators),in order to attract fundingand allow for internationalcomparisons, thereby cooperatingwith the internationalmonitoringofthe epidemic. 51 Annex 5: ProjectCosts BURUNDI:BurundiSecondMultisectoralHIV/AIDS Project Project CostBy Component and/or Activity Local Foreign Total US $million US $million U S $million 52 Annex 6: ImplementationArrangements BURUNDI: BurundiSecondMultisectoralHIV/AIDS Project 1. The Government of Burundi has establishedan institutionalframeworkthat reflectsthe multi- sectoral nature of the nationalHN/AIDS program and facilitates the establishment of an effective partnership betweenall sectors and civil society for a concertedand decentralized responseto the epidemic. The new Projectwill rely on the same structure as the National Programandthe previousIDA Project,composedofthe following agencies. 2. The National Council for the Fight against HIV/AIDS (CNLS) The Conseil National de Lutte Contre le SyndromeImmuno-Dejcitaire Acquis (CNLS) is placedunder the Office of the President and operates pursuantto the DecreeNo. 100196datedNovember 04, 2004, Amendingthe Decree No. 100/032 dated March 1,2002. This Decree clarifies the relationshipbetweenthe Ministry of Healthand HIV/AIDS andthe CNLS. The CNLS is charged with providingthe general orientationofthe national HIVIAIDS programand overseeing its implementationand relieson the PermanentExecutiveSecretariat (SEP/CNLS), its technicalarm, for the day-to-day coordinationofthe National Programandprojects.The GeneralAssembly constitutesthe plenary body of CNLS.It is chaired by the President of Burundiand is 50 percent composedof Membersof Government includingthe 2 Vice-presidentsandthe Permanent ExecutiveSecretary of CNLS; and 50 percent of CSO/CBO/FBO andprivate sector representatives.UN Organizations are also allowedto designate representativesto seat on the General Assembly meetings. The GeneralAssembly meets quarterly.During its fourth annualmeeting, the General Assembly ofthe CNLS will reviewandapprove implementationplans for the following year. These plans will be formally submittedto the Bank for comments and review. 3. The CNLS Executive Committee is the coordinatingbodywhich is partofthe CNLS. It is chaired by the MSPLS, andcomposedoftwo representativesof civil society andthe Director ofthe PermanentExecutiveSecretariat. The PermanentExecutiveCommittee is charged with coordinatingthe implementationofthe nationalHN/AIDS program. Itwill be responsiblefor the overallcoordinationof the Project, and inparticularfor promotionofthe Project, review of fundingexceptionally large proposals (i.e. equivalent or above US$ 100,000) andmonitoringof progress. 4. The CNLS Permanent Executive Secretariat (SEPKNLS) is the administrativeandtechnical arm ofthe CNLS, responsiblefor programcoordination.It is headedby the Secretaryto the Executive Committee andcomposedof at least six full-time contracted staff selectedon a competitivebasis (specialists inthe area of HIV/AIDS, training, monitoringand evaluation, financial management and accounting, andprocurement)at bothcentralandprovinciallevels.The SEP will ensurethe day-to-day projectcoordination.Specifically, the SEP-CNLS is responsible for: (a) Development of its annualwork programsandbudget; (b) Procurementand disbursement activities; (c) Monitoringand evaluation; (d) Financialmanagement; and (e) Reportingto andassistingthe CNLS. 5. The SEP/CNLS is also expectedto promote local andprovincialactivitiesandto provide support for the formulationof fundingproposals.The SEP/CNLS will reviewthe annualwork programs and 53 budget proposalsby ministriesand other governmental institutions.The activities and projectsthat appear inthe ministriesannual programswill then beconsideredapprovedfor funding. The SEP/CNLSwill also review individual funding proposalsfor either: (i)submissionto the CNLS ExecutiveCommittee, or (ii) approvalfor proposalsamountingto US$lO,OOO 1 00,000; (b) CNLS PermanentExecutive Secretariat proposals< 100,000 and> 10,000; (c) ProvincialHIV/AIDSCommittees proposals < 10,000 and > 3,000; 54 (d) Communal HIVIAIDS Committees proposals <3,000 10. ImplementingAgencies. As with the previous project, activities funded under the project will be implemented by public and private organizations and implemented in an incremental manner starting with line ministries, NGOs, CBOs and FBOswhich already have HIV/AIDSwork plans and projects. Coverage will be extended to other public sectors and civil society organizations as their implementation capacity is strengthened and their work plans and projects are prepared. 11. Onthe Government side, public entities at the national, provincial, and communal/local levels will prepare fundingproposals. These will be consolidated annually by line ministries in a work plan and budget for each fiscal year, and the proposals will be implemented by public entities at national, provincial or local levels once they are approved by the CNLS. The capacity o f these entities has been strengthened duringthe previous Project. Sectoral focal points involving representatives o f Government institutions and private organizations have been established for each sector to spearhead development o f the various sector strategies. The focal teams will validate proposals to ensure their conformity with sectoral standards, monitor implementation, and report to CNLS on progress. 12. The funds that line ministries receive from the project will be complemented with contributions from line ministry budgets to ensure provisions for focal points or HIV/AIDS units in each sector. Line ministries will develop and implement plans through their existing central, provincial, and communal/local units.ministrieswill provide administrative and technical support to their implementationunits, including relevant guidelines, training, routine monitoring and evaluation, and resources will be channeledto provincial and communal/local entities to enable a decentralized response to HIV/AIDS.A formal contract including a work program and budget with agreed input and output indicators will guide the relationship between line ministries and the SEP/CNLS. Through its technical and financial units, the SEP/CNLS will be responsible for providing technical assistance and quality control to line ministries. 13. The private implementingagencies will present their project proposals to the respective national, provincial or communal/local committees and will be responsible for executing their projects. Any private agency may decide to enter into contract with an NGOto assist inthe preparation and implementation o f projects. The cost o f such assistance should not exceed 20 percent o f the total project cost. Communities will contribute inkindto sub-project financing for a minimumamount o f 2 percent o ftotal project costs. Civil society organizations (including NGOs, religious organizations, associations, unions, and private commercial enterprises) may present sub-project proposals o f a national, provincial, or communal scope to be directly financed by the project. Some private sector organizations may also be contracted to implement specific project activities inthe areas o f research and evaluation or in any other topic area, as deemed necessary. 14. The eligibility and the level o f funds allocated to each organization will be determined according to a set o f criteria established for different categories o f applicants. A roster o f over 200 civil society organizations working in HIV/AIDS has been compiled and categorized by experience, geographic coverage, target beneficiaries and ability to carry out HIV/AIDS projects. The roster will be updated to include private sector organizations and other associations and will be reviewed twice a year during project implementation. 15. The MSPLS will be related to a more direct financial decentralization particularly through the creation o f a dedicated MSPLS sub-account. This sub-account would be managed by the general directorate o f resources o f the MSPLS. This directorate will hire a chief accountant, an assistant accountant and a procurement specialist to manage those resources inaccordance with IDA procedures. 55 Annual disbursementsto that account will be agreed uponat the latest inthe monthof October each year, after approvalby the SEP/CNLS and IDA of an annualwork planandperformance indicatorsfor the next year. Interms of decentralizationof locally-recruitedpersonnelto provincial level, the Projectwould follow the current practice of provincialaccountsto bejustified regularly. 16. Procurement procedures. Procurement procedures will closely follow those usedunder the first Project.Detailedprocurement procedures, methodsand prior reviewthreshold are described in Annex 8. 