Document of The World Bank FOR OFFICIAL USEONLY ReportNo: 32319-MG PROJECTAPPRAISAL DOCUMENT ONA PROPOSEDCREDIT INTHEAMOUNT OF SDR20.2 MILLION (USD30 MILLIONEQUIVALENT) TO THE REPUBLIC OF MADAGASCAR FOR A SECOND MULTISECTORALSTI/HIV/AIDS PREVENTIONPROJECT June 13,2005 HumanDevelopment111 Country Department 8 Africa Region This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not otherwise be disclosedwithout World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate EffectiveFebruary 23,2005) Currency Unit = Ariary 1943.45 = USDl U S D = S D R 1 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS AiDB African DevelopmentBank M&E Monitoring and Evaluation AGF Agence de gestion Financikre (Financial Management Agency) MIS Management Information System AIDS Acauired Immuno Deficiencv Svndrome M o H Ministrv o f Health and Familv Plannine 1Organization) CPAR ICountry Procurement AssessmentReport IOSE I Organisme de Suivi & Evaluation (Monitoring & Evaluation Organization) CPFA Country Profile o f FinancialAccountability ovc %ham and Vulnerable Children CRESAN IDA-financed Health Sector Support Project PCN Project ConceptNote crus Comiti Rigional de Lutte contre le SIDA (Regional AIDS Com.) PID Project Information Document csw Commercial Sex Workers PLWHA People Living With HIVIAIDS DHS Demographic and Health Survey PRSC PovertyReduction Strategy Credit FAP Fond d'Appui a la Prevention (Fund for STI/HIV/AIDS PRSP Poverty ReductionStrategy Paper Vice President: Gobind Nankani Country Managermirector: James Bond Sector Manager: LauraFrigenti Task Team Leader: Nadine T. Poupart 2 FOROFFICIAL USEONLY MADAGASCAR SecondMultisectoralSTI/HIV/AIDS Preventionproject CONTENTS Page A . STRATEGIC CONTEXT AND RATIONALE ............................................................. 8 1. Country and sector issues.................................................................................................... 8 2. Strategic alignment with CAS. PRSP. and the health sector ............................................ 10 3. Rationale for Bank involvement ....................................................................................... 11 4. Eligibility for Repeater Status........................................................................................... 11 B . PROJECTDESCRIPTION ........................................................................................... 14 1. Lending instrument ........................................................................................................... 14 2. Project development objective and key indicators............................................................ 14 3. Project components........................................................................................................... 15 4. Lessons learned and reflected inthe project design.......................................................... 17 5. Alternatives considered and reasons for rejection ............................................................ 18 C. IMPLEMENTATION .................................................................................................... 19 1. Partnershiparrangements: Progresstowards the "Three Ones" ....................................... 19 2. Institutionaland ImplementationArrangements .............................................................. 19 3. Monitoring and evaluation of outcomes/results................................................................ 21 4. Sustainability..................................................................................................................... . . . 22 5. Critical risks andpossible controversial aspects............................................................... 22 6. Loadcredit conditions and covenants............................................................................... 23 D . APPRAISAL SUMMARY ............................................................................................. 23 1. Economic and financial analyses ...................................................................................... 23 2. Technical........................................................................................................................... 24 3. Fiduciary ........................................................................................................................... 24 4. Social................................................................................................................................. 25 5. Environment...................................................................................................................... 27 6. Safeguard policies ............................................................................................................. 27 1 - 1 7. Policy Exceptions and Readiness...................................................................................... 27 /Thisdocument has a restricted distribution and may be used by recipients only in the performance of their official duties I t s contents may not be otherwise disclosed. . without World Bank authorization. Annex 1: Country and Sector or Program Background ......................................................... 