Document of The World Bank Report No. 21420 CM PROJECT APPRAISAL DOCUMENT ONA PROPOSED CREDIT IN THE AMOUNT OF US$50 MILLION (SDR 39.2 MILLION) TO THE REPUBLIC CAMEROON FORA MULTI-SECTORAL HIV/AIDS PROJECT December 18, 2000 Rural Development 2 Country Department 7 Africa Regional Office URRENCY EQUIVALENTS (Exchange Rate Effective November 2000) Currency Unit = CFA Franc I CFA Franc = US$0.00 129 US$1 = CAF Franc 777.25 FISCAL YEAR July I June 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Antiretroviral (Drugs) AZT Zydovudine (Anti mother-to-child HIV transmission) CAA Caisse Autonome d'Amortissement CAPP Provincial Drug Procurement Agency CAS Country Assistance Strategy CBOs Community Based Organizations CC Correspondant Communal CENAME Central Drug Procurement Agency CHAC Communal HIV/AIDS Committee CLLS Local HIV/AIDS Committee CNLS National WHV/AIDS Committee CPAR Country Procurement Assessment Review CQ Selection Based on Consultants' Qualifications DFID Department for International Development DOTS Directly Observed Treatment Strategy EA Environmental Assessment EMP Environmental Management Plan EOI Expressions of Interest FAO Food and Agriculture Organization FP Sector Specific Focal Points GDP Gross Domestic Product GOC Government of Cameroon GPN General Procurement Notice GTC Groupe Technique Central GTP Groupe Technique Provincial Vice President: Callisto E. Madavo Country Director: Robert Calderisi Sector Manager: Joseph Baah-Dwomoh Task Team Leader: Jan Weetjens GTZ Gesellschaftffur Technische Zusammenarbeit HIPC Heavily Indebted Poor Countries HIV Human Immunodeficiency Virus IAPSO The Inter-Agency Procurement Services Office IBRD International Bank for Reconstruction and Development ICB International Competitive Bidding IDA International Development Association IEC Information, Communication, and Education IPIP Interim Program Implementation Procedures LC Letters of Credit LCS Least Cost Selection LHAC Local HIV/AIDS Committee M&E Monitoring and Evaluation MAP Multi-Country HIV/AIDS Program MINEFI Ministry of Finance MINSANTE Ministry of Public Health MTCT Mother-to-Child Transmission NAERP National Agricultural Extension and Research Program NBF Not Bank-financed NCB National Competitive Bidding NGOs Non-Governmental Organizations NHAC National HIV/AIDS Committee PHAC Provincial HIV/AIDS Committee PIM Program Implementation Manual PLWHA People Living with HIV/AIDS PMR Project Management Report POs Private Organizations PRSP Poverty Reduction Strategy Paper PSR Project Status Report QBS Quality Based Selection QCBS Quality and Cost Based Selection RFP Request for Proposal SFB Selection under a Fixed Budget SOEs Statement of Expenditures SPN Specific Procurement Notices STDs Sexually Transmitted Diseases SSS Single Source Selection STI Sexually Transmitted Infection SYNAME National System for Procurement of Drugs TANESA Tanzania-Netherlands HIV/AIDS NGO TOR Terms of Reference UNAIDS Joint United Nations Programme on HIV/AIDS UNDB United Nations Development Business UNDP United Nations Development Program UNICEF United Nations Children's Fund VCT Voluntary Counseling and Testing WFP World Food Programme WHO World Health Organization CAMEROON MiULTI-SECTORAL HIV/AIDS PROJECT CONTENTS A. Project Development Objective Page 1. Project development objective 2 2. Key performance indicators 2 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 3 2. Main sector issues and Government strategy 4 3. Sector issues to be addressed by the project and strategic choices 8 C. Project Description Summary 1. Project components 9 2. Key policy and institutional reforms supported by the project I1 3. Benefits and target population 12 4. Institutional and implementation arrangements 13 D. Project Rationale 1. Project alternatives considered and reasons for rejection 17 2. Major related projects financed by the Bank and other development agencies 17 3. Lessons learned and reflected in proposed project design 19 4. Indications of borrower commitment and ownership 20 5. Value added of Bank support in this project 21 E. Summary Project Analysis 1. Economic 22 2. Financial 22 3. Technical 22 4. Institutional 22 5. Environmental 23 6. Social 24 7. Safeguard Policies 26 F. Sustainability and Risks 1. Sustainability 26 2. Critical risks 27 3. Possible controversial aspects 29 G. Main Credit Conditions 1. Effectiveness Condition 29 2. Other 29 H. Readiness for Implementation 30 I. Compliance with Bank Policies 30 Annexes Annex 1: Project Design Summary 31 Annex 2: Detailed Project Description 43 Annex 3: Estimated Project Costs 60 Annex 4: Benefit Analysis Summary 61 Annex 5: Financial Summary 62 Annex 6: Procurement and Disbursement Arrangements 63 Annex 7: Project Processing Schedule 76 Annex 8: Documents in the Project File 77 Annex 9: Statement of Loans and Credits 78 Annex 10: Country at a Glance 80 Annex 11: Monitoring and Evaluation 82 Annex 12: Organizational Charts 87 MAP(S) Map of Cameroon CAMEROON Multi-sectoral HIV/AIDS Project Project Appraisal Document Africa Regional Office AFTR2 Date: December 18, 2000 Team Leader: Jan Aime E. Weetjens Country Director: Robert Calderisi Sector Manager: Joseph Baah-Dwomoh Project ID: P073065 Sector(s): HA - HIV/AIDS Lending Instrument: Specific Investment Loan (SIL) Theme(s): Rural Development; HealthlNutritionlPopulation; Social Protection; Gender And Development; Urban Poverty Targeted Intervention: N Project Financing Data [ ] Loan [X] Credit [ ] Grant [ Guarantee [ Other: For Loans/CreditslOthers: Amount (US$m): 50.00 Proposed Terms: Standard Credit Grace period (years): 10 Years to maturity: 30 Commitment fee: Service charge: 0.75% Financing Plan: Source Local Foreign Total BORROWER 7.50 0.00 7.50 IDA 40.00 10.00 50.00 LOCAL COMMUNITIES 2.50 0.00 2.50 Total: 50.00 10.00 60.00 Borrower: REPUBLIC OF CAMEROON Responsible agency: MINISTRY OF PUBLIC HEALTH - NATIONAL HIV/AIDS COMMITTEE Address: Comite National de Lutte contre le SIDA (CNLS) c/o Ministere de la Sante Publique Yaounde Cameroun Contact Person: Prof. Koulla Shiro Tel: 237 22 01 72 Fax: 237 22 02 33 Email: CNLS_GTC@hotmail.com Estimated disbursements ( Bank FYIUS$M): fY A 2001 2002 2003 2004 2005 Annual 7.50 10.00 12.50 13.00 7.00 Cumulative 7.50 17.50 30.00 43.00 50.00 Project implementation period: 4 years Expected effectiveness date: 06/30/2001 Expected closing date: 12/31/2005 OCS PAD F- R.v M~AD, 2 A. Project Development Objective 1. Project development objective: (see Annex 1) To curb the spread of the HIV/AIDS epidemic in Cameroon and to mitigate its impact for all those who are infected or affected by HIV/AIDS through the strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implementation of sector specific HIV/AIDS strategies. 2. Key performance indicators: (see Annex 1) The following constitute the summary impact, output and process indicators of the project. Given the nature of the epidemic and the experience in other countries, it would be difficult to achieve measurable impact in terms of reduction of HIV/AIDS prevalence in the overall adult population, or increase in life expectancy within the project period. However, measurable impact can be expected among certain target groups as mentioned in the impact indicators. A more extensive list of indicators appears in the logical framework (Annex 1). A. Impact Indicators % decrease of HIV/AIDS prevalence among pregnant women age 15 to 19 % decrease of HIV/AIDS prevalence among the military age 18 to 24 % decrease of HIV/AIDS prevalence among commercial sex workers age 15 to 24 60% of tuberculosis patients having completed Directly Observed Treatment Strategy (DOTS) B. Output Indicators 5,000 communities will have established HIV/AIDS committees by the end of year 4 of the project 300 communes will have established HIV/AIDS committees by the end of year 4 of the project All 10 provinces will have established HIV/AIDS committees by the end of year I of the project Staff in 50 implementing agencies will have been trained to support community based participatory development of HIV/AIDS action plans Basic services, medication and equipment for care of AIDS patients will be available in 60% of front line health posts Sector Focal Points will have been identified and will have established work plans to design and implement sector specific strategies 50 Voluntary Testing and Counceling centers will have been established GTC and GTP in place and fully operational at national and provincial level - 2 - C. Process Indicators Number of Community HIV/AIDS Committees receiving support to implement their action plans Number of implementing agencies to facilitate the organization of local responses at the community level Number of sector agencies (private and public) that have prepared HIV/AIDS strategies Number of testing centers, and distribution points for drugs Flow of funds to communities, various implementing agencies, and HIV/AIDS committees at various levels Regularity of supervision and support missions by staff of coordinating units to implementing agencies and communities Regularity of ex-post controls of use of financial resources B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1) Document number: 15275-CM Date of latest CAS discussion: June 15, 2000 The CAS Update of June 2000 outlined the Bank's strategy for the following 18 months before a full CAS is prepared. The objective of this strategy is to address poverty reduction issues more rapidly and effectively, with particular emphasis on governance, corruption, HIV/AIDS and the social sectors. The strategy links the Bank's work directly to Cameroon' s participation in the enhanced HIPC initiative. In the context of the HIPC, the Government is preparing a full poverty reduction strategy paper (PRSP) which should be completed by early 2002. The full CAS will be prepared in parallel with the PRSP. Using a variety of analytical and advisory activities, the Bank will support the Government to prepare the PRSP which will address the challenges of how to better integrate growth, poverty reduction, and governance objectives in the country's development. In particular, the PRSP will focus, inter alia, on reform and rehabilitation of the education and health sectors. In these sectors, the Government has already carried out important up-front actions for initiating reforms and has prepared satisfactory strategies. This work will be deepened and enhanced with further reforms to be carried out and with the implementation of the sector strategies. Furthermore, expenditure frameworks for the health and education sectors will also be developed. Gender issues and the HIV/AIDS threat are key aspects of the PRSP and are being given particular focus in the design of the spending plans for HIPC resources. Finally, the participatory consultations and public dialogue over the PRSP should provide the Government with an opportunity to mobilize broader support for these issues. The Government's strategy is to center HIPC debt savings on seven priority sectors; education, health, HIV/AIDS, social affairs, rural development, basic infrastructure and governance. The Bank is working closely with the Government to finalize spending programs and projects in these sectors which are specifically targeted to reducing poverty and reaching vulnerable groups. - 3 - 2. Main sector issues and Government strategy: Epidemiological Situation of HIV/AIDS Cameroon's first AIDS case was reported in 1986. By 1998, an estimated 550,000 people were infected with the HIV virus. The latest HIV/AIDS surveillance results (September 2000) indicate an HtIV prevalence rate of 1 1% amo-ng the sexually active population, representing an estimated 937,000 infected people. Today, an estimated 650 people are newly infected with the HIV virus in Cameroon every day. By December 1994, the total number of full-blown AIDS cases registered was 5,375 and, in 1998, the cumulative AIDS cases had reached 20,419. By the year 2005, the Government estimates 10,000-14,000 new AIDS cases. Subtype 0, a rare variant of HIV, has been detected in Cameroon. Approximately 90% of HIV transmission is by heterosexual contact, resulting in a roughly equal number of men and women being infected. However, among youth, the number of infected young women is twice as high as young men due to behavioral (age difference with sexual partner) and biological reasons (greater physiological vulnerability). The vast majority of reported cases - 75% - are found between 20-39 years of age. Cam er oon H IV /A IDS p reva le n c e rates 1 9 8 7 - 2000 am ong sexually active population 12 . 1 0 i 8 6 4 2 co co cc 0) 0 a ) 0) 0) 0) 0) 0) 0) 0) 0 0) 0 0) 0 00) )M cm 0) 0) 0) 0) 0) ) 0D Year 4- It is widely recognized that HIV/AIDS is a major threat to Cameroon's development. It affects all levels of society and is rapidly canceling the development gains made since the end of the depression in 1994. However, the precise macroeconomic impact of AIDS is difficult to assess. Most studies have found that estimates of the macroeconomic impacts are sensitive to assumptions about how HIV/AIDS affects savings and investment rates and whether AIDS affects the best-educated employees more than others. Studies in certain sub-Saharan African countries have found that the rate of economic growth could be reduced by as much as 25% over a 20-year period. A simulation model of the economy of Cameroon concluded that the annual growth rate of GDP could have been reduced by as much as 2 percentage points during the 1987-1991 period because of HIV/AIDS. Kambou, G., Shantayanan, D., and Mead, 0. 1992. "The Economic Impact of AIDS in an African Country: Simulations with a Computable General Equilibrium Model of Cameroon", Journal of African Economies, Volume 1, Number 1. Up to very recently, HIV/AIDS has been addressed primarily as a health issue. However, it is increasingly becoming a national crisis that impacts negatively most sectors and exacerbates poverty. In the agriculture sector, several studies by FAO, WFP, and DFID have shown how poverty increases at the household when assets (e.g., livestock and/or land) are sold to cover the cost of medical expenses. In addition, subsistence agriculture is very sensitive to labor availability which is reduced by HIV/AIDS, both directly, by affecting productive members of the household and, indirectly through diverting labor to caring for the sick. The transport sector is another sector particularly vulnerable to HIV/AIDS and important to its prevention. A survey of bus and truck drivers in Cameroon found that they spent an average of 14 days away from home on each trip. 68% had sex during the most recent trip and 25% had sex every night they were away AIDS Analysis Africa, Vol. 4 (5), September/October 1994. Another study conducted in 1993-1994, found that 15% of truck drivers tested positive for HIV infection in Douala. A similar study carried out in the southwest and coastal areas found 17% of truck drivers positive for HIV infection. In the urban areas, considerable progress has been achieved in terns of sensitization to HIV/AIDS. Among urban youths, 89% are aware of the pandemic and 57% have already used condoms. Of pregnant women in urban settings, 73% are aware of mother-to-child transmission (MTCT) during birth and 84% of urban women know of the existence of condoms. The situation is somewhat different in the rural areas. Only 20% of men in rural areas have already used a condom (as compared to 73.5% in Yaounde/Douala). The Ministry of Public Investments and Regional Development along with 13 ministries has launched a pilot operation for comrnmunity mobilization to control the spread of HIV/AIDS. The Ministry of Agriculture, in conjunction with local authorities and CBOs/NGOs, is providing technical assistance to this operation. By December 2000, close to 200 villages will be covered and the objective is to scale-up to achieve national coverage. In addition, with support from UNAIDS, the National Agricultural Extension and Research Program (NAERP) has trained 2,045 extension workers on HIV/AIDS and 560,000 rural families have been sensitized on HIV/AIDS. In spite of all these efforts and positive achievements, basic awareness remains minimal in the - 5 - extreme northern areas. In addition, high-risk behavior is quite widespread. In 1998, 35% of single women infected with HIV in Yaounde did not use a condom during their most recent sexual contact; 13% of men had a relation with commercial sex workers; and 20% had extramarital affairs. The challenge facing Cameroon is now on two fronts. One is to translate the high level of awareness into behavioral change to prevent the spread of HIV/AIDS both in the rural and urban areas. The other is to identify the promising governmental and non-governmental HIV/AIDS prevention, mitigation, and care initiatives and rapidly replicate them to achieve national coverage. National Strategic Plan Cameroon started addressing the HIV/AIDS epidemic in 1986 by establishing the Committee to Fight against HIV/AIDS. Since then, four short and medium term plans were designed and implemented: (1) the Short Term Plan of 1987, (2) the Medium Term Plan I (1988-1992), (3) the Medium Term Plan 11 (1993-1995), and (4) the Framework for the Fight against HIV/AIDS (1999-2000). However, these interventions had mixed results due to several factors, including insufficient coordination among the various stakeholders; ineffective integration and cooperation across sectors; and scarcity of human and financial resources. As a result, the HIV/AIDS situation worsened considerably: the HIV prevalence rate in Cameroon increased from 0.5% in 1987 to 11% in 2000. Faced with this pandemic, the Government decided to "declare war" on HIV/AIDS and finalized the current emergency HI V/AIDS strategy in a record three months. In September 2000, the Prime Minister launched the highly-publicized National Strategic Plan for the Fight Against AIDS in Cameroon (2000-2005). The preparation of the Strategic Plan was coordinated by the Ministry of Public Health with technical support from UNAIDS. It is the outcome of a participatory process involving most line ministries, the private sector, non-governmental organizations, civil society, and the donor community. Its main objective is to improve the national response to the HIV/AIDS pandemic. The elaboration of the National Strategic Plan followed a five-step process which started in June 1999. First, a training workshop for representatives of the provincial governments and members of the Groupe Technique Central (GTC), the executive body of the National Committee for the Fight Against HIV/AIDS, on the process of developing the Strategic Plan. This was followed by a decentralized situation analysis of the HIV/AIDS epidemic at the provincial and district levels. Third, an analysis of the response to the epidemic, previously planned at the district level, was carried out at a national workshop in Yaounde to speed up the process. The fourth step, UNAIDS consultants drafted a preliminary strategic plan. And, in the last step, three meetings grouping all the stakeholders, representing line ministries, NGOs, the private sector, and religious organizations finalized the National Strategic Plan for the Fight Against HIV/AIDS in Cameroon. The National Strategic Plan comprises an operational plan covering six priority areas of - 6 - intervention and an emergency plan for 2000-2002. It highlights the following priority areas for action: * Prevention of HIV/AIDS and STI transmission through behavior modification * Prevention of HIV transmission in hospital settings and through blood transfusion * Provision of clinical and home/community-based care for People Living with HIV/AIDS (PLWHA) * Establishment of an ethical, legal, and human rights framework for PLWHA * Increase in HIV/AIDS research and surveillance * Program management and coordination The emergency plan focuses on three aspects: (1) the use of condoms (masculine and feminine) - "100% condom strategy; (2) voluntary testing and counseling (VTC); and (3) the promotion of behavior change among young people 15-24. It will mostly target the "high-risk" population, namely the military, police, customs officials, penitentiary personnel, students, commercial sex workers, and truckers. In addition, the National Strategic Plan includes a major expansion of HIV/AIDS activities that will be implemented by the following line ministries: National Education, Higher Education, Agriculture, Defense, Labor, Social Affairs, Women's Affairs, Information, Public Health, Youth and Sports, and Local Administration. These activities cover the full spectrum of prevention, treatment, care, and support and target both the staff and the clients of the Government entities. In addition to the public sector, the Strategic Plan looks at the role of the private sector, non-governmental organizations, civil society, and the donor community in combating the spread of HIV/AIDS. To complement the new National Strategic Plan and reflect its multi-sectoriality, a ministerial decision was issued in October 2000 to reorganize the Groupe Technique Central (GTC - executive body of the National HIV/AIDS Committee). The new GTC is managed by a Permanent Secretary and is composed of five sections: (i) a section for support to local responses; (ii) a section for support to sector responses; (iii) an operational section, responsible for monitoring and evaluation of the entire program, monitoring of support and care for PLWIA, and epidemiological surveillance; (iv) a section responsible for information, communication, and education (IEC); and (v) a financial management section. The Groupe Technique Provincial (GTP - executive body of the Provincial HIV/AIDS Committees) is managed by a provincial manager and comprises the same sections as the GTC. A second decision issued on December 5, 2000 established the Commission Mixte de Suivi which will meet on a quarterly basis to oversee the National Committee for the Fight Against AIDS, review the quarterly progress reports, and ensure the proper use of funds. This commission is composed of representatives from the Ministries of Territorial Administration, the Finance, the Public Investment, the Public Health, PLWHA, employer organizations, religious groups, and donors (UNAIDS, bi-lateral and multi-lateral). Representatives from the President's Office, the Services of the Prime Minister, Parliament, and the Judiciary, sit on the Commission as independent observers. -7 - 3. Sector issues to be addressed by the project and strategic choices: The sector issues to be addressed include the following: Multi-sectoral nature of the fight against HIV/AIDS. Although the Government has made important progress since April 2000 to step up the fight against HIV/AIDS, the full integration of all sectors is not yet sufficiently tangible. Most sectors are still struggling to clarify their respective strategies. At the same time, the current National [IV/AIDS strategy is still quite limited to health sector interventions. While these interventions are of critical importance, they will need to be complemented with simultaneous efforts in the other sectors. The architecture of the GTC already outlines the Government's vision to develop a truly multi-sectoral approach to the fight against HIV/AIDS. The project will assist the Government in translating this multi-sectoral vision into action on the ground. Use of sub-contracting agencies to implement HIV/AIDS strategies. There is a consensus that none of the Government agencies alone will have the resources or capacity needed to address the HIV/AIDS crisis. The structures which have been put in place to coordinate the Government's fight against HIV/AIDS reflect the Government's strategic choice to use a multitude of implementing agencies to carry out the various activities in the field. This, however, is a novelty in Cameroon and will call for a change in institutional culture and increased capacity with regard to policy and strategy definition, supervision, monitoring and evaluation, and financial control. The program has an important capacity building component to address this challenge. Transfer of resources directly to communities. As with the option to use a multitude of sub-contracting agencies to implement the program, the choice to transfer resources directly to communities constitutes an important new development. The Government has opted, through the preparation of this program, to provide financial resources to those communities which have adequate HIV/AIDS action plans. However, to make this possible, the financial sector has to address the challenge of the presence, reliability, and efficiency of financial institutions in remote areas. Many communities are currently more than a day's travel away from the nearest financial establishment (bank branch, saving and credit organization, cooperative, post office, etc.). Staff from the Central Bank, with the assistance of the Bank's financial sector specialists, are currently examining ways and means to improve this situation. This work cannot be finalized before the effectiveness of the project, but will continue as part of its implementation. Strengthening of the national, provincial, and communal HIV/AIDS committees. The national and provincial HIV/AIDS committees have, until now, been extremely weak. Although there is a token representation from various levels of society (different sectoral ministries, PLWHA, civil society, etc.) the actual involvement of stakeholders remains very weak. Also the capacity for policy and strategy definition in the HIV/AIDS committees at various levels is weak. At the communal level, HIV/AIDS committees do not yet exist. The Government has decided to revamp the various HIV/AIDS committees and to staff them with adequate representation from various stakeholders. An important effort in capacity building will be required to assist these efforts. Strengthening of coordinating units. Until the preparation of this program, the coordinating unit - 8 - responsible for the supervision of the implementation of the national HIV/AIDS strategy was understaffed. With the creation of the "Groupe Technique Central" (GTC) the Government has committed to try and attract qualified people who will work in the coordinating units on a full time basis. C. Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): The project will support the implementation of the National HIV/AIDS strategy through the NHAC/GTC. No special implementation arrangements will be made or institutions created for the purpose of this project. The NHAC/GTC coordinates the contributions of various donors (national, bi-lateral, and multi-lateral) within the broad framework of the National HIV/AIDS programn. The IDA Credit will be only one of several sources of financial and technical assistance, each contributing to the effective implementation of (parts of) the National HIV/AIDS strategy. Thus, several other donors such as UNAIDS, the Agence Frangaise de Developpement, GTZ, UNICEF, WHO or the European Union also contribute with new or ongoing projects to the strengthening and implementation of the same national HIV/AIDS program. The National HIV/AIDS strategy which this project supports is based on two major pillars: local responses (support to rural and urban communities to develop and implement their own HIV/AIDS action plans) and sector responses (support to various sectors in the economy to develop and implement sector-specific strategies for HIV/AIDS). To strengthen the work on local responses and sector responses, three support functions are included in the Government's strategy: communication, planning/monitoring and evaluation, and coordination. Organizational charts representing the design of the program are included in annex 12. The responses developed by local communities and in each of the sectors will deal with prevention as well as mitigation of the impact of HIV/AIDS. While the main focus of attention will go to prevention, special attention will be given to the monitoring of the treatment, care and support provided to people infected or affected by HIV/AIDS. To this effect, the Government has committed to the full inclusion of PLWHA in the design and implementation of local and sector responses, in the planning, monitoring, and evaluation of the programs, and in policy formulation and control. To meet the challenge of national coverage - starting with the rapid coverage of high risk areas and groups and moving on to gradually cover all groups and areas in the country - the Government has chosen to work through a multitude of implementing agencies. Not one organization or sector in the country has the capacity or resources to take on the HIV/AIDS challenge alone. However, by drawing upon all available capacity (in private and public sector, among NGOs, civil society, religious groups, traditional healers' associations, community based organizations, etc.) and resources (national budget, HIPC resources, donor-funded projects) the Government hopes to establish the institutions and mechanisms needed to sustain the effort to address HIV/AIDS over the next ten to fifteen years. -9- Components: The project will have five components: (a) support to local responses; (b) support to the health sector response; (c) support to the design and implementation of sector strategies; (d) capacity building; and (e) coordination. (a) Support to local response: The project will support communities' efforts with regard to prevention and mitigation of the impact of the HIV/AIDS crisis. Under this component, communities - facilitated by local sub-contracting agencies and NGOs - elaborate their action plans, constitute their own HIV/AIDS committees, submit their action plans to the communal (county) HIV/AIDS committee, open a bank account, and receive financial resources directly from the project to assist with the implementation of their action plans and to match their own contributions (in cash and/or kind). Strong emphasis is given to the participatory nature of the development of community action plans, to the inclusion of all (especially vulnerable) groups in the planning and implementation of the activities, and to the involvement of PLWHA. As part of the component, the participatory methodologies - which are already under implementation in the IDA funded National Extension and Research Program (Cr. 3137 CM) - will be adapted through action/research activities to accommodate specific work on HIV/AIDS in various social settings such as villages, urban neighborhoods, prisons, unions of truck drivers, commercial sex workers, orphans, street children, etc. (b) Support to health sector response: The implementation of specific targeted health sector interventions geared to HIV/AIDS will be supported through the program. These include the establishment of voluntary testing and counseling centers, the improvement of blood transfusion safety and the management of blood banks, the increase in availability of drugs to treat opportunistic infections, the distribution of equipment and materials for home care of the sick, the support to private companies' efforts to fight against HIV/AIDS, the elaboration of a tool kit and the training of traditional healers and birth attendants on HIV/AIDS prevention and mitigation, etc. (c) Support to the design and implementation of sector strategies: Under this component, support will be provided to focal points in key sectors to design (or continuously improve existing) specific HIV/AIDS strategies. Targeted sectbrs include health, communication, transport, defense, education, agriculture, public works, youth and sport, tourism, women affairs, mining, environment, social affairs, etc. The sector focal points will be assisted to elaborate an action plan for the development of sector strategies. These action plans will spell out how private enterprises, semi-private organizations and public administrations will participate in the exercise. The sector strategies will have to address the challenges of prevention and mitigation both among the people working in the sector, and among the public which is being served by the sector. The strategies will also include sector-specific communication strategies with regard to HIV/AIDS. The sector strategies will be funded through HIPC resources, the reallocation of existing public budgets, budgets from private enterprises, and through retrofitting of existing and new donor-funded projects. (d) Capacity building: The project will provide resources to help address the challenge of rapid capacity building among those in the public sector, in the private sector, and in civil society - 10 - who are involved in the fight against HIV/AIDS. This component will include: training of facilitators in implementing agencies on methodologies for community participation (in rural areas, urban neighborhoods, and among special vulnerable groups); training of HIV/AIDS committee members at communal, provincial and national level on strategy definition, supervision and budgeting mechanisms, and control; training of focal points in the various sectors on the development and implementation of HIV/AIDS strategies; training of staff in financial institutions on the mechanisms required to ensure adequate transfer of funds in support of communities' action plans; and training of managers, field staff, financial management staff, planners, and controllers on their roles, functions, and job descriptions. (e) Coordination: The establishment of a relatively small implementation and coordination unit at the national and provincial levels -Groupe Technique Central (GTC) and Groupe Technique Provincial (GTP) - will be supported through this component. This component will also support the operations of one staff in every commune. In addition, support will be provided to the operations of HIV/AIDS committees at national, provincial, and communal levels. The GTC and GTP will be responsible for (i) support to local responses; (ii) support to sector responses; (iii) monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) information, communication, and education (IEC); and (v) financial management. Indicative Sank- % of Component Sector Costs % of financing Bank- ._______________________ _ f(US$M) Total (U$S I) financing Support to local response 30.70' 51.2 27.00 54.0 Support to health sector response 6.10 10.2 5.00 10.0 Support to the design and 3.20 5.3 2.21 4.4 implementation of sector strategies Capacity building 8.40 14.0 7.45 14.9 Coordination 11.60 19.3 8.34 16.7 Total Project Costs 60.00 100.0 50.00 100.0 Total Financing Required 60.00 100.0 50.00 100.0 2. Key policy and institutional reforms supported by the project: Institutional reform: As in several other countries which participate in the Multi-Country HIV/AIDS Program, there is a consensus within Government to keep the Ministry of Public Health responsible for the overall coordination and oversight of the fight against HIV/AIDS. The obvious disadvantage of this arrangement is that the Ministry of Health does not have the mandate to exercise authority over other line or central ministries and would hence be hampered to ensure implementation of a truly multi-sectoral approach to the HIV/AIDS fight. Nevertheless, the arguments put forward by members of Government - mainly that less time would be available for the day-to-day monitoring and supervision of the program if it were to be housed in the Prime Minister's Office or the President's Office - do have merit and seem to be confirmed by experience in Cameroon. - 11 - To ensure the multi-sectoral nature of the program, and to provide adequate external control over project implementation and the use of resources, an independent Commission Mixte de Suivi has been created. This commission is composed of representatives from the Ministry of Territorial Administration, the Ministry of Finance, the Ministry of Public Investment, the Ministry of Public Health, PLWHA, employer organizations, religious groups, UNAIDS, bi-lateral and multi-lateral donors. Representatives from the President's Office, the Services of the Prime Minister, Parliament, and the Judiciary sit on the Commission as independent observers. On the basis of its external monitoring and control, the Commission Mixte de Suivi can decide about corrective action that needs to be taken by the GTC. Policy reform: As mentioned earlier, the current version of the National HIV/AIDS strategy is still very much focussed on the health sector. While the strategies and activities provided for are sound, the strategy could be strengthened if the participation of other sectors is reinforced. The strategy would also benefit from a more accurate reflection of the current option of the Government (mirrored in the design of this program) to base the fight against HIV/AIDS on the two pillars of local response by urban and rural communities, and sector responses. The current strategy is considered by the Government to be a "work in progress" and as such, there is great willingness on the part of Government to continuously integrate further improvements in the National HIV/AIDS strategy. The on-going work on developing and implementing the full PRSP will also be important in ensuring a multi-sectoral focus for fighting HIV/AIDS. Condom availability: While the social marketing program of condoms has achieved important results (the NGO which is implementing the social marketing program claims to distribute about one million condoms per month), a recent study ("Risk attitude, sexual behavior and spread of AIDS and STDs in Cameroon, a situation-assessment study", Ndi Alfred, August 2000) indicates that availability and price remain important problems. Condoms are mainly available in the large cities and urban centers. By contrast, many young people in rural areas who, as a result of a growing awareness about HIV/AIDS would like to practice safe sex, do not readily have access to condoms. As part of the program, Government will undertake studies to clarify where the bottlenecks are to make condoms more widely available and affordable for all. These studies will allow the Government to prepare policy reforms for more effective distribution and pricing of condoms which adequately respond to the need to remove these bottlenecks. 3. Benefits and target population: Benefits Target Population Reduction in the spread of HIV/AIDS in General population, especially youth, Cameroon women, and vulnerable groups Improvement of care and support for Close to one million people currently living PLWHA with HIV/AIDS in Cameroon - 12 - Increased capacity to deal with the Rural and urban communities, vulnerable HIV/AIDS crisis groups, decision makers, managers and staff in various sectors. Increased capacity for policy and strategy HIV/AIDS committees at national, provincial formulation and communal levels Streamlined procedures for transfer of Rural and urban communities, saving and resources to communities credit organizations, financial institutions 4. Institutional and implementation arrangements: Project implementation: The institutional and implementation arrangements are described in detail in annex 2. An organizational chart is reflected in annex 12. The project will support the existing national structures and institutions for the fight against HIV/AIDS and no new temporary implementation units will be created for the purpose of this project. The overall responsibility for the implementation of the national strategy for the fight against HIV/AIDS lays with the National HIV/AIDS Committee (NHAC) and its decentralized entities at provincial (PHAC), communal (CHAC), and local (LHAC) level. The HIV/AIDS Committees are responsible for the strategy definition, the approval of annual work plans and budgets, and the supervision of the implementation of the strategies at their respective levels. To ensure proper implementation, the HIV/AIDS Committees are supported by technical units. At the national level, the NHAC implements its strategy through the Groupe Technique Central (GTC). At the provincial level, the PHAC works through the Groupe Technique Provincial (GTP), and at the communal level, the CHAC is assisted by a Correspondant Communal (CC). The staff in the GTC, GTP, and CC work on a full time basis. The Groupe Technique Central (GTC) is managed by a Permanent Secretary and is composed of five sections: (i) a section for support to local responses; (ii) a section for support to sector responses; (iii) an operational section, responsible for monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) a section responsible for information, communication, and education (IEC); and (v) a financial management section. The Groupe Technique Provincial (GTP) is managed by a provincial manager and comprises the same sections as the GTC. Several aspects of the program implementation will be sub-contracted. These include: - Facilitation of community participation processes: At the beginning of program implementation, the PHAC/GTP will identify all organizations in the province who have capacity to facilitate participation processes at the community level. Annual contracts will be established - 13- between the PHAC/GTP and these organizations to specify which organization will be responsible for facilitation of participatory processes in which areas. The contract will also stipulate the financial and technical support the sub-contracting agencies will receive from the project to carry out their assignment. The sub-contracting agencies' field work will be supervised by the PHAC/GTP. - Communication strategy: The design and implementation of NHAC/GTC's communication strategies, which constitutes one of the key tools in the fight against HIV/AIDS, will be sub-contracted. Initially, the GTC will recruit a specialized agency to develop an appropriate communication strategy. Depending on the features of the strategy, one or more agencies will be contracted to implement (aspects of) the strategy. Within the GTC, the section responsible for IEC will ensure supervision of the sub-contractors. - Accounting and transfer of funds: The GTC will have the overall responsibility for the financial management of the program, but will execute this financial management through private firms. To maximize efficiency, the accounting of the program, the transfer of funds to communities, and the preparation of documentation to be submitted to the CAA for the replenishment of the special accounts will be contracted out. - Epidemiological and behavioral surveys: While the operational section of the GTC is responsible for the implementation of the epidemiological and behavioral surveys and for the timely production of reports, the actual surveys will be sub-contracted. By doing so, the GTC hopes to gain in efficiency, and to avoid having to recruit an important number of staff to carry out these surveys. The development of the sector specific HIV/AIDS strategies will be implemented by focal points in the respective sectors. To ensure ownership of the sector strategies by the various actors in each sector (private companies, public administrations, civil society, and the public at large), the focal points will remain employed by their respective sector organizations. The focal points will establish work plans in conjunction with representatives from all partners in the sector to elaborate the sector specific strategies. The relationship between the focal points and the GTC will not be hierarchical, but will be one of coaching and support: the GTC will provide technical guidance to ensure that the strategies are sound and to avoid duplication between the various sector strategies. The NHAC/GTC will also finance the activities that will be carried out to develop the sector strategies. However, the financing of the implementation of the sector strategies will be assured through HIPC, through reallocations in the existing sector budgets, and through reallocation within donor-funded projects. Project supervision, reporting, and audit requirements: The Program Implementation Manual (PIM) will delineate processes and responsibilities for general management, procurement activities, and financial management and control, including Terms of Reference for internal and external audits acceptable to IDA. The PIM, which will be submitted to IDA for its approval, will be finalized and adopted as a condition for Credit Effectiveness. As the proposed implementation arrangements are partially based on experience in - 14 - other countries, the adaptation of these arrangements will need to be seen as a continuous process responding to local circumstances. Consequently, the PIM will be reviewed and amended by mutual agreement with IDA as and when needed, with the first revised PIM being issued before January 31, 2002. In order for implementation to proceed without having to wait for the preparation of the PIM, Interim Program Implementation Procedures (IPIP) were developed during project preparation. The IPIP will first be reviewed during the launch workshop which will take place before February 28, 2001. All parties involved in the implementation of the different components of the project as well as representatives from beneficiaries will participate in the workshop. The NHAC/GTC will submit to IDA an annual work program and on this basis will submit quarterly progress reports on achievements and problems. Similarly, it will obtain annual work programs and quarterly progress reports from all implementing agencies. The PIM will further elaborate on reporting requirements. Financial audits for all accounts and components will be carried out annually by an independent auditor in accordance with Bank Guidelines. Financial audits will be submitted by the GTC to the Commission Mixte de Suivi and to IDA not later than six months after the end of each fiscal year. Performance and impact audits as set out in the PIM will also be carried out to assess the project's contribution to Cameroon's HIV/AIDS program. In addition to the mandatory annual audit exercises, any of the members of the Commission Mixte de Suivi can order at any time an audit or examination of any complaint received by the Commission Mixte de Suivi about the implementation of the program or about the use of the resources. IDA's supervision of the project will need to be full-time and staff-intensive, given the "learning-by-doing" concept used for the project design. This will be especially important prior to Credit effectiveness as a host of activities must be undertaken to maximize implementation in the four years of the project. In the first project year, IDA staff will have to take active part in the project launch and PIM review workshops, the workshop to review implementation progress toward the end of the year, and workshops on project implementation experience (preferably to take place at the provincial level). To be able to make effective contributions during the various workshops, IDA staff will have to focus on field visits to supervise the start-up of the program on the ground. The supervision needs for the following three years are unlikely to diminish, as the community-level program will see rapid expansion each year. On an annual basis, workshops will be organized to discuss experience and to scale up best practices. Supervision support from the Country Office will include close monitoring by the financial management specialist, the procurement specialist, and the disbursement specialist. Procurement procedures: The above implementation arrangements will be supported by procurement procedures that take into account the urgency of the project as well as the nature of the participating institutions. Procurement for all IDA-financed activities will be carried out in accordance with the Bank's Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995 and revised in January and August 1996, September 1997, and January 1999), in particular Section 3.15, - 15- Community Participation in Procurement. Consulting services by firms, organizations, or individuals financed by IDA will be contracted in accordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997, revised in September 1997 and January 1999). With respect to the support to local responses, the Bank's simplified Procurement and Disbursement Procedures for Community-Based Investments will be used. To facilitate speedy import of items valued at less than US$ 100,000 equivalent required urgently for diagnosis/treatment and institutional strengthening, contracts may be made based on international shopping and national shopping procedures, respectively, per IDA Procurement Guidelines (Clauses 3.5 and 3.6), provided contract awards are made within 12 months of the Credit effectiveness date. International procurement will also take place through procurement from the United Nations (i.e. IAPSO). Given the urgency of the project, a wide-ranging General Procurement Notice (GPN) for the first year of operations will be placed on the United Nations Development Business web site without a need for hard-copy publication. The Borrower will prepare a procurement plan for the first year of project operations to be included in the PIM. The plan will include relevant information on goods, works, and consulting services under the project as well as the timing of each milestone in the procurement process. The procurement schedule will be updated every quarter and reviewed by IDA. Procurement performance (including community based procurement activities) will be assessed on an annual basis (in the form of procurement/physical audits by an external agency). In addition to the formal annual audits, ad-hoc procurement reviews will be conducted periodically. Details of procurement arrangements are provided in annex 6. Financial management: The project will have an adequate financial management system in place by Credit effectiveness. Appropriate safeguards will be included in the design of the financial management system; these safeguards include the appointment of an internationally qualified Financial Manager, the sub-contracting of accounting to a specialized private company, the direct transfer of funds to communities, the direct payment from PHAC/GTP to sub-contracting agencies responsible for the support to local communities, and close links between and analysis of financial and physical progress reports. Not all executing entities (e.g., sectoral focal points, GTC, etc.) have established financial management systems adequate for the project's demands. Before disbursing funds to these entities, the NHAC/GTC will need to confirm that appropriate financial management systems are in place, including the opening of project bank accounts and employment of qualified accounts staff. A detailed assessment of the financial management and internal control systems is presented in Attachment 2. - 16- Disbursement procedures: Under this Credit the estimated IDA financing for the first six months of project implementation will be disbursed into two Special Accounts in a commercial bank acceptable to IDA. Both Special Accounts will be operated by the Caisse Autonome d'Amortissement. All disbursements against expenditures originating from local currency project accounts will be made against statements of expenditure (SOEs). All procurement contracts not subject to IDA prior review will be disbursed against SOEs and documentation will be retained by the respective administrations and made available for review by IDA financial management and procurement specialists and project financial and procurement auditors. Expenditures by communities will be subject to simplified accounting procedures, review of interim reports, and random ex-post financial, physical, and technical audit to be carried out by financial and technical consultants employed by the NHAC/GTC and PHAC/GTP. D. Project Rationale 1. Project alternatives considered and reasons for rejection: The project preparation team was guided by the work done under the first phase of the Multi-country HIV/AIDS Program for the Africa Region. In addition, the team drew upon field experiences from Cameroon and from other African countries to ensure that the program would be truly multi-sectoral and would focus heavily on the empowerment of communities in the fight against HIV/AIDS. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned). l Latest Supervision Sector Issue Project j (PSR) Ratings = I ~~~~~~~~~~~~~~~~~(Bank-financed projects only) Implementation Development Bank-financed Progress (IP) Objective (DO) Health, Fertility and Nutrition U U Project National Extension and S S Research Support Project Transport Sector Project S S Cameroon Petroleum Environment Capacity Enhancement Project (not yet effective) Public-Private Partnerships for Growth and Poverty Reduction (not yet effective) - 17- Other development agencies WHO/UNDP/CMRJ97/002 Health Sector project for the fight against HIV/AIDS. The project includes management of the project, assistance on IEC and epidemiological surveillance of the disease, treatment for sexual transmitted diseases, and medical and psychological support for people living with WV. Cooperation Frangaise (FAC/AIDS) Health Sector project for the fight against HIV/AIDS. Support includes IEC and epidemiological surveillance of the disease, treatment for sexual transmitted diseases, and laboratories. GTZ Health sector: support for epidemiological surveillance of HIV/AIDS. European Union Health sector: support for epidemiological surveillance of HIV/AIDS. UNICEF Health sector: support to IEC, media and NGOs working on HIV/AIDS. HIV/AIDS Peer education program. Support to the planning, monitoring and evaluation of sector specific HIV/AIDS strategies. IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) - 18 - 3. Lessons learned and reflected in the project design: Scaling up to reach national coverage: From experience in Cameroon and elsewhere, it became clear that the biggest challenge for HIV/AIDS programs was the scaling up. As in other countries, several excellent initiatives on HIV/AIDS exist. However, these initiatives tend to be fairly small in size and work in an isolated fashion. As a result, only a small fraction of the needs with regard to supporting the fight against HIV/AIDS are covered. The strategies for scaling up have been derived from experience gained through large programs such as the agricultural services programs in several African countries. Sub-contracting: The experience with most projects in Cameroon (Health and Nutrition Project, Micro-credit, Extension and Research, etc.) indicates that the public service alone does not have the implementation capacity required for this type of operation. During the design of the Multi-Country HIV/AIDS Program, the preparation team reached agreement with Governnent on the need to work through a multitude of implementing agencies, which is also one of the criteria to qualify for MAP eligibility. Community participation: From experience throughout Africa, it became clear that information, education and communication alone do not lead to behavior change in the fight against HIV/AIDS. However, when community participation methodologies are being used, a change in behavior can be seen. These findings were extensively discussed and documented by delegations from eighteen African countries during a workshop on community participation and HIV/AIDS which was organized in Mwanza, Tanzania in June 2000. Several experiences - among others TANESA (Tanzania), Gaoua (Burkina Faso), Abengourou (Ivory Coast) and others - have adequately demonstrated that behavior change can be reached through participatory approaches to the development of local responses. These findings have been at the basis of the design of the local response component of the proposed program. Transfer of resources to communities: The experience with social funds and community based operations illustrates clearly the gains in efficiency and effectiveness of micro-projects if communities are given direct access to the financial resources. The proposed design of this operation builds upon the lessons from the cornmunity based development operations and features the direct transfer of financial resources to communities. This seems especially appropriate in the Cameroonian context where the high degree of centralization of budget allocation decisions, and the tedious character of transfer of resources to the front line are specific constraints that need to be overcome. - 1 9- 4. Indications of borrower commitment and ownership: Since April 2000, there has been a remarkable increase in commitment by the Government with regard to HIV/AIDS. After many years of very modest commitment to the fight against HIV/AIDS, the Government has recently - with the help of UNAIDS - accellerated the production of an emergency strategy. This strategy, while still heavily focussing on the health sector, is considered by the Government to be a working document and will continuously be improved as the understanding of how to best address the HIV/AIDS crisis in Cameroon deepens. Specifically, the Government plans to flesh out how to make the strategy truly multi-sectoral. The Prime Minister launched the strategy in an official ceremony with the entire cabinet and in the presence of the donor community and civil society. At the occasion of the launching, the Prime Minister made a very strong speech, outlining the catastrophic dimensions of the epidemic in Cameroon, the impact it is having on all sectors of society, and the risks for an even bigger catastrophe if no immediate action is taken. The PM's speech was printed in its entirety in the newspapers on two different occasions, and articles/programs about HIV/AIDS appear almost daily on TV and in the written press. The breaking of the silence on HIV/AIDS in Cameroon has been translated in budgetary allocations. The 2000 budget of the Ministry of Public Health was increased by 2 billion CFAF to address the HIV/AIDS crisis. In addition, the fight against HIV/AIDS is one of the seven priority areas of intervention for using the HIPC resources. Of late there have also been an increasing number of occasions where individual members of Government such as the Ministers of Health, Agriculture, Communication, and Social Affairs have staged a push to increase the effectiveness of their respective departments' responses to HIV/AIDS. For example, the National Extension and Research program has currently trained over 560,000 farm families on HIV/AIDS and the ways and means to prevent it. All staff of the National Extension Service receive weekly allocations of condoms. Another example was a joint initiative by the Minister of Health and the Minister of Communication to organize meetings with all private and public press organizations (written press, radio and TV) to launch the process to determine and implement adequate communication strategies. Because of its compliance with the eligibility criteria, Cameroon has been included in the list of countries that can apply for access to the MAP resources: Satisfactory evidence of a strategic approach to HIV/AIDS: With the official launching of the HIV/AIDS strategy on September 12, 2000, the Prime Minister and the entire Government have put their political weight behind the implementation of the strategy. The strategy already provides a reasonable framework for the design of the MAP program. At the same time, it is clear that the National HIV/AIDS committee (NHAC) and the Minister of Health want to continually improve the strategy to incorporate lessons learned through implementation. A high-level HIV/AIDS coordinating body: The NHAC, which has been weak in the past, is currently being revamped. The Minister of Health also appointed the technical units (GTC and GTP) which will be responsible to assist the NHAC and the PHAC with the implementation of the national program. IDA has received satisfactory evidence that both the committees and the GTC - 20 - are being staffed with qualified people. Appropriate implementation arrangements: The Government has articulated a two-pronged implementation strategy focussing on support to local responses from communities (urban, rural, and vulnerable groups) and on the development and implementation of sector specific strategies. The bulk of activities will be sub-contracted to a multitude of implementing agencies, both in the private and public sectors. Use and funding of multiple implementation agencies: As part of the project preparation process, the Government is actively involved in consultations and meetings with communities, people living with HIV/AIDS, religious leaders, NGOs, and traditional healers. There is a clear understanding that the implementation of the HIV/AIDS strategy will require the full participation of all these actors. There is also a consensus that the bulk of the resources to be mobilized under the MAP will have to be channeled to communities to support the implementation of their HIV/AIDS action plans. Communication strategy: In addition to the progress on the four eligibility criteria for the MAP, the Government has also understood the need to develop an adequate and diversified communication strategy. While considerable media attention goes to HIV/AIDS, it is clear that much remains to be done to develop a diversified communication strategy, tailored to the needs of various groups. The development of this communication strategy figures prominently in the broader HIV/AIDS strategy. 5. Value added of Bank support in this project: Through its involvement in various sectors in Cameroon and its experience with supporting large, decentralized and field oriented operations such as the National Extension and Research Program, IDA is well placed to assist the Government to make the national effort to fight HIV/AIDS truly multi-sectoral and field-oriented. As an active member of the UNAIDS group, IDA can contribute to galvanizing the support from various international agencies and donors. IDA's involvement in the support to the HIV/AIDS program is leveraged by the focus given to HIV/AIDS in the public expenditure review exercises, the on-going Health, Fertility and Nutrition Project, the Poverty Reduction Strategy, the allocation of HIPC resources, and the possible retro-fitting of existing operations. Thanks to the availability of resources under the Multi Country HIV/AIDS Program (MAP), IDA is able to quickly mobilize the financial resources needed to support the Government in the implementation of its emergency HIV/AIDS program. Finally, IDA's support can also be instrumental to attract other donor's attention to complement the IDA Credit with additional grant money. In addition, IDA has worked closely with the Government to develop specific HIV/AIDS prevention and mitigation measures for both the pre-construction and construction phases of the Chad/Cameroon pipeline. This will benefit communities along the pipeline route and migratory workers who will be involved in the pipeline construction and who constitute one of the most vulnerable groups. Due to IDA's work, the inclusion of HIV/AIDS prevention measures in the Chad/Cameroon Pipeline Project is a flagship example of galvanizing government, private sector - 21 - and Bank partnerships for anticipating risks on HIV/AIDS and tackling the issue in the framework of a non-health operation. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): CJ Cost benefit NPV=US$ million; ERR = % (see Annex 4) C' Cost effectiveness * Other (specify) 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) Mobilization of grant resources: To be able to cover the cost of the HIV/AIDS program in Cameroon, the proposed IDA credit alone will not be enough. Additional grant resources are being sought. At the time of preparation, it was not yet clear to what extent and under which timetable these resources could be mobilized. Allocation of HIPC resources: It was specified in the HIPC documents that HIV/AIDS should be one of the priority areas to allocate resources stemming from the debt reduction. During appraisal, it was agreed with Government that sector specific HIV/AIDS strategies would be eligible for HIPC funding after certification by the NHAC/GTC that the strategy is sound and without duplication of other sector strategies. Use of sector budgets: Beyond additional grants and the allocation of HIPC resources, each sector will have to re-allocate resources out of their respective budgets to finance the sector-specific HIV/AIDS strategies. Each sector will, in addition, have to examine to what extent existing donor-funded projects can be retro-fitted to include HIV/AIDS. Fiscal Impact: N/A 3. Technical: N/A 4. Institutional: 4.1 Executing agencies: The program will be implemented through a multitude of sub-contracting agencies. Given the very limited experience in Cameroon with program implementation through (semi-)private organizations, special attention should be given to the procedures and modalities for selecting and contracting these agencies. The Interim Implementation Manual clarifies the procedures that will be used. Before the launching workshop, the Interim Implementation Manual will be updated to include samples of contracts between implementing agencies and the national and provincial - 22 - HIV/AIDS committees. 4.2 Project management: At the time of appraisal, the Permanent Secretary and all the Section Chiefs in the GTC had been appointed. This team has been the driving force behind the development of the Interim Implementation Manual and has moved agressively to start with the implementation of the program in the field. 4.3 Procurement issues: More than half of the resources made available through this program will be channeled directly to communities to support the implementation of their action plans. The Bank's guidelines for community based procurement will be adapted to the Cameroonian situation and to the specific needs for this program so as to simplify as much as possible the procedures that will be used for procurement at the community level. The overall procurement risk in Cameroon is high. In October 2000, the Bank carried out a major exercise to review procurement arrangements in Cameroon. As a result of that mission, efforts are going on to simplify, streamline, and strengthen procurement procedures in the country. With regard to ICB, there is an agreement of principle with the Minister of Health, who is chairing the National HIV/AIDS Committee, that IAPSO will be used to the extent possible. By doing so, the program should be able to escape the considerable difficulties and delays other Bank projects have suffered from when going through the National Tender Board. 4.4 Financial management issues: During appraisal, it was agreed that the accounting of the operation and the direct transfer of funds to communities would be sub-contracted to specialized firms and agencies. A financial management manual will be submitted to the Bank within two months after Board approval. Since most of the resources to communities and to sub-contracting agencies will be transferred on the basis of work programs or action plans, special attention will go to the random ex-post auditing and control mechanisms and to establishment of clear procedures for penalties and refund of monies in case of mis-use of funds. 5. Environmental: Environmental Category: C (Not Required) 5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The handling and disposal of HIV/AIDS infected materials is the most significant environmental issue in the context of this program. In many countries, the inappropriate handling of HIV/AIDS infected materials constitute a risk not only for the staff in hospitals and in municipalities who are involved in waste handling, but also for families and street children who scavenge on dump sites. Some aspects of project implementation (e.g. the establishment of testing clinics, the purchasing of equipment by communities for home care of the sick, etc.) could constitute an increase in the environmental risk with regard to the handling of HIV/AIDS infected waste. The examination on the current practices with regard to the handling of hospital waste will verify - 23 - both the management of waste within the hospitals and the management of waste by municipal authorities once it has left the hospital. It will also look into the level of knowledge among staff (hospital orderlies, municipal managers and workers) about the practices to be adopted, and into the availability of equipment such as incinerators to deal with this type of waste. 5.2 What are the main features of the EMP and are they adequate? Prior to Credit Effectiveness, the GTC will develop an Environmental Management Plan (EMP) to address the issues mentioned above. Specifically, the EMP will provide hospitals, clinics and HIV/AIDS testing centers with appropriate equipment for the disposal of HIV/AIDS infected materials. The plan will also provide for the training of staff in medical facilities as well as staff and managers involved in waste disposal at the municipal and communal level on the techniques and procedures for proper treatment and handling of HIV/AIDS related waste. Finally, the EMP will provide for the discussion of the environment hazard of HIV/AIDS waste in the participatory processes with specific vulnerable groups such as the street children and people living in waste disposal areas. 5.3 For Category A and B projects, timeline and status of EA: Date of receipt of final draft: N/A 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? Specific discussions and consultations will take place in the framework of the development of the Health Sector HIV/AIDS strategy and in the context of the HIV/AIDS committees at provincial and communal level. 5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? The monitoring indicators will be identified in the course of the development of the EMP. 6. Social: 6.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes. Two social issues should be flagged: (a) the involvement of people living with HIV/AIDS (PLWHA) in the design and the implementation of the program, and (b) the inclusion of highly vulnerable groups such as prisoners, commercial sex workers, street children, truck drivers, etc. With regard to PLWHA, the experience in Cameroon and other countries shows that special measures should be taken to protect the rights of PLWHA. The program has addressed these issues through the integration of PLWHA in the design of the project. PLWHA will also be systematically associated in the implementation so that critical issues can be flagged by the beneficiaries themselves and so that appropriate action can be taken in a timely fashion. Concerning highly vulnerable groups, the participatory methodologies which have been developed for rural and urban areas may not always be appropriate. For example, the methodologies will need to be adapted to the various specific social environments (prison, street, waste dump sites, etc.). Action/research will be undertaken as part of the program to ensure the adaptation of these - 24 - methodologies. 6.2 Participatory Approach: How are key stakeholders participating in the project? Stakeholders Participation in the program People living with Will participate through representation in the HIV/AIDS HIV/AIDS committees at all levels (National, Provincial, and communal). PLWHA will be explicitly represented in each of these committees as well as in the organism that will have the responsibility to overlook and control the entire program in all its aspects. Rural, urban, and special Will participate through the establishment of priority action communities plans as the result of participatory exercises. They will receive direct financial resources to support the implementation of priority action plans. Sector organizations Private and public enterprises and organizations will participate actively in the development and implementation of sector-specific HIV/AIDS strategies through the appointment of (and support to) sectoral focal points. These focal points will have the responsibility to coach the sector-specific strategy definition and to ensure full involvement of all organizations in the sector. NGOs, civil society, Civil society organizations will participate as sub-contracting religious groups agencies both for the implementation of the local response component, and for the development of sector-specific responses. Organizations that enter into contractual arrangements with the respective HIV/AIDS committees will receive specific terms of reference as well as budgetary envelopes to allow proper implementation. These organizations will also receive supervision of field activities and random control on the use of funds. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? NGOs will be involved as implementing agencies, especially in the local response component. The role of NGOs will be to assist communities with the participation process to determine action plans. The implementation manual will spell out the procedures and criteria for identification, selection and contracting of NGOs. During program launching, workshops will be organized in each of the ten provinces and at the national level to discuss and agree with the potential implementing agencies on the methodologies, work organization, budgets, supervision - 25 - mechanisms, and procedures for financial control. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? NGOs and civil society organizations (organizations of PLWHA, religious groups, members of Parliament, etc.) will be members of the HIV/AIDS committees at the various levels (communal, provincial and national) and will be members of the Commission Mixte de Suivi, the body which is providing the external control to the program. The role of the organizations of PLWHA should be especially emphasized. Their systematic inclusion in the steering and supervision of the program should ensure that the needs and priorities of PLWHA are being adequately addressed, or that proper remedial action is being taken when this is not the case. 6.5 How will the project monitor perfonnance in tenns of social development outcomes? Social outcomes and key human development indicators will be monitored as part of the HIPC initiative, and particularly those resources allocated to HIV/AIDS. 7. Safeguard Policies: 7.1 Do any of the following safeguard policies apply to the project? I:lic VAt0000N140; AD00 00 *pplicabi Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) C Yes 0 No Natural habitats (OP 4.04, BP 4.04, GP 4.04) 0 Yes * No Forestry (OP 4.36, GP 4.36) O Yes * No Pest Management (OP 4.09) 0 Yes 0 No Cultural Property (OPN 11.03) C Yes * No Indigenous Peoples (OD 4.20) 0 Yes 0 No Involuntarv Resettlement (OD 4.30) 0 Yes * No Safety of Dams (OP 4.37, BP 4.37) 0 Yes 0 No Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) C Yes * No Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60) C Yes 0 No 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. N/A F. Sustainability and Risks 1. Sustainability: Given the very low probability that an HIV/AIDS vaccine would be developed in the near future, and given the rampaging spread of the HIV/AIDS crisis in Cameroon, it is a near certainty that Cameroon will have to address the issue of prevention and mitigation of the HIV/AIDS crisis over at least the next ten to fifteen years. Apart from the humanitarian dimension - close to one million people in Cameroon are already infected with the virus and (even under the most optimistic program implementation scenario) several hundreds of thousands are likely to be added to this number - coping with HIV/AIDS is a prerequisite to safeguard any economic or social progress the country has made in the past and will make in the future. The design of the program is made in such a way that the efforts which are being deployed now can be sustained over a ten to fifteen year period. Specifically, this has implications for the - 26 - allocation of budgetary resources and the remuneration of staff. With regard to budgetary resources, a conscious decision has been made to use the proposed program as a leverage tool to mobilize additional resources within the budgets of various sectors, and in donor-funded projects. Thus, the sustainability of the effort is increased by spreading the budgetary burden over a larger number of sources of financing. With regard to the remuneration of staff, the Government has decided to provide only such compensation which can be sustained over a longer period of time. The litmus test for the sustainability of the program will lay with the quality of the field and sector work. To the extent that the various stakeholders and people in all different social groups take ownership of the fight against HIV/AIDS, Cameroon will be able to build up its capacity to deal with the crisis over an extended period of time. This is one of the reasons why special attention is being given during the preparation and launching period of the program to adapt the participatory methodologies which are known from ongoing community development efforts to the specific HIV/AIDS challenge. 2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1): Risk Risk Rating Risk Mitigation Measure From Outputs to Objective Government reverses or fails to follow-up M Detailed discussion of sub-contracting on the strategy to implement HIV/AIDS arrangements with various stakeholders in program through multitude of Government and among civil society to ensure sub-contracting organizations. ownership of the proposed implementation arrangements. Sufficient capacity to implement the M Organization of provincial workshops to ensure HIV/AIDS program is not found among that all available capacity is being mobilized; NGOs, CBOs, religious groups, etc. Provision of substantial capacity building component to strengthen capacity where needed. HIV/AIDS program fails to transfer S Attempt to sub-contract financial management resources to communities in a timely and and transfer of resources to private firm. transparent fashion. Due to fear, shame and denial, M Action/research being carried out to develop and communities resist to address HIV/AIDS. adapt participatory methodologies to address specifically HIV/AIDS at the community level. Financial sector institutions are too thinly S Study implemented by Central Bank with spread to allow transfer of resources assistance from World Bank Financial Sector directly to communities. Specialists to map financial agencies in the country. Frequent delays in transfer of resources S Study to identify and alleviate constraints and between various financial institutions and causes for delays with regard to the transfer of from their HQ to their respective front resources to communities. line agencies. Failure of MOH to mobilize additional M Discussions with the HIPC committee and resources to finance implementation of bilateral donors about the allocation of HIV/AIDS health strategy. resources. - 27 - Condoms not used by recipients. M Preparation of reforms needed to ensure better availability of condoms and to provide type of condoms in line with consumer preferences. Sufficient capacity not found among M Training of sectoral focal points provided for in private and public organizations in the capacity building component various sectors to establish teams to elaborate sector-specific HIV/AIDS strategies. Coordination units not adequately staffed. S Training of staff provided for in capacity building component. From Components to Outputs Lack of capacity at local, communal, M Training provided in capacity building provincial, and national level to component implement the program. Government fails to rely on multitude of M Detailed discussion of sub-contracting implementing agencies to support local arrangements with various stakeholders in responses. Government and among civil society to ensure ownership of the proposed implementation arrangements. Failure to transfer resources to S Collaboration with financial sector specialists to communities identify and alleviate bottlenecks. Unappropriate use of resources due to H Strong audit and control mechanisms. weak governance Overall Risk Rating S Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk) - 28 - On the Bank side: Given the multi-sectoral nature of the country project design, the limited capacity of the newly created NAC, the number of concerned public and private parties involved in project implementation, and the use of funding mechanisms through new structures that have not been tried and tested, Bank supervision and monitoring of project implementation will require more than standard supervision. The Bank will have to ensure that: i) funding substantially above current supervision coefficients is provided; ii) the supervision task team is composed of Bank staff from various sectors and from both headquarters and country offices; iii) specialists in key fiduciary areas such as financial management, procurement, monitoring and evaluation, and social assessment are part of the supervision team; iv) the HI V/AIDS project receives regular attention from country and sector management, especially during the first year of implementation; v) the Country Of fice maintains its capacity to provide close supervision to the implementation of the project; and vi) ACTafr ica, UNhAIDS, and major stakeholders outside the Bank remain involved in assessing progress. In addition, the existing partnership between the Bank's country team and ACTafrica should be continued. 