Report No. PID8820
Project Name                     Eritrea-HIV/AIDS, Malaria, STDs & TB (@)
(HAMSET) Control Project
Region                           Africa Regional Office
Sector                           Basic Health;  Targeted Health
Project ID                       ERPE65713
Borrower(s)                      GOVERNMENT OF ERITREA
Implementing Agency
Address MINISTRY OF HEALTH
Project Management Unit (PMU) based in the
Ministry of Health (MOH), in
coordination with the Ministry of Education
(MOE), Medical Services of the
Ministry of Defense, Ministry of Labour and
Social Welfare (MOLSW),
Ministry of Tourism, Ministry of Local
Government, Ministry of
Information, Ministry of Agriculture,
Ministry of Finance, Ministry of
Land, Water and Environment and Zoba
Governments.
PMU, Ministry of Health, Asmara, Eritrea
Contact Person: Ministry of Health,
Dr. Eyob Tekle
Tel: (291) 112-4199
Fax: (291) 112-4357
Email: pmu@gemel.com.er
Environment Category             B
Date PID Prepared                November 3, 2000
Projected Appraisal Date         September 18, 2000
Projected Board Date             December 19, 2000
1. Country and Sector Background
BackgroundSince independence in May 1992, the Government of Eritrea (GOE)
has made great strides in supporting development and improving the living
conditions of its population. Basic social infrastructure has been
rehabilitated and expanded. Gross primary school enrollment has changed
from 36.3% to 64%.   Overall access and use of health services has
increased from 30% to 60%; EPI coverage has increased by 125%; attended
deliveries have more than tripled; and antenatal care visit-coverage has
more than doubled during the same period. Yet, Eritrea remains one of the
poorest countries in the world (GDP/capita US$ 200). It is eminently rural
(about 20% of the population lives in urban areas and 30% is semi-nomad).
Its population pyramid follows an early development pattern with nearly
70% of the population composed of children and women of child-bearing
age. The primary causes of morbidity and mortality among children under
five are acute respiratory infections (ARI), malaria, and diarrhea. Life
expectancy is 51 years (SSA 50); infant mortality is 72/1000 live births
(SSA 72); under 5 mortality is estimated at 135/1000 (SSA 93) and maternal



mortality at 1000/100,000 live births (SSA 500/100,000). In the general
population 62t of the burden of disease (BOD) is caused by
perinatal/maternal causes, malaria, diarrhea, ARI, and tuberculosis (TB).
Two thirds of the population live in malaria endemic areas. In 1997 and
1998 above average rainfall triggered a malaria epidemic, making this the
leading cause of mortality (over 509 in all areas) and morbidity (60-80w
depending on the area) across all ages. The reproductive health situation
is very poor: first pregnancy occurs at an early age (21. of 17 year olds
and over 50t for 19 year olds), the fertility rate is high (5.6), and
female genital mutilation--discouraged by government -- is prevalent in
certain regions. This situation is compounded by an increase in STDs and
the emergence of HIV/AIDS (3,6w adult population). The number of AIDS
cases is believed to be doubling each year. Nutritional status is poor:
10t of under-five children are wasted, 66t stunted, and 41, underweight;
and 50t of the children have anemia. Diarrhea, anemia and malaria are
interconnected and increase vulnerability to other HAMSET diseases.This
situation has worsened in 1999 due to the May 2000 military conflict with
Ethiopia and to the drought.   About 20t of the population (men and women)
has been mobilized; a third has been displaced and is without adequate
shelter, sanitation, food and basic services. Although widespread famine
and disease outbreaks have not occurred, partly owing to Government
efforts to mitigate the related adverse impact by providing food and other
assistance, there is a growing concern that the situation will deteriorate
in the coming months; early warning signals, such as rising morbidity
rates and falling livestock prices, are already evident.     The Ministry of
Health (MOH) is responsible for the state health system and regulates and
controls the provision of private and NGO's health services. The public
sector is virtually the only provider of health care. Private clinics and
pharmacies exist only in larger cities and serve a limited proportion of
the population. All hospital beds are in the public sector. At the
village and district level, the PHC network consists of health posts and
health centers staffed with one or several nurses. Health centers have a
laboratory, in-patient, and delivery facilities. Many remote villages
have no health facility. Every village or cluster of villages has
teachers, extension, social workers and malaria agents. They often work
in cooperation with health facilities, sometimes referring patients. At
the regional level (zoba) the recently established zoba health team
manages the PHC network. The Government is completing a network of
referral hospitals (one in each zoba). With support from WHO, the MOH has
approved an essential drug list and has developed treatment guidelines.