17. FinancialManagement,Flow of Fundsand Audit Arrangements FinancialManagement, Flow of FundsandAudit Arrangements will closely follow those usedunder the first Projectwith the exception of funds transferred to the MSPLS. Detailsonthose procedures are found inAnnex 7. 56 Annex 7: FinancialManagementandDisbursementArrangements BURUNDI: BurundiSecond MultisectoralHIV/AIDS Project 1. This report is a record o f the results o f the assessment o f the existing financial management arrangements for Executive Secretariat o f BurundiSecond Multisectorial HIV/AIDS Project (SEP/CNLS) under the National Council for HIV/AIDS Control. The objective o f the assessment i s to determine: (a) whether SEPKNLS has adequate financial management arrangements to ensure funds will be used for purposes intended in an efficient and economical way; (b) SEPKNLS financial reports will be prepared in an accurate, reliable and timely manner; and (c) the entities' assets will be safeguarded. The financial management (FM) assessment was carried out in accordance with the IDA Financial Management Practices Manual issued by the Financial Management Sector Board on October, 2007 CountryIssues 2. The Country Financial Accountability Assessment (CFAA) concluded in 2004 documents the evaluation o f the Public Financial Management (PFM) environment in Burundi. It revealed several weaknesses in the P F M system attributed to years o f conflict. Notable areas o f weaknesses included budget formulation and execution, financial reporting, oversight systems as well as weak linkages between agreed policies budgeting planning and execution. However since then, significant progress has been made in all areas. Notable are the following areas: (a) The introduction and now full operationalization o f an interim Financial Management Information System (FMIS) which generates standard quarterly budget execution reports and reports on poverty-reducing expenditure andor HIPC expenditure execution. (b) The adoption and implementation o f a new unified functional and economic budget classification system and a double-entry accounting system has served to improve budget monitoring while weakened treasury controls are being addressed and the closing o f Government's extra- budgetary accounts is successfully on track. (c) The establishment of the Audit Court (Cow des Comptes) in 2004, was an important step towards the strengthening o fjurisdictional control over public finance management RiskAssessement and Mitigation 3. The specific objectives of the Project's financial management system include: (a) To ensure that Project funds are used only for their intended purposes in an efficient and economical way; (b) To ensure that Project funds are properly managed and flow smoothly, adequately, regularly and predictably inorder to meet the objectives o fthe Grant; (c) To enable the preparation o f accurate and timely financial reports; (d) To enable Project management to monitor the efficient implementation o fthe Grant; and (e) To safeguard Project assets and resources. 4. The following are necessary features o fa strong financial management system: (a) The Financial Management Unit should have an adequate number and mix o f skilled and experienced staff; (b) The internal control system should ensure the conduct o f an orderly and efficient payment and procurement process, and proper recording and safeguarding o f assets and resources; 57 (c) The integratedinformationsystem should support the Project's requests for funding and meet its reportingobligationsto fund providers includingGovernment of Burundi, IDA, other donors, and local communities; (d) The system should be capable of providing financial data to measure performancewhen linked to the output ofthe Project; and (e) An independent, qualified auditor should regularly review the Project's financial statements and internal controls. 5. The table below shows the results of the risk assessment from the Risk Rating Summary. This identifies the key risks SEPKNLS management may face in achieving Grant objectives and provides a basis for determininghow management shouldaddressthese risks. CountryLevel H Burundiis still not consideredpolitically stable. W Entity Level L The projecthas successhl implementedthe first SEP/CNLS 1 The project has previously implemented a Project Level L decentralized structure with provincial offices in the country. ControlRisk Budgeting L -Accounting units at the targeted implementing Accounting M agencies will be strengthened. -Updated procedures manual reviewed and approved by IDA InternalControl L Funds Flow L Financial CNLS will ensure that quality reports are obtained for Reporting L consolidation from the implementingagencies. CNLS will work closely with the World Bank to Auditing L ensure TORS, and the selection of auditors is acceptableto IDA. The project experience previously with decentralized OverallRiskRating L institutional arrangement of and its adequate controls in place, the project risk remains low. A minimum o f 1 on site supervisionwill be conductedeachyear. H-High S - Substantial M-Modest L-Low 58 6. The action plan below indicates the actions to be taken for the SEPICNLS to strengthen its financial management system and the dates that they are due to be completed by. Strengtheningaccountingunits at the Grant effectiveness SEP/CNLS/Imple- targetedimplementing agencies. menting agencies 2. Updatedprocedures manualreviewed and Grant effectiveness SEP/CNLS & IDA approvedby IDA. 7. The CNLS under its Executive Secretary will be responsible for the overall implementation o f the project. The Secretariat is currently implementing the first BurundiMultisectorial HIV/AIDS Project. Duringproject the execution SEP/CNLS will coordinate the project implementation through: (a) Project monitoring, reporting and evaluation; (b) Contractual relationships with IDA and other co-financiers; (c) Financial management and record keeping, accounts and disbursements; (d) Handling Project procurement matters. AccountingArrangements Books of Accounts 8. The SEP/CNLS will maintain adequate books o f accounts which shall included ledgers, journals and the various registers. The accounting system will be used to track, record, analyze and summarize its financial transactions and adequately capture those o f the implementingagencies. The Project's accounts will be preparedon a cash basis in accordance with the Grant agreement, the laws and regulations in Burundiand best accounting practice. The accounting systemwill allow for the proper recordingof SEP/CNLS financial transactions, including the allocation o f expenditures in accordance with its components, disbursement categories, and sources o f funds. Appropriate controls over the preparation and approval o ftransactions should be put in place to ensure that all transactions are correctly made, recorded, and reported upon. Inthis regard, SEP/CNLS will ensure proper books o f account have been maintained, a revised and updated chart o f accounts has been adopted and ideal accounting software i s in place. Staffins arrangements 9. The present SEP/CNLS accounting department is headed by a Director o f Finance, a financial controller, a chief accountant, an assistant accountant and a cashier, all housed at the management unit eightprovincial accountants at the providing support to provincial HIV/AIDS councils. With the proposed decentralized approach, the Director o f Finance together with his team housed at the management unitwill maintainthe overall responsibility over the financial matters while the provincial councils and other nationalbeneficiary entities will be strengthened by integrating the provincial accountant within its hierarchy to provide quality assurance o f funds flow to the decentralized unitsand to ensure the Grant funds are used for the intended purpose. With regards to the envisaged activities, the 59 current staffing arrangements will be adequate for SEPKNLS to ensure that funds are properly accounted for. 10. The Director of Finance will be responsible for approving payments to contracted service providers, suppliers of equipment and goods, and implementing agencies and for submitting consolidated financial monitoring and audited financial statements to IDA. The Internal Auditor will review the financial monitoring reports and will carry out regular internal audit controls. These controls will include ex-post verification of expenditure eligibility, as well as physical inspection of goods and any works acquired during the implementation of the Project. The findings and recommendations of the Internal Auditor will be used by the financial management of SEP/CNLS to improve project implementation in areas related to financial management and procurement. 