28 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies .................35 Annex 3: Results Framework and Monitoring ........................................................................ 36 Annex 4: Detailed Project Description ...................................................................................... 41 Annex 5: Project Costs............................................................................................................... 45 Annex 6: Implementation Arrangements ................................................................................. 46 Annex 7: Financial Management and DisbursementArrangements ..................................... 51 Annex 8: Procurement Arrangements ...................................................................................... 58 Annex 9: Safeguard Policy Issues .............................................................................................. 62 Annex 10: Project Preparation and Supervision ..................................................................... 63 Annex 11: Documents inthe Project File ................................................................................. 65 Annex 12: Statement of Loans and Credits .............................................................................. 67 Annex 13: Country at a Glance ................................................................................................. 69 Additional Annex 14: Detailed Monitoringand Evaluation Arrangements ......................... 71 Additional Annex 15: Supervision Plan .................................................................................... 75 Map: IBRD 34097 4 MADAGASCAR SECOND MULTISECTORAL STI/HIV/AIDS PREVENTIONPROJECT PROJECT APPRAISAL DOCUMENT AFRICA AFTH3 Date: June 13,2005 Team Leader: Nadine T. Poupart Country Director: James P. Bond Sectors: Other social services (65%); Health Sector ManagerBIirector: LauraFrigenti (35%) Themes: HIV/AIDS (P); Other communicable diseases (P); Participation and civic engagement (S); Gender (S); Other social protection andrisk management (S) Project ID: PO90615 Environmental screening category: Partial Assessment Lending Instrument: Specific Investment Loan Safeguard screeningcategory: Limitedimpact Project Financing Data [ ] Loan [ 3 Grant [ ] Guarantee [ 3 Other: ~~ [ X I Credit For Loans/Credits/Others: Total Bank financing (USDm.): 30.00 Proposedterms: Financing Plan (USDm) Source Local Foreign Total BORROWERRECIPIENT 0.00 0.00 0.00 IDAGRANTFOR HIV/AIDS 24.70 2.30 30.00 Total: 24.70 2.30 30.00 Borrower: Government of Madagascar PrCsidence de la Republique Comite National de Lutte contre le VIH/SIDA Nouvel Immeuble ARO Ampefilola 2eme Ctage Antananarivo 101 - Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 Secretariat ExCcutifdu CNLS : secnls@dts.mg ResponsibleAgency: Unitede Gestion duProjet Nouvel Immeuble ARO Ampefiloha, Escalier B 2 Antananarivo 101- Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 u,m(ii.wanadoo.mrr 5 4nnual 6.00 8.00 8.00 8.00 0.00 0.00 0.00 0.00 0.00 kmulative 6.00 14.00 22.00 30.00 0.00 0.00 0.00 0.00 0.00 Expected effectiveness date: October 7, 2005 Expected closing date: December 31,2009 Does the project depart from the CAS incontent or other significant respects? Re$ PAD A.3 [ ]Yes [XINO Does the project require any exceptions from Bank policies? Re$ PAD D.7 [ ]Yes [XINO Have these been approved by Bank management? [ ]Yes [XINO Is approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical risks rated "substantial" or "high"? Re$ PAD C.5 [XIYes [ ] N o Does the project meet the Regional criteria for readiness for implementation? Re$ PAD D.7 [XlYes [ ]No Project development objective. Re$ PAD B.2, Technical Annex 3 The MSPPII's development objectives are the same as those o f the MSPP. Those objectives are to support the Government o f Madagascar's efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread o f HIV/AIDS on its territory. To do so, the project will intensify and build capacity to carry out the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread o f HIV/AIDS. Inaddition, the MSPPIIwill seek to improvethe quality oflife o fpersons livingwithHIV/AIDS through increased access to quality medical care and to non-medical support services. Given the current epidemiological situation, the project will put an even stronger focus than the original project on at-risk groups inhighprevalence areas, while moderately expanding services to other affected groups (e.g., orphans and other vulnerable children). Project description. Re$ PAD B.3, Technical Annex 4 The proposed follow-on MSPPII will finance five components: 1) Harmonization, dono1 coordination, and strategies; 2) Support for health sector response; 3) Fund for STI/HIV/AIDS prevention and care-taking activities; 4) Monitoring and evaluation; and 5) Project managemenl and capacity building. Component two is the only new component that was