Drug purchase and distribution follows two systems: the pharmaceutical
department of the MOH and Pharmecor. The pharmaceutical department of the
MOH supplies the public health facilities. It is well organized, has an
adequate monitoring system, and is supplied almost exclusively by
donations from bilateral and multilateral agencies. Pharmecor is a
parastatal, for-profit organization that imports and produces
pharmaceuticals. While there are other pharmaceutical importers in the
country, Pharmecor is the only producer. Private sector pharmacies can
purchase drugs from any importer and public sector facilities purchase
from Pharmecor those items that are not available through the MOH.Issues
Highly mobile and disperse population compounded by military conflict:
Despite being a relatively small country, Eritrea has heterogeneous
ethnic-cultural groups and economic cultures, varying geographic and
climatic zones, various vector habitats, and remote areas that are
traveled by nomadic groups (about 30t of the total population in Eritrea
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is composed of semi-nomads agro-pastoralists). There are seasonal
migrations to and from the breadbaskets of the country. This previously
isolated country is now open to trade, Eritreans from the diaspora, and
foreign investors who travel in and out of the country. In the last two
years, armed conflict has displaced about 3.5w of the internal population
added to the 200,000 (7%) returnees. The combination of varied geography,
high mobility, and openness after isolation stimulates the spread of
communicable diseases, and complicates MOH capacity to reach the
population. In the aftermath of the recent conflict, there is an expected
increase in morbidity and mortality due to malaria, water-born diseases,
as well as an increase in the transmission of tuberculosis, STDs and
HIV/AIDS.Changing epidemiological profile: The factors listed above,
compounded with changes in social mores and climatic conditions, have
changed Eritrea's traditional epidemiological profile. Eritrea has a high
case-fatality rate of malaria. Malaria resistance to chloroquine has been
documented in 40t of cases in certain areas, and cases of endemic malaria
have been detected in previously malaria-free areas. In '97 and '98
malaria was the main killer in adults (65%)--especially pregnant
women--and the main cause of morbidity among all ages (70W-90%). The
prevalence of malnutrition increases the overall morbidity and mortality
cases. Existing diseases, such as STDs and TB, are on the increase;
however, it is difficult to estimate the exact numbers because of the
social stigma attached to these pathologies. HIV is initiating its
spread, and there is no reason to expect that the epidemic in Eritrea
will--without significant, well planned and focused intervention--follow a
different pattern from that in neighboring countries.    In 1995, over 11
of commercial sex workers in Assab (the main harbor and a key base of
Eritrean economic activity) were HIV positive. Moreover, demobilization
and the openness of the country is changing mores and attitudes,
especially those of young people in urban areas. TB is a major public
health problem with an annual risk of infection (ARI) of about 2.3w, i.e
about 4000 people are expected to develop new smear-positive, infectious,
TB cases each year. A similar number of people will develop
non-infectious, pulmonary and extra-pulmonary, tuberculosis every year. As
a consequence of the HIV/AIDS epidemic, the incidence of TB is expected to
continue to increase. The recent massive population movements due to the
conflict with Ethiopia and the mobilization of about 20t of the population
to the front can have repercussions on the transmission patterns of
malaria, STD, HIV/AIDS and TB that are difficult to predict. Lack of
information on the epidemiological situation and effectiveness of current
interventions: Health policy is made incrementally, based on experience
rather than on data-based evidence. Data are collected but not always
shared across sectors, and analytical capacity is poor across the board.
Systematic monitoring and evaluation of interventions is virtually
non-existent across all sectors.   Because of the conflict, it has been
difficult to carry out country-wide surveys. While there are on-going
entomological studies on the malaria vector, little is known about:    a)
population practices, behaviors, incentives, and motivations for health
behavior change; b) the incidence of STD, TB and HIV/AIDS by different
age, gender, and socio-economical groups and regions;   c) insecticide and
drug resistance to malaria, TB and STD; and d) the impact of education and
communication activities on health behavior. Statistical data on TB case
notification are incomplete and unreliable. Insufficient and inefficient
use of resources: Despite Government commitment and efforts (social
sector expenditure amounts to 60t of Government's expenditure), the
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country can afford to spend only about US$5 per capita on health. As a
result, certain programs known to be cost-effective, such as social
marketing of condoms and directly observed treatment strategies (DOTS) for
TB, cannot be expanded. Expenditure patterns are inefficient with most
financial resources (70%-) concentrated largely on curative rather than
preventive measures. While there is a series of policies to deal with
different issues, including PHC, malaria, TB, and HIV/AIDS-STD control,
there is very little coordination among the different programs of the MOH.
Skilled staff are very scarce particularly in the rural areas. Capacity
building is a key element of the Government policy, but lack of a sector
strategy results in ineffective training for staff. The military conflict
has further undermined the capacity as young staff had been called to the
front. However, with the cease fire, staff are getting back to their
posts.     Poor quality of health care and blood safety:    Diagnostic
capacity is limited. In the case of TB, the distribution of diagnosed
patients indicates substantial underdiagnosis of new smear-positive and
overdiagnosis of smear-negative pulmonary and extra-pulmonary
tuberculosis. This may be due to poor quality of smear microscopy and/or
poor diagnosis of patients based on clinical findings only. Treatment
guidelines are used rarely, and inadequate treatment is common. Outreach
activities are limited and so are preventive activities. Except for a
Central Blood Bank being built in Asmara with IDA financing, there are no
blood banks in the country. Most transfusions are done on a person to
person basis without testing for HIV or other critical diseases.