3. Possible Controversial Aspects: N/A G. Main Credit Conditions 1[. Effectiveness Conditions *The Project Account has been opened and the Initial Deposit of CFAF 450 million paid into the Project Account; - the NHAC/GTC has adopted a program implementation manual in form and substance satisfactory to IDA; * the NHAC/GTC has adopted a financial and accounting procedures manual in form and substance satisfactory to IDA; * the NHAC/GTC has established an accounting and financial management system for the Project satisfactory to IDA; and * the NHAC/GTC has employed accounting firms for GTC and GTPs. 2. Other LclassifY according to covenant types used in the Legal Agreements.] * The Ministerial decision required for the establishment and operation of the GTPs in each of the ten Provinces will be a disbursement condition for subprojects. * An agreement between the Ministry of Finance, the Ministry of Public Health and CENAME on terms and conditions satisfactory to IDA for the provision of drugs to treat HI V/AIDS related opportunistic infections, including availability and price ceilings, will be a condition for the release of US$500,000 for the procurement of drugs through CENAME. The agreement will also specify the modalities for the finanlcial management of the fund. - 29 - H. Readiness for Implementation O 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. 1 1. b) Not applicable. O 2. The procurement documents for the first year's activities are complete and ready for the start of project implementation. O 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. Zi 4. The following items are lacking and are discussed under loan conditions (Section G): The GTC has elaborated an Interim Implementation Manual which was reviewed during appraisal. Within two months after Board presentation, the Interim Implementation Manual will be completed with standard TOR for various sub-contracting agencies, and standard contracts for sub-contracting agencies. A consulting firm was hired to prepare the financial management manual. During appraisal, a first draft of this manual was reviewed by the Appraisal team's financial management specialists. The manual will be completed within two months after Board presentation. A detailed procurement plan for the first year of project implementation will be elaborated before January 31, 2001. The GTC has recruited a procurement specialist to ensure the timely completion of this task. 1. Compliance with Bank Policies O 1. This project complies with all applicable Bank policies. 1 2. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. OP/BP 10.02 calls for the expenditures for audit reports to be considered as operating costs. However, for reasons of disbursement percentages and procurement methods, it will greatly facilitate the project if audits are included in the disbursement category "Consultancies, Training, and Audits". ime E. Weetjens Joseph Baah-Dwomoh Robert Calderisi Team Leader Sector Manager Country Director - 30 - Annex 1: Project Design Summary CAMEROON: Multi-sectoral HIVIAIDS Project Kay Perfoiiance Hierarchy of Ofebtives ltsndkom MonIoorg & Evalyaon Critic Assumptions Sector-related CAS Goal: Sector Indicators: Sectorl country reports: (from Goal to Bank Mission) To mitigate the negative social By 2005 HIV prevalence will National HIV/AIDS Commitment by Government and economic impact of be reduced to below 10% surveillance reports, midterm to maintain the leadership in HIV/AIDS in Cameroon. among young pregnant review, and end of project the fight against HIV/AIDS women (age 15 - 19 years evaluation. old). National HIV/AIDS 60% of tuberculosis patients surveillance reports, midterm will have completed DOTS by review, and end of project 2005 evaluation. - 31 - lllerarph of 0 111I , Evalt&on Critical Assumptions Project Development Outcome I Impact Project reports: (from Objective to Goal) Objective: Indicators: To curb the spread and the HIV/AIDS prevalence among Base line and follow-up The use of participatory impact of the HIV/AIDS young pregnant women (age surveys. methodologies to design and epidemic in Cameroon 15 to 19) under 10%. implement community action through the strengthening of Base line and follow-up plans and the elaboration of communities' capacity to 5000 rural and urban surveys/ reports. sector specific HIV/AIDS design and implement action communities will have strategies will lead to plans for HIV/AIDS and designed and implemented attitudinal and behavior through support to the design their action plans for change. and implementation of sector HIV/AIDS prevention and specific HIV/AIDS strategies. mitigation. Availability of local NGOs Base line and follow-up with sufficient capacity to The following sectors will surveys. implement community-based have designed and initiatives. implemented their sector specific HIV/AIDS strategies: Willingness of NGOs, civil health, education, agriculture, society, private sector and communication, transport, public administrations to defense, tourism, youth and participate. sport. Close coordination with health Access to treatment for sector activities designed to opportunistic infections Annual reports. reduce the spread of increased from 30% to 50%. HIV/AIDS and its impact. Annual production of The Secretariat will have HIV/AIDS prevalence sufficient autonomy to operate surveillance results and in an effective manner. HIV/AIDS vulnerability mapping. - 32 - Key Pertonnance Hierarchy of Objectives Ifdicators Monitor1rkg& EvazuftIon Crffcal Assumptions Output from each Output Indicators: Project reports: (from Outputs to Objective) Component: 1. Capacity of HIV/AIDS 1.1. Functioning HIV/AIDS 1.1. Reports from Communal, Continued Government Councils, Government Councils with well established Provincial, and National support to deveop partnerships Agencies, Non Governmental work programs will have HIV/AIDS committees. with NGOs, CBOs, POs, and Organizations (NGOs), increased as follows: Civil society. Community Based - 1,000 communities will have Continued Government Organizations (CBOs), Private councils by the end of year 1; support to funding sector, and Civil society at all - 5,000 communities will have mechanisms. levels built. councils by the end of year 4; - 100 communes will have councils by the end of year 1; - 300 communes will have councils by the end of year 4; - All 1O provinces will have councils by the end of year l; 1.2. Staff in implementing 1.2. Reports from Provincial agencies will have been and National H1V/AeDS trained to support Committees. participatory development of action plans as follows: - Staff in 30 implementing agencies trained by the end of year 1; Staff in 100 implementing agencies trained by the end of year 4t. 1.3. Sector Focal Points will 1.3. Reports from Focal Points and National and Provincial have been trained on the HVAD omtes design, budgeting, and HIV/AlDS Commitees. coordination of sector specific HIV/AIDS strategies involving both public administration and private enterprises as follows: - 8 Focal Points will have been trained at the national level by the end of year l; - 80 Focal Points will have been trained at the provincial 1.4. Reports from coordination level by the end of year 4. unit. 1.4. Managers and staff in the coordination units at the national, provincial and communal level will have been trained. - 33 - 2. Community HIV/AIDS 2.1. Provincial HIV/AIDS 2.1. Reports from Provincial Government's continued Committees establish and Committees will have HIV/AIDS Committees; willingness to work through a implement action plans for identified and contracted Contracts with implementing variety of implementing HIV/AIDS prevention and implementing agencies to agencies; Financial records. agencies; mitigation. facilitate participatory Availability and willingness of processes at the community implementing agencies to level and to support participate in the process; communities in the development of their HIV/AiDS action plans as follows: - 30 implementing agencies identified and contracted by the end of year I of the project; - 50 implementing agencies identified and contracted by the end of year 4 of the project; 2.2. Implementing agencies 2.2. Reports from Willingness of communities to will have facilitated the implementing agencies; discuss HIV/AIDS and to participatory design and reports from Provincial design and implement their implementation of community HIV/AIDS Committees. action plans. action plans against HIV/AIDS as follows: - 1,000 communities will have designed their HIV/AIDS action plans by the end of year I of the project; - 5,000 communities will have designed their HIV/AIDS action plans by the end of year 4 of the project; 2.3. Communities will have 2.3. Reports from financial Financial sector provides opened accounts and received management unit; reports adequate institutional capacity funding from the from ex-post audit exercise; to accommodate several Multi-Sectoral HIV/AIDS reports from Communal thousands of accounts for Project as follows: HIV/AIDS Committees. communities in (sometimes - 1,000 communities will have remote) rural and urban areas. opened accounts and received Diligence in financial at least one tranche of funding management and by the end of year I of the disbursement procedures project; allows timely replenishment of - 5,000 communities will have community accounts. opened accounts and received at least one tranche of funding by the end of year I of the project; - 34 - 3. Implementation of the 3.1. Drugs for the treatment of Reports from MOH; Reports MOH can mobilize additional Health Sector HIV/AIDS STD and tuberculosis and from Communal and resources to finance health strategy opportunistic diseases will be Provincial HIV/AIDS sector HIV/AIDS strategy available in 90% of health Committees; Reports from through HIPC and through institutions in participating associations of PLWHA donor financing; Communes by end of the project; 3.2 30 Voluntary Counseling Reports from MOH; Reports and Testing Centers from associations of PLWHA established and operational by end of Project; 3.3. Availability of medication Reports from MOH, Reports to prevent mother-to-child from Communal & Provincial transmission in 50 % of natal HIV/AIDS Committees; clinics. Reports from associations of PLWHA 3.4. Systematic screening of Reports from MOH, Reports blood in 60 % of blood banks. from Communal & Provincial HIV/AIDS Committees The condoms distributed will 3.5. Increase from 30% to 60 Reports from MOH, Reports be used by the recipients. % in covering of demand for from Communal & Provincial condoms. HIV/AIDS Committees 3.6. Availability of gloves and Reports from MOH, Reports basic equipment for home care from Communal and of terminal HIV/AIDS Provincial HIV/AIDS patients in 50 % of front line Committees; Reports from health facilities. associations of PLWHA 3.7. Toolkit will be available Reports from MOH, Reports and Traditional Healers and from Communal and Traditional Birth Attendants Provincial HIV/AIDS will have been trained on Committees; Reports from HIV/AIDS prevention and associations of traditional mitigation. healers. - 35 - 4. Design and implementation 4.1. Elaboration of action Reports from National Sectors identify qualified of sector-specific HIV/AIDS plans by sector Focal Points to HIV/AIDS Committee people to serve as focal points. strategies. develop sector specific Both private and public sector strategies with the are willing to participate. involvement of all public, private and semi-private agencies and organizations in the sector as follows: - 8 Focal Points at the national level will have established action plans by the end of year I of the project; - 80 Focal Points at the national level will have established action plans by the end of year 4 of the project; 4.2. Sector strategies address: Reports from Focal Points and - prevention and mitigation from line ministries among staff working in the sector and their families; - prevention and mitigation among the public being served by the sector (e.g. pupils and students in education, tourists in tourism, farmers in agriculture, etc.) - adequate communication strategy geared to the sector-specific needs and challenges. 4.3. Re-allocation of available resources to finance Poverty Oriented Public implementation of Expenditure Review. sector-specific strategies (use of HIPC resources, re-allocation of public resources, retro-fitting of donor financed projects). - 36 - 5. Project activities and 5.1. Project coordination units Reports from National and Sufficiently trained staff resources well coordinated and staffed as follows: Provincial HIV/AIDS available at national and managed. - All national staff and Committees provincial level. Provincial coordinators appointed by Credit Effectiveness; - All Provincial staff and Communal staff appointed 6 months after Credit Effectiveness. 5.2. Timely replenishment of Financial management reports accounts of communities and implementing agencies as follows: - Two-yearly replenishment of community accounts upon presentation of activity report; - Two yearly replenishment of accounts of implementing agencies upon presentation of activity report. 5.3. Procurement of goods and services executed in Reports from National and accordance with procurement Provincial HIV/AIDS plan Committees 5.4. Regular ex-post control and audits of community Annual audit reports accounts, implementing agencies, Sectoral Focal Points, and Coordination Unit. 5.5. Supervision of implementing agencies Reports from National and according to work plan. Provincial HIV/AIDS 5.6. Adequate involvement of Committees PLWHA in the Reports from PLWHA implementation of the program. 5.7. Environmental Management Plan completed and implemented. - 37 - lllorrh tObctIv.p i; &:-a On Ae in o Project Components I Inputs: (budget for each Project reports: (from Components to Sub-components: component) Outputs) 1. Support to local response US$30.7 Million Project Reports Activities to include. a) Funding community Continued commitment from initiatives for the care, Government to work through prevention and control of a multitude of implementing HIV/AIDS; agencies to ensure facilitation of participatory processes at b) Identification, selection, the local level; and contracting of implementing agencies Continued commitment from (NGOs, Civil society Government to transfer organizations, projects, service resources directly to delivery organizations); communities and HIV/AIDS Committees at various levels c) Providing resources and in support of the methodological guidance to implementation of their action implementing agencies to plans; facilitate the participatory diagnosis and development of Willingness of communities to community HIV/AIDS action discuss and confront plans; HIVIAIDS; d) Expanding the capacity and visibility of PLWIHA to control HIV/AIDS and to be the custodians of human rights against stigma, denial and discrimination. - 38 - 2. Support to Health Sector US$6.1 Million Project reports response Reports from Ministry of Health Activities to include: Beneficiary Assessment a) Procurement and Improvement in management distribution of drugs for the of provincial agencies for drug treatment of STDs, supply tuberculosis, and opportunicstic infections; Improvement in distribution systems and social marketing b) Establishment of of condoms Counceling and Testing Centers through both Availability of capacity in sub-contrcacting agencies and private sector to establish the Ministry of Health; testing and counseling centers c) Procurement and distributions of drugs to prevent mother-to-child transmission; d) Equipment of blood banks to screen blood samples and training of staff on the management of blood banks; e) Social marketing of condoms in both rural and urban areas and free distribution of condoms to specific target groups. - 39 - 3. Design and implementation $US3.2 million Project reports of sector specific HIV/AIDS Reports from Sectoral focal strategies points HIPC monitoring reports Activities to include: a) Constitution of sector Willingness among sector working groups under the leadership (both public and leadership of a Focal Point to private) to address HIV/AIDS include all private and public organizations active in the Willingness among political sector as well as leaders, CEOs and donors to representatives from the reallocate resources as needed public served by the sector; Capacity in sectors to establish b) Workshops, training HIV/AIDS strategies sessions and seminars to elaborate sector specific Availability of adequate HIV/AIDS strategies; capacity in private and public sector at local, communal, c) Negotiations to obtain provincial, and national reallocation of resources in levels; national budgets, private enterprises, donor-funded projects, and any other sources of funding in the sector. d) Elaboration and implementation of sector specific communication strategies. - 40 - 4. Capacity building US$8.4 Million Project reports Activities to include: a) Development of training guides on adequate methodologies and management procedures for members of various types of coordination and implementation units in the program, including members of - Community HIV/AIDS Committees - Communal HIV/AIDS Committees - Communal staff - Provincial HIV/AIDS Committees - Provincial staff - Implementing agencies to support the participatory processes at community level - National HIV/AIDS Committee - National staff - Sector Focal Points b) Selection and contracting of agencies capable of training managers and staff at various levels; c) Organization of workshops and training sessions for committee members, managers and staff at various levels; -41- 5. Project Coordination and $USI 1.6 Million Project reports Management Activities to include: a) Establishment of coordination units at the national and provincial level; b) Recruitment of staff at the Availability of qualified staff communal level; at communal level c) Establishment of a control body with the participation of PLWHA, donor organizations, NGOs, religious groups, key ministries, and members of parliament; d) Identification, selection, and contracting of qualified auditors to ensure ex-post control of use of resources by communities, sub-contracting agencies, and HIV/AIDS committees at various levels; e) Establishment of HIV/AIDS councils at communal, provincial and national level. f) Procurement of equipment. g) Elaboration of budgets and action plans for various units. h) Field supervision i) Monitoring and evaluation j) Production and dissemination of information and material on vulnerability, HIV/AIDS prevalence, and best practices to support sectors and communities in the elaboration of their respective strategies and action plans. k) Design and implementation of an HIV/AIDS communication strategy. -42 - Annex 2: Detailed Project Description CAMEROON: Multi-sectoral HIV/AIDS Project The project will have five components: (a) support to local responses; (b) support to the health sector response; (c) support to the design and implementation of sector strategies; (d) capacity building; and (e) coordination. By Component: Project Component I - US$30.70 million Support to local responses The project will support communities to develop and implement their own HIV/AIDS action plans in a participatory way. In rural areas, communities correspond in general to villages. In urban areas, communities are groups of people who are affiliated along religious, geographic, professional, or other lines. In addition to rural and urban communities, the project will support communities among vulnerable groups (commercial sex workers, inmates, truck drivers, university students, street children, etc.) and PLWHA. Special emphasis will go to the participation of traditionally vulnerable groups such as women, youth and orphans in the process. The result of the participatory process at the community level will be the establishment of a local HIV/AIDS committee (LHAC), the elaboration of a specific action plan for the prevention and mitigation of HIV/AIDS at the community level, and the identification of specific implementation arrangements to carry out the community action plan. One group which will receive special attention and support are the PLWHA. Through support to their organizations, the project will increase their capacity, visibility, and activities to better mitigate the epidemic, in addition to addressing human rights and fighting against stigma, denial, and discrimination. In addition, funding will be provided to the associations of PLWHA in the areas of care and support for affected families, training of succession planning and positive living, social and household support, the promotion of advocacy, the creation of PLWHA organizations and networks, and updates on medical research. Another group requiring special attention are orphans. The HIV/AIDS crisis will most likely orphan over a million children in Cameroon, and it should be anticipated that the capacity of society to carry the additional burden of orphan care will be strained to its limits. As part of the local responses of communities, careful attention will go to the organization and provision of orphan care. This can take the form of assistance to foster parents, the provision of school fees for orphans, the organization of orphan homes etc. At the early stages of implementation, the project will carry out action/research to adapt and fine-tune the participatory methodologies which are already well known and implemented in Cameroon. This action/research should address the challenge of adapting participatory methodologies to the specific topic of HIV/AIDS and to various socio-economical settings (such as rural communities, urban neighborhoods, prisons, work areas of commercial sex workers, universities and schools, etc.). A group of selected specialists from within and outside the country will carry out this action/research. At regular times throughout the implementation period, the - 43 - action/research will be repeated to incorporate lessons learned and to foster a continuous learning-by-doing process. Field staff from various sub-contracting agencies will facilitate the communities to carry out the participatory process to determine their HIV/AIDS action plans. The PHAC/GTP will be responsible for the identification, selection, and contracting of these sub-contracting agencies to implement the facilitation of participatory processes. Through press announcements, all institutions working with communities in a given province will be invited to express interest in the program and to provide information about the operations and organization of the institution. After an initial screening process on the basis of the information provided, those organizations that appear to have sufficient capacity will be invited to a provincial workshop. During the workshop, the participatory processes will be discussed in detail, and discussions will be conducted to determine which organization will be responsible for the facilitation of participatory processes at the community level in which areas. Depending on the amount of communities covered, the sub-contracting agencies will receive financial assistance from the program to meet their incremental costs. The agreement between the PHAC/GTP will be formalized in a contract which is renewable on an annual basis. Prototype contracts will be included in the implementation manual. In addition to the facilitation support provided by the sub-contracting agencies, communities will receive the support of the technicians at communal level. These technicians are deconcentrated staff of the PHAC/GTP and are responsible to provide assistance to communities in the elaboration and implementation of their HIV/AIDS action plans. The technicians will also serve as the front-line for monitoring the effectiveness of the intervention of sub-contracting agencies. Commnunities who (a) went through the participatory process; (b) established their LHAC; (c) elaborated their action plan; (d) obtained legal status; and (e) opened a bank account will receive direct financial support from the program to assist with the implementation of their action plans. The financial support to communities will serve to finance a number of specific eligible activities. These include IEC, awareness, and prevention campaigns, the preparation and diffusion of didactic material in local languages (radio, video, pamphlets, newsletter), VCT activities, condom distribution, promotion of HIV/AIDS related drama and folk shows, support to orphans, community-based care activities (including the purchasing of selected drugs for AIDS patients, equipment of HIV/AIDS waste management, etc.), income generating activities, support to HIV/AIDS clubs, financial assistance to AIDS patients and orphans, provision of drugs for opportunistic infections, sensitization campaigns against stigma and discrimination, promotion of behavior change, psychological support, targeted life-skills training to vulnerable groups, school fees and school allowances. Since it is most likely that the financial needs to implement the community HIV/AIDS action plans will far exceed the resources which can be made available under the program (an average of about $2,000 per community per year over a four year period) it was decided not to link the level of financing to the project proposals in the action plans. The level of financial resources the communities will receive will instead depend on a standard formula which takes the level of vulnerability and the number of community members into account. Hence, communities with very - 44 - high vulnerability will receive per capita more resources than communities with a lower level of vulnerability. An indicative table to determine the total financial resources to be transferred to communities over the course of one year is as follows: Level of vulnerability Low Medium Low Medium High High Population <1,000 $280 $300 $330 $350 1,000 to 5,000 $700 $750 $825 $875 5,000 to 10,000 $2,100 $2,250 $2,475 $2,625 10,000< $4,200 $4,500 $4,950 $5,250 The fornula to estimate vulnerability remains to be decided but will take HIV/AIDS prevalence and socio-economical factors into account. Because of the de-linking of the level of financing from the specific project proposals in the community action plans, there will be no need for appraisal of community projects. As soon as a community meets the five conditions mentioned