added to the project, in order to provide 2 stronger role to the health sector. Which safeguard policies are triggered, ifany? Re$ PAD D.6, TechnicalAnnex I O Environment: The proposed project has been classified as category "B" for environmental screening purposes, given the risks associated with the handling and disposal o f medical wastes. Safeguard policies: The only safeguard triggered i s the environmental assessment, because i Medical Waste Management Plan (MWMP) i s required. A full environmental assessment o f the health sector, which included HIV/AIDS, was also carried out as part o f the preparation o f the IDA-financed Second Health Sector Support Project (CRESANII). A MWMP was developecl for the MSPP. and has been imdemented since Mav 2004. The M o H has installed 200 small- 6 scale bumers to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that bumers are used at the sites supervised (district hospitals of Ankazobe, Antanifotsy and Faratsiho). The construction o f full incinerators at district level i s underway; some o f them should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out inMadagascar's different types of health facilities. The M o H has demonstrated the ability to plan for and prepare these activities, as well. Significant, non-standard conditions, if any, for: Re$ PAD C.7 Boardpresentation: None Loadcredit effectiveness: Recruitment of auditors acceptable to IDA Covenants applicable to project implementation: 0 Submission o f the updatedProject ImplementationManual, including updated administrative, accounting and financial Parts to IDA by August 31,2005 0 Submission o f the updatedFAP procedures manual to IDAby September 30,2005 0 Finalization o f revised National M&E Planand validation by all stakeholders by June 30, 2005 0 Completion o f a technical audit o f FAP sub-projects by October 31,2005 7 A. STRATEGIC CONTEXT AND RATIONALE 1. Country and sector issues The proposed Second Multisectoral STYHIV/AIDS Prevention Project (MSPPII) i s a repeater o f the IDA-financed Madagascar Multisectoral STI/HIV/AIDS Prevention Project (MSPP) that i s supported by a USD20 million IDA credit, and i s expected to close late 2005. This section highlightsthe key country and sector issues since the start ofthe original project in2002. Country Issues. Madagascar continues its recovery from a historical decline in per capita income until 2001. Since the 2002 political and economic crisis, the newly elected Government has embarked on many courageous reforms, which are unique to Madagascar in the post- independence period. These reforms have helped growth to rebound, to 9.8 percent in 2003. The macro-economic environment in 2004 was difficult, however. The year was marked by exogenous shocks which included two cyclones, the sharp depreciation o f the exchange rate, and highinflation (27 percent). Inspite ofthese setbacks, the Government has continued to steadily implement its reform program, and growth is still projected to be robust. Yet, Madagascar remains a poor country with a per capita income o f USD300 (2004), and low social indicators. Poverty is mainly prevalent in rural areas with 77 percent o f the rural population being poor in 2001 compared to 44 percent inurbanareas. Sector Issues. Untilrecently, Madagascar was considered an anomaly to HIV/AIDS epidemics in Sub-Saharan Africa: despite high sexually transmitted infections (STI) prevalence in approximately 20 at-risk zones countrywide, and risky sexual practices, HIV/AIDS prevalence among blood donors, STI patients,' and sex workers had remained remarkably low.2 However, infection rates have inexorably progressed (fiom 0.01 percent in 1996 to 0.15 percent in 1999 to 0.3 percent in 2001). HIV/AIDS prevalence rates may continue to grow unless Madagascar further strengthens its management efforts and targets the areas where HIV transmission i s most likely to occur. HIV/AIDS. Characteristic o f low prevalence countries, Madagascar has lacked sufficient data to track the progression o f the epidemic with precision. However, several recent studies and the initiation o f a second generation surveillance system can now provide national and local authorities with current prevalence rates and behavioral data on at-risk groups. The first nationally representative survey, conducted in 2003, indicates that 0.95 percent o f pregnant women are i n f e ~ t e d . ~ 'The proportion o f sex workers inthe sample i s not known, and may have been low. The apparent paradox between high STI rates (8% among pregnant women in 2003) and sexual promiscuity especially in some parts of the country on the one hand, and a l o w HIV HIV/AIDS prevalence rate on the other hand, may be explained by (i) circumcision which is generalized; (ii) transport infrastructure; and (iii)o w limited l herpes prevalence. The 2003 HIV-prevalence survey among pregnant women (Ministry o f Health) shows a HIV/AIDS prevalence rate o f 1.1%. However, this rate was not regionally weighted. It was recently (January 2005) corrected to 0.95%. HIViAIDS prevalence in the general adult population