Unfortunately, during the heat of the conflict there was no other way to
transfuse some of the wounded.    Commitment to multisectoral disease
control but lack of coordination across sectors: GOE has adopted a
multisectoral approach to address the challenges of HAMSET diseases, but
this approach is as yet uncoordinated across sectors. The Ministry of
Health, as the lead agency in combating the diseases, has prepared a five
year plan of action and strategies for each of them. While those
strategies are technically sound overall, they need to be adapted to local
situations. The Ministry of Education has begun a pilot program of
HIV/AIDS clubs in senior secondary schools and recognizes the importance
of malaria as a cause of absenteeism in primary schools in epidemic
regions. The MOE adult education Mass Media Unit currently reaches 75%- of
the rural population with messages addressing malaria. The Ministry of
Labor uses its labor organizations to promote health messages, as does the
Ministry of Information with its highly organized community networks. The
National Union of Eritrean Youth actively promotes HIV/AIDS awareness
among adolescents, and the army's medical service performs the same
function for conscripts. Effective coordination of these activities would
strengthen an existing infrastructure that reaches all target groups
within the population. Shortage of qualified health personnel: Training of
health professionals is done at the Institute of Health Sciences in Asmara
and at the College of Health Sciences at the University of Asmara. There
is no training of medical doctors in the country. There are only 145
physicians and 391 nurses, working mainly in the urban areas. Other health
professionals such as laboratory technicians, entomologists and health
educators, are in critical shortage. Furthermore, there are no staffing
patterns in relation to service delivery and the development of
infrastructure.Poor communications capacity and ineffectiveness of past
communication efforts: Professional communication skills and experience
beyond the field of journalism are limited within government agencies as
well as the private sector. HAMSET messages are often contradictory and
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carry the potential to either extend or create negative
socio-environmental impacts. Moreover, despite significant efforts
regarding participation, community mobilization is still mostly limited to
implementation of government programs. Participation mechanisms lack
comprehensive involvement that reflects the rich traditional and cultural
knowledge possessed by the communities. Insufficient knowledge of health
practices and use of services by the population. For the most part,
Eritreans have limited knowledge of how preventive health measures and
social practices affect health outcomes. Despite public efforts, literacy
is low in the country, particularly among women (70%). The country has a
large share of orphans and female-headed households, which typically have
a lower health status than that for the general population, and are less
likely to seek health care by themselves. Nutritional practices are poor
among adults and children who live in areas of the country with low intake
of vegetables and proteins. Low population density in most rural areas
limits access to primary health care services where health personnel
(especially skilled staff) may not speak the local language. Finally,
there is substantial stigma and societal exclusion against patients that
have TB, AIDS, and STD. All those factors severely lower the use of
preventive and basic health services. Environmental: The lack of adequate
disposal for contaminated refuse from health facilities provides a serious
source of contamination. Household tasks and social activities and
behavior promote vulnerability to malaria.    Several daily tasks and
workplace hazards increase the vulnerability to infection by HIV-AIDS.
After independence, GOE initiated major efforts to develop the country,
such as construction of dams and terraces, expansion of surface
irrigation, reforestation, and resettlement of displaced people and
returnees. All those activities contribute to increase HAMSET disease
transmissions. The epidemiological profile of malaria in Eritrea implies
that, according to WHO Guidelines for malaria control, effective control
of the disease requires the use of pesticides to reduce vector density and
for personal protection. Government StrategyThe objective of the GOE
overall Macro Policy is to eradicate poverty and to foster economic growth
through, among others, national policies on human resources development
and food security. The health policy supports this objective through
activities that aim to: (a) minimize and eventually eliminate easily
controlled diseases; and (b) enhance awareness of good health practices in
order to improve workforce productivity. The education policy seeks to
develop self-consciousness and self-motivation among the population in
order to fight poverty and disease. Current state policy acknowledges the
necessity of empowering vulnerable groups to enable them to become
productive members of society. Finally, capacity building is a key
strategy for fostering development as the GOE invests a large part of its
resources in updating staff skills and in-service training. The following
are key strategic priorities for the GOE:Development of human resources:
The work on a human resources development policy is underway. It will be
finalized during the year 2000 together with a plan for matching training
programs and staffing needs. In addition to external training, there are
efforts to improve the quality of in-country health programs. Curricula
have recently been reviewed with a focus on competencies and on horizontal
integration.Improvement in the information base for decision making: The
GOE plans to develop a social sector integrated information system to
monitor living conditions and effectiveness of interventions. The
nation-wide integrated food security system will serve as a model. As most
ministries have developed their own information systems, GOE is studying
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how to connect and integrate the different databases, and enhance the
capacity to analyze and use information at the zoba level. In the health
sector, it intends to build on the MOH management information system
(SEMISH) and develop an effective surveillance and epidemic preparedness
system.Decentralization and inter- and intra-sectoral coordination: The
decentralization law creates an environment conducive to coordination of
planning, budgeting, and implementation activities. Intersectoral
committees at national and zoba level are being re-activated. Recent
projects supported by IDA stress coordination and have a strong
multisectoral framework. For example, agricultural and fishery extension
programs will be revised to include health promotion activities. The year
2001 marks the beginning of government budgeting. The GOE intends to use
this instrument to boost coordination.Community education and
empowerment: The government has a strong adult literacy campaign to
increase awareness of specific diseases and mobilize community for vector
control. GOE is also fully supportive of the social marketing of condoms
and is studying similar strategy for insecticide treated materials (ITMs).
In its effort to empower the community, the GOE supports the efforts of
other key stakeholders such as the National Union of Eritrean Women (NUEW)
and the National Union of Eritrean Youth (NUEY) in AIDS counseling and in
providing malaria prophylaxis to students during their social service. In
their effort to minimize the stigma associated with HIV/AIDS, the MOH and
other agencies are recruiting well- respected, often war heroes to meet
with students and other vulnerable groups. Minimizing environmental
damage: The GOE recently adopted the "National Environmental Assessment
Procedures and Guidelines" to be used in all projects, regardless of the
funding source. The MOH is responsible for the related work and compliance
in the health sector. The MOH is aware of the potential negative impacts
of the current use of pesticide use for malaria control, and is committed
to address the issue by establishing: a) full control of chemical
application, including handling and disposal of leftovers, and monitoring
of both effectiveness and negative impact; and b) introducing safer
alternatives to pesticides currently used for public health purposes. At
the same time, the MOH is preparing standards for bio-hazardous waste
management for health facilities.Humanitarian crisis and reconstruction:
The GOE has promptly reacted to the May 2000 humanitarian crisis on two
fronts: (i) by providing emergency relief and assistance to the displaced
and the hosting communities; and (ii) by organizing the available human
and financial resources in order to start the process of reconstructing
and rehabilitating the areas damaged by the recent conflict. The process
of reconstruction and rehabilitation of the country will be tackled in two
phases: (i) a first set of immediate needs will be met through the
financing of the Eritrea Reconstruction Program; the activities financed
will enable the country to restart some productive activities and repair
the infrastructure necessary to allow this process; (ii) the remaining and
less urgent needs will be addressed through individual sector programs
prepared and financed in collaboration with the development community.