11. Members of the SEPENLS accounting department are familiar with the World Bank Financial Management and Disbursement Guidelines. However additional training if deemed necessary may be arranged in consultation with the Financial Management Specialist during the implementation of the SEPKNLS activities. Information systems 12. SEP/CNLS has an integrated management information system, that is currently working well and fully operational. The staff have had both on the job training and structured classroom training on the use of the software. The information system is working satisfactorily. Financial Reporting and Monitoring 13. Interim Financial Reports are currently being prepared under SEPKNLS in the format complying with World Bank guidelines on the preparation of IFRs for borrowers and submitted on a quarterly basis to the World Bank for review. These will be reviewed to ensure that they provide quality and timely information to the Project management, implementing agencies and various stakeholders monitoring the project's performance. The IFR for SEP/CNLS will comprise of: (a) Designated Account Activity statement (b) Sources and uses of funds statement (c) Uses of funds by project's activity (d) The accounting policies and procedures adopted and notes to the financial statements will be disclosed in the report. Audit Arrangements 14. Annual financial statements of the Project will be audited by independent external auditors under terms of reference acceptable to IDA. The finance section of the CNLS manual of procedures will establish the procedures required for implementing agencies to submit periodic financial data for the preparation of consolidated financial statements for the project audits. Annual audit reports including a management report will be submitted to IDA within six months following the end of each financial year. The auditors will provide a single opinion on the project financial statements, the designated accounts and statements of expenditures. They will be required to carry out a comprehensive review of the internal control procedures and provide a management report outlining any recommendations for their improvement. Terms of reference for the external audit take into consideration the various implementation agencies to ensure the efficient use of funds for intended purpose and state that the audit shall be conducted in accordance with International Standards in Auditing. 60 Accountingand Internal Control 15. The Projectinternalcontrolswill be documented in a revised CNLS proceduresmanual(CPM) updatedto reflectthe new decentralized institutionalarrangement. The accountingsystems, policiesand proceduresemployed by the SEPKNLS in accountingfor and managingProjectfunds will thus are documented inthe CPM.The accounting policieswill specify the accounting treatment for the SEP/CNLS financial transactions and will constitute basic principlesdesignedto ensurethat the accounting records are complete, relevant and reliableandthat accounting practices are followed consistently.The revised CPMwill be usedby: (i)IDA to assess the acceptabilityof the SEP/CNLS accounting, reportingand InternalControl Systems; (ii)staff as a reference manual; and (iii) by the auditors to assess its accounting systems and controlsand in designing specific project audit procedures. 16. Specific procedureswill be documentedfor decentralized units(MSPLS, CPNLS andother implementingagencies) accounting function, depictingdocument andtransaction flows, the appropriate filing of projectdocuments, management approvals and organizationalduties andresponsibilities.The accounting systemwill consist ofthe methods andrecords established to identify, assemble analyze, classify, recordand report the transactions of a project, andto maintainaccountability for the related assets and liabilities. The aspectsto be covered in the CPM will include:(i) flow of funds; (ii)financial and accounting policies; (iii)accounting system(includingcenters for maintenanceof accountingrecords, Chart of Accounts, formats of books andrecords, accounting and financial procedures); (iv) procedures for authorizationof transactions, budgeting, and financial forecasting; (v) financial reporting(including formats of reports, linkageswith Chart ofAccounts andproceduresfor reviewingfinancial information); (vi) auditingarrangements; and(vii) aspects of humanresources. 17. Inaddition, the CPMdocumentsthe arrangementsthat havebeenmadefor recordingProject's impact, outcomes, inputs and outputs, which are requiredto assess progresstowardthe achievement of Projectobjectives.Italso documents the proceduresundertakenfor the replenishmentof IDA designated account (DA). The CNLS maintains an oversight role ofthe SEP/CNLS giving assurance over the levelof control exercised. The internalauditor reviews the SEP/CNLS operations andreportsto the ES. DisbursementsArrangements and Methods 18. The SEPKNLS will continue receivingdisbursementsfrom IDA on the basisof incurredeligible expenditures(reimbursementmethod).An advance disbursement from the proceedsofthe Grant will be deposited into SEPKNLS operatedDesignatedAccount to expedite Projectimplementation.The Direct Payment method, whereby the IDA may sendpayments direclty to a third party for eligible expenditures at the Recipient's request, is offeredas an option. Another acceptable methodof withdrawingproceeds from the IDA grant is the Special commitmentsmethodwhereby IDA may pay amounts to a third party fore eligible expenditures under special commitmentsentered into, inwriting, at the Recipient's request and onterms agreedbetweenthe Bank andthe Recipient. 19. The SEPKNLS will continue maintainingthe following bank accounts for the purposesof implementingthe Grant: (a) A designatedaccount denominated inUS dollars currentlybeingusedto implement the Grant. (b) An appropriate number of sub-national accounts for the provincialoffices and implementing agencies. 20. Monthly bank reconciliationsare preparedby the chief accountantreviewedby the financial controller andapproved by the Directorof FinanceandAdministration.The SEP/CNLS account 61 signatorieswill be in case of any change updated inthe CPM by definingthe positionsofthose authorized as signatories.The current signatories include: (a) ExecutiveSecretary of SEPKNLS (b) Director of FinanceandAdministrationSEPKNLS, RSSP (c) TechnicalDirector of SEPKNLS FundFlow:IDA and CounterpartFunds 21. IDA will make an initial advance disbursement from the proceedsofthe Grant by depositinginto CNLS DesignatedAccount (DA) opened in a commercialbank acceptable to IDA upon receivinga duely authorized withdrawalapplication.To ensure timely and reliableflow of funds to communitieswho need them for program activities, sub designatedaccounts will be openedin commercialbanks acceptable to IDA. For the same reason, a sub-designatedaccount will be openedfor the MSPLS. which is considered an intermediaryagency inthe context of DisbursementProcedures for HIV/AIDs Projects'0".The sub designatedaccount will be managedby the implementingand'intermediary agencies under the close watch of CNLS PermanentExecutiveSecretariat andwill cover transactions relatedto all the project components.After the initial advance, disbursementsto the DesignatedAccountwill be basedon submissionof CustomizedStatementof Expenditures" for eligibletransfers madeto subprojects, and service contracts.The customized SOE forms for those two types of expenditures were agreed upon negotiations andwill be annexedto the Disbursementletter. Statements of Expenditures (SOEs) will be usedfor all other expenditures. 22. Disbursement of Fundsfrom the SEP/CNLS to the implementing agencies will be done through advanceproceduresin conformitywith the terms of contract signed betweenthe CNLS andthe implementingagencies. Subsequentreplenishmentswill be basedon review of monthly financial and physicalprogress reportsaccompaniedwith adequatesupportingdocuments, such as technical inspection certificates, progress andcompletionreports andminutesof decision meetings, submitted to the SEP/CNLS by its satellite office andthe implementingagencies. Fundsdeposited inthe designated account will also be usedby the SEP/CNLS for directpaymentto suppliers of goods and services. However,an advancemadeto implementingagencies for subprojectscan be reportedto IDA as expenditure. At the endofproject implementationa reconciliationof disbursements with the actual expenditures incurredis preparedto ensure disbursements recordeddo not exceedactual expenditures. Supportingdocumentationfor payments madeto subproject is a summary statement which details paymentsto subprojects. 