o f Madagascar i s most probably lower than among pregnant women. Sexually Transmitted Infections (STI). STI rates are extremely high in Madagascar. In 1998, active syphilis inpregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions. In a 2000 study o f approximately 1,000 sex workers inAntananarivo and Tamatave, 82 percent had at least one STI. Recent analysis o f a sample o f households surveyed for the Demographic and Health Survey (DHS) 2003-04 showed syphilis prevalence at 6.3 percent among adults aged 15-49. Government Strategy. The Government, at the highest level, continues to be strongly committed to the fight against STI/HIV/AIDS. This commitment is a critical element behind the achievements o f the MSPP. Over the past three years, the Government has taken the lead in mobilizing public opinion and organizing the Government's response to the epidemic. At the end o f 2002, the President o f Madagascar established the National AIDS Commission ("Comite` National de Lutte Contre le SIDA" or CNLS) and appointed an Executive Secretariat to coordinate the implementation o f the HIV/AIDS program. A thematic group, made up o f representatives from the UN agencies and World Bank, was established under the auspices o f UNAIDS to advise the Government in developing and implementing its response to the epidemic. A National Strategic Plan for HIV/AIDS (2001-2006) and a Monitoring and Evaluation (M&E) Planhavebeen adopted. After a slow start and a mid-2003 re-structuring, the original project has rapidly increased its activities and has had a number o f successes. More than 300 communal AIDS prevention committees, o f which more than 25 percent have produced local HIV/AIDS plans, have been established. Some 850 sub-projects have been carried out, promoting preventive interventions across a range o f target populations and sponsored byNGOs and community-based organizations (CBOs). About 400,000 STIkits have been distributed through bothpublic andprivate channels. A comprehensive communications strategy hasbeendeveloped, and isnow beingimplemented. The Government's strategy is evolving in several ways in response to a better understanding o f the epidemic and o f STI/HIV/AIDS management. First, the initial mass media campaigns for HIV/AIDS focused on raising awareness and communicating basic messages about HIV/AIDS prevention to the population as a whole. With awareness now raised, the Government's new HIV/AIDS communication strategy complements the original media campaigns by focusing more on interpersonal communication and actions that lead to behavior change and reduction o f stigma. The use o f local radios will be favored over print and television media, given radio's relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement o f influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers' associations). The cinemobile strategy has recently been revised to become more interactive. Even in mass communication, interactivity through televised debates, hot lines, etc. will be introduced. Efforts to involve peoplelivingwith HIV/AIDS (PLWHAs) inprevention efforts will also be intensified. Second, under the local response (Fund for STI/HIV/AIDS prevention and care-taking activities) the MSPP supported general prevention efforts throughout Madagascar, with a loose focus on most at-risk zones. The Government recently recognized the need to strengthen its focus on at- risk communes and prioritize interventions inthese communes on the most at-risk groups. This evolution is in line with evidence from other countries at the same stage o f the epidemic that 9 shows that halting the spread o f the infection among these groups significantly attenuates wider scale transmission. Third, the Government has produced partial anti-retroviral (ARV) treatment guidelines, in collaboration with several partners. Untilnow, the treatment o f about 29 AIDS patients has been supported by the Association Rive from the Rkunion. However, treatments are not standardized, and drugs are mostly non-combined drugs of many different types. This increases the risks o f prescription errors, lack o f patient compliance to treatment, drug resistance, and complicates the drug procurement and distribution process. Furthermore, the cost o f treatment ranges from USD300 to USD6,000, which makes its use financially unsustainable if 3,000 new patients need ARV therapy each year, as projected. These factors do not allow rapid scaling-up o f ARV treatment in the Malagasy context. The World Bank looks forward to receiving the complete Government's ARV treatment guidelines that will address issues such as use o f standardized treatment regimens and Fixed Dose Combination, management o f medical supply cycle, compliance and adherence to treatment monitoring, capacity building program including for counseling. A medical and management expert committee should be set up to complete the guidelines. Fourth, the Government and its partners have taken steps to tackle highSTI prevalenceunder the MSPP by: (i) training both the public and private health providers