The HAMSET control project supports the above policies by adopting a
coordinated intra- and inter-sectoral approach to tackling the diseases
that impose a heavy disease burden on the Eritrean population, and that is
based on environmentally sound disease management. While it does not
answer directly to the humanitarian crisis, it is part of the sectoral
efforts to minimize the impact of the recent conflict. It will ensure,
among other things, that there are enough supplies to support the GOE's
malaria and TB control efforts and will provide basic drugs for the
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treatment of STDs and counseling and testing for conscripts that are
demobilized.    Social sector activities supported by financing partners
With support of the USAID-funded Environmental Health Project, studies are
being undertaken to help refine the malaria strategy, and social marketing
of condoms is being implemented in selected areas. The Italian
Cooperation, through WHO, is assisting in the design and implementation of
an integrated disease surveillance system, the development of a human
resource policy, and the control of Tuberculosis (TB). An ongoing
IDA-financed social fund is supporting the expansion of education and
health infrastructure. An IDA and NORAD-financed health project is, among
other things, constructing a Central Blood Bank and two referral hospitals
at the zoba level, equipping PHC health facilities, and supporting an
in-depth analysis of the health sector. The recently launched IECD
project focuses on nutrition, education and health issues of children
under five and pregnant mothers, as well as on orphan protection. UNICEF
is supporting community-based water and sanitation programs, school health
and AIDS clubs, and malaria control through ITMs. WHO provides technical
assistance on several technical issues including malaria and TB, and
finances a pilot community-based program for the integration of
individuals with disabilities in the community. Apart from that, an
emergency program is being prepared to cope with the impact of the
conflict and to reconstruct the country. Several donors (including EU and
Italian cooperation) have pledged assistance. During appraisal, the
Government has reiterated its interest in developing a comprehensive
health sector strategy and a health investment program in collaboration
with all the partners. The consultative process on the first phase, i.e.
the sector review, has been initiated.
2. Objectives
To reduce the mortality and morbidity of the Eritrean population due to
HIV/AIDS, malaria, sexual transmitted diseases and tuberculosis (HAMSET)
through an increase in utilization of quality, effective and efficient
health services for HAMSET prevention, diagnosis and treatment, supported
by health practices.
3. Rationale for Bank's Involvement
The comparative advantage of IDA is the involvement and ability to work
across sectors, which will facilitate the proposed multi-sectoral
approach. Furthermore, there are clear links with other IDA-funded
projects, such as the Community Development Project, the Early Childhood
Development project, the Human Resource Development Project, and the
proposed Nutrition Project. IDA involvement will help: (i) ensure
coordination, (ii) prevent duplication of efforts, and (iii) exploit the
complementary aspects of the different projects. As the Bank is a key
partner in the global Roll Back Malaria partnership, STOP TB Initiative
and UNAIDS, the ability to play a facilitating role in identifying
expertise and possible partners is also an asset. Lastly, the Government
of Eritrea has explicitly and urgently requested the Bank to support and
extend the ongoing efforts to control malaria and HIV/AIDS. Multi-Country
HIV/AIDS Program (MAP)Management has recommended that HAMSET be included
as part of the Multi-Country HIV/AIDS Program (MAP) for Africa. The MAP,
approved by the Board in September 2000, is a "horizontal" adaptable
program lending (APL) instrument developed to strengthen the Regional
response to HIV/AIDS. The MAP will support efforts to expand national
prevention, care, support, and treatment programs, and to prepare
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countries to cope with the unprecedented burdens they will face as the
millions living with HIV today develop AIDS over the next decade. The
first phase of the MAP will consist of individual lending operations up to
an aggregate amount of US$500 million. Provided they meet specific
eligibility criteria, including eligibility for IDA credits, the MAP will
enable countries to more rapidly access resources needed for the expansion
of national HIV/AIDS programs. It is proposed that HAMSET be included
under Phase lb of the MAP (Phase la was constituted by the first two
countries approved for MAP funding). As detailed below, HAMSET meets the
MAP eligibility criteria: Satisfactory evidence of a strategic approach
to HIV/AIDS, developed in a participatory way: The GOE 's comprehensive
five-year plan for HIV/AIDS is multisectoral and has been developed using
a participatory approach. Establishment of a high-level HIV/AIDS
coordinating body, with broad representation of key stakeholders from all
sectors, including people living with HIV/AIDS: A National HAMSET
Steering Committee will provide overall strategic and policy guidance to
the implementation of the program. This Committee includes
representation from the Ministries of Health, Local Government, Labor and
Social Welfare, Education, in addition to all six Zoba Governors and
representatives of people living with HIV/AIDS. Government commitment to
quick implementation arrangements, including channeling grant funds for
HIV/AIDS activities directly to communities, civil society, and the
private sector: The GOE is committed to the rapid implementation of
HAMSET, and has emphasized the need for mechanisms to strengthen
community-based responses. Agreement by the government to use multiple
implementation agencies, especially community-based and non-governmental
organizations: HAMSET will be implemented through a partnership of
several Ministries, the National Union of Eritrean Women, the National
Union of Eritrean Youth, among others. The inclusion of malaria within
the HAMSET MAP is highly unusual and is not intended to set a precedent
for future MAP country projects. In brief, the integration of HIV/AIDS
and malaria in this project was considered necessary for two major
reasons: (i) as a means of achieving economies of scale, and (ii)
disease-specific programs face a higher risk of failure when implemented
in parallel.   This rationale is further detailed in Annex 4 ("Adequacy of
the Sector Policy Framework") of the PAD. It should also be noted that
the malaria specific component of HAMSET constitutes only 7 percent of the
credit.