23. Disbursementof Fundsfrom the SEP/CNLS to theMSPLS or otherpotential intermediary agencieswill follow the results-baseddisbursement method. The MSPLS will usethose resourcesto purchase goods and services andto enter into results-basedagreementswith service providers.An initial advancement will betransferred to the MSPLSonthe basesof an agreementsigned betweenthe SEPKNLS andthe MSPLS, satisfactory to IDA that will include: (a) The annualactivity plan; (b) The total amounts to be disbursed by the SEP/CNLS andtheir frequency; ~ lo Refersto "World Bank GroupHIV/AIDS Program: A Guidance Note on Disbursement Procedures availableat 'I httdiintresources.worldbank.ordLOANS/ResourceslHIV-Aids.pdf 1 1CustomizedSOE is proposedfor subprojectsandthe componentsthat will follow the results-baseddisbursement mechanismfor which supportingdocumentationrequirements(documentationthat providesevidencethat results financedby the grant proceedshavebeenachieved. 62 (c) The intermediate results to be achieved by the MSPLS against which the SEPKNLS will disburse; (d) The final results to be achieved; (e) The type of documentation and content of the reports needed tojustify the expenditures; and (0 A package nomenclature describing details of the treatment received the number of visits etc. Flow of FundsChart I IDA 1 Counterpart Funds SEP/CNLS designated account SEPKNLS Project account inan inan acceptable commercial acceptable commercial bank bank denominated inUSD denominated inFBu L I I Implementingagencies ' I MSPLS Provincial Authorities Key ministries T w o n medical projects) t I Implementing I agencies (medical projects) - .c i Goods & Services inUSD or FBu Flow o f funds B Financial agreements, technical inspection certificates, progress and completion reports or equivalent documentation asjustification of expenditure to SEP/CNLS 63 24. The MSPLSwill sign agreements with service providersand will also transfer resources to them on the bases of results.The agreements betweensMSPLS andthe service providersincludesimilar provisionsto those listedabove and are reflectedin an internalMSPLSproceduresmanual. 25. Reporting to IDA on the use of advances made to theMSPLSand other implementingentities. Advances madeto implementingentitiesfor subprojects under parts l(a), l(b), 2(c), and3 ofthe project can be reportedto IDA as expenditure usinga Customized SOE in the form specifiedinthe Disbursement Letter as Attachment 3a. At the end of project implementationareconciliationof disbursementswith the actual expenditures incurredis preparedto ensure disbursements recorded do not exceed actual expenditures.A Summary Statementwhich details paymentsmadeto subprojects is the required supportingdocumentationto be submittedto IDA.Advances made to the MSPLS under parts (le) and (2a) of the project will be reportedto IDA on a monthlybasis usinga Customized Statement of Expenditures inthe form specifiedinthe DisbursementLetter as Attachment 3b which will be supported by the documentationto be providedas per para22(e). Advances made to SEPKNLS for purposes of all the other activitiesunder components 1,2, and4, should be reported on at least a monthlybasis usingstatement of expenditures andother documentation as specifiedinthe disbursement letter. 26. Reporting to IDA on the use of advances madefor subprojects. Advances madeto implementingentities for subprojects under will be reportedonthe basis of an agreedmodified SOE as described inthe DisbursementLetter. Advances madeto SEPKNLSfor purposesof all the other activitiesunder components 1,2,3,4 that are not managedby MSPLS, should be reportedon at least a monthlybasis usingstatement of expenditures and other documentation as specifiedinthe disbursement letter. 27. Actual expenditure will be reimbursedby IDA to the SEP/CNLS throughsubmission of Withdrawal Applicationsand against the differenttypes of Statements of Expenditure.The SEPICNLS will consolidate all projectexpenditures together with those of implementingand intermediaryagencies which will form the basis of a monthlySOE. 28. The payment of Projecttransactions regardlessofthe currency will be done throughthe bank and converted at the day's meanexchange rate. BudgetingArrangements 29. The budgetingarrangementswill be well documented inrevisedCPM. SEPKNLS has had adequatebudgetingarrangementsand adequatestaffto fulfill the functions. Budget analysis will be conductedto ensure budgetvariances are addressedon an adequateandtimely manner. The SEPICNLS will ensure that an all-inclusive system for proper planningfor the implementationof its activities is in place to allow adequatebudgetingarrangements. Conclusion of the Assessment 30. The FinancialManagementarrangement above indicatesthat they satisfy the Bank's minimum requirementsunder OPBP 10.02. SEPKNLSwill however undertaketo strengtheningaccounting units at the targeted implementingagencies andto reviewand updatethe CPM and have it approvedby IDA as part of strengthening its financial arrangementsto provide with reasonableassurancethat the funds will be usedfor the intendedpurpose. 64 SupervisionPlan 3 1. Giventhe experiencewith decentralizedinstitutionalarrangement,a minimumof one on site supervisionwill conductedeachyear to commensuratewith the Project'slow risk rating.The objectiveof the supervisionmissionswill be to ensurethat strong financialmanagementsystems are maintainedfor the Grant throughthe life ofthe project.Reviewswill be carried out regularlyto ensurethat expenditures incurredby SEPKNLSremaineligiblefor IDA funding.The ImplementationStatus Report(ISR) will includea FinancialManagementratingfor the FMcomponent andwill be arrivedat by the Financial ManagementSpecialistafter an appropriate review. 65 Annex 8: Procurement Arrangements BURUNDI: Burundisecond Multisectoral HIV/AIDS Project A. GENERAL 1. Procurement for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" published in May 2004 revised in October 2006; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" published in May 2004 revised in October, and the provisions stipulated in the Legal Agreement. The general description of various items under different expenditure category are described below for ach contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank project team in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. 2. Procurement of Works: Any works carried out under the Project will be limited to the minor rehabilitation of health facilities, youth centers, and communal meeting facilities under subprojects (Components 1 (a), 2 (c), and 3 of the Project). No ICB is foreseen as no contract above the equivalent of US$250,000 is expected. Works contract would be small and spread in the whole country. It would be procured through a combination of National Competitive bidding (NCB) and shopping using the SBD provides by the Project Implementation Manual (PIM). 3. Procurement of Goods: Goods to be procured by the grant would include pharmaceutical products, HIV test kits and other reagents, condoms, laboratory equipments, vehicles, furniture, office supplies and computer equipment. The above mentioned goods would be procured through a combination of the following procedures: (a) International competitive bidding for contracts estimated to cost more than the equivalent of US$250,000; (b) limited international bidding for contract estimated to cost more than the equivalent of USD250, 000 where there is only a limited number of suppliers.(c) national competitive bidding for contracts of value amounted more than the equivalent of US$50,000 but less than US$250, 000 and; (d) United Nations agencies in accordance with the procedures described in paragraph 3.9 the guidelines (e) shopping for contracts estimated to cost less than the equivalent of US$50,000. However, contracts for drugs, reagents, and medical equipment estimated to cost more than US$50,000 may be procured under shopping method as recommended. In situations and circumstances that are in compliance with the provisions of paragraph 3.6 of the Guidelines for procurement direct contracting may be used with Bank prior review. 4. Procurement of non consulting services: Non consulting service to be financed under the Grant would include office and equipment maintenance, rental expenses, communication costs, transport and insurance. Regarding the size and nature of these types of contracts, the procurement process will be conducted under procedures acceptable to IDA and that would be described in the project implementation Manual and in the project financial and administrative manual. Both manuals will have to be reviewed and found acceptable to IDA. 5. Procurement under the Community participation. Under components 1, 2 and 3, the project will finance performance based preventive services targeted to high risk group, performances based clinical and community based service for AIDS patients and small grants to families living with HIV/AIDS and high risk groups. The type of performance based agreement or convention to be financed 66 under these components will be defined in the project's implementation manual. This kind of activity will be implemented with civil society organizations or groups. It is not possible to determine the exact mix of goods and services to be procured under this component due to their demand driven nature. 