above, an initial deposit of half the annual allowance will be transferred to the community account. The community will receive the second half of the allowance upon submission of a report to the CHAC about the implementation progress and the use of the financial resources. Participatory monitoring and evaluation will be an integral part of the community action plans. Communities will identify indicators they will use to measure success. The indicators will both measure the effectiveness of the activities carried out by the community members themselves, and the effectiveness of services delivered by technicians from the various sectors (teachers, nurses, health workers, NGO staff, extension workers, etc.). A simple form will be designed and included in the implementation manual. This formn will assist communities to collect the infornation in a systematic way and to transmit it to the CHAC. While the ex-ante control of community action programs is simplified as much as possible, the ex-post control will be strengthened. Special attention will be given during the participatory process at community level to explain which activities can be financed with the grants, and what the penalties will be for funding of ineligible activities (no further replenishment of the village account until ineligible expenditures have been reimbursed). Independent auditors will continuously do random controls of the use of funds at the community level, and communities will be informed during the initial participatory process about the likelihood to receive an impromptu audit to examine the use of the financial resources. The Bank's Africa Region 's Guidelines for Simplified Procurement and Disbursement, dated March 1998, will be used as a reference for procurement and disbursement at the local level, but - 45 - cognizance of local practices and the capacity of communities to manage the process will be an important consideration. As community projects funding is within the accepted upper limit for local shopping, at least three qualified local bidders would be invited to make offers for each contract. The details of the process and a model contract will be provided in the IPM. This should not be taken as the only method to be used. Direct contracting should also be acceptable when competition is not available or not practical, and this will apply especially to the financial support to communities with less than 1,000 members (most likely, the majority of communities in urban areas and among special groups will fall into this category). If consultants need to be employed, single-source selection will be permitted, but other procedures such as those based on qualifications could also be used. These procedures will be further elaborated in the financial management and procurement manual. The GTC and GTP will engage audit firms who will conduct random checks to ascertain whether the prices paid and the quality of work performed are within acceptable limits. The limited availability of financial services in rural areas constitutes a special challenge for communities in the fight against HIV/AIDS: all financial institutions in Cameroon combined have only about 680 local offices throughout the country. With the assistance of the Bank financial sector specialists, the Central Bank and commercial banks are examining ways and means to increase the presence of financial institutions throughout the country. In this effort, special attention goes to the strengthening of the linkages between savings and credit cooperatives and the formal banking system. Project Component 2 - US$6.10 million Support to health sector response The response of the health sector will include three major components : (a) surveillance, both epidemiological and behavioral; (b) prevention through treatment of STIs, voluntary testing and counseling, prevention of Mother to Child Transmission, universal precautions and blood safety; and (c) care and treatment of PLWAs. The two latter components will be offered in an integrated way. Treatment of STIs, VCT and prophylaxis and treatment of opportunistic infections are part of an integrated package of services offered to people living with HIV so they can live better, longer and protect their partners and children. Drugs for the treatment of opportunistic infections and STIs will be purchased through CENAME. An agreement between the Ministry of Finance, the Ministry of Public Health and CENAME on terms and conditions satisfactory to IDA for the provision of drugs to treat STIs and HIV/AIDS related opportunistic infections, including availability and price ceilings, will be a condition for the release of a US$500,000 revolving fund for the financing of those drugs. The modalities for the financial management of the fund will be an integral part of the agreement. Epidemiological and behavioral surveillance Surveillance of HIV prevalence in the general population will be conducted in 30 sentinel sites among pregnant women attending antenatal care, along with surveillance of syphilis. Surveillance activities will also be implemented among other key vulnerable groups: STD patients (11 sites), military (3 sites) , sex workers (5 sites), universities (3 sites). The surveillance sites for the - 46 - vulnerable groups will be organized in a way to stimulate safe behaviors including use of condoms and treatment of STIs. The utilization of the female condom will be promoted among the commercial sex workers attending the sites. Notification of cases will also be reorganized and strengthened. In parallel to the sero-surveillance, behavioral surveillance will be organized in several sites to monitor the behavior change among some key groups over time: youth between 15 and 24 years old, military, truck drivers, commercial sex workers. The behavior of comparable groups will be monitored over time to detect evolutions in behavior and tailor prevention interventions and messages. Risk mapping will also be institutionalized and combined with prevalence and response mapping. A software will be purchased and customized to ensure regular update and use of the mapping data. The epidemiological unit of the MOH will be reorganized and its institutional capacity will be reinforced for it to lead the surveillance effort. Prevention and voluntary testing and counseling The MOH strategy for prevention is four-pronged: (a) ensuring broad availability of and stimulate demand for treatments of sexually transmitted infections (STIS); (b) ensuring availability of testing counseling in all district hospitals and urban health centers as well as in rural health centers when relevant; (c) ensuring availability of prophylactic ARV and quality infant feeding counseling to reduce mother to child transmission of HIV; and (d) ensuring quality of medical procedures with safety of blood transfusion and universal precautions Treatment of sexually transmitted infections is considered one of the most effective ways to prevent the transmission of HIV in Africa. According to a study conducted in Tanzania, improvement of routine management of these infections could curtail incidence of HIV by 40%, and is highly cost-effective. (Grosskurth et al 1995.) Currently the management of STIs in Cameroon encounters two main obstacles: low use of formal services (high use of informal providers and self medication) and inadequate treatments in both duration and type of drugs used (leading to inefficacy and raise of resistance). To address these issues the MOH is launching an effort to market a quality standard approach to treatments in both the public and the private sector. The treatments will be based on the syndromic approach which allows to rationalize the treatments according to pre-determined clinical criteria organized in algorithms. Treatments will be sold as full treatment kits including the necessary drugs (in both quality and quantity) for treating a given syndrome. Kits will be bought pre-packed or will be pre-packed in the central medical store (CENAME) and made available to regional medical stores (CAPP) for distribution to all public facilities as well as non for profit private facilities. Seven different kits are to be developed: 1. Uretritis first line; 2. Uretritis second line; 3. Leucorrhea first line non pregnant woman; 4. Leucorrhea second line non pregnant woman; -47 - 5. Leucorrhea first line pregnant woman; 6. Leucorrhea second line pregnant woman; and 7. Genital ulcerations. Kits will be included in the drug revolving fund system and sold at a price set as a national standard, following the pricing standards of the National procurement and distribution system (SYNAME). A dialogue will also be initiated with the private pharmacies to make these kits available. Health staff will be trained to use the syndromic approach and prescribe the use of the treatment kits. Social marketing technique will be used to promote the use of these kits in both the public and the private sector. Costs of this strategy include the clinical testing and validation of the syndromic approach, the purchase of an initial seed stock of kits and the implementation of two pilot operations in Douala and Yaounde. In these two pilot sites, staff will be trained and intensively supervised for the syndromic approach to be systemically used and operational obstacles to its scaling up identified. Social marketing tools and information, and communication material will also be developed to stimulate demand for these quality treatments. Voluntary Counseling and Testing for HIV has been shown to trigger behavior change especially in stable relationships. (Coates et al. 2000). The MOH of Cameroon aims at rapidly making VCT for HIV widely available both inside health services and outside health services. This will require defining a national VCT strategy for Cameroon, training the counselors, and offering intensive on-site supportive supervision to counselors in place. Developing counseling will require to clearly define the various types of counseling and testing services to be offered - for example anonymous for the general population, confidential for patient's diagnosis, systematic group pre-test for pregnant women etc. - defining the profile of counselors, and developing a curriculum for the training of counselors. The HIV tests will also have to be made available and sold through CENAME with a minimum margin corresponding to stock and distribution costs. HIV rapid tests will be used as first line test. A second rapid test or an Elisa test will be used as a second line. The Government has included the national expansion of the prevention of Mother To Child Transmission as a key priority for its 3 years emergency plan of action against HIV/AIDS to be financed by debt relief proceeds. The Prevention of Mother to Child Transmission by a short regimen of anti-retrovirals and adequate infant feeding has been shown to be highly cost effective in the African context, especially so when the HIV prevalence among pregnant women is above 5% (Marseille et al, 1998; Dais et al, 1999). In addition to the funding made available to develop centers of excellence in each province through domestic resources liberated, the project will help scaling up the intervention by developing national standards for the regimens for Prevention of Mother To Child Transmission and Infant Feeding Counseling as well as training curricula for the nursing and medical staff. It will also ensure that anti-retrovirals to prevent transmission from mother to child such as Zidovudine (AZT) tablets and syrup and Nevirapine will be available by creating a revolving fund in the CENAME for these drugs. The project will also help provide support to networks of women living with HIV as a way to minimize stigma and discrimination towards women living with HIV. - 48 - The health sector also has to ensure safe blood supply and universal precautions at all levels. All provincial and district hospitals will either receive tested blood or have the possibility to test it. Health staff will be trained in universal precautions and be provided improved access to post-exposure prophylaxis. Training for health staff will also cover the proper treatment and disposal of HIV/AIDS waste. Testing and counseling will be promoted among health staff as a measure to raise awareness and empathy to people living with HIV. Care and treatment of People living with HIV Ensuring availability and stimulating the use of treatments and prophylaxis of opportunistic infections for People Living with HIV/AIDS (PLWHA) is inexpensive, cost-effective, prevents life threatening infections among PLWHA and will benefit the poorest AIDS patients who may otherwise have gone untreated. As part of the project PLWHA will have access to a basic package of cost effective treatments. The drugs and consumables necessary for basic treatment and care of people living with AIDS will be made available at both district hospital and health center level. Drugs to treat tuberculosis (about US$ 50 per treatment) will be provided free of charge by the government and will be directly funded from HIPC funds. Capacity to diagnose TB needs to be reinforced and basic lab services be put in place. Support to Directly Observed Treatment Strategy (DOTS) implementation will also have to be provided with extensive supervision and monitoring. Prophylaxis of tuberculosis (US$3 a course of 9 months of Inh) may be offered when active TB has been excluded. Prophylaxis of Pneumocystis Carinii and other infections by cotrimoxazole will also be made available to all PLWHA at a standardized minimized price, amounting to about US$ 10 per person per year. Conditions for offering the prophylactic regimen need to be defined including symptom (at least one defining infection) and lymphocyte counts. Basic treatment for fungal infections (nystatine, amphotericine) B and diarrhea and dehydration (ORS, Ringer solution) will also be part of the standard package. Health staff will be trained in diagnosing these infections and providing the appropriate treatment. These training will be offered as part of a curriculum of specialization for some key staff. Indispensable support activities will include clear definition of the package and of treatment indications and standards, training and supervision and elaboration of a standardized pricing scheme for all the treatments. Finally the Government is currently dialoguing with the pharmaceutical industry to raise access to combined anti-retrovirals at a minimum cost. Although much reduced, drug prices are still relatively high (Bilous, 1999) and there are many issues in implementation and compliance that can reduce its effectiveness. However the government will pursue its broker role to help raise financial access to care. Currently treating all AIDS patients with combined therapies in Cameroon would amount to 3 to 4 times the overall health budget of year 2000, even using the cost benchmarks of Senegal and Brazil, two countries where the cost of ARV has been decreased -49 - substantially. Training of traditional healers and birth attendants About 80% of Cameroonians consult traditional healers and birth attendants. The NHAC recognizes the potential for working closely with traditional healers and birth attendants in the fight against HIV/AIDS, especially with regard to prevention, the treatment of opportunistic infections, and socio-psychological care for people with full-blown AIDS. At the same time, the NHAC and the Ministry of Health will curtail existing practices whereby people, under the image of traditional medicine, extort patients on the promise of miracle cures for AIDS. The program will provide for the training of traditional healers and birth attendants including training on storage of herbal materials and hygienic preparation; diagnosis and treatment of opportunistic infections; nutrition; maternal and child health; pre- and post-natal care; personal hygiene; and sanitation. The methodologies used during the training will take into account that many traditional healers and birth attendants are illiterate. Appropriate training materials will be used. At this stage, there are numerous and uncoordinated associations of traditional healers and birth attendants. To ensure reaching the majority of traditional healers and birth attendants and to avoid duplication, the NHAC and the Ministry of Health will work with the existing organizations to strengthen coordination, and to foster the emerging of a national association. Project Component 3 - US$ 3.20 million Support to the design and implementation of sector strategies There is a strong consensus in the country that the fight against HIV/AIDS can only be won if in addition to the health sector, all other sectors elaborate and implement specific HIV/AIDS action plans. The program will support the development of sector specific strategies to ensure that the quality of the strategies are sound, and that the various actors in each of the sectors (private, public, civil society) are actively participating both in the design and the implementation of the strategies. Obviously, sector specific strategies will differ from each other according to the nature of the sector. However, each sector strategy will have to articulate how prevention and care will be organized among people working in the sector, among the public which is reached by the sector (e.g. pupils and students in the education sector, rural families in the agricultural sector, etc.), and will have to develop a communication strategy which is adapted to the needs and nature of the sector. Another feature which will be common to the various sector strategies will be the support to private sector companies to fight against HIV/AIDS. Private companies will be encouraged to recruit a person living with HIV/AIDS to organize the sensitization campaigns in the company, and to assist human resources management units with the development of strategies to deal with HIV/AIDS in the company. Part of the salaries of the PLWHA who are recruited to carry out this specific assignment will be financed under the sector strategy. As described in the component on - 50 - support to the health sector response, a revolving fund will be made available to CENAME to ensure the availability of drugs to treat opportunistic infections and STIs at affordable prices. This will also lighten the financial burden of those private companies that opt to assist their staff in providing treatment for opportunistic infections as part of their HIV/AIDS strategy. Each sector will be responsible for the development of a specific HIV/AIDS strategy. To coordinate this process, focal points will be identified in each sector. The focal points are small teams of two to three senior staff who will guide the process of strategy definition in the sector. To ensure that the sector specific strategies are being elaborated by the sectors - and notfor the sectors - the people in the focal points will not become staff of the GTC, but will remain in their respective sectors. However, they will work on a full time basis to ensure the development and the implementation of the sector strategies. The GTC will provide support to the focal points in terms of training on methodologies for strategy definition, training on sector-specific HIV/AIDS issues, and guidance on the development of the sector specific communication strategies. At the outset of the program, the GTC will organize a workshop for senior managers and decision makers of the various sector agencies. This workshop will have as an objective to sensitize attendants on the HIV/AIDS epidemic, to explain how the epidemic is affecting the various actors in the sector (private enterprises, public administrations, semi-public entities, trade unions, consumer organizations, and the public at large). As a result of the workshop, there should be a clear understanding among the senior decision makers in the sector about the need to rhobilize and to develop specific strategies for prevention and mitigation both among the people working in the sector, and among the public. Consensus will also be reached about the appointment of focal points within each sector and about the process of strategy definition and implementation. Once the focal points identified, they will be trained by the GTC with the assistance of international consultants on the methodologies for strategy definition. With the help of UNICEF, a training program in this vein for sector staff has already started, and the project will continue to support this effort. As a next step, each focal point will elaborate a specific proposal detailing how they will identify a working group of staff from the various actors in the sector (and in each sub-sector), and what the process will be to elaborate the sector strategies. The GTC will organize workshops for four to five focal points at a time where these proposals will be discussed, where focal points will exchange experiences, and provide feed-back on their respective proposals. Special attention will be given during this workshops to ensure that the focal points can cement the full participation of the various actors in the sector. The workshops will also review to what extent the various dimensions which need to be covered by the sector strategies are being taken into account. Once an agreement reached on the action plan to develop the sector strategy, the focal points start implementing the action plan. During the process, the GTC will continue to provide support and feed-back to the focal points. The focal points can also request the assistance from national and/or international consultants where needed. When and if this assistance is required, the consultants will be selected and recruited with the assistance of the GTC. - 51 - The project will finance the entire process of strategy definition. This includes the various workshops, consultancies, and logistical support to the process. The project will also ensure the proper supervision and coaching of the elaboration and implementation of the respective HIV/AIDS sector strategies through the GTC and GTP. However, the available financial resources do not allow the financing of the implementation of the respective HIV/AIDS sector strategies through the Credit or through the NHAC. To ensure proper financing of the sector strategies, they will be presented to the Ministry of Finance which agreed to include them under the priority programs to be funded under the HIPC initiative. However, only those sector strategies which have been certified by the GTC to be sound and not to constitute overlapping with activities programmed in other sectors will be eligible for HIPC financing. The coordination of the implementation of the respective sector strategies and the coordination between sector strategies and the action plans elaborated by local communities will take place in the HIV/AIDS Committees at national, provincial, communal, and local community level. In the respective HIV/AIDS Committees, representatives from the various sectors and representatives from civil society meet. This platform will be used to ensure that the respective sectors provide adequate support to local communities, that the action plans of local communities are truly multi-sectoral, and that the sector strategies complement (rather than overlap) each other. To facilitate this coordination, the GTC, GTP, and the technician at the communal level will play an important role of technical assistance to their respective HIV/AIDS Committees. Project Component 4 - US$8.40 million Capacity building To meet the tremendous challenge of training and strengthening of capacity at various levels, the project will have an important capacity buitding component. This component will include: strengthening of HIV/AIDS committees at various levels; training of project staff at national, provincial, and communal level; training of sectoral focal points; training of staff of sub-contracting agencies responsible for the facilitation of participatory processes at community level; training of communication specialists on HIV/AIDS related issues; training of financial management staff on the procurement, disbursement and accounting procedures; and training of community members on methods for community based procurement, transparency, and record keeping. Strengthening of HIV/AIDS committees: members of HIV/AIDS committees at national, provincial, communal, and local community levels will require training to better master their role of strategy definition and supervision of the respective implementation units. The training will be provided partly by members of the implementation units, and partly by national and international consultants and NGOs. In addition to formal training sessions and workshops, provisions have been made to facilitate visits of members of HIV/AIDS committees to colleagues in other provinces or abroad to exchange experiences and to learn from best practices elsewhere. Training of project staff at the national, provincial, and communal levels: to reflect the multi-sectoral nature of the HIV/AIDS program in Cameroon, project staff will be recruited from various sectors. At the outset of the program, the various section chiefs of the GTC will provide - 52 - training to their staff at the national, provincial and communal level to ensure full understanding of the program design, the institutional framework, the methodologies to be used to carry out the work programs, and the respective terms of reference of staff. Refresher courses will be organized on an annual basis to facilitate learning-by-doing and to exchange best practices. Training of facilitators of participatory processes at the community level: field staff and managers from sub-contracting agencies will receive training on methodologies for community participation. The section for support to local responses will be responsible for the organization of this training which will be organized in the field and will be very practical in nature. The objective of the training is to ensure that facilitators are well versed in the specific HIV/AIDS methodologies for community participation as adapted to various sociological settings through the action/research program (see above: support to local responses component). The initial training will be followed by annual refresher courses where staff can exchange experiences and incorporate lessons learned. Training of sector focal points: people who will be identified by the sectors to act as sector focal points will be trained on the methodologies and organization of the elaboration of sector specific action plans. This training will also strengthen specific knowledge on how HIV/AIDS affects the sector. In addition, focal points will be trained as needed in facilitation skills to strengthen their capacity to coach their counterparts from the various sector agencies in the process of designing and implementing the HIV/AIDS strategies. Other key aspects of the training include the strengthening of capacity of sectoral focal