4. Description
The majority (47.2%) of Bank financing is for component C, which supports
the major health sector interventions: diagnosis, care and counseling for
HAMSET diseases. These activities are strengthened by smaller components
which help to target care, control transmission in the community and
promote community-managed responses to HAMSET diseases. A. Collect and
Analyze Information on HAMSET to Facilitate Evidence-Based Decision Making
and Rapid Response This component will strengthen the GOE's capacity to
collect comprehensive information on HAMSET diseases in a timely and
efficient manner, to analyze it and to use the information for planning
and to responding appropriately to changes in disease trends. That
capacity would exist at the central, zoba, and sub-zoba levels and would
allow a quick response to epidemics. Activities supported by the credit
would contribute to: (i) improve HAMSET surveillance techniques; (ii)
establish an epidemic forecasting and preparedness system; (iii) improve
country's capacity to carry-out operational research for identifying
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changes in HAMSET; (iv) introduce methods to link the results of research
and M&E to policy formulation, annual planning and budgeting; and (v)
strengthen management of communicable diseases at the MOH.B.
Multi-Sectoral Control of HAMSET TransmissionB.1. Promote healthy
behaviors through multi-level communication. The project will enable the
MOH /IEC unit to coordinate the communication activities of all
implementing partners and build capacity at zoba and sub-zoba levels. It
will enable zoba level IEC staff to: (i) conduct formative research to
gain a better understanding of target audience attitudes and beliefs about
benefits and barriers to adoption of desirable behaviors; (ii) develop a
communication strategy and conduct communication activities to support
project objectives and promote healthy behavior among target populations;
(iii) coordinate and supervise the work of partner agencies at the zoba
and sub-zoba level; and (iv) develop a system to track changes in
knowledge, attitudes, beliefs, and behavior among target audiences reached
by communication campaigns. The project will also support orientation of
leaders of NGOs, and senior officials of other line ministries as well as
national advocacy efforts.B.2 Promote healthy lifestyle through the
education system. . The framework of the FRESH partnership (Focusing
Resources on Effective School Health - WHO, UNESCO, UNICEF & IDA) has been
used to prioritize the most cost-effective actions, particularly for the
poor and disadvantaged. The approach will be implemented through the
Ministry of Education (MOE) school health program in both the formal and
non-formal systems. The project will finance activities that aim to: (i)
strengthen central and regional skills in school health programming; (ii)
promote in students and teachers healthy practices and behavior change;
(iii) establish school based support and health services; and (iv) promote
healthy practices and behavior change in adults.B.3 Enhance access to
preventive, diagnostic and treatment services for conscripts. The project
will: (i) promote healthy behaviors through multiple channels of
communication, (ii) strengthen health care services available to
conscripts (including the availability of voluntary counseling and
testing), (iii) promote the increased use of condoms and insecticide
treated materials (ITMs), and (iv) establish a program to address HAMSET
concerns in the context of demobilization. B.4 Promote environmentally
sound and cost-effective techniques for Malaria vector control by
implementing a pesticide management plan (PMP) that will: (i) identify,
test, validate and introduce safe, cost-effective chemicals to replace
DDT; (ii) test and validate malaria biological vector control; (iii)
develop a strategy for pesticide use and control; (iv) test community
acceptance of validated methods and techniques; and (v) replicate
socio-environmentally validated malaria vector control methods. The
testing of the alternative chemicals will provide a reliable method to
replace the current residual DDT house-spraying by chemicals and methods
safer to the environment and to human health.C. Strengthen HAMSET
Diagnostic, Health Care and Counseling Services.C.1 Establish safe blood
banks in zoba hospitals. The project will support the establishment of
four blood banks for zoba hospitals. This will complement the current
health project which is establishing two blood banks in the remaining
zobas as well as a national blood bank in Asmara.C.2 Improve diagnostic,
treatment and counseling of HAMSET diseases through integrated in-service
and on the job-training on HAMSET prevention and detection, case
management, syndromic and laboratory diagnosis of HAMSET disease, as well
as pre- and post-HIV-voluntary counseling and testing (VCT). The primary
strategies for HAMSET disease management include: directly observed
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therapy, short-course (DOTS) for TB; rapid detection and treatment of
malaria in health facilities and in the community, including IMCI for
children < 5 years of age, with laboratory confirmation when available;
management of severe malaria at referral facilities; voluntary counseling
and testing for HIV; management of opportunistic infections in
HIV-infected persons; syndromic management of STDs, with laboratory
confirmation when available.C.3 Improve availability of basic medical
materials and drugs required to diagnose and treat HAMSET diseases in
health facilities. The project will support procurement and distribution
of basic essential drugs and diagnostic materials to treat HAMSET diseases
(only opportunistic infections in the case of HIV/AIDS), surveys to
assess the availability of drugs and medical materials, in-service and
on-the job resource management training for MOH staff specially at
facility level, and transport for drugs, medical materials and to provide
supervision. D. Community-Managed Response Program.The project will
identify community-based affordable, effective mechanisms for minimizing
the transmission and impact of HAMSET diseases and have them ready for
replication nationwide. The component consist of two sub-components: (A)
Community Counseling and Support Groups; (B) Community-Managed Response.
Sub-component A will strengthen community support services provided by the
MOLHW to provide counseling and establish support groups for AIDS
patients. Sub-component B will test the capacity of the communities
--under their own community structure and socio-cultural fabric to: (i)
respond to technical information about the HAMSET diseases for their
prevention, care and cure; (ii) organize their internal mobilization,
discussion and decision mechanisms on the support they deem necessary to
assess and otherwise manage the diseases; (iii) identify and input their
grassroots and socio-cultural contribution to HAMSET messages, prevention,
care and cure methods, and available support services; and (iv) identify,
decide on and implement available methods to prevent or mitigate the
diseases and related impacts in the community. Lessons learned during the
initial phases will be incorporated into the plans for subsequent phases.