6. Funding for these activities would be in the form of Grants. Therefore, the types of activities to be financed and their procurement details would depend on the needs identified following the process defined in the Project Implementation Manual. The goods and services would be procured following simplified procurement procedures as described in the PIM. 7. Selection of consultants, training and workshop: consultant services to be procured under this Grant would include, technical studies, technical assistance, monitoring and evaluation activities performed firms and individual consultants. 8. Contracts estimated to cost the equivalent of US$100,000 or more, would be procured through Quality-and Cost-Based Selection (QCBS). The contracts for services estimated to cost less than the equivalent of US$ 100,000 per contract may be procured under contracts based on Consultants' Qualifications in accordance with the provisions of paragraphs 3.1 and 3.7 of the Consultant Guidelines. 9. Financial and technical audit estimated to cost less than the equivalent of US$100,000 may be procured under Least Cost Selection (LCS) in accordance with the provisions of 3.1 and 3.6 of the Consultant Guidelines Consultant for services meeting the requirements of section V of the consultant guidelines may be selected under the provisions for the Selection of Individual Consultants, i.e. in essence through the comparison of the curriculum vitae of at least 3 qualified individuals. No civil servant can be hired as consultant. 10. To ensure that priority is given to the identification of suitable and qualified national consultants, Consultant Guidelines for (i) training; (ii) consulting assignment provided by NGOs or local other organization (iii) for consultant assignment estimated to cost less than the equivalent US$10,000 per contract. Single source selection may be used exceptionally in accordance with paragraph 3.9 to 3.12 of the 11. To ensure that priority is given to the identification of suitable and qualified national consultants, short-lists for contracts estimated under US$100,000 equivalent may be comprised entirely of national consultants (in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines), provided that a sufficient number of qualified individuals or firms (at least three) are available at competitive costs. Training, workshops, conference attendance and study tours would be carried out on the basis of approved annual work programs that would identify the general framework of training or similar activities for the year, including the nature of training/study tours/workshops, number of participants, and cost estimated. 12. Operating costs: Operating costs to be financed under the Grant include the non consulting services above mentioned plus per diem, supervision cost and salaries of locally recruited staff. These costs shall exclude salaries, bonuses, and fees for government civil servants. These expenses will be procured using procedures acceptable to IDA and that would be described in the PIM and in the project financial and administrative manual. B. ASSESSMENT OF THE AGENCIES' CAPACITY TO IMPLEMENT PROCUREMENT 67 a significantnumber of deficiencies:(i)The legaland institutionalframework is outdated; (ii)the environment is not conduciveto effectiveprocurement, as it plaguedby political interference; and(iii) there is a lack ofaccountability,as well as non-compliancewith the existingprocedures either becauseof rules andregulations not widely knownand/or due to the absence of capacity to handle procurement in an efficient manner. 14. In June2005, the steeringcommittee reviewed and updatedthe government action and merged itwith the CPIP action plan.The integratedprocurementreformactionplan is built on five components namely: (i)the revisionof the institutionaland legalframeworkwith a view to separatingthe executionfunctionfromthe regulatoryfunction; (ii)the modernizationof procurement procedures; (iii) the strengtheningof procurement capacity; (iv) the setting up of an independent ex-post control system; and (v) the enforcingof adequatemeasuresagainst corruption. 15. The implementation of the NationalProcurementReformAction Planis behind schedule. Finally, a new procurement code and institutionalframework consistentwith the recommendations of the procurementreformaction planwas promulgated in February 2008. However the new procurement and new institutional framework is expectedto be effectiveby end 2008. 16. Assessment of the agencies.Procurementactivitiesunder the projectwould includethe following actors: (i)The CNLS-PermanentExecutiveSecretariat (SEP- CNLS) and(ii)The Ministry of HealthandHIV/AIDS Control.It should be noticedthat NGOs and Provincial authoritieshave no procurement activitiesas such, but are rather service providersaccordingto performancebasecontracts. 17. An assessment of the capacity of agenciesthat will implement procurement actions for the Projectwas carriedout by the ProcurementSpecialistinthe BurundiCountryoffice, in February 2008. The assessmentreviewedthe organizationalstructure for implementingthe projectandthe interactionbetweenthe staff responsiblefor procurement inthe institutionthat would be involvedinthe procurementprocess. 18. The SEP/ CNLSwas responsiblefor the procurementactivitiesof the first Project.Its performanceas far as procurement is concernedwas satisfactory from the beginningto the end of the project.The project never experiencedprocurementproblemsanddifficulties that we are worth mentioning.All recommendationsmadeby the Bank were generally appliedin due course. The SEPI CNLS would continue to handleprocurement relatedto its own needs.Duringthe first year the SEP/CNLS will also provideoversight to the MSPLS regardingactivitiesassessedas complex or sensitive. Progressively depending onthe resultofthe programaimed at strengtheningthe capacity ofthe MSPLS and other public,the procurement responsibilitywould be completelytransferred. 19. The MSPLS experience as far as procurementis concerned is limited.As already mentioned since the countrywas embarked inthe conflict, the resourcesallocatedto investment in healthsector throughthe nationalbudgetwere very limited. When the Government was in a positionto carry out constructionor rehabilitationof health infrastructureor to supply drugs andmedicalequipment these activitieswere procuredthroughprojectimplementationunit supervised by a donor or directly procured by the donors. However, inrecentyears the GeneralDirectionof Resources(DGR) ofthe MSPLS, has prepareddossiers for the procurement of goods upto US$ 1.5 million, works upto US$ 780, 000 and of drugs up to US$ 1.6million. Final approval ofthose dossierswas done throughthe centralizedunit of Public Procurement inthe MoF. Therefore the MSPLS experienceon complex procurement it is somewhat limited. 20. In order to mitigate the riskfrom procurementby the MSPLS it was agreed that: (i)the transfer of procurement responsibilityfrom the SEP/ CNLS to the MSPLSwouldbe progressive, hence 68 duringthe first year of implementation,internationalcompetitivebidding, complex procurement contract and requestfor proposals estimatedto cost morethan the equivalentofU S $ 100, 000 would be carried out under oversightof the SEP/ CNLS; (ii)in additionto nationalprogramaimedat strengthening the procurement capacity of the mainprocuringentities ofthe country financedby an IDA financedproject, a planto strengthenthe DGRofthe MSPLSis plannedto start in June 2008; (iii)The MSPLSwill develop a PIMcontainingthe standardbiddingdocument to be usedNCB, nationaland internationalshopping ; and (iv) the MSPLSPIMwill provide a detaileddescriptionofthe minimumrequirements for a proper filing. 