Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB4620 Project Name AIDS-SUS (National AIDS Program - National Health Service) Region LATIN AMERICA AND CARIBBEAN Sector Health (100%) Project ID P113540 Borrower(s) GOVERNMENT OF BRAZIL Implementing Agency Republica Federativa do Brasil – Ministério da Saúde - Unidade III Programa Nacional de DST/AIDS-SVS/MS SEPN 511 W/3 Norte - Bloco: "C" - 2° andar 70750-543 - Brasília/ DF - Brasil Fone:+55 (61) 3448.8001 a 8006 Fax: +55 (61) 3448.8224 Environment Category [ ] A [ ] B [X] C [ ] FI [ ] TBD (to be determined) Date PID Prepared April 2, 2009 Estimated Date of Appraisal Authorization June 22, 2009 Estimated Date of Board Approval October 27, 2009 A. Key development issues and rationale for Bank involvement 1. About one third of all people living with HIV in Latin America reside in Brazil. In the early 1990s, the epidemic was increasing in Brazil at the same rate as in Africa. Due to the efforts of the National Program (PN), however, Brazil has been able to contain the epidemic at 0.6% of the adult population and has halved the number of AIDS-related deaths. The Brazilian epidemic is still concentrated in highly vulnerable groups, with 50% of AIDS cases reported among men who have sex with men (MSM), sex workers (SW) and injecting drug users (IDUs). The incidence of AIDS among MSM is 250 per 100,000, while among heterosexual men it is 27 per 100,000. Unprotected sex between men is estimated to account for about half of all HIV infections that are sexually transmitted in Brazil. Injecting drug users (IDUs) and sex workers (SWs) are also at significantly increased risk of infection as compared with the population in general. 2. Brazil faces, however, a changing epidemic, with different epidemic profiles that may require different Program answers by group and regions of the country. In recent years, the epidemic has been spreading to females, poorer groups, and towards the country’s interior region. Heterosexual transmission is now more important for both genders. It is estimated that a large proportion of infections among women can be attributed to the behavior of their male sexual partners. The epidemic is expected to continue to grow in the North, Northeast and Center-West regions, where the socio-economic conditions and health services are more precarious. Page 2 3. The government has invested heavily in the prevention and treatment of HIV/AIDS and other sexually transmitted infections (STIs), providing condoms to highly vulnerable groups, and antiretroviral treatment to all identified patients who qualify for it, free of charge. However, significant challenges persist, relating, among others, to poor coverage of highly vulnerable groups (MSM, SWs, IDUs), the different epidemic profile throughout the country, increased expenditures and other needs posed by PLHIV survival, monitoring and evaluation (M&E) capacity at all levels, and weak fiduciary capacity at decentralized levels. B. Rationale for Bank involvement 4. By focusing on highly vulnerable groups and on program governance, the project would complement previous Bank assistance to the prevention and control of HIV/AIDS and STIs in Brazil. Successfully navigating these new challenges will keep Brazil in the forefront among developing countries as it transitions from a single-disease focus to a more systemic approach. The proposed AIDS-SUS project would improve the AIDS Program performance and contribute to health system strengthening, which is the main aim of the Bank’s Health, Nutrition and Population Strategy, by (i) coordinating and integrating provision of prevention and care with primary health care programs ( Atenção Básica and Saúde da Família ) to respond to the changing epidemic (ii) putting in place a robust M&E system, which can serve as a model for other health systems; and (iii) implementing a performance-based financing mechanism to transfer funds to states, municipalities and NGOs. In addition, the proposed project would complement activities undertaken by other Bank-financed health projects - VIGISUS, Family Health and QUALISUS – to improve the governance of the health system as a whole. The new project aligns closely with both the current public sector reform processes underway in Brazil and with World Bank strategy in the country. C. Proposed objective(s) 5. The proposed project development objectives (PDOs) are the following: (i) Increase usage of prevention, care and treatment services by highly vulnerable groups. (ii) Improve the National STIs and AIDS Program transparency, accountability and social control by promoting performance-based management, and organization of services involving relevant networks. (iii) Increase the use of evidence in policy making by the three levels of government by promoting monitoring and evaluation of HIV/AIDS and STIs. D. Preliminary project description 6. The project would be implemented nation-wide, reaching out to the 27 federal units, with the North, Northeast, and Center-East regions as a priority. The $200 million Brazil AIDS-SUS Project would be co-financed by a Specific Investment Loan (SIL) of US $67 million to be disbursed in four years (2010-2014). The project would follow a Sector Wide Approach (SWAp), with the Bank loan co-financing a percentage of Government Eligible Expenditure Programs (EEP). Disbursements would be triggered by the execution of the agreed subprograms and achievement of specific result targets. Page 3 Component 1. Improving the Governance of the National STI and AIDS Program (US$57 million) 7. This component follows a SWAp approach by financing a percentage of the following Eligible Expenditure Programs (EEPs): ƒ Policy and Institutional Arrangements. This program would focus on o Policy Formulation and Regulation . Develop policies, guidelines and technical regulations for the health care network to better reach highly vulnerable groups; improve the logistic system for provision of condoms and pharmaceutical drugs for HIV/AIDS and other STI. o Information Management . Integrate epidemiological surveillance of HIV/AIDS and other STI, R&D and monitoring and evaluation; monitor and evaluate R&D; develop tools and processes to make the information available to key stakeholders. o Research and Technology Innovation . Promote research and technology development in innovative, priority areas to better reach highly vulnerable populations, and to develop vaccines and other prevention products; cooperation between research institutes, private sector and development agencies; develop technology assessment. o National and International Cooperation . Development of national and international networks to improve national response; increase South-South cooperation, especially in the context of MERCOSUR and with Lusophone countries in the world; and integrate the efforts of the relevant health subsectors, especially those linked to surveillance, primary health care, and reproductive health, as well as public and private sectors and civil society. ƒ Management, Financing and Results . This program would focus on o Decentralized Performance-based Management and Financing . Establish performance-based financing of STI and HIV/AIDS programs in states, municipalities and NGOs. This would include performance incentives for State and Municipal Secretariats and NGOs. o Network Organization . Organize a network of care integrating primary secondary and tertiary care to expand the provision and quality of services in the areas of prevention, and diagnosis and treatment of STIs and HIV/AIDS, focusing on highly vulnerable groups; o Transparency, Accountability and Social Control . Strengthen social participation in the formulation and control of policies for HIV/AIDS and other STI, and increase transparency and visibility of Program inputs, processes, activities and results. Component 2. Building the Capacity of the National STI and AIDS Program (US$ 10 million). 8. This component would finance specific technical assistance and training for expanding prevention and care for highly vulnerable groups, and improving the Program’s governance. Page 4 E. Safeguard policies that might apply The project would not present any potential impacts that would be of environmental concern, and would not involve any resettlement. Although PO 4.01 would not be triggered, the project would develop (i) adequate monitoring guidelines for reducing health risks; (ii) guidelines on proper handling and disposal of waste; (iii) training program of health care workers and all new participating entities on handling of blood products and delivering health care to PLHIV; and (iv) a communication strategy for proper usage and disposal of condoms. OP 4.10 is triggered, and an Indigenous People Planning Framework will be developed in the context of the project social assessment. F. Tentative financing Source: ($m.) Borrower 133 International Bank for Reconstruction and Development 67 Total 200 G. Contact point Contact: Joana Godinho Title: Sr Health Spec. Tel: (202) 458-1988 Fax: Email: Jgodinho@worldbank.org