The component will link with the IDA-financed Eritrean Integrated Early
Childhood Development IECD as adequate. The component will cover all Zobas
and sub-zobas two in each cultural area, including semi-nomads but one
Kababi each in Year 1 and 2 and expand to other Kababis in Year 3 and 4.
This phasing will allow for internalizing of community based processes
among field staff and community based workers and the testing of a number
of assumptions in the initial phases.E. Project Management and
Evaluation. The project will strengthen the current PMU (located in the
MOH) that is managing the Health Project, with an emphasis on evaluation
and monitoring of activities.
A. Collect and analyze information on HAMSET to facilitate evidence-based
decision making and rapid response.
B. Multi-sectoral control of HAMSET transmission.
C. Strengthen HAMSET diagnostic, health care and counseling services.
D. Community-managed response program.
E. Project Management and Evaluation.
F. PPF Refinancing
5. Financing
Total ( US$m)
GOVERNMENT               8.45
IBRD
IDA                      40
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LOCAL COMMUNITIES        1.55
Total Project Cost       50
6. Implementation
Implementation Period:    5 yearsDetailed implementation arrangements are
part of the PIP (project implementation plan). The Bank has received the
revised draft of the PIP which will be discussed further during
negotiations. The following are initial details for project
arrangements.Executing Agencies. The Ministry of Health will serve as the
overall coordinating agency, in addition to its existing responsibility as
the lead executing agency. In addition, the following agencies will
implement relevant aspects of the project in accordance with their
existing sectoral aims and mission: the Ministries of Education, Local
Government, Labor & Human Welfare, Agriculture, Information, and Defense
Medical Services as well as the National Unions of Eritrean Women and
Youth. Project Oversight and Policy Guidance. A National HAMSET Steering
Committee will provide strategic directions and policy guidelines. It will
be chaired by the Minister of Health and will include Ministers of Local
Government, Labor and Social Welfare, and Education as well as the six
Zoba Governors. The Director General of Health Services (DG HS) will be
the Secretary. This Committee will meet at least quarterly.Management of
Project Activities. Figure 1 illustrates the management structure of the
project. It adopts the existing organizational structure of the MOLG, thus
promoting coordination and cooperation at all administrative levels, in
line with the Government decentralization policy. This is achieved through
the following arrangements: At the central level, there will be a National
HAMSET Technical Committee chaired by the DG HS. The Director,
Communicable Diseases Control Division (CDC) will be the secretary. This
committee will provide the technical guidance for all project activities.
Technical experts designated by the Ministries of Health, Education, Labor
and Human Welfare, Local Government, Tourism, Agriculture and the Medical
Services of the Ministry of Defense as well as the associations of Women
and Youth and the Confederation of Eritrean workers, will be members of
this committee and will meet once a month or more often if necessary to
review all technical aspects and progress of the project. The Technical
Committee will report to the Steering Committee through the DG HS.      The
Coordination, planning, financial management, and procurement at National
Level will be the responsibility of the Project Management Unit (PMU) set
up for the present health sector project (credit 3023). The PMU will be
strengthened with the addition of one Operations Manager exclusively for
HAMSET, three Program Officers to coordinate different project components,
finance/accounts and procurement personnel and minimum support staff. Its
manager reports directly to the Minister of Health. Both the procurement
and financial management capacity of the Unit have been evaluated and
found satisfactory. The project will add a sub-unit to the PMU, staffed
with a deputy-project manager, financial management officer, procurement
specialist, and appropriate support staff and equipment. Special training
in project management will be provided for the new staff with special
emphasis on monitoring and evaluation of activities. The expanded PMU will
be responsible for compiling and preparing budget and plans, disbursing
funds to participating Ministries and agencies, and managing the special
account, financial management and accounting, bulk procurement of goods
and services, and management of the Credit. The PMU will also be
responsible for ensuring compliance with the Development Credit Agreement
(DCA) and project coordination across ministries and the regional
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administration and agencies. At the Zoba level, the overall coordination
will rest with the Zoba HAMSET Coordination Committee to be formed with
the Zoba Governor as the Chairperson. The members will include all
multi-sectoral implementing ministries and agencies at the Zoba. The
Executive Director of Zoba Administration will be the Co-chairperson, the
Director of Social Services the vice-chairperson, and the Zoba Medical
Director the Secretary of this committee. The committee will meet every
month. There will also be a Zoba HAMSET Technical Committee with the
technical experts from the line departments and agencies as members. The
technical committee will meet every two weeks to review all technical and
implementation aspects. The Zoba Medical Director will chair the technical
committee and the HAMSET program officer will be the Secretary. 39. The
day-to-day management and coordination of the project at the zoba level
will be handled by a small project Management Unit under the Zoba Medical
Director. The Executive Director of Zoba Administration and the Zoba
Medical Director will be co-signatories to the Project Account in the
Zoba. One Project Officer and one Project Accountant will be full time
project staff at the PMU. The workload in the initial two years may
require an assistant project officer to support the Project Officer. The
specific job responsibilities will be included in the Project
Implementation Manual. Planning, accounting, financial, reporting, and
auditing arrangements. The development of the financial management system
will have two phases: interim and final. The interim phase will involve
expanding and/or adapting the existing financial management and accounting
structure, and will be in place when the project becomes effective. The
final phase will involve piloting and ensuring that the existing system is
ready to adopt PMR-based disbursements. During appraisal, the capacity of
the implementing agencies and Zoba level structures were reviewed. Due to
the limitations regarding accounting and finance management at
decentralized levels, a number of steps have been agreed with the
Government, as follows.As part of the PIP, a Financial Management Manual
to document the operation of the project's financial management system
will be finalized by credit effectiveness. The manual will inter alia