points on log-frame techniques, the identification of monitorable indicators, the clarification of implementation arrangements and institutional settings, and the elaboration of budgets. Training of communication specialists on HIV/AIDS related issues: part of the responsibility of the section responsible for IEC is the strengthening of capacities among communicators with regard to HIV/AIDS. Specifically, training will be provided to members of the press to increase their knowledge and access to accurate and up-to-date information on the HIV/AIDS crisis, about progress made in research, about availability of treatment and care, etc. As part of the communication strategy of the NHAC, consultants will be recruited to assist in the strengthening of the communication strategies developed under the program. Training of financial management staff on the procurement, disbursement and accounting procedures: the financial management staff at the national and provincial level will receive training on the procedures that will apply under this program and which are detailed in the financial management manual. Special attention will go to the training of staff at the communal level on community based procurement. Training of community members on methods for community based procurement, transparency, and record keeping: to mitigate the risk of abuse of funds at the community level, the program will provide for the training of community members on financial management, transparency and record keeping. This training will be an integral part of the services provided by the sub-contracting agencies responsible for the facilitation of participatory processes at the community level. Also the professional staff working at the communal level will provide assistance to communities to strengthen their financial management capacities. In addition to the - 53 - training by the professional staff, provisions have been made for visits between members of communities from different parts of the country to encourage exchange of experience and best practices. Project Component 5 - US$11.60 million Coordination Under the coordination component, investment and recurrent costs of the HIV/AIDS Committees at various levels and of the GTC, GTP, and communal technicians will be financed. The description of the HIV/AIDS committees and the GTC and GTP are provided in the section below on implementation arrangements. Implementation arrangements Organizational charts reflecting the implementation arrangements are included in annex 12. The HIV/AIDS Committees at National level (NHAC), Provincial level (PHAC), Communal level (CHAC), and local community level (LHAC) are responsible for the definition of the HIV/AIDS strategies and action plans at their respective levels and for the implementation of these action plans. To ensure the day-to-day implementation of the entire program, the NHAC has created a Groupe Technique Central (GTC). The GTC comprises a Permanent Secretary and about twenty staff. Similarly, at the provincial level the PHAC is assisted by a Groupe Technique Provincial (GTP). The GTP comprises a provincial manager and about seven staff. At the communal level, every CHAC will be assisted by a technician. To reflect the multi-sectoral character of the operation, staff at the national, provincial, and communal level will come from various sectors (e.g. education, health, communication, agriculture, and finance, etc.). The organization, composition, and staffing of the program at the national, provincial and communal level are described in detail in the implementation manual. At the grassroots level, local HIV/AIDS Committees (LHAC) will be created through a participatory process in every community: communities in urban areas (associations based on professional, confessional, geographic, and other affiliations), communities in rural areas (villages), and communities among special vulnerable groups (commercial sex workers, inmates, truck drivers, university students, street children, etc.). The HIV/AIDS committees at various levels hold their respective implementation units accountable - GTC, GTP, and technician at respectively national, provincial, and communal level. At the local community level, the LHAC holds the community members responsible for the implementation of the community action plans accountable. The HIV/AIDS Committees at various levels are the nexus where the "local responses" and the" sector responses" meet and are coordinated. In the committees, representatives from various sectors (responsible for the design and implementation of sector specific HIV/AIDS strategies), political authorities, and members of civil society (responsible for the design and implementation of local responses) participate. The HIV/AIDS Committees provide guidance to the various stakeholders so that the community action plans elaborated through the local response component - 54 - are sound, and so that the various sectors provide adequate responses to the community action plans. The Groupe Technique Central (GTC) is managed by a Permanent Secretary and is composed of five sections: (i) a section for support to local responses; (ii) a section for support to sector responses; (iii) an operational section, responsible for monitoring and evaluation of the entire program, monitoring of support and care for PLWHA, and epidemiological surveillance; (iv) a section responsible for information, communication, and education (IEC); and (v) a financial management section. The Groupe Technique Provincial (GTP) is managed by a provincial manager and comprises the same sections as the GTC. The Permanent Secretary is responsible for the overall coordination and implementation of the program. (S)he oversees the elaboration of the annual work programs and budgets in line with the national HIV/AIDS strategy and presents the annual work plan and budget to the NHAC for approval; holds the staff in the GTC at the national and provincial levels accountable for the proper implementation of the work programs; is accountable to the NHAC with regard to the implementation of the work programs, the diligent use of resources, and the implementation of activities carried out through sub-contracting agencies; and assumes the function of secretary to the NHAC. At the provincial level, the provincial manager is responsible for the elaboration of annual work plans and budgets, for the implementation of the work plans (mainly through sub-contracting agencies), and for the supervision of field activities. The provincial manager assumes the function of secretary to the PHAC. The section for support to local responses is staffed at the national level by a section chief and three senior staff (one for rural areas, one for urban areas, and one for vulnerable groups). At the provincial level there is one provincial coordinator for support to local responses. The section for support to local responses is responsible for the development and implementation of HIV/AIDS strategies at the grassroots level. Facilitation of community participation processes will be subcontracted to organizations (NGOs, projects, religious organizations, public sectoral agencies such as the extension service, private companies, etc.) which are already established in the field. The section staff will determine the methodologies to be used, will identify, select, and contract implementing agencies, and will provide training, supervision, and financial support to these agencies. They will also supervise field staff at the communal level who assist communal and grassroots HIV/AIDS Committees in the elaboration and implementation of their action plans. The section for support to sector responses is staffed at the national level by a section chief and three senior staff (one for social sectors, one for economic sectors, and one for politico-administrative sectors). At the provincial level there is one provincial coordinator. The section for support to sector responses is responsible for assisting various sectors (health, education, defense, communication, rural development, transport, public works, tourism, financial sector, women affairs, etc.) with the development and implementation of sector specific HIV/AIDS strategies. The actual development of the sector strategies will be done by sectoral focal points (staff in the respective sectors who have been designated for this purpose). The section staff will ensure the training of the focal points of the various sectors, will assist the various sectors with the development and implementation of the sector specific strategies, and will - 55 - ensure that the sector strategies are geared to respond to the demands stemming from local communities. The operational section is staffed at the national level by one section chief and three staff (one in charge of monitoring support and care for PLWHA, one in charge of epidemiological and behavioral surveillance, and one in charge of monitoring and evaluation). At the provincial level, there will be one provincial coordinator and one staff responsible for monitoring and evaluation. The role of the section is to ensure that people living with HIV/AIDS receive as good care as possible, and to generate accurate information about the evolution of the HIV/AIDS crisis in Cameroon. In addition, the section is responsible to monitor the operations on the ground and to make regular evaluations of the impact of the program. Most of the activities will be carried out through sub-contracting or partner agencies. The medical care of PLWHA will be coordinated by the Ministry of Health and implemented through public and private health sector agencies (in this case, there will be no sub-contracting arrangements: medical care for PLWHA - including voluntary testing and counseling - is an integral part of the health sector response to HIV/AIDS). Epidemiological and behavioral surveillance will be sub-contracted to specialized agencies. Data collection for monitoring and evaluation will be carried out partially through the internal reporting systems of the GTC, and partly through independent surveys (such as beneficiary assessments). The section for information, communication, and education is staffed at the national level by one section chief and three staff. At the provincial level, the section has one staff. The section is responsible for the development and implementation of the communication strategy of the NHAC and for assisting the various sectors in the elaboration of their sector specific communication strategies. The design of the NHAC's communication strategy will be sub-contracted to a specialized agency which will be selected through a tendering process. The GTC will indicate a minimum list of activities that should be included in the communication strategy (such as public awareness campaigns, Cameroon HIV/AIDS web-site, regular production of fact sheets and press conferences, etc.). However, the contracting agency will have freedom to develop and suggest additional features for the NHAC's communication strategy. Once the strategy approved and adopted by the NHAC, the implementation of the strategy will be sub-contracted to one or more specialized agencies. The section staff will be responsible for supervising the work of the sub-contracting agency, for the assessment of the level of HIV/AIDS awareness in the national press, for ensuring the dissemination of accurate information on HIV/AIDS in general and on the evolution of the epidemic in Cameroon in particular, and for the technical support to the various sector units with regard to the design and implementation of their respective communication strategies. The financial management section is staffed at the national level by one section chief and two staff. At the provincial level, the section has one staff. With regard to financial management, the accounting of the entire program at the national and the provincial level will be sub-contracted to specialized accounting firms. Also internal audits of the various components of the program, including the financial management at the community level, will be sub-contracted. The operations of the financial management section are further explained below. The Commission Mixte de Suivi will be responsible for external auditing and control of the entire - 56 - program. This Commission is composed of representatives from the Ministry of Territorial Administration, the Ministry of Finance, the Ministry of Public Investments, the Ministry of Public Health, PLWHA, employer organizations, religious groups, UTNAIDS, bi-lateral and multi-lateral donors. Representatives from the President's Office, the Services of the Prime Minister, Parliament, and the Judiciary will sit on the Commission as independent observers. The Commission has statutory meetings on a quarterly basis, but will also meet at any time at the request of any of the independent observers. The Commission will verify to what extent program implementation actually reflects the directions provided through the National HIV/AIDS strategy. The Commission will also order external audits to verify the proper management and use of resources at the various levels of program implementation and will instruct the GTC on any corrective action to be taken when needed. The minutes of the Commission's meetings will be transmitted to the President's Office, the Prime Minister, the Minister of Finance, the Minister of Planning, and the donor community. Financial Management The NHAC will be responsible for the entire project coordination and the GTC insures coordination of all technical aspects at the national level for the NHAC. The CPLS insures coordination at the provincial level and reports to the CNLS, while the GTP insures coordination of the technical aspects at the provincial for the PHAC. Flow of Funds The disbursement system has been set-up to ensure timely and reliable flow of funds to the end user at the community level. Although there is only one implementing agency, IDA funds will be deposited in two independent Special Accounts, Special Account A and Special Account B, held in commercial banks acceptable to IDA. Government counterpart contributions will be lodged at the CAA in a separate Project earmarked account. The HIPC funds will not flow through the project but will be managed separately through the Treasury and the national budget according to the national budgetary and accounting process. Special Account A would be used exclusively to channel IDA funds to the communities in order to isolate the flow of project funds to the communities from the rest of the project disbursements. Special Account A will facilitate the monitoring of funds flows to communities and will improve the reliability and ease of bank reconciliations with project accounts. In addition, Special Account A will be replenished exclusively on the basis of actual flows to Provinces and additional advances to Special Account A, from IDA, made on the basis of cash flow projections while Special Account B will be replenished based on actual expenditure as evidenced by SOEs and supporting documentation. Ten sub-accounts to Special Account A, one in each Province, will be opened in local banks/financial institutions acceptable to IDA, and will be used to receive IDA funds from Special Account A and to disburse funds directly to communities' bank accounts. Special Account B will be used for all other project disbursements, including reimbursements to the Project Account whenever necessary. Ten sub-accounts to Special Account B , one in each province, will be opened in local banks/financial institutions acceptable to IDA. However, these sub-accounts will only be relied upon to the extent that the allocation of counterpart funds in the Project - 57 - Account is insufficient to cover project expenditures. The Project Account will receive counterpart funds to be used exclusively for project expenditure and not for community level activities. Ten sub-accounts of the Project Account will also be maintained in each Province. Cash and Document Flow: Special Accounts Caisse Autonome d'Amortissement Special Account A Special Account B Project Account 1. 1 NHAC/ GTC _ _ _ _ Sub account A Sub-account B Project account PHAC/GTP A CH ~~~~~~~~~ICash flow LHAC A Document Flow Accounting Overall responsibility for maintaining projects accounts in a manner acceptable to the Bank will rest with GTC. Project accounts will also be maintained by the 10 GTP and will be consolidated by GTC. Supervision of the accounts kept by GTP will be done by GTC, which will be responsible for consolidation of the project accounts. Except for community level expenditure, GTC and GTP will maintain supporting documentation for all project expenditure in a manner acceptable to the Bank. Accounting at the community level will be minimal, and will include recording of expenditures, reconciling with bank statements and ensuring that supporting documentation is available. Payments made by GTP directly to communities will be recorded as project expenditure under disbursement category 1, but given the dispersion of funds to approximately 13,000 villages and end-users, the actual detailed expenditure made by communities will not be consolidated with the overall project expenditure accounts. The supporting documentation held by communities will be audited by external auditors on a random - 58 - basis. Annual expenditure budgets will be prepared by the project and will include activities at GTC, GTP and community levels. Budget at the community levels will use standard costs for all activities, as determined by the project management. Private accounting firrns will be recruited by GTC and the ten GTP to provide accounting services for the project. The project Chief Financial Officer will be responsible for the overall project financial management and will closely supervise the work of the accounting firms. The project accounting and financial management team will be mobilized before project effectiveness. In order for the project to comply with the Government's public finance regulations, all project expenditures at the GTC and GTP levels will be subjected to ex-post control by the MINEFI controllers (Controleurs financiers). A project financial and accounting procedures manual which should be acceptable to the Bank is currently under preparation by a private accounting firm. The financial and accounting procedures manual will be completed prior to effectiveness, and will include all forms required for reporting project expenditure, including forms designed for communities to report their activities, specifically costs and outputs. GTC will not have the capacity to produce PMRs initially, but during the first year of project implementation, the project capacity to produce PMR for disbursement purposes will be assessed and a determination will then be made of when the project will be in position.to convert to PMR based disbursements. The following action plan has been agreed with the Borrower: - appointrnent of a Chief Financial Officer - done; - appointment of one/several accounting firms to provide accounting services - before effectiveness; - completion of the financial and accounting procedures manual acceptable to IDA - before effectiveness; - setting-up of an accounting and financial system, including project tailored software - before effectiveness; - production of PMR - to be assessed by November 30, 2002. - 59 - Annex 3: Estimated Project Costs CAMEROON: Multi-sectoral HIV/AIDS Project Local Foreign Total Project Cost By Component US $million US $million US $million Support to local responses 30.00 0.53 30.53 Support to health sector responses 3.43 2.52 5.95 Support to the design and implementation of sector strategies 2.30 0.74 3.04 Capacity building 4.80 3.00 7.80 Coordination 8.40 2.70 11.10 Total Baseline Cost 48.93 9.49 58.42 Physical Contingencies 0.38 0.15 0.53 Price Contingencies 0.69 0.36 1.05 Total Project Costs 50.00 10.00 60.00 Total Financing Required 50.00 10.00 60.00 LocalI Foreign Total Project Cost By Category I US $million us llio S $million Subprojects 25.00 0.00 25.00 Goods 1.10 2.40 3.50 Services, Training and Audits 9.40 5.60 15.00 Operating costs 12.00 2.00 14.00 Beneficiaries contributions 2.50 0.00 2.50 Total Project Costs 50.00 10.00 60.00 0 Total Financing Required 50.00 10.00 60.00 - 60 - Annex 4 CAMEROON: Multi-sectoral HIV/AIDS Project Benefit Analysis Summary An economic analysis of the impact of HIV/AIDS and a cost-benefit analysis of the Multi-sectoral HIV/AIDS project prepared under the Multi-Country AIDS Program was discussed in Annex 5 of the Project Appraisal Document of the Multi-Country HIV/AIDS Program for the Africa Region. In addition to this economic analysis it may be mentioned that the proposed project will benefit the population of Cameroon in numerous ways: - It will directly benefit highly vulnerable groups such as commercial sex workers, men and women in uniform, truckers, university students and plantation workers, who will be able to protect themselves as well as their partners thanks to accessible and affordable means of prevention; - It will also highly benefit pregnant women and young people, by enhancing reproductive health education and raising access to prevention and treatments of sexually transmitted infections; - It will benefit the Cameroon society overall by reducing the risk of acquiring HIV of the general population, beyond these vulnerable groups and avoiding more than one million new infections among adults before 2005; - It will contribute to decreasing the HIV infection rates of children, avoiding the contamination of more than 50,000 children before 2005 and contributing to increase in life expectancy; - It will reduce the impoverishing impact of AIDS on households by reducing the loss of income due to illness and deaths of breadwinners as well as by providing accessible, affordable care and transfers; It will help communities to cushion the economic impact of AIDS and help diminish the economic vulnerability of women by raising access to income generating activities; - Communities'capacities will be strengthened and "dialogue" and empowerment structures supported and reinforced; - The social capital of Cameroon will be protected by supporting solidarity mechanisms and care to orphans; - It will benefit the economic development of Cameroon, protecting its human capital, reducing loss of productivity and producing significant savings on health expenditures for the government, firms and households. - 61 - Annex 5: Financial Summary CAMEROON: Multi-sectoral HIVIAIDS Project Years Ending 7757 I Yearl |Year2 I Year3 I Year4 I Year5 Year6 Year 7 Total Financing Required Project Costs Investment Costs 14.0 8.8 11.8 11.8 0.0 0.0 0.0 Recurrent Costs 3.0 4.2 3.2 3.2 0.0 0.0 0.0 Total Project Costs 17.0 13.0 15.0 15.0 0.0 0.0 0.0 Total Financing 17.0 13.0 15.0 15.0 0.0 0.0 0.0 Financing IBRDIIDA 14.5 10.0 12.5 13.0 0.0 0.0 0.0 Government 2.0 2.5 1.7 1.2 0.0 0.0 0.0 Central 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Provincial 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Co-financiers 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Beneficiaries 0.5 0.5 0.8 0.8 0.0 0.0 0.0 Others 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total Project Financing 17.0 13.0 15.0 15.0 0.0 0.0 0.0 Main assumptions: - 62 - Annex 6: Procurement and Disbursement Arrangements CAMEROON: Multi-sectoral HIV/AIDS Project Procurement General A Country Procurement Assessment Review (CPAR) is under way in Cameroon. The national procurement system needs a major reform. Procedures for procurement of works, goods, and services are weak in several areas. The Government seems to be ready to make changes in this regard and is considering the Bank's assistance to help in the preparation of a new procurement code which is schedule to be completed by the end of 2001. In the meantime, Cameroon's procurement laws and regulations do not conflict with IDA Guidelines. No special exceptions, permits, or licenses need to be specified in the Credit since Cameroon's procurement practices allow IDA procedures to take precedence over any contrary provisions in local regulations. Guidelines No civil works are scheduled for the project. Goods financed by IDA will be procured in accordance with Bank's Guidelines under IBRD Loans and IDA Credits (January 1995 revised in January and August 1996, September 1997, and January 1999), and Bank Standard Bidding Documnents, and Standard Evaluation Report will be used for ICB. National Competitive Bidding (NCB) advertised locally would be carried out in accordance with Cameroon's procurement laws and regulations, acceptable to IDA, provided that they assure economy, efficiency, transparency, fair participation, and broad consistency with key objectives of the Bank Guidelines. For NCB procedures, the Government has given assurances during negotiations that: (i) bids will be advertised in national newspapers with wide circulation; (ii) methods used in the evaluation of bids and the award of contracts are made known to all bidders and not be applied arbitrarily; (iii) any bidder is given adequate response time (four weeks) for preparation and submission of bids; (iv) bid evaluation and bidder qualification are clearly specified in bidding documents; (v) no preference margin is granted to domestic manufacturers; (vi) eligible firms, including foreign firms are not precluded from participation; (vii) award will be made to the lowest evaluated bidder in accordance with pre-determined and transparent methods; (viii) bid evaluation reports will clearly state the reasons to reject any non-responsive bid. Standard Bidding Documents to be used for NCB will be reviewed by IDA before Credit effectiveness. Consultant Services contracts financed by IDA will be procured in accordance with the Banks Guidelines for the Selection of Consultants by World Bank Borrowers (January 1997 revised in September 1997, and January 1999). The standard Request for Proposal, as developed by the Bank, will be used for appointment of consultants as well as the Sample form of Evaluation Report for the Selection of Consultants. Simplified contracts will be used for short-term assignments, i.e. those not exceeding six months, carried out by firms or individual consultants. The Government has been briefed during the appraisal mission about the features of the new Consultants Guidelines, in particular with regards to advertisement, bid opening and various steps of IDA reviews. -63 - Community Participation in Procurement will be based on Simplified Procurement and Disbursement Procedures for Community-Based Investments (February 1998). Advertising Given the urgency of the project, a General Procurement Notice (GPN) for the first year of operations will be prepared and issued in the United Nations Development Business (UJNDB) web site without the need for hard-copy publication, as well as in the local newspapers to advertise for any ICB for goods and for major consulting