in the syndromic approach nationwide; and (ii) developing STI treatment kits for several sets o f symptoms, which have been sold at highly subsidized prices inpublic health facilities and inprivate facilities, through social marketing. Moreover, Population Services International (PSI) established a network o f franchised clinics runby generalists specially trained inproviding reproductive health care to the youth, including the treatment o f STIs in several large urban centers (Antananarivo, Diego, Mahajanga, Tamatave). A syphilis elimination program targeting pregnant women and their spouses i s also being set up inhospitals and 350 peripheral health centers. There are a few areas o f strategy that remains to be finalized. The Government hasjust produced a draft revised strategy for condom distribution (with USAID and SantCnet support), and a draft strategy on prevention o f mother-to-child transmission (MTCT). A committee has been set up to develop a strategy on care for orphans and vulnerable children. Finally, a strategy on blood transfusion will be prepared shortly in the context o f an African Development Bank (AfDB) project which will finance the control o f communicable diseases. 2. Strategic alignment with CAS, PRSP, and the health sector a) Strategic alignment with the CAS and PRSP The Country Assistance Strategy (October 2003, p.17) recognizes that the Bank will continue to support the fight against HIV/AIDS through financing o f the second phase o f the MSPP. The MSPPII will directly support the PRSP's third pillar, to foster and promote systems for ensuring human and material security, by managing the HIV/AIDS epidemic through implementation of the National Strategic Plan (NSP). Board discussions for the MSPP also highlighted the importance o f effective containment o f HIV/AIDS in Madagascar's poverty reduction efforts. Both the MSPP and the MSPPII support MillenniumDevelopment Goals 7 and 8, which aim to halt and reverse the spread o f HIV/AIDS and malaria and other diseases by 2015. Progress 10 towards these targets, in turn, will strengthen the human capital needed to achieve sustained reduction in poverty. Finally, the Secretariat o f the New Partnership for Africa's Development has specifically requested the Bank's support in fighting HIV/AIDS in Africa since the project directly supports its goals. b) Strategic alignment with the health sector While the original project's design considered the Ministry o f Health and Family Planning (MoH) to be a clear project stakeholder, the Project Management Unit (UGP) and the M o H collaborated more than what was originally envisioned in the course o f MSPP implementation. Specifically, the UGP and the M o H were able to develop coherent and coordinated coverage o f HIV/AIDS-related interventions in the health sector, especially on STI treatment. The MSPPII formalizes this collaboration through the creation o f a stand-alone health component. Moreover, as the HIV/AIDS epidemic rolls out and more HIV positive persons are being diagnosed, including within the framework o f the MTCT prevention, and treated, more resources need to be devoted to the M o H for diagnosis, ARV and opportunistic infection treatment as well as nutritional support for AIDS patients. Finally, since the management o f medical waste and the implementation o f universal precautions i s lagging behind due to lack o f funds as well as crowding o f multiple priorities in the health sector, the MSPPII will devote resources to scaling upthese interventions. 3. Rationale for Bank involvement The rationale used to justify the Bank's involvement inthe MSPP remains valid for the MSPPII. While many donors support the Government's efforts to expand the fight against HIV/AIDS, no partner other than the World Bank is able to mobilize resources sufficient to finance implementation o f the key activities outlined in the NSP. The Bank's financial support also provides the Government o f Madagascar (GoM) with: (i)the credibility to leverage other partners' resources, and (ii)flexibility inthe allocation o fresources, as the donor o f last resort. Inaddition, the Bank contributes its cross-country experience inthe design, implementation and evaluation o f Multi-Country AIDS Programs. Through its regional AIDS Campaign Team for Africa, the Bank i s well-positioned to provide the G o M with regional and international experiences and share lessons learned. Moreover, through involvement in various sectors in Madagascar and experience in support to decentralized, community-based projects (e.g., the social fund and community nutrition projects), IDA is well placed to continue to assist the Government in its national effort to fight HIVIAIDS in a truly multi-sectoral and community- oriented manner. The Bank's technical input to the revision o f the NSP and the national M&E planwill be substantially increased under the MSPPII. 