contain a description of financial policies and procedures applicable to
the project, channels and arrangements regarding the flow of funds, the
Financial Management System and sub-systems (budgeting, accounting, and
reporting), and internal controls. During negotiations, IDA will obtain
confirmation of the recruitment of an additional financial officer, and
reviewed and updated action plan for the upgrading and implementation of
the financial management system. Effective implementation and
operationality of those systems will be part of the conditions for credit
effectiveness.An independent and qualified audit firm with staff
experienced in similar audits will carry out an annual audit of the
project accounts. During negotiations, a short list of firms acceptable to
IDA will be agreed upon. A one-year contract, renewable year by year,
subject to annual performance satisfactory to the Government and IDA, will
be signed between the Borrower and the selected firm. Terms of reference
for the annual audits will be agreed upon at negotiations, and will cover
all requirements for audit of the project accounts and review of internal
controls. Audit reports (consisting of the auditors opinion and a
management letter) will be submitted within six months following the end
of each fiscal year. The cost of such audits is incremental and is
therefore included in the project cost.Monitoring, evaluation, and
reporting arrangements. A detailed monitoring and evaluation system will
be developed and included in the Project Implementation Manual. The
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monitoring and evaluation of the project will be based on the indicators
outlined in Annex I and the Development Credit Agreement. Studies carried
out during the first year and a half of the project will establish base
line data and subsequent studies, and results from the surveillance and
effectiveness monitoring systems will support evaluation of project
progress. Representation of the government agencies at the sub-regional
and village (community) levels makes it possible to supervise the details
of program implementation, follow up activities, and cross-sectoral
coordination at all administrative levels.    Project M & E will be
undertaken through: (1) IDA supervision missions and annual progress
reviews, (2) regular quarterly meetings of the Project Central Steering
Committee, (3) semi-annual progress reports based on implementation
targets defined in the Annual Work Plan and Budget, (4) mid-term review of
the project no later than 30 months after effectiveness to identify
project successes and issues to be addressed, and (5) baseline and
follow-up surveys of beneficiaries. A project Implementation Completion
Report will be prepared within six months of the project closing date.
7. Sustainability
Prevention of a full-blown HIV/AIDS epidemic will impact sustainability of
all development efforts in Eritrea. The social and economic impact of a
rapidly spreading epidemic is hard to quantify, but it is clear that the
costs across all sectors would be very high. It is of no use to train,
educate, or cure people if they will, subsequently, die of AIDS.
Mitigating the epidemic will therefore reduce costs of treatment,
mortality, and morbidity in the future.The project will increase the
health sector's institutional capacity to develop policies, implement
programs, collect and analyze data as well as monitor and evaluate
effectiveness of interventions. HAMSET diseases require a long-term
effort to be effectively controlled and contained. Therefore, this
increased capacity will enhance sector sustainability by enabling a
long-term, well-targeted, and multi-sectoral response as adequate.
Inclusion of cost-recovery mechanisms in this project would hamper the
immediate response necessary to strengthen the sector, and unacceptably
delay project implementation. The potential cost-recovery mechanisms will
be analyzed during the sector review. The analysis will provide a basis to
ensure future sustainability in the sector.The project constructs minimal
infrastructure. Instead it rehabilitates existing structures to make them
more effective. Prior to consider construction of new social centers the
local government will carry out an inventory survey of existing facilities
at village and sub-zoba level to identify existing structures that could
be used for social purposes and propose how to maximize their use. In war
affected areas, there may be a need to replace destroyed infrastructure.
This will be done through the emergency recovery project now under
preparation. It is, therefore, expected that the incremental recurrent
costs will be negligible. The cost tables of the project identify
incremental recurrent costs. GOE , and specifically the Ministry of
Finance, has indicated that it is ready to increase per capita allocation
for activities related to HAMSET control. At negotiations, the GOE and IDA
will agree on a plan indicating how incremental recurrent costs will be
covered after project implementation.Drugs, condoms and laboratory
reagents: Despite the fact that these can easily be considered recurrent
costs, they have been considered investments costs in this project. The
key reason is the very low GDP of Eritrea, and the limited possibility to
increase health budget in the coming five years. During the project the
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Government will carry out studies that will allow it to propose a plan for
transferring the financing of those items progressively to the Government
budget. However, it is reasonable to expect that no substantial
contribution can be made from GOE funds and that external financing might
have to be relied upon in the short to medium term. Strategies to ensure
HAMSET program sustainability in the medium to long-term will be one of
the important areas to focus on in the preparation of the health sector
review.
8. Lessons learned from past operations in the country/sector
The proposed project would be the second IDA-financed health operation in
Eritrea. Several relevant lessons learned from the first health project
and IDA health projects in other countries include: (i) the need for
flexibility to adapt approaches to better respond to local needs; (ii)
government commitment and institutional capacity are needed to ensure
efficient implementation of program activities and achievement of
development objectives; (iii) overly centralized management structure of
many health ministries have impeded the efficiency and effectiveness with
which project activities are implemented; it also deters
stakeholder/beneficiaries from participating in project implementation,
leading to little project ownership and, in many instances, low
sustainability of operations in the future; and (iv) adequate provision
for recurrent costs is critical to ensure quality of services and to
sustain operations, especially where hospital capacity is under
expansion.Lessons learned from previous projects in Eritrea: The Eritrea
Community Development Fund experience--rated as Highly Satisfactory--has
shown that both a decentralized system and an emphasis on strengthening
institutional capacity were important contributors to project success.