21. The overallprojectrisk for procurementis highas apart from the SEP-CNLS the other procuringentities have somewhatlimitedexperience in procurement. C. PROCUREMENT PLAN 22. The recipientof the Grant submitted, at appraisal, a ProcurementPlanfor project implementationwhich providesthe basisfor the procurement methods.This planhas beenagreed betweenthe recipientof the Grantandthe ProjectTeam on March31and is available at the offices ofthe SEPICNLS (Chausse`ePrince Louis RwagasoreImmeuble Banque de la ZEP). It will also be availableinthe Project's databaseand inthe Bank's external website. The Procurement Plan will be updated in agreement with the ProjectTeam annually or as requiredto reflectthe actual project implementationneeds and improvements in institutionalcapacity. D.FREQUENCY OFPROCUREMENTSUPERVISION 23. In additionto the prior review supervision to be carriedout from Bankoffice, the capacity assessment of the implementingagencieshas recommendedat least two supervisionsmissionsto carry out post review of procurement actionsand yearly procurement audits. F.DETAILSOFTHE PROCUREMENTARRANGEMENTINVOLVING INTERNATIONAL COMPETITION. 24. Goodsand Works and non consultingservices: (a) List of contract Packageswhich will be procuredfollowing ICB and direct contracting; 1 2 3 4 5 6 7 8 9 Ref. Contract Estimated Procurement P-Q Domestic Review Expected Comments No. (Description) cost Method Preference by Bank Bid-Opening (yeslno) (Prior I Post) Date 1 Equipment for 300,000 ICB No No Prior 12/12/08 biomedicalwaste management (b) ICB Contracts estimated to cost above US$250,000per contract and all direct contractingwill be subject to prior review by the Bank. 69 25. ConsultingServices: (a) List o f ConsultingAssignments with short-list of international firms; 1 2 3 4 5 6 7 Ref.No. Description of Estimated Selection Review Expected Comments Assignment cost Method by Bank Proposals (Prior 1 Submission Post) Date None (b) Consultancy services estimatedto cost above US$ 100,000 per contract for firms, all Single Source selection of consultants (firms& individuals) and assignments estimated to cost above US$ 50,000 for individuals will be subject to prior review by the Bank; and (c) Short listscomposed entirelyof nationalconsultants:Short lists o f consultants for services estimated to cost less than US $ 100,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines. 70 Annex 9: Economic and FinancialAnalysis BURUNDI: BurundiSecondMultisectoralIV/AIDS Project A. Context and Introduction 1. HIV/AIDS representsa difficult healthand development problemin Burundi.As seen in Table 3 the last national sero-prevalence survey of 2002 found overall adult prevalence of 3.2 percent although current estimatesput the incidence in 2007 at around 4.8 percent. The epidemic is a large health problem, constituting the second cause of mortality for adults and the fourth cause for children 6-14 registered inhospitals. Additionally, UNAIDS (2006) estimatesthat there are about 150,000 people living with the disease and about 120,000 orphans inthe country due to the epidemic. Table3: EstimatesofHIV/AIDS prevalence inBurundi Source Urban Semi-urban Rural National 1989-90National survey (15-49 years) 11.3 14.7 0.7 1.5 2002 National survey (12-49 years) 9.4 10.5 2.5 3.2 2007 National Survey (preliminary results) 3.7 5.1 4.8 4.8 2. Incidencein rural areas hasincreasedover the years. Data from the two national sero- prevalence surveys show that the epidemic seems to have stabilized inthe cities; however, it has tripled in rural areas, where the prevalence increasedfrom less than 1percent in 1989-90to about 3 percent in 2002. 3. The economiccosts of this epidemic are massive.Cross-country regressions for the 1990s showed that the epidemic reducedthe rate of growth of Africa's per capita income by 0.7 percentage points per year (Bonnel, 2000). This reduction is due to the epidemic effect on physical, human, and social capital. The epidemic inthe longrun can affect physical capital by increasing governments' fiscal deficit and reducing private savings and thus decreasing investment. As the epidemic affects larger shares of the population the cost of treatment increases and thus fiscal deficits are likely to increase. It might also reduce private savings as families affected by the disease would be forced to deplete their savings to pay for treatment. The effects on human capital are devastating; the epidemic usually affects young people 25- 35 years when productivity is the highest. Indeed, at the moment there is an estimated 150,000 adults livingwith HIV in Burundi and about 13,000 deaths a year. By destroying the social structure o f local communities and eroding social networks the epidemic can also negatively affect economic growth. B. Justificationfor GovernmentIntervention 4. Government intervention in the activities financed by this Grant is justified as these activities are aimed at lessening market failures such as the presence of externalities or public goods. In addition, the Grant will also finance activities aimed at decreasing inequalities in access to HIV/AIDS treatment and at lessening income inequalities by providing some financial support to vulnerable groups. 5. I t is recognizedthat when preventing or treatingan infectiousdisease,such as HIV/AIDS, individualsdo not necessarilytake intoaccountthe effect of their action (or lackthereof)on others (externalities).Without government intervention the level of preventive and curative efforts will be lower than optimal. This Grant finances many activities aimed at preventing and treating this disease. 71 6. In additionsome ofthe activitiesfinanced throughthis Grant can be characterizedas publicgoods. Informationcampaignsfor activitieswithout a marketableproductassociatedwith it, fall in this categoryjustifying government intervention.The Projectwill finance campaignsto sensitizehigh- risk groups on behavior change, as well as campaigns to promote male circumcision. 7. Equity considerations alsojustify government intervention.The secondcomponent of the Grant will support the geographic extension of ARV treatment andopportunistic infectionprophylaxis andtreatment inunderservedareas of the country.For that reasonthe Grant will finance small grants to families livingwith HIV/AIDS andhighrisk groups such as widows. This government interventioncan bejustified on equity grounds as it lessens income inequalitiesby offering some financial support to very poor andvulnerable sectorsof the populationsuch as orphans andwidows. C. Financial Gap 8. The national budget allocation to the fight against HIV/AIDS has increased significantly in the last few years showingthe government's commitmentto this fight. In2006 the budget allocatedto the then Presidential Ministry in charge of HIV/AID control increased in real terms more than 2500 percent compared to the previousyear. This increase in public resources goingto HN/AIDS was possible thanks to the enhanced HIPC initiative. In2007 the total public resources goingto HIV/AIDS represented about US$0.3 per capita. Despite increasing Government's funds for the sector, the fight against this epidemic depends and will depend in the future on foreign assistance. In2005 the total external resources allocatedto combat HN/AIDS were about US$3.15 per capita, in 2006 US$ 2.8, and in 2007 US$1.37 (World Bank, 2007). Table 4: Trends inHIV/AIDS controlministry (MINSIDA) budget, real and nominal,2001-2007 per capita -4% I -11% I 2460% I -40% Per capita MINSIDA budget inUS$ 0.0I 0.0 I 0.0 I 0.0 I 0.3I Source: Ministry of Financeand World Bank estimations 9. At the moment, only 35 percent ofthe funds neededto finance the NationalStrategic Plan for the Fight against HIV/AIDS 2007-2011 are available.The main donors in the sector are the Global Fund and 72 the World Bank. However, the country was not selected in the 7'h round of the Global Fund resulting in such a large financial gap. This projecttherefore aims at closingpart ofthis gap. Table5: FinancialResourcesto finance the NationalStrategic Planfor the Fightagainst HIV/AIDS 2007-2011 (thousands of US$) Source: CNLS V. Cost-EffectivenessofInterventionsfinanced by the Grant 10. The funds for this Grant will be dividedacross four components comprisingdifferent preventive and curativeactivities, as well as capacity buildingand income support activitiesfor HIV/AIDS affected families and other high risk groups. 