4. Eligibility for Repeater Status . a) The MSPPII complies with general repeater requirements. Project status report ratings. Since the project's original institutional arrangements were modified in early 2003, implementation problems have been mostly resolved, and project status report ratings have consistently been satisfactory. At the project's Mid-Term Review in 11 December 2004, the MSPP had: (i) disbursed USD12.2 million (54 percent o f the credit); (ii) committed an additional USD5.0 million; and (iii) planned to disburse the balance o f the credit bythe end o f 2005. Impact. Project impact has generally been consistent with original PAD expectations, exceeding expectations on certain components while experiencing difficulties on others. In terms o f knowledge change, the proportion o f the population who knows o f HIV/AIDS has progressed significantly since 1997: 79 percent o f women know what HIV/AIDS i s today, up from 69 percent in 1997. In terms of the treatment o f STIs, a major driver o f HIV/AIDS transmission, STI treatment protocols are now consistently applied, and STI treatment kits are widely available. These advances inthe treatment o f STIs may have resulted inthe lowering o f syphilis prevalence: at the time of the MSPP design, active syphilis in pregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions, while the 2003/04 DHS surveyindicates that syphilis prevalence is now at 6.4 percent for women aged 15-49. In terms of behaviour change, however, the initial project's impact has been less apparent. Condom use remains extremely uneven despite the distribution o f about 32 million condoms over the last four years, and the promotion o f condom use in mass media campaigns and sub- project activities. In the general population, only 4 percent o f men and 2.2 percent o f women used condoms the last time that they had sex. In high-risk groups, condom use varies considerably: use by women with non-regular sex partners varies between a higho f 71percent in Mahajanga to a low o f 24 percent in Ilakaka. Condom use will need to be consistently higher in high-risk groups inorder for HIV transmissionto be effectively reduced. Fiduciary, environmental, social and safeguard issues. There are no unresolved fiduciary, environmental, social or safeguard problems. An environmental assessment o f the health sector, which included HIV/AIDS, was camed out as part of the preparation o f the IDA-financed Second Health Sector Support Project (CRESANII). The assessment included preparation o f a medical waste management policy and plan, which has been discussed with all stakeholders to ensure full ownership. The plan includes specific actions which need to be camed out in terms o f medical waste disposal and management for the various types o f health facilities in Madagascar. In addition, specific training programs are recommended for each type o f health worker. The implementation of these waste management policies and actions started in M a y 2004. Fund availability from other agencies, supplemental funding or cost savings. The CNLS has undertaken a mapping exercise, comparing estimated financial requirements with available resources. It has concluded that even with important contributions from the Global Fund (USD13.4 millions in 2004-06, with a possible addition o f USD6 million in 2007) and the expected contribution from the AfDB (USD11 million in2005-07), there is a funding shortfall o f approximately USD31 million through 2007. There i s not yet any clarity on the financial gap beyond that date. No other partner agency is currently able to scale up its activities or to make up for this funding shortfall, and the shortfall will have the sharpest impact in areas where the MSPP has already invested significant resources. Based on the fimding gap as well as past and projected MSPP expenditures, it seems clear that the MSPPII goals cannot be achieved via a supplemental credit or cost savings. 12 b) MSPPII complies with the MAP repeater requirements. Strategy. Incollaboration with UNAIDS, bilateral donors, NGOs and other civil society entities, the G o M prepared a draft NSP to combat HIV/AIDS in 2000. The NSP was refined through an intensive participatory process at the regional and community levels, and was adopted in 2002. Budgeted action plans have been completed, and were used in the financial mappinggap analysis. The NSP is currently being updated to take lessons learned into account, and to integratenew initiatives (e.g., the Global Fund's project). Coordination by the National AIDS CounciVlVational AIDS Secretariat. The CNLS and its Executive Secretary (SE) have been strengthened to carry out their coordinating role with the involvement o f civil society and clear public accountability. After the 2002 political crisis, the Cellule de Coordination Nationale des Actions de Lutte Contre le VIHBIDA (CCN) was formally created to lead the development o f the NSP and to coordinate the multi-sectoral HIV/AIDS effort. It has since been re-named the Comitb National de Lutte contre le SIDA (CNLS). The CNLS is made up o f representatives o f the public and private sectors and civil society organizations, and i s now placed under the direct authority o f the President of the Republic. In late 