Sector effectiveness was particularly high in health and education, and
community satisfaction and participation high in both sectors. Two
constraints on community participation were (1) lack of consultation and
underutilization of local knowledge, and (2) cultural factors limiting
access of women and girls to some benefits in some regions. The present
project is based upon an implementing structure decentralized to the zoba
level--with a specific component of institutional strengthening--and with
a strong emphasis on strengthening the infrastructure of health and
education in the communities. A strong communications component supports
the enhanced transparency of governance, and there is a specific role of
the community in monitoring inputs and outcomes.Lessond learned from
HIV/AIDS program development /implementation in other countries show that
despite the lack of a cure or a vaccine, preventive measures such as
awareness programs to bring about behavior change, social marketing of
condoms, treatment of sexually transmitted infections and opportunistic
infections such as tuberculosis, voluntary counseling and testing, a safe
blood supply, and preventing mother-to-child transmission have all proven
highly effective in reducing HIV transmission. Community-based programs
have been especially effective in enhancing prevention, care, support, and
treatment for those infected and affected by HIV/AIDS. Lessons learned
during the implementation of effective HIV/AIDS programs in various
countries have been integrated into the project as appropriate. Lessons
learned from previous cross-sectoral and sector-wide projects: In January
1999 the HNP Quality Group reviewed 21 PADs, including 5 SIPs. This review
was used by the HAMSET project team to direct project preparation overall,
but specifically with regard to 5 key questions of particular relevance to
cross-cutting projects:Is there indication of support from key
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politicians? This project has the support of the President's office, which
indicates the importance of the adopted structure in which the MOH takes a
lead coordinating role, and also has the support of the Minister or
Secretary of each of the nine participating agencies.Is there a detailed,
phased and flexible implementation schedule? The project is based around a
process approach that is described and planned in detail for the first
year, is phased thereafter, and is deliberately designed to allow rapid
roll out with maximum subsequent flexibility.Has the project conditioned
disbursement against prior adoption of agreed institutional reform?
Appraisal was dependent upon the adoption of agreed coordination and
collaboration mechanisms, and effectiveness upon their formal
implementation.Are the agencies involved kept to a minimum? There are nine
agencies which were each able to demonstrate clear, synergistic and
non-duplicatory roles in implementing the project. These agencies cover:
health, education, information, youth, women, demobilized conscripts, and
the agricultural, industrial and construction work forces. Given the
epidemiology of HIV/AIDS/STD, all of these activities and populations were
considered priorities.Is implementation progress subject to an annual
review plan? The project establishes two technical committees--one at the
central and one at the zoba levels which meet regularly and monitor
progress and direction. The approach to institutional coordination is also
based around experience other than that in HNP. The new Guinea Quality
Education for All Project builds on this approach to include the Ministry
of Women and Social Affairs, and is the model for the institutional
management of the Senegal Quality Education for All Project. In Nutrition
the original Madagascar Food Security and Nutrition Project led to the
1998 Community Nutrition Project that links nutrition and health with the
education sector. Lessons learned during the implementation of effective
HIV/AIDS programs in various countries have also been integrated into
HAMSET, as appropriate. Despite the lack of a cure or a vaccine,
preventive measures such as awareness programs to bring about behavior
change, social marketing of condoms, treatment of sexually transmitted
infections and opportunistic infections such as tuberculosis, voluntary
counseling and testing, a safe blood supply, and preventing
mother-to-child transmission have all proven highly effective in reducing
HIV transmission. Community-based programs have been especially effective
in enhancing prevention, care, support, and treatment for those infected
and affected by HIV/AIDS.
9. Program of Targeted Intervention (PTI)     Y
10. Environment Aspects (including any public consultation)
Issues     :  An Environmental Analysis (EA) was undertaken to
review the elements of the National Malaria Control Program that may lead
to negative environmental impacts unless properly planned and managed,
namely the use of chemicals. The EA reflects and responds to both the
GOE's "National Environmental Assessment Procedures and Guidelines" for
project preparation, and the IDA's requirement regarding OP4.09
(Operational Procedures 4.09-Pesticide Management). The EA was cleared by
the Eritrean Department of Environment (DOE) on June 20, 2000. The EA has
been made available to stakeholders, including the civil society, through
distribution to the 6 zobas, national and bi- and multilateral agencies,
NGOs and several civil society groups (see consultation in 5.4 below). The
EA concluded that the main concern of the Malaria Control Program (MCP) is
the use of DDT for residual house-spraying. The EA however concluded that:
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a) only 16t of the houses at risk of malaria are sprayed with DDT; and b)
as currently used, and as proposed in the HAMSET project, this use is
consistent with WHO guidelines (WHOPES) and the POPS exemption (which
determines "specific use in health when effective, and in high risk areas
to prevent epidemic conditions"). The EA recommends improving
surveillance and monitoring of malaria trends to improve efficacy of both
vector control, and prevention of epidemics, as well as replacing DDT by
safer chemicals. A Pesticide Management Plan (PMP) was prepared following
the EA conclusions and recommendations. Accordingly, pesticide selection,
distribution and use will follow the EA recommendations and will be done
by fully trained health personnel. During negotiations, the Government
will give assurances that : (i) the PMP will be implemented in a manner
satisfactory to IDA.; (ii) procurement of chemicals for control of
malaria epidemic, will fully abide by IDA standards which follow WHO
guidelines. Procurement documents will clearly state that all chemicals to
be procured will be manufactured, packaged, labeled, handled, stored,
disposed of, and applied according to standards acceptable to the IDA; and
( iii) MOH will present by the end of the second year, a program and
schedule for substituting DDT residual house-spraying by chemicals or
techniques that are safer to the environment and human health, as
satisfactory to IDA.
11. Contact Point:
Task Manager
Eva Jarawan
The World Bank
1818 H Street, NW
Washington D.C. 20433
12. For information on other project related documents contact:
The InfoShop
The World Bank
1818 H Street, NW
Washington, D.C. 20433
Telephone: (202) 458-5454
Fax:        (202) 522-1500
Web: http:// www.worldbank.org/infoshop
Note: This is information on an evolving project. Certain components may
not be necessarily included in the final project.
This PID processed by the InfoShop during the week ending November 10, 2000.
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