assignments to obtain expression of interest. The requirement for printed publication of GPN has been waived by the RPA office. The GPN will also be issued in the national press for contracts to be let under NCB. The detailed GPN for the subsequent years will be prepared for the project and published in UNDB. It will be updated annually for all outstanding procurement. Specific Procurement Notices (SPN) and Expressions of Interest (EOI) for large contracts for consultants services (above US$200,000 equivalent) will also be advertised in Development Business and sufficient time will be allowed for responses to such specific notices (minimum 30 days) before preparing the short list. In order to accelerate project implementation, the Government wish to proceed with the initial steps of procurement before signing the related Credit Agreement. The procurement procedures, including advertising, will be done in accordance with the Guidelines in order for the eventual contracts to be eligible for Bank financing, and the normal review process by the Bank will be followed in accordance with the Procurement Guidelines for Goods and Consultants mentioned above. Procurement Implementation Arrangements The overall responsibility for the implementation of the national strategy for the fight against HIV/AIDS lays with the National HIV/AIDS Committee (NHAC) and its decentralized entities at provincial (PHAC), communal (CHAC), and local (LHAC) levels. The HIV/AIDS Committees are responsible for the strategy definition, the approval of annual work plans and budgets, and the supervision of the implementation of the strategies at their respective levels. To ensure proper implementation, the HIV/AIDS Committees are supported by technical units. At the national level, the NHAC implements its strategy through the Groupe Technique Central ( GTC). At the provincial level, the PHAC works through the Groupe Technique Provincial (GTP). The GTC is managed by a Permanent Secretary and is composed of five sections. The financial management section will include two procurement specialists who are currently under recruitment. The GTP, managed by a provincial manager will comprise the same sections as the GTC and would also include a person in charge of the procurement at this level. GTC will be responsible for preparation of bidding documents, bid evaluation and award, contract monitoring and management at central level. The procurement of vehicles, motorcycles, office equipment, computers and audio visual material will be handled by the GTC. Procurement of items such as IEC materials, workshops, training, and supplies will also be handled by GTC at the - 64 - central level using the specified procurement methods identified for the project. GTP will be responsible only for the procurement of operating goods, (office supply, gasoline, etc.) and the procurement of services of implementing agencies responsible for the facilitation of participatory processes at the community level. The GTP will be authorized to sign contracts with these agencies in accordance with the provisions of the Program Implementation Manual (PIM), but will require prior review by the GTC for any contracts of a value of more than $US20,000 equivalent. Procurement Capacity & Procurement Plan An assessment of procurement capacity of the GTC to verify whether it will be able to handle the procurement workload under the project is ongoing, and an action plan will be discussed to correct any management deficiency in the implementation agency's capacity to administer procurement in an efficient and transparent way. This assessment will also help set parameters for prior review limits and the frequency of procurement supervision. Given the workload in procurement during the first year, the GTC will be reinforced through (i) recruitment of two procurement specialists; (ii) procurement training at the Regional procurement center (Senegal) if necessary; and (iii) under exceptional circumstances basis, hiring of short-term consultants. The GTC is currently recruiting of procurement specialists. In addition, procurement proficient staff will be recruited in the GTP prior to Credit effectiveness. More than 50 percent of the project funds are allocated to local initiatives under community-based or "community involved" sub-projects. The procurement plan for the first year was prepared during appraisal and has been finalized during negotiations. It is based on the initial needs of the National HIV/AIDS Committee (NHAC), and the work-programs submitted by the GTC and GTP. Costs beyond Project Year 1 for the subsequent years are only indicative at the time of project appraisal. The exact mix of procurement will be determined on an annual basis during the annual joint reviews between NHAC, IDA, and other partners, where a draft procurement plan for the following financial year will be presented and agreed upon. During the first 12 months of project operations, the detailed procurement plans for the following years will be developed and submitted to IDA for review and approval. The plan will include relevant information on goods, and consulting services under the project as well as the timing of each milestone in the procurement process. The procurement schedule will be updated every quarter and reviewed by IDA during each supervision mission. The procurement plan will be part of the Manual of Financial Management and Accounting Procedures and the Project Implementation Manual. The PIM should solicit the participation of all stakeholders, set out the procurement plans, assess the local counterpart fund requirements, specify responsibilities for commitment and implementations, and identify the risks that need to be controlled. Financial and Accounting Procedures Manual and Agreements A Financial and Accounting Procedures Manual on administrative procedures and internal organization at central and decentralized levels will include: (i) eligibility criteria for selecting sub-projects for implementation under the proposed project; (ii) procedures for calling for bids, selecting consultants and vendors, and awarding contracts; (iii) internal organization for - 65 - supervision and quality control; and (iv) financial management, budgeting, accounting, and disbursement procedures. The drafting of this manual was initiated during preparation and a first draft has been discussed during negotiations. In any case, the adoption of the manual in a formn acceptable to IDA will be a condition of credit effectiveness. As a condition for negotiations, the Government has reviewed and agreed with IDA: (a) a draft procurement plan for the first year of the project prepared during appraisal; (b) a draft version of the Project Implementation Manual with target time periods for the various procurement phases; (c) a draft standard bidding document format to be used under NCB procedures for goods; a plan for training the GTC. Before credit effectiveness, a consensus will be reached on the proper monitoring of procurement as well as on the standard bidding documents to be used for NCB. The Government has given assurances at negotiations that it will: (a) use a Financial and Accounting Procedures Manual and a Project Implementation Manual satisfactory to IDA; (b) use the Bank's Standard Bidding Documents, for ICB, the Standard Request for Proposals for the selection of consultants, and the Standard Bid Evaluation report; (c) apply the procurement procedures and arrangements outlined in the above documents; (d) update the procurement plan on a regular basis during annual reviews with IDA, to compare target times and actual completion, and transmit it to IDA, during implementation, with all procurement-related documents; and (e) carry out, during annual reviews, an assessment of the effectiveness of bidding procedures and performance, as they relate to the project's procurement experience, and propose for IDA's consideration any modification to the current procedures to the extent that would accelerate procurement, while still maintaining compliance with the Bank's Procurement Guidelines and adequate control over contract awards and payments. Procurement methods (Table A) The program elements by expenditure category, their estimated costs, and procurement methods are summarized in Table A below. Thresholds for procurement methods and prior review are summarized in Table B. Goods The total cost of goods is estimated at US$3.5 million for the project. Procurement of goods will be bulked where feasible into packages valued at US$100,000 equivalent or more per package and will be procured through International Competitive Bidding (ICB). Preference for domestically manufactured goods will apply in accordance with the World Bank Guidelines. Contracts for office furniture and equipment, and materials locally available which cost more than US$20,000 but less than US$100,000, up to an aggregate amount of US$ 1 million would be procured through National Competitive Bidding (NCB) procedures acceptable to IDA. Other Procedures. Procurement of small office equipment, furniture for GTC and GTP, printed materials for IEC, and other instructional materials costing less than US$20,000 up to an aggregate amount of US$0.5 million equivalent will be procured through prudent International Shopping and National Shopping in accordance with the provisions of paragraph 3.5 of the Guidelines. Solicitations will be issued in writing to at least three reputable suppliers (preferably - 66 - more) in order to receive at least three competitive quotations. Solicitations will give specifications, and if not immediately available, the delivery time. Written quotations will be opened at the same time for evaluation and records of award decisions will be kept for Bank supervision missions and audits. Specific shopping procedures to be followed will be reflected in the procurement section of the Manual of Procedures. Procurement of spare parts, minor off-the-shelf items, and other specialist equipment and proprietary items costing less than US$10,000 equivalent per contract up to an aggregate of US$0.30 million equivalent, may be procured directly from manufacturers and authorized local distributors. Given the urgent nature of the project, it will be critical for successful implementation to ensure mobility of staff and circulation of information as quickly as possible. As indicated in the introduction to this annex, the current procurement procedures in Cameroon call for substantial revision. The experience with other IDA-funded projects has indicated that procurement through the National Tender Board for items such as motorcycles or cars can take as long as 15 months or more. This kind of delays would keep the project staff at the critical early stage of project implementation from reaching communities and from supervising the work of sub-contracting agencies responsible for the facilitation of participatory processes at the community level. To ensure that the project can be effective as early as possible in the implementation phase, motorcycles, vehicles, and computers for a total amount not exceeding US$1.5 million over the life of the project could be purchased through specialized agencies of the United Nations ( IAPSO). Direct contracting (Sole source) may be exceptionally used for the procurement of HIV rapid tests with the prior no-objection of the Bank provided: (a) this test is proprietary and obtainable only from one source at a reasonable price and, (b) the aggregate amount of such contracts does not exceed the equivalent of US$200,000 over the project life. The aggregate values for NCB or other non-ICB procurement methods for goods are limitative and cannot be exceeded without the prior no-objection of the Bank. The GTC will maintain a tracking system to monitor such procurement in order to alert the Bank timely when this may occur. The procedures followed, and total aggregate amount for all shopping methods under the project, will be reviewed after six months of project operations; depending on performance, and the results of the review, the total aggregate amount may be adjusted downward where necessary. Standard request forms and establishment of guidelines for conduct of the shopping method (as per the June 9, 2000 Memorandum "Guidance on Shopping") should be prepared and included in the PIM). These aggregate limits do not include contracts under the Support to Local Response Component. Community-Based Procurement The Africa Guidelines for Simplified Procurement and Disbursement for Community-Based Investments (February 1998) will be used in the design of procurement under this aspect of the project but cognizance of local practices and the capacity of communities to manage the process - 67 - will be an important consideration. The GTC will be responsible for ensuring compliance with these guidelines, and ex-post reviews of random sub-projects will be conducted periodically by the Bank and independent consultants appointed by the GTC. Simplified procurement and disbursement procedures for community-based programs, including the positive list of items qualifying under this component, will be developed and included in the Project Implementation Manual for approval by IDA. The PIM will also include procedures for IDA prior review thresholds for NGOs, private sector, and other community initiatives. Several aspects of the program implementation will be sub-contracted including facilitation of cotnmunity participation processes: At the beginning of program implementation, the PHAC/GTP will identify all organizations in the Province who have capacity to facilitate participation processes at the community level. Annual contracts will be established between the PHAC/GTP and these organizations to specify which organization will be responsible for facilitation of participatory processes in which areas. The contract will also stipulate the financial and technical support the sub-contracting agencies will receive from the project to carry out their assignment. The sub-contracting agencies' field work will be supervised by the PHAC/GTP. Field staff from various sub-contracting agencies will facilitate the communities to carry out the participatory process to determine their HIV/AIDS action plans. The PHAC/GTP will be responsible for the identification, selection, and contracting of these sub-contracting agencies to implement the facilitation of participatory processes. Through press announcements, all institutions working with communities in a given province will be invited to express interest in the program and to provide information about the operations and organization of the institution. After an initial screening process on the basis of the information provided, those organizations that appear to have sufficient capacity will be invited to a provincial workshop. During the workshop, the participatory processes will be discussed in detail, and discussions will be conducted to determine which organization will be responsible for the facilitation of participatory processes at the community level in which areas. Depending on the amount of communities covered, the sub-contracting agencies will receive financial assistance from the program to meet their incremental costs. The agreement between the PHAC/GTP will be formalized in a contract which is renewable on an annual basis. Prototype contracts will be included in the PIM. The total cost for this activity is US$1.25 million equivalent. Consultants services The consulting services required will be mostly in the areas of HIV/AIDS education, IEC applied research, training, community development, financial management, monitoring and evaluation, information dissemination, auditing, and accounting. The exact mix (types of consultancy, budgets, procurement methods) will be discussed and agreed annually during joint reviews. Consultants will be hired through competition based on Quality-and Cost-Based Selection (QCBS) among qualified short-listed firms, by evaluating the quality of the proposals before combining quality and cost evaluation, by weighting and adding the quality and cost scores. Least Cost Selection (LCS) in accordance with para. 3.1 and 3.6 of the Consultant Guidelines, will be used for audit contracts costing less than US$100,000; the firm with the lowest price will be selected, provided its technical proposal received the minimum mark. Services for facilitation of - 68 - community participation processes and sub-contracted activities estimated to cost less than US$20,000 equivalent per contract, up to an aggregate amount not to exceed US$400,000 equivalent, may be procured under contracts based on Consultant's Qualifications in accordance with the provisions of paragraph 3.7 of the Consultant Guidelines. The selection of Individual Consultants Services for small studies and other assignments will be on the basis of comparison of curriculum vitae in accordance with paras 5.1 through 5.3 of the Consultant Guidelines. Single Source Selection (SSS) will be used exceptionally for (a) training, (b) for specific task in a case where only one firn has specific qualified experience, and (c) for consulting assignments costing less than US$10,000 up to an aggregate of US$200,000 in accordance with para. 3.8 - 3.11 of the Consultant Guidelines. The GTC would ensure widely publicized procurement notice to get candidacy from consultants (firms and individuals). Based on agreed upon criteria, the GTC will maintain and update a list of consultants which will be used to establish short-lists. To ensure that priority is given to the identification of suitable and qualified national consultants, short-lists for contracts estimated under US$50,000 or 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. However, if foreign firms have expressed interest, they will not be excluded from consideration. The Standard Request for Proposal (RFP) as developed by the Bank will be used for requesting proposals, and for selection and appointment of consultants. Simplified contracts will be used for short-term assignments-simple missions of standard nature (i.e., those not exceeding six months) carried out by individual consultants or firms. The Government was briefed during appraisal about the special features of the new guidelines and the RFP, in particular with regard to advertisement, public bid opening, and evaluation criteria. The total cost of training, workshops, and study tours is estimated at US$4.35 million for the project. Training, workshops, conference attendance and study tours will be carried out on the basis of approved annual work programs that will identify the general framework of training or similar activities for the year, including the nature of training/study tours/workshops, the number of participants, and cost estimates. The training institutions for all workshops/training with costs exceeding US$5,000 should be identified in the annual program. For training programs costing US$ 15,000 or more, a competitive selection method will be used. Any and all "out of country" training is subject to prior review by IDA. Post-reviews will be conducted from time to time to review the selection of institutions/course contents/trainees and justifications thereof, and costs incurred. IDA Reviews Goods. IDA-financed contracts for goods above the threshold value of US$100,000 equivalent will be subject to IDA's prior review procedures. Contracts awarded below this threshold will be subject to post-review during IDA's supervision missions with the exception of the first three NCB contracts which will be subject to prior review. Draft standard bidding document formats for NCB will be reviewed by IDA before credit effectiveness. - 69 - Consultants. Prior IDA review will apply to contracts for the recruitnent of consulting firms and individuals estimated to cost more than US$100,000 and US$50,000 equivalent, respectively. The prior review will also apply to the Terms of Reference of contracts, regardless of value, to single-source hiring, to assignments of a critical nature as determined by IDA, or to amendments of contracts rising the contract value above the prior review threshold. In addition, the first two contracts for sub-contracting the facilitation of community participation in each of the ten provinces financed under the Support to Local Response Component, will be submitted to IDA for prior review. For consultants contract estimated above US$100,000, opening the financial envelopes will not take place prior to receiving the Bank's no-objection to the technical evaluation. For contracts estimated to cost less than US$100,000 and more than US$50,000 the borrower will notify IDA of the results of the technical evaluation prior to opening the financial proposals. Documents related to procurement below the prior review thresholds will be maintained by GTC for ex-post review by auditors and IDA supervision missions. All thresholds stated in this section shall be reviewed by the Borrower and IDA on an annual basis. Modifications may be agreed upon, based on performances and actual values of procurement implemented. Amendments to the Credit Agreement may be prepared as necessary. Table A: Project Costs by Procurement Arrangements (US$ million equivalent) Procurement Method Expenditure Category ICB N.B.F. Total Cost 1. Works 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 2. Goods 2.10 0.90 0.50 0.00 3.50 (1.90) (0.70) (0.40) (0.00) (3.00) 3. Services 0.00 0.00 16.90 0.00 16.90 Training & Audits (0.00) (0.00) (14.50) (0.00) (14.50) 4. Subprojects 0.00 0.00 28.00 0.00 28.00 (0.00) (0.00) (25.00) (0.00) (25.00) 5. Drugs 0.00 0.00 0.60 0.00 0.60 (0.00) (0.00) (0.50) (0.00) (0.50) 6. Operating Costs 0.00 0.00 11.00 0.00 11 .00 (0.00) (0.00) (7.00) (0.00) (7.00) Total 2.10 0.90 57.00 0.00 60.00 _________________________ (1.90) (0.70) (47.40) (0.00) (50.00) Figures in parenthesis are the amounts to be financed by the IDA Credit. All costs include contingencies 2/ Includes goods to be procured through national and international shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to manage the project. - 70 - Table Al: Consultant Selection Arrangements (optional) (US$ million equivalent) Consultant Selection Method Services Expenditure QCBS QBS SF8 LeS CQ Other N.B.F. Total Cost Category A. Firms 1.95 0.00 0.00 0.05 0.50 0.30 0.00 2.80 (1.75) (0.00) (0.00) (0.05) (0.40) (0.20) (0.00) (2.40) B. Individuals 0.00 0.00 0.00 0.00 0.00 0.60 0.00 0.60 (0.00) (0.00) (0.00) (0.00) (0.00) (0.50) (0.00) (0.50) Total 1.95 0.00 0.00 0.05 0.50 0.90 0.00 3.40 ( (1.75) (0.00) (0.00) (0.05) (0.40) (0.70) (0.00) (2.90) 1\ Including contingencies Note: QCBS = Quality- and Cost-Based Selection QBS Quality-based Selection SFB = Selection under a Fixed Budget LCS = Least-Cost Selection CQ = Selection Based on Consultants' Qualifications Other = Selection of individual consultants (per Section V of Consultants Guidelines), Commercial Practices, etc. N.B.F. = Not Bank-financed Figures in parenthesis are the amounts to be financed by the Bank Credit. - 71 - Prior review thresholds (Table B) Table B: Thresholds for Procurement Methods and Prior Review' CO"tract ValueContracts Sujeict to Threshold Prourement PrMo Review Expe6diture Category (U$$ thousands} Method (US$ millions) 1. Works 2. Goods >$ 100,000 ICB /lAPSO 2,1 >$20,000- 100,000 NCB /IAPSO First 3 contracts (0, 1 5) <$20,000 NS No <$5,000 Community Participation 3. Services Firms >$I00,000 QCBS 1,50 >$50,000-100,000 QCBS 0,30 <$20,000 CQ First 2 contracts in each province <$100,000 LCS 0,05 Individuals >$50,000 Comparison of 3 CVs 0,01 <$50,000 Comparison of 3 CVs All TORs & Single Source 4. Subprojects N/A N/A N/A 5. Drugs N/A N/A N/A 6. Operating costs N/A N/A N/A Total value of contracts subject to prior review: 4,5 US$ millions Overall Procurement Risk Assessment High Frequency of procurement supervision missions proposed: One every 4 months (includes special procurement supervision for post-review/audits) Thresholds generally differ by country and project. Consult OD 11.04 "Review of Procurement Documentation" and contact the Regional Procurement Adviser for guidance. - 72 - Disbursement Allocation of credit proceeds (Table C) Table C: Allocation of Credit Proceeds Ezpendfitui C riy -1* 7 Figancing Pe e Subprojects 25.00 100% of amounts disbursed Goods 2.00 100% of foreign expenditures (a) for vehicles, materials and 85% of local expenditures equipment (b) Drugs and supplies for the treatment 0.50 100% of foreign expenditures of opportunistic infections and STIs 85% of local expenditures Consultancies, Training, and Audits 12.00 100% Incremental Operating Costs 7.00 80% of local expenditures PPF refinancing 0.78 Amount due Unallocated 2.72 Total Project Costs 50.00 Total 50.00 . Disbursement Method Until such time as the Borrower opts to disburse on the basis of PMRs, disbursements will be made in accordance with procedures outlined in the Bank's "Disbursement Handbook", as specifically tailored above. Disbursement Percentages The disbursement percentages have been calculated in accordance with the Bank's policy on not financing locally-levied taxes/duties. On operating costs and goods, IDA will finance 80% of the total cost including taxes. With regard to consultants, IDA will finance 100% of the total cost excluding taxes. The borrower will therefore ensure that (a) taxes/duties (where applicable) are stated on submitted invoices and the disbursement percentage applicable to local expenditures for goods will be applied to the tax-inclusive invoiced amount (such that taxes are excluded); and (b) the disbursement percentage applicable to local expenditures for consultants will be applied to the tax-exclusive invoiced amount. Use of statements of expenditures (SOEs): Expenditures flowing through Special Account "A" will not be fully-documented and will be disbursed entirely on the basis of a modified SOE, similar to the Bank's Form 1903-4 "Statement of Expenditures - Free Format" through which the borrower can claim an expenditure volume, based on actual disbursements flowing from GTP second generation special accounts, to communities, during a specific time period without itemizing specific purchases. The NHAC will design their own form and submit it to the Bank for review/comments prior to disbursement commencing. Expenditures flowing through Special Account "B" will be claimed on the basis of SOEs for all - 73 - expenditures related to contracts below the prior review limit as specified in Table B. Expenditures related to contracts above the prior review limit will be fully-documented. Special account: The project will have two Special Accounts: A and B. Both Special Accounts will be held in a commercial bank. Both Special Accounts will have ten sub-accounts, one in each Province. Special Account A, will be used exclusively for transferring funds to communities through the ten sub-accounts. An initial advance of six months of estimated annual disbursements (CFAF 2,800,000,000) will be necessary for the Special