2003, the SE was appointed to manage the MSPP, which substantially improved project performance. Management of fund for STmIV/AIDS prevention and care-taking activities. The Financial Management Agency (AGF) established under the MSPP has ensured both the timely processing o f grant applications and the regular flow of funds. Since assuming the grant management responsibility inMarch 2003, the AGF has processed more than 850 sub-projects valued at more than USD7 million. More than 75 percent o f approved sub-projects were for small grants of USD10,000 or less. The parallel establishment o f a "Facilitating Organization" (OF) that helped CBOs to develop their sub-project applications reduced proposals' revision rate from 60-70 percent o f all proposals to 30 percent. Explicit measures linked disbursements to performance, although these tended to be more administrative in nature (i.e., submission o f the requisite reports) than technical. The MSPPII will build on these strengths, while makingimprovements in the supervision and evaluation of sub-projects. Of all approved sub-projects, less than 10 percent were supervised and/or evaluated, primarily due to a shortage o f personnel. To remedy to the lack o f oversight o f approved sub-projects, Regional Coordination Bureaus will take on greater responsibility for sub-project supervision under the MSPPII, and OFs will be awarded contracts by region, instead o f nationally as under the MSPP. Contracting by region will place the OFs closer to the ground, increasing their ability to supervise sub-projects. Technical support for sub-projects and public sector activities. Technical support for sub- projects is provided by different actors, depending on sub-project size. For example, CBOs and NGOs that apply for small sub-project funds receive assistance in developing their proposals from OFs, while proposals over USD100,OOO are reviewed by the technical sub-committee o f the UNAIDS Thematic Group. The MSPP also provided technical support for the development o f public sector strategies and pilot projects. There were significant difficulties in providing support to some ministries. Institutional issues related to the implementation o f pilot projects reduced some ministries' interest in the development o f public sector strategies and pilot projects. Because the institutional issues are not likely to be resolved in the short- to medium- term, the MSPPII will initially focus on a limitednumber o f sectors that were able to effectively 13 use MSPP technical support, and that play an especially important role inHIV/AIDS prevention or care-taking. These sectors have been identified primarily as health, education and security. Monitoring and evaluation system. The MSPP financed a fully operational national M&E system. The M&E system was developed at two levels: (i) the national level, through at development o f an M&E plan guided by the SE and Institut National de la Statistique Malgache (INSTAT); and (ii) the project level, through the design and implementation o f a management at information system (MIS). Though significant strides inputtingan M&E system into place were made under the MSPP, the composite parts o f the MIS need to be fully integrated (in a common sofhvare platform); second generation surveillance data needs to be better used in national programming and project decision-making; andproject activities need to be evaluated. B. PROJECTDESCRIPTION 1. Lendinginstrument The lendinginstrument i s an investment credit with a medium-termfocus (four years) to finance services, training, and goods in support o f implementation o f STI/HIV/AIDS interventions. The Country Financing Parameters, approved on M a y 12, 2005, allow for up to 100 percent project financing, including taxes. The financing parameters also allow for recurrent cost financing where required, provided that the implications o f recurrent cost financing on Madagascar's fiscal situation and debt sustainability are taken into consideration. 2. Projectdevelopmentobjectiveand key indicators The MSPPII's development objectives are the same as those o f the MSPP. Those objectives are to support the Government o f Madagascar's efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread o f HIV/AIDS on its territory. To do so, the project will intensifyand build capacity to carry out the national response to HIV/AIDS and STIs, a key riskfactor for andcontributor to the spreado fHIV/AIDS. Inaddition, the MSPPIIwill seek to improve the quality oflifeofpersons livingwithHIV/AIDS through increased access to quality medical care and non-medical support services. Given the current epidemiological situation, the project will put an even stronger focus than the original project on at-risk groups inhighprevalence areas: while moderately expanding services to other affected groups (e.g., orphans and other vulnerable children). The achievement of the development objectives will be measured by the following key indicators: Decrease by 20 percent in syphilis prevalence among commercial sex workers (data pending). Madagascar has experimented with the "PLACE" method, which uses local ethnographic and contextual data rather than blood testing inorder to identify sites where HIVprevention activities could be particularly productive. A PLACEpilot studywas camed out inMay, 2003 inseven towns judged at high-risk for sexual transmitted infections because of their activities (e.g. mines, large cattle markets, tourism, ports.) Preparation o f a 2005 PLACE study is ongoing. 