11. The most cost effectiveinterventionsto controlthe spread of HIV/AIDS are preventive interventionsas seen in Table 6 below. Inconsequence,the largest share ofthe Grant goes preciselyto the first componentto finance the following preventiveinterventions: all preventiveinterventionstargeting highrisk groups and in particularsexual workers, VCT, PMTCT, andthe promotionof male circumcision. Table 6: Cost-Effectivenessof HIVPrevention and ARV TreatmentInterventionsMeasuredin Cost Per Life-Year Saved I Cost Per Life- Focus I Intervention I Year Saved I Prevention I Blood screeninnfor HIV 3.35 STD controland managementfor sex workers 3-95 Single-dosenevirapinefor pregnant women (PMTCT) 11.24 VCT 22.03 STDmasstreatment for generalpopulation 22.32 Short-courseARV treatment for pregnantwomen (AZT) 213.66 Treatment Donated drugs 857.95 Proposedprice for generic drugs 1,3 17.26 UNAIDS negotiatedprice 2,028.78 Full price in 2000 10,707.09 73 12. Inselectingthese activitiesthecost-effectivenessoftheinterventions,theirimpact, andthe availability of other sources of funds were taken into account. The table below shows the resultsof acost- effectiveness analysis carriedout inEast and SouthernAfrica countries (Bollinger and Stover, 2007). As seen in the table all the activities funded by the first component are highly cost effective. The only activity that is highly cost-effectiveand has also high impact that was not includedwas bloodsafety as this interventionis already financedthroughother sources of funds. Table 7: Cost-Effectiveness and Impactof VariousHIV/AIDS Interventionsin East and Southern Africa Cost per Infection Impact . Averted (percentofinfectionsaverted) (US$) Low (0-10%) I Medium(10-20%) I High (>20%) Low (<1,000) ...csw . w PMTCT Bloodsafety MSM I Medium(1,000 - Community Condom . 3,000) I mobilization I distribution I I VCT Education High(>3,000) ...Mass media STItreatment Workplace interventions 14. Some of the income support activities in component 3 are also preventiveinnature. The Global HIV PreventionWorking Group(2007) considers as componentsofa comprehensive HIV prevention strategies the following: preventivesexualtransmission, preventiveblood-bornetransmission, preventive mother-to-childtransmission, and socialstrategies and support policies.Some ofthe activities founded by component 3 follow intothe last category as it includesgender equity and women's empowerment initiatives, involvementof communitiesand HIV-infected individuals,and anti-stigmameasures. 15. As seen in Table 7 preventiveinterventionsare muchmore cost-effectivethan treatment and thereforethe Grant focuses on preventiveactivities.However, a combinationof botheffectiveprevention and treatment has beenfoundto minimizethe number ofnew infectionsandresults inthe least number of deaths as seen in Table 9. This is the case as without treatment there is only a limited incentivefor people to get tested. Similarly, treatment without effective preventioncan only have limited successas the number of peoplerequiringtreatment would continuouslygrow. Basedonthese results, the Grant also funds the geographical extensionofARV treatment to underservedareas. 74 Table %TotalNew Adult Infectionsand Deaths in Sub-Saharan Africa, 2004-2020 Under Different InterventionScenarios Interventions Source: Salomon, et al. (2005) References Bailey, Robert C., StephenMoses, Corette B. Parker, KawangoAgot, IanMaclean, John N.Krieger, CarolynF. M.Williams, RichardT. Campbell, andJeckoniah 0.Ndinya-Achola(2007). Male Circumcisionfor HIV Prevention in YoungMen in Kisumu, Kenya: A RandomizedControlled Trial. The Lancet.Vol369. Feb. 24. Bollinger, Lori andJohn Stover (March3,2007). The PotentialImpactof HIV/AIDS Interventionson the HIV/AIDS EpidemicinAfrica: A Simulation Exercise for the World Bank.Glastonbury, CT: FuturesInstitute. Bonnel, R. 2000. "HIV/AIDS: Does it Increaseor DecreaseGrowth in Africa?" ACTAfrica and World Bank. Gray, RonaldH.,GodfreyKigozi, David Senvadda, FrederickMakumbi, StephenWatya, FredNalugoda, NoahKiwanuka, LawrenceH.Moulton, MohammedA. Chaudhary, Michael Z. Chen, Nelson S. Sewankambo, FredWabwire-Mangen, Melanie C. Bacon, CarolynF.M. Williams, Pius Opendi, StevenJ. Reynolds, Oliver Laeyendecker, Thomas C. Quinn, and MariaJ. Wawer (2007). Male Circumcisionfor Prevention in Men in Rakai, Uganda: A Randomised Trial. The Lancet.Vol. 369. February 24. Masaki, Emiko,RusselGreen, FionaGreig, JuliaWalsh, andMalcolm Potts (n.d.). Cost-Effectiveness of HIV Interventionsfor Resource Scarce Countries: SettingPrioritiesfor HIV/AIDS Management. BayArea InternationalGroup, University of Californiaat Berkeley.Study funded by Bill and MelindaGates Foundationand Hewlett Foundation. Salomon, Joshua, Daniel Hogan, John Stover, Karen Stanecki, Neff Walker, Peter Ghys, and Bernhard Schwartlander (2005). Integrating HIVPrevention and Treatment: From Slogans to Impact. PLoS Medicine,Vol. 2, Issue 1. January. World Bank.Forthcoming.Burundi: HealthFinancingStudy. 75 13. The country procurement system is a matter of concern for the Government and stakeholders. In 2004 the Bank conducted a Country Procurement Issue Paper (CPIP) which was issued in June 2004. The Government and Bank assessments concluded that Burundi procurement system shows Annex 10: Safeguard Policy Issues BURUNDI: Burundi Second Multisectoral HIV/AIDS Project 1. The project has triggered OP 4.01 Environmental Assessment due to the potential adverse environmental impacts of poor medical waste management. The environmental category is B, and the safeguards category is S2. 2. In an effort to mitigate potential adverse environmental and social impacts effectively, the project has prepared a study: "Etude sur la mise en place de plans de Gestion des Dechets Biomedicaux", November 2007. This study has been disclosed in Burundi on February 6, 2008, and at the Bank's Infoshop on February 11, 2008. 3. The study assessed current medical waste management practices in Burundi and made general recommendations for improvements. It noted that health care professionals have a very limited understanding of the dangers of medical waste, and the public information campaigns via radio and other channels do not highlight the risks of poor medical waste management. The most serious risk is the potential spread of HIV/AIDS due to improperly handled and disposed medical waste (blood, urine, syringes, sharps, bandages, laboratory waste etc.). The main recommendations centered on the importance of training health center personnel in safe medical waste management and to ensure its safe disposal. 4. The appraisal mission discussed the recommendations of the above study with representatives of the SEP/CNLS; USLS/Sante; Departement de la Promotion de la Sante; and the Ministry of Environment. It was determined that the proposed project would fund the following activities under component 4 (total cost estimate: $105,500): (a) Update of the norms and standards for health centers providing HIV/AIDS services to include safe medical waste management practices (consultant); (b) Identification, quantification and description of materials needed for safe medical waste management in the health centers (consultant); (c) Preparation of a training module on safe medical waste management (consultant); (d) Multiplication and dissemination of the training module to about 500 health centers; (e) Training of health center personnel; and (f) Acquisition of protective gear and equipment for health care personnel for safe medical waste management. (g) The SEP/CNLS will be responsible for implementing the above measures. 5. The monitoring of the above measures will be the responsibility of SEP/CNLS and the implementation will be the responsibility of the MSPLS. There is a very low probability that the Project will include some minor rehabilitation of health facilities, youth centers, and communal meeting facilities under subprojects (Components 1 (a), 2 (c), and 3 of the Project). 6. The study was prepared in consultation with health care personnel, hygiene and sanitation personnel, representatives of the Institut National pour 1'Environnement et la Conservation de la Nature (MECN), Bureau Burundais de Normalisation et de Controle de Qualite, Ministry of Public Health, provincial sanitation facilities, and environmental health specialists, and involved site visits to several representative health care facilities. Their views have been reflected in the study. 