Account A considering the great dispersion of communities, amounting to several thousand, and the uncertainty relative to the timing and availability of community level disbursement information. Funds transferred from Special Account A sub-accounts to communities, which may not exceed CFAF 200,000,000 representing 90 days of estimated cash requirement, will be based on a previously approved work plan although actual payments to communities will be calculated on the number of inhabitants and the risk factor relative to each community. Replenishments of the Special Account A will be made quarterly, or more often if initiated by the borrower, and will be based on actual disbursements supported by: (i) evidence of satisfactory utilization of previous funds by communities based on their quarterly reports to GTP, and (ii) community bank statements showing evidence of actual disbursements by the communities. For each replenishment application, the borrower will attach bank statements for the Special Account A at the beginning and end of the period under consideration, a recoticiliation showing the amounts advanced to and outstanding at each of the ten provincial sub-accounts. A spreadsheet format may be used by the borrower to provide for each provincial sub-account, the actual net amounts transferred to the communities for the period under consideration. No itemized detail of specific expenditure will be reported on the replenishment application given the volume and diversity of the expenditures at the community level. Review of the detailed expenditures at the community level to ascertain their eligibility will not be assumed by Bank staff under a HQ type review, but will be transferred to internal auditors, local operational audits and annual external audits Special Account B will be used for disbursement of other project expenditures and will be replenished based on SOEs (IDA form 1903, page 3) and backed by actual supporting documentation held at GTC and GTP. The initial advance to Special Account B could be equivalent to four months of budgeted expenditure (CFAF 2,450,000,000). The maximum deposit into any of the second generation Provincial accounts funded through Special Account B is CFAF 50,000,000. Reporting and Auditing Quarterly progress reports from the community level will first be consolidated at the Commune level then submitted to the GTP level for further consolidation and ultimately to the GTC where the final consolidation will be completed and the project activity report finalized. A standard comrnmunity level reporting format will be used that would include at a minimum, the eligible activities undertaken and actual costs compared to standard estimates for such eligible activities. - 74 - Standard estimated costs for eligible activities are necessary project management and will be determined prior to effectiveness. Any expenditure which cannot be justified or which is outside the scope of the agreed activities would be clearly identified and reimbursed to GTP. Such amounts would be excluded from replenishment requests made by GTP to GTC until they have been reimbursed by the communities. Annual financial consolidated statements for the project will prepared by GTC in accordance with generally accepted accounting standards as required by IDA. The project annual financial statements will be audited annually by external auditors, acceptable to IDA. The audited project financial statements will be submitted to IDA not later that six months after the end of each fiscal year. Appointment of external auditors acceptable to IDA will be done prior to project effectiveness. - 75 - Annex 7: Project Processing Schedule CAMEROON: Multi-sectoral HIV/AIDS Project Time taken to prepare the project (months) 3 3 First Bank mission (identification) 09/10/2000 09/10/2000 Appraisal mission departure 11/05/2000 11/05/2000 Negotiations 11/29/2000 12/04/2000 Planned Date of Effectiveness 06/30/2001 Prepared by: National HIV/AIDS Committee of Cameroon, World Bank, UNAIDS Preparation assistance: A USD 780,000 PPF was approved for this project. DFID provided financing for a local staff. Three consultants were financed out of the Netherlands/Bank Trust Fund on Village Participation. Bank staff who worked on the project included: Name Speciality ____-__ Jan Weetjens (Team Leader, AFTR1), Adriana Jaramillo (Education Specialist, AFTH2), Agnes Soucat (Senior Health Economist, AFTH2), Andre Ryba (Lead Banking Sector Specialist, AFMCM), Angeline Mani (Team Assistant, AFMCM), Bachir Souhlal (Lead Natural Resources Management Specialist - Peer Reviewer, AFRHV), Bakuzakundi Michel (Rural AIDS Specialist, AFMCM), Bernadette Ryan (Consultant), Bertrand de Chazal (Senior Financial Management Specialist, AFTQK), Claudine Morin (Senior Counsel, LEGAF), David Freese (Disbursement Officer, LOAAF), Eavan O'Halloran (Operations Analyst, AFC07), Faustin Koyasse (Program Officer, AFMCM), Guy-Joseph Malembeti (Procurement Officer, AFMCM), Hawanty Page (Program Assistant, AFTR2), Helene Ndjebet Yaka (Disbursement Assistant, AFMCM), Hitoshi Shoji (Senior Operations Officer, AFTPI), Jean-Pierre Okalla (Consultant), John Lambert (Consultant, AFTR2), Jonathan Brown (Lead Operations Specialist, AFTQK/AFRHV), Joseph Bonlong (Financial Management, AFMCM), Juvenal Nzambimana (Disbursement Analyst, LOAAF), Keith Hansen (Senior Economist - Peer Reviewer, AFRHV), Luc Lapointe (Procurement, AFTQK), Mark Blackden (Lead Specialist, AFTI1), Moctar Thiam (Senior Transport Specialist, AFTTR), Remi Kini (Environmental Economist, AFTE1), Rima Al-Azar (Consultant, AFTR2), Serigne Omar Fye (Senior Environmental Specialist, AFTE 1), Soulemane Fofana (Operations Analyst, AFTR2), Tairou Wakili (Consultant), Willem Zijp (Lead Operations Specialist - Peer Reviewer, AFTQK). - 76 - Annex 8: Documents in the Project File* CAMEROON: Multi-sectoral HIV/AIDS Project A. Project Implementation Plan Interim Program Implementation Manual Draft manual for financial management and accounting procedures First year procurement plan B. Bank Staff Assessments Project Appraisal Document No 20727 - Multi Country HIV/AIDS Program for the Africa Region Environmental and Social Data Sheet C. Other National HIV/AIDS Strategy for Cameroon *Including electronic files - 77 - Annex 9: Statement of Loans and Credits CAMEROON: Multi-sectoral HIV/AIDS Project Difference between expected and actual Original Amount in USS Millions disbursements Project ID FY Borrower Purpose IBRD IDA Cancel. Undisb. Orig Frm Rev'd P000411 1995 Cameroon HLTH/FERT/NUTRITION 0.00 43.00 20.10 10.80 30.30 350 P000311 1995 Cameroon BIODIVERSITY CONS. GEF 6.00 0.00 0.00 1.60 2.10 000 P041553 1996 Cameroon PEITA 0.00 12.60 0.00 4.20 4.90 0.00 P000393 1996 Cameroon TRANSPORT SECTOR 0.00 60.70 0.00 23.10 17.00 000 P055684 1998 Cameroon IUT DOUALA (LIL) 000 4.90 0.00 4.50 3.10 000 P054443 1998 Cameroon SAC III 0.00 204.10 0.00 88.00 73.70 77.90 P045348 1999 Cameroon AG.EXT.&RES. SUPPORT 0.00 15.10 0.00 13.00 4.90 000 P051059 2000 Cameroon CHAD/CAM PIPELINE 53.40 0.00 0.00 53.40 0.00 0.00 P048204 2000 Cameroon ENVIRONMENT OIL TA 0.00 5.80 0.00 5 80 0 00 0.00 P065927 2000 Cameroon PUBLIC/PRIVATE PART. 0.00 20.90 0.00 20.60 0.00 0.00 Total: 59.40 367.10 2010 22500 136.00 8140 - 78 - CAMEROON STATEMENT OF IFC's Held and Disbursed Portfolio In Millions US Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1995/2000 AEF Comp Avicole 0.25 0 0 0 0.25 0 0 0 1996 AEF Notacam 0.65 0 0 0 0.65 0 0 0 1994/96 AEF Proleg 0.21 0 0 0 0.21 0 0 0 1999 AEF Saicam 0 0 0.36 0 0 0 0.25 0 1994/96 AEF United Trspt 0.21 0 0 0 0.21 0 0 0 1979 Alucam 0 0.93 0 0 0 0 0 0 186/95 CICAM 1.8 0 0 0 1.8 0 0 0 1992/94 Pecten Cameroon 48 0 0 152 14.81 0 0 46.89 Total Portfolio: 51.12 0.93 0.36 152 17.93 0 0.25 46 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic 2000 AEF Complexe II 0.16 0 0 0 2000 AEF Hobec 0.34 0 0 0 2000 BICEC 0 0.70 0 0 2000 AEF Complexe 11 0 0.17 0 0 1999 AEFEPA 1.0 0 0 0 1999 AEFLUNA 0.25 0 0 0 Total Pending Commitment: 1.74 0.87 0 0 -79 - Annex 10: Country at a Glance CAMEROON: Multi-sectoral HIV/AIDS Project Sub- POVERTY and SOCIAL Saharn Low- - Cameroon Africa income Development diamond' 1999 Population, mid-year (millions) 14.7 642 2.417 Life expectancy GNP per capita (Atlas method. US$) 580 500 410 GNP (Atlas method, US$ billions) 8.5 321 988 Average annual qrowth, 1993-99 Population (%) 2.7 2.6 1.9 Labor force M%) 3.1 2.8 2.3 Gt4P Gross per primary Most recent estimate (latest year available, 1993.99) capita e enrollment Poverty (% of population below national poverty line) 51 - Urban population (% of total Population) 47 34 31 Life exPectanCy at birth (years) Se 50 60 Infant mortality (per 1,000 live births) 77 92 77 Child malnutrition (% of children under 5) 29 32 43 Access to safe water Access to imoroved water source (% of population) 44 43 64 Illiteracy (% of population age 15+) 26 39 39 Gross Drimarv enrollment (% of school-ape poDulation) 78 78 96 Cameroon Male 89 85 102 - Low-income group Female 73 71 86 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1979 1989 1998 1999 Economic ratios' GDP (US$ billions) 5.8 11.1 8,7 9.2 Gross domestic investmentlGDP 28.5 17.1 18.4 19.5 Trade Exports of goods and services/GDP 21.1 20.9 26.5 24.4 Gross domestic savings/GDP 21.4 20.1 19.9 19.0 Gross national savings/GDP 16.2 18.9 15.7 15.2 Current account balance/GDP -12.5 1.8 -27 -4.3 omestic Interest pavments/GDP 1.2 1.2 3.4 3.5 Domes Investment Total debt/GDP 36.4 43.1 96,9 83.6 avigs Total debt servicelexports 14.1 17.2 19,7 18.0 Present value of debtGDP . . .. 78.1 Present value of debt/exDorts . .. 314.0 Indebtedness 197949 1989-99 1998 1999 1999-03 (average annual growth) GDP 4.8 0.5 5.0 4.4 5.1 Cameroon GNP per capita 3.3 -2.5 3.7 2.2 2.2 -Low-income group Exports of goods and services 8.2 1.4 11.1 12.9 5.2 STRUCTURE of the ECONOMY 1979 1989 1998 1999 Growth of investment and GDP (%) (% of GDP) Aqriculture 30.8 26.1 41.2 42.3 20 Industry 20.6 29.7 21.0 19.7 sK Manufacturing 8.1 14.4 10.4 10.6 o, 7 Services 48.5 44.2 37.8 38.0 -ro 9s 97 9s 99 Private consumption 69.4 69.2 71.0 71.0 -20 I General government consumption 9.2 10.8 9.2 10.0 -GDI 0 GDP Imports of goods and services 28.2 18.0 25.0 24.9 1979-89 1989-99 1998 1999 Growth of exports and Imports (%) (average annual growth) Agriculture 2.8 4.6 6.8 6.8 20 Industry 8.8 -2.9 7.7 6.3 l. Manufacturinq 7.8 -0.5 8.0 6.6 Services 1.8 -0.6 9.1 1.8 Private consumption 4.5 1.8 1.2 -1.0 -s 9 97 General government consumption 7.5 -0. 1 16.1 10.8 Gross domestic investment 1.3 -0.7 17.9 6.1 -20 Imports of goods and services 5.9 3.6 13.2 3.1 Exports m mports Gross national Product 6.2 0.4 6.6 5.0 Note: 1999 data are preliminary estimates. The diamonds show four kev indicators in the countrv fin bold) compared with its income-group averaae. If data are missing, the diamond will be incomplete. - 80 - Cameroon PRICES and GOVERNMENT FINANCE Domestic prices 1979 1989 1998 1999 Inflation (%) (% change) 30 Consumer prices 6.6 -1.7 3.9 2.9 20 Implicit GDP deflator 12.9 -1.8 1.1 -1.2 Government finance o79599 (% of GOP, includes current grants) 0 94 95 so 97 98 99 Current revenue .. 16.0 16.2 15.5 -10 Current budget balance .. 0.4 1.2 0.3 - GDP deflator - e CPI Overall surplus/deficit .. -4.5 -1.4 -3.2 TRADE (US$ millions) 1979 1989 1998 1999 Export and import levels (USS mill.) Total exports (fob) 1,354 1,837 1,800 1,689 2,000 Fuel 109 746 592 472 T Cocoa 296 207 298 302 1,500 Manufactures 75 300 423 281 , 000 Total imports (cif) 1.271 1.352 1.452 1,498 i Food 80 155 173 194 500 Fuelandenerqy 104 10 149 86 Capital qoods 370 424 403 407 0 93 94 95 96 97 90 99 Export price index (1995=100) 97 52 105 84 Import price index (1995=100) 50 50 101 100 * Exports a Imports Termsoftrade(1995=100J 194 104 104 84 BALANCE of PAYMENTS (US$ millions) 1979 1989 1998 1999 Current account balance to GDP (%) Exports of goods and services 1,248 2,307 2,306 2,249 0 Imports of goods and services 1,672 1,980 2,176 2,289 Resource balance -424 327 130 -40 Net income -336 -218 -469 -469 Net current transfers 33 85 105 117 _111111 Current account balance -728 195 -235 -393 Financinq items (net) 781 -66 197 426 Changes in net reserves -54 -129 38 -34 -l Memo: Reserves including qold (US$ millions) .. 11 11 Conversion rate (DEC, locaVUS$) 216.6 315.4 602.1 588.5 EXTERNAL DEBT and RESOURCE FLOWS la 11979 1989 1998 1999 (US$ millions) Composition of 1999 debt (USS mill.) Total debt outstanding and disbursed 2.117 4.806 8,430 7.679 IBRD 130 572 350 294 G: 91 A 294 IDA 127 239 701 735 F: 686 : 735 Total debt service /b 178 406 454 404 C 176 IBRD 12 80 97 96 IDA 1 4 10 11 D441 ComPosition of net resource flows Official qrants .. .. 276 Official creditors 268 337 237 Private creditors 245 327 1 0 Foreign direct investment .. .. -50 22 Portfolio equity .. .. 0 0 E: 5,256 World Bank program Commitments 0 150 185 28 A - IBRD E - Bilateral Disbursements 50 109 82 112 B-IDA D- Other multilateral F - Private Principal repayments 3 38 75 74 C - IMF G- Short-term Net flows 47 71 7 38 Interest payments 9 47 33 32 Net transfers 37 25 -26 6 Development Economics 8130/00 - 81 - Additional Annex No.: 11 Monitoring and Evaluation Cameroon: Multi-sectoral HIV/AIDS Project Introduction The monitoring and evaluation component of the program will put in place a system to measure the evolution of the program (process indicators), the products created by the program (output indicators) and the success of the program in reaching its goals (impact indicators). Ideally, given that the principal objective of the project is to curb the propagation of HIV/AIDS in Cameroon, the success of the program should be measured by the reduction in the prevalence rates of HIV/AIDS across the country. Unfortunately, this is easier said than done and experts have advised that it is very difficult to predict with accuracy the reduction in the spread of HIV/AIDS among the general population over the next four years as a result of this project. Nevertheless, epidemiological and behavioral studies are an integral component of the long-term National Strategy for the Fight Against HIV/AIDS and will continue to be carried out by the MINSANTE and overseen by the Epidemiological Unit of the Operational Section of the GTC. To monitor the impact of the program as accurate as possible, the decrease of HIV prevalence among young pregnant women, the military, and commercial sex workers will be tracked as well as the raise in % of tuberculosis. The epidemiological and behavioral studies will build on the work already initiated with the support of UNICEF, Ministry of Research (AIDS Research Program), MINSANTE, and the Polytechnic School at the University in Yaounde. As part of these studies, a map of the vulnerability (risk) and prevalence of HIV/AIDS in Cameroon by region was initiated. This information was presented and analyzed using the mapping software MAPINFO. Underlying principles of the M&E system Over the next four years, given the limitations of epidemiological studies, the process and output indicators will carry a lot of weight when judging the success of the program. Fortunately, accurate process and output indicators can be collected relatively easily and can be managed and presented using the same geographical tools as the epidemiological and behavioral studies. Managing the process and output indicators using a geographical framework is advantageous because it makes it easy to: * present and identify interregional patterns and disparities of indicators * present and identify intra-regional relationships by overlaying related indicators * list and analyze all indicators by geographical unit * present the different layers of responsibility and coverage in decentralized system * identify strengths and weaknesses of the program to re-target resources * present the programs response (and progress) in high risk or high prevalence areas * brake down regions into sub-regions to present more detailed maps (province, - 82 - commune) * tailor what indicators are presented on the map based on specific needs of analysis * organize all indicators in one system * extract unit specific information to perform more complex analysis Because of the power and its capacity to analyze date from various different levels and angles, the project will use mapping software to monitor and evaluate the program. Since each indicator is logically linked to a given geographic unit - such as a village, commune or province or other area (depending on the indicator) - the mapping software can be used to dissect and overlay indicators from different angles according to the point of reference of the observer and the objective of the analysis. For example, managers of the program can easily overlay output indicators - such as the location of financial institutions, coverage of NGO/Associations, and the establishment of coordinating committees - on the same map as that of the impact indicators - such as risk areas or prevalence rates. Presenting the indicators in this simple but effective manner will enable managers to quickly identify strengths and weaknesses in the implementation of the program and to target resources to re-enforce capacity or infrastructure as needed. As another example, the mapping tool can be used to monitor process indicators - such as the allocation of resources to communities - by shading the different regions with varying intensity according to amount of funds transferred. This information would be useful to the NHAC and the PHAC to monitor the effectiveness of the various financial institutions involved in the transfer of resources to communities and would enable them to engage partners in the financial sector to take corrective action as and where needed. The strength of the mapping tool for monitoring the outputs and impact of the program will depend on the relevance of the indicators and reliability of the data collected. To ensure these, the project will implement a simplified system of data collection and transmission. In the course of preparation, the project team has also identified a number of key indicators as well as the units that will be responsible for collecting the information on these indicators. A system was developed to ensure adequate transmission of information collected in such a way that report writing is kept to a minimum and that information recorded can be checked on its reliability at any time. Details are described in the Implementation Manual. Table I below provides an overview of the indicators and units responsible for the data collection on the respective indicators. The first two columns in Table 1 list some of the indicators that will be used to monitor the program and the corresponding zone of coverage for each indicator. In several cases, the precise zone of coverage can be approximated based on features particular to the indicator, such as area of population within a reasonable distance from a financial institution. The last column in Table 1 refers to the section of the executing bodies of the program (GTC, GTP, and CC) that is responsible for recording, collecting, consolidating and verifying the information for each indicator. - 83 - Table 1: Indicator Geographic Coverage Section of Responsibility Vulnerability to and prevalence of Region of population served Operational (Health) HIV/AIDS Sentinel Site Condom use and regular condom Province Operational (Health) use Utilization of STD treatment Province Operational (Health) services Proportion of pregnante women Province Operational (Health) tested for HIV Proportion of pregnant women with Province Operational (Health) HIV/AIDS who have receive anti-retro virals Establishment of LHAC Village or Community Local Response Establishment of CHAC Commune GTP-Provincial Coordinator Establishment of PHAC Province GTC-Permanent Secretary NGOs/Associations trained and Village or Community Local Response contracted to facilitate participatory process Submission and approval of Village or Community Local Response community action plans Open community bank accounts Village or Community Local Response Availability of basic services, Region of population served by Operational (Health) medication, condoms and hospital or clinic (village, commune, equipment in front line health posts etc.) Sector Specific Focal Points Nation Sector Response Identified Sector Specific Focal Point Nation, province, or other region Sector Response established work plans to design (will depend on the decentralization and implement sector specific the specific sector strategy) strategies - 84 - Execution units in place at the Nation, province, commune GTC-Permanent national, provincial and communal Secretary levels Communities receiving funds for Village or Community Local Response action plans NGO/Associations identified to Province, commune, or other region Local Response facilitate participatory process (will depend on the region of intervention of the organization) Sector agencies (public and Nation or region of population Sector Response private) that have prepared sector served by the sector agencies strategies Testing centers and drug Region of population served by Operational (Health) distribution centers center (village, commune, etc.) Financial institutions Region of population served by Finance and institutions (village, commune, etc.) Administration IEC documentation centers Region of population served by IEC center (village, commune, etc.) Flow of funds to communities Village or community Finance and Administration Regularity of ex-post controls of Village or community Finance and use of financial resources Administration Data collection and analysis The program has four levels of execution: community, commune, province and nation. Information on the indicators is observed and recorded at the lowest level of supervision based on the information necessary to manage and coordinate the program at that level. At the next level, information is verified, consolidated and analyzed so that management decisions can be based on the actual situation. As a principal the higher level will be responsible to collect information from the lowest level. This will provide managers with additional incentives to go to the field and to ensure that information recorded in reports is checked on the ground. The implementation manual provides the details about the responsibilities of data collection, transmission, and analysis. While each level will be responsible to extract information on an ad-hoc basis to obtain reliable feed-back on the performance of the program, the data will eventually culminate at the national level in the M&E Unit which is housed in the Operational Section of the GTC. The M&E Unit has the responsibility of consolidating the information from all the sections by extracting pre-defined indicators from each of the reports and inputting the - 85 - indicators into the central database using the geographic information system which was already put in place under the UNICEF program. The M&E Unit will prepare monthly standard summary tables of indicators for each section and maps pre-tailored for the needs of each section. Each map presents only the information necessary for the section' s individual analysis, but may contain indicators from other related sections to enable the managers to easily identify the progress of prerequisite activities in other domains. This information will allow managers at various levels to identify strengths and weaknesses, correlation among indicators, and patterns across the country. However, it will be important to cross-check the information generated through the M&E system with the information gathered during field visits. The first-hand information from field visits combined with the information generated through the M&E system will allow each section to plan activities and to address possible weaknesses on the ground. Monthly action plans will be discussed at the monthly management meetings at all levels. Quarterly, each section will prepare a more detailed analysis and presentation of indicators within their domain and the interrelationships among activities in other sections. In addition to its potential as a management tool, the entire system should enable the HIIV/AIDS Committees and their respective implementation units to generate timely and reliable information for the purpose of informing stakeholders and decision makers in the country and among external partners. - 86 - Additional Annex No.: 12 Organizational Charts ORGANIZATIONAL CHART OF GTC/GTP National level: Groupe Technique Central |Penmanent Sec:re7tary |Local Sector ICOperational Finance and IResponse Response Administration Monitoring and Surveillance Evaluation Treatment Provincial level: Groupe Technique Provincial | ennnt Secretary |Local ||Sector | ; n |Operational ||Fnnen IResponse Response Adnisrto Communal level: Correspondant Communal| - 87 - CAMEROON National HIV/AIDS Program Local Response I Coordination Sector Response (Organization of Demand) I I (Organization of Supply) (1) NHAC |Sector A | |Sector B| (2) GT ainl| |National| (3) PHAC a) c- _ _ o Sub-contracting agencies for facilitation of community participation processes (9) X~~~~~~~~~~~~~~~~~~ 3c cn <()C S Urban Groups Rural Comm. Vulnerable Groups (7) 03 o 9i (1) National HI V/AIDS Committee (NHAC) (2) Groupe Technique Central (GTC) (3) Provincial H/V/AIDS Committee (PHAC) (4) Groupe Technique Provincial (GTP) (5) Communal HI V/AIDS Committee (CHAC) (6) Communal Correspondent (CC) (7) Local HIVAIDS Committees (LHAC: Urban, Village and Local vulnerable groups) (8) Sector Specific Focal Points (FP) (9) Subcontractors for community participation activities (NGOs, associations, etc.) - 88 - IBRD 27082 MALI J NIGER 1r _ t ~ ~ aka Chad ( ~SUDAN \ i \ FASOINt.> ~ -e? CHAD The boundaries, cohors, \ i8ENIN ) other Informationd shownr\ < \ / NIGERIA rJH <\- g < imply, on this po of not \-- CENTRAL AFRICAN ~~any judgment an Omhega HANAt i f .| j ~~CENTRAL AFRICAN _The World Bonlr Group, < - -J/ REPUBLIC .~ status of any t rritory, GuiTor q-2;AMERO0N R C < or any endorsement Kouueri CHAD ir or acceptance of such ~~AMEROON\\ ~~~~~~~~~~boundaries. tiUAr UINceA 1< NGABOIN nROMOTErB 0 20 40 60 oo 100 120 140 160 AnANTL'JC CC/AN GA N .v________________________ , ,, . . . . t EXTREME MILES_ _ u 20 40 a 0 10 Marc NORD } \ { ~~~~~YrJgow \ CAMEROON Ka oX0 10- bbi~~~~~~~~~~~~~~~~~~~~~~~2der Y96\ o SELECTED TOWNS , J # rGAROU S PROVINCE CAPITALS PAVED ROADS UNPAVED ROADS j... RAILROADS ,_ G bu o. -- RIVERS 0 0 % i _ _ _ PROVINCE BOUNDARIES TchoHir- -_ INTERNATIONAL NORD - 8BoOUNDARIES 1 , J \\r r UNDERE NIGERIA,..-' Wum( m ) eu / :/bngwi t, -6- - (-~~~~~- ~ r- OUE,S 3! /Gr 6' Momfe CENTRAL UD- B Poumbon. Ndo~~~~~~~~~~~Yd~~ AFRICAN CENTRIT Ž --- REPUBLIC / OUEST P6\ cog nng undembo No . n Kumbo~~ *. - Ebolco BER1OU <\y~ctouo a\ Bdro U LITTORA no NeI kAk.r%QIingo\ *\ -ST Yokodoumy)E\ -9tKO \8N <9 " * Xomi6 > EQUATORIAL , , rignilli GUINEA j e SUD t',i .ATA7COCEAN I EAN \g\',,*oloundw I ) RiCl MUNI , GA ON CONGO JUNE 1995