14 0 Increase in percentage o f people in high-risk groups (truck drivers, military, commercial sex workers) who can cite three methods o f HIV/AIDS prevention, from 52 percent to 85 percent o f truck drivers, from 48 percent to 85 percent o f military, and from 50 percent to 75 percent for commercial sex workers. 0 Increase in percentage o f people in high-risk groups (truck drivers, military, commercial sex workers) who reject two major misconceptions about HIV/AIDS transmission, from 60 percent to 90 percent o f truck drivers, from 78 percent to 90 percent o f military, and from 48 percent to 85 percent for commercial sex workers. 0 Increase in proportion o f commercial sex workers reporting the use o f a condom in their last act o f sexual intercourse with a client from 76 to 90 percent. 0 Decrease inpercentage o f men and women aged 15-49 who report having sex with a non-regular partner in the last 12 months, from 16.8 percent to 9 percent for women and from 38.1 percent to 20 percent for men. Some key performance indicators were changed since the MSPP to reflect an increased project emphasis on high-risk areas and the behavior of people likely to frequent those areas. In addition, the MSPP Mid-Term Review found that some key MSPP indicators were too ambitious, inappropriate or unavailable. A more complete list of the indicators that were validated with the UNAIDS thematic group in April 2005 (as part of the revision of the M&E Plan) is presented inAnnex 1. 3. Project components The proposed follow-on MSPPIIwill finance five components. Component two is the only new component that was added to the project inorder to provide a stronger role for the health sector. Details o f the project components are described inAnnex 2. 15 Component and Sub-components Indicative o/o of costs Total (USDM) 1. Harmonization, donor coordination, and strategies ~ 1.5 5yo a) Harmonization and donor coordination 0.03 b) Updating o fthe national strategic plan 0.1 c) Implementing the STI/HN/AIDS communications 1.3 strategy and actionplan d) Sector strategies and actionplans 0.07 2. Supportfor health sector response 3.5 12% a) Support for STI control. 1.5 b) Support for care and treatment o fPLWHAs 1.4 c) Other health sector response activities 0.6 3. Fundfor STmIV/AIDSprevention and care-taking activities (FAP) 16.5 55% a) Sub-projects 14.5 b) Fundmanagement 2.0 4. Monitoring and evaluation 2.9 10% a) Monitoring 1.20 b) Epidemiologicaldata collection 1.20 c) Impact studies/Evaluation 0.5 5. Project management and capacity building 2.5 8Yo 0.8 3yo 2.3 7yo 100% Total FinancingRequired 30.0 100% Parameters for Madagascar. Capacity implications of the scaled-up activities. There i s little concern about whether the UGP has the capacity to scale-up project activities, as the MSPPII credit amount o f USD30M is a reasonable progression from the MSPP credit amount o f USD20M. The two areas inwhich the budget has been significantly increased from the MSPP to the MSPPII are the financing o f the Fund for STI/HIV/AIDS prevention and care-taking activities (FAP), from USD13.9M to USD16.5M, and the support to the health sector component, which did not exist under the MSPP and will receive USD3M under the MSPPII. No significant problems are anticipated with the increase involume o fthese activities. There are two broader, capacity-related concerns, however. The first i s whether the UGP will have the capacity to successfully re-orient a larger volume o f finance towards high-impact activities in a much more limited geographic area (given the MSPPII's focus on core-transmitter groups within high-risk communes). The project will need to shift from supporting general knowledge-building activities to supporting knowledge and behavior change in Madagascar's high-risk areas. To manage this concern, the project has commissioned a demographic and epidemiological profile to identify "hot" communes on an empirically sound basis. It also will undertake an ex ante cost-effectiveness analysis to assess which o f the eligible sub-project activities are likely to be the most effective in changing knowledge and behavior in high-risk 16 areas. Finally, it will provide support - potentially through the hiring o f a "supra" facilitating organization - to facilitating organizations in how to best help CBOs to develop and carry out high-impact activities inhigh-risk communes. The second concern is whether the UGP - and the CNLS more broadly - will be able to implement an M&E System which is more ambitious than under the MSPP. The MSPPII is expected to generate more monitoring data than did the MSPP. It will also aim to use