76 Annex 11:ProjectPreparationand Supervision BURUNDI: BurundiSecond MultisectoralHIV/AIDS Project Planned Actual PCN review 11/21/2007 11/21/2007 Initial PID to PIC 01/22/2008 12/03/2007 Initial ISDS to PIC 12/03/2007 12/07/2007 Appraisal 02115/2008 02/22/2008 Negotiations 03/22/2008 0410112008 Board/RVP approval 06111/2008 05/13/2008 Planned date of effectiveness 0910112008 Planned date of mid-term review 09115/2010 Planned closing date 08/31/2012 Key institutions responsible for preparation o fthe project: Permanent Secretariat o f the National Council for HIV/AIDS Control. Secre'tariat Permanent du Conseil National de Lutte contre le VIHSIDA (SEPKNLS) ". " Bank staff and consultants who worked onthe project included: Name Title Unit Montserrat Meiro-Lorenzo Task Team Leader AFTH3 Maria Eugenia Bonilla-Chacin Health Economist AFTH3 Pamphile Kantabaze Public Health Specialist AFMBI ProsperNindorera Procurement Specialist AFTPC Dominique Puthod Operations Officer AFMBI Omar Fye Environmental Specialist AFTEN Otieno Ayany FinancialManagement Specialist AFTFM Sameena Dost Sr. Counsel LEGAF Juliana Victor-Ahuchogu Monitoring and Evaluation Specialist HDNGA Adjaratu Ndiaye Consultant, M& E Specialist HDNGA Astania Kamau Language Program Assistant AFTH3 Aurelien Beko Poverty Economist AFTPM Bank funds expendedto date on project preparation: 1. Bank resources: $170,000 2. Trust funds: $0 3. Total : $170,000 (repeater) Estimated Approval and Supervision costs: 1. Remaining costs to approval: $0 2. Estimated annual supervision cost: $105,000 77 Annex 12: Documentsinthe ProjectFile BURUNDI:BurundiSecondMultisectoralHIV/AIDS Project A. PROJECT DOCUMENTS Missions: Statement of Mission Objectives & Back-to-Office Report Pre-Appraisal Mission, January 2008; and Statement of Mission Objectives & Back-to-Office Report Appraisal Mission, February 2008; ProjectRelatedDocuments: Minutesof Project ConceptNote Review Meeting, November 2007; MinutesQER Review Meeting, January 2008; Minutes Decision Meeting, February 2008; Presidential Decree adopting the National HIV/AIDS Strategy, 2007-2011; Nomination of the National Health Accounts SteeringCommittee; National HIV/AIDS operational Plan including IDA Project Plan 2007-2011. PPF Request OrdonnanceMinisterielle sur la Gestion des Dechets Medicaux ;and MinutesofNegociations. B. REPORTS Medical Waste Management Plan, February 2008; Burundi - National HIV/AIDS Strategy, 2007-2011; Burundi - Health Sector Strategy Note, October 2006; Burundi -Poverty Reduction StrategyPaper, 2006; Burundi - National Health Sector Development Plan 2007-2010; Burundi - Global Fund Round 5 Firsttranch. Evaluation report. Burundi - National Health Policy 2005-2015; Midterm ofthe MAP 1(PSMLO) review report. Burundi - Mainstreaming HN/AIDS (UNAIDS, 2006) 78 Annex 13: Statement of Loansand Credits BURUNDI:BurundiSecondMultisectoralHIV/AIDSProject Differencebetween expected and actual Original Amount in US$Millions disbursements Project ID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Fm. Rev'd PO64557 2007 BI-Educ.Sector Reconstr.(FY07) 0.00 20.00 0.00 0.00 0.00 18.87 -0.40 0.00 PO95211 2007 Bl-Community and Social Dvpt SIL 0.00 40.00 0.00 0.00 0.00 39.40 0.23 0.00 (FY06) PO64558 2005 B1-Agr Rehab& SustainLandMgmt 0.00 35.00 0.00 0.00 0.00 8.83 0.45 0.00 (FY05) PO64876 2004 BI-RoadSec Dev SIM (FY04) 0.00 51.40 0.00 0.00 0.00 28.21 18.29 0.00 PO78627 2004 BI-Econ Mgmt Supt SIL (FY04) 0.00 26.00 0.00 0.00 0.00 18.56 12.77 0.00 PO81964 2004 BI-Demobilization& Reint Prj (FY04) 0.00 33.00 0.00 0.00 0.00 8.35 6.37 7.57 PO71371 2002 BI-MultiSec HIV/AIDS & Orph APL 0.00 36.00 0.00 0.00 0.00 1.53 -5.53 0.00 (FY02) PO65789 2001 RegionalTrade Fac.Project Burundi - 0.00 7.50 0.00 0.00 0.00 5.57 -2.28 1.52 Total: 0.00 248.90 0.00 0.00 0.00 129.32 29.90 9.09 BURUNDI STATEMENT OF IFC's Held and DisbursedPortfolio InMillions ofUS Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. Total portfolio: 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic. Total pendingcommitment: 0.00 0.00 0.00 0.00 79 Annex 14: Countryat a Glance BURUNDI:BurundiSecondMultisectoralHIV/AIDS Project Sub. POVERTY and SOCIAL Saharan Low- Burundl Afrlca Income 2006 Population,mid-year(miillons) 7.8 770 2,403 GNIpercapita (Atlas method, US$j 00 e42 650 Lifeexpectancy T GNI(Atlas method, US$ billions) 0.78 548 1562 Average annual growth, 2000-06 I Population (%J 3.1 2.4 19 Laborforce (%) 4.3 2.6 2.3 GNI Gross per primary M o s t recent estlmate (latest year avallable, 2000.06) capita enrollment Poverty (% of populationbelownationalpoverfyllne) Urbanpopulation(W of totalpopulation) 0 36 I 30 Lifeexpectancyat birth (pars) 45 47 59 1 Infant mortality (per 1000live birfhs) t14 96 75 Childmalnutrition(%ofchildrenunder5) 45 30 Access to improvedwatersource Access to an improvedwatersource (%ofpopulation) 79 56 75 Llteracy(%ofpopulation age rS+ 59 59 61 Gross pnmaryenroilment (%of school-age population) 85 92 0 2 ---Burundi Male 91 98 0 8 -Low-incomegroup Female 78 86 96 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1986 I996 2005 2006 Sconomlc ratloll* GDP (US$ billions) 12 0.87 0.80 0.90 Gross capitalformatiordGDP 116 8.2 0.8 6.7 Exports of goods andsewices/GDP 117 5.8 n 4 0.9 Trade Gross domestic savingsiGDP 11 -17 -23.1 -20.2 Gross national savingsiGDP .. 2.1 13 Currentaccount balance/GDP -6.6 -6.1 -5.2 -6.3 Interestpayments/GDP 10 10 15 Domestic Capital Total debtlGDP 47.5 00.1 '66.0 savings formation Total debt service/exports 24.5 54.2 56.8 Present valueof debt/GDP 0.7 Present valueof debt/eWrts Q3.6 Indebtedness 19 18 6-06 2006 2006 D6-IO (averageannualgrottth) GDP -0.3 16 0.9 5.1 -Burundi GDP percapita -2.3 -0.7 -2.7 13 Low-income group Exports of goods andsewices 3.3 STRUCTURE o f the ECONOMY (%of GDPj Agriculture 58.5 572 348 Industry 0.5 12.6 200 Manufacturing 88 6.7 8.8 Services 28.0 30.1 45.1 " 0 Householdfinal consumption expenditure Generalgov't final consumption expenditure 9.8 20.0 26.5 29.3 Imports of goods and sewices 22.3 15.8 45.3 47.8 -GCF -GDP (averageannualgroMhj Agriculture -0.7 -13 -6.6 industry -17 -3.8 -62 Manufacturing -2.7 Services Householdfinal Consumption expenditure -13 Generalgov't final consumption expenditure 11 01 02 03 04 05 OB Gross capitalformation 12 ---Exports - e - l r Q O r t l imports of goods andservices 03 Note:2006data are preliminaryestimates. This tablewas producedfrom the Development Economics LDB database. 'Thediamonds showfourkeyindicators inthecountry(inbold)comparedwith its income-groupaverage. tdata aremissing,thediamondwill beincomplete 80 Burundi PRICES and GOVERNMENT FINANCE 1986 1996 2005 2006 Domestic prices (%change) Consumer prices 17 264 DO 2 8 Implicit GDP deflator -43 145 6 6 2 6 Government finance (%of GDP.includes current granfs) Current revenue 157 6 1 307 Current budget balance 2 5 -2 1 27 Overall surplusldeficit -3 5 -100 -a4 -IGDPdeflator -CPl TRADE 1986 1996 2005 2006 (US$ millions) Export and Import levels (US$ mill.) Totalexports (fob) a9 40 56 250 Coffee 106 29 43 Tea 5 5 10 200 Manufactures 9 5 7 150 Total imports (cif) 207 M 234 Food 6 11 100 8 Fuel andenergy 27 I? 40 50 Capital goods 63 31 74 0 Export pnce index(2000=WOJ 214 a 9 121 00 01 02 03 04 OS 08 Import pnce index(2000=WO) 62 77 112 @Exports mlmports T e n s of trade (200O=WO) 342 B8 108 BALANCE of PAYMENTS 1986 1996 2005 2006 (US$ millions) Current account balance to GDP (Oh) Eqorts of goods andservices 141 51 68 Imports of goods and services 268 a 7 291 Resource balance -727 -66 -223 Net income -21 -14 -33 -33 Net current transfers 47 214 Current account balance -80 -53 -42 -57 Financing items (net) 106 -24 61 Changes innet reserves -26 77 -20 Memo: Reserves includinggold (US$ millions) 76 146 101 131 Conversion rate (DEC,local/US$) 1142 3028 1,0816 10284 EXTERNAL DEBT and RESOURCE FLOWS 1986 1996 2005 2006 (US$ millions) Composltlon o f 2005 debt (US$ mill.) Total debt outstanding anddisbursed 570 It31 1322 IBRD 0 0 0 0 ,, IDA 8 1 588 751 797 Totaldebt service 35 31 39 IBRD 0 0 0 0 IDA 2 7 t3 22 Compositionof net resourceflows Officialgrants 51 72 276 Officialcreditors 88 23 20 Pnvate creditors -6 -1 -5 Foreigndirect investment (net inflows) 2 0 1 Portfolio equity(net inflows) 0 0 World Bank program Commitments 32 0 8 0 A-IERD Disbursements 44 fr 27 29 E- Bilateral E-IDA D-Otherrmltllaterai F-Private Principal repayments 1 3 9 6 C - I M F G. Short-terr Net flows 43 14 T3 n Interest payments 1 4 6 Net transfers 42 a4 15 6 NoteThis table was producedfrom the Development Economics LDB database 9/28/07 81 IBRD 33380 BURUNDI SELECTED CITIES AND TOWNS MAIN ROADS PROVINCE CAPITALS PROVINCE BOUNDARIES NATIONAL CAPITAL INTERNATIONAL BOUNDARIES RIVERS 29°E 30°E 31°E Lake To Kivu This map was produced by the Map Design Unit of The World Bank. Kigali The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any To endorsement or acceptance of such boundaries. Gitarama Lake Kagera Lake Rweru Cohoha RWANDA To K I R U N D O Cyangugu Kirundo To Butare To Kanyaru Rulenge Ruvuvu C I B I T O K E M U Y I N G A N G O Z I Muyinga To Cibitoke Nyakanura Ngozi Kayanza Rusiba 3°S Musada Ruvuvu Buhiga 3°S Bubanza K AYA N Z A To Karuzi Mwerusi Kakonko Rusizi B U B A N Z A K A R U Z I C A N K U Z O Cankuzo To Uvira M U R A M V YA Muramvya Ruvuvu BUJUMBURA Gitega DEM. REP. M WA R O Mwaro Luvironza Ruyiga OF CONGO B U R A R U Y I G I B U J U M(2,670 G I T E G A To Kibondo Mt. Heha m) Bukirasazi Rumpungu TANZANIA Matana B U R U R I Mutangaro R U TA N A Bururi Most distant Rutana Rumonge headwater of the Nile River 4°S 4°S Makamba M A K A M B A BURUNDI Mabanda Lake Muragarazi Tanganyika Nyanza-Lac To Kasulu 0 10 20 30 40 Kilometers 0 10 20 30 Miles 29°E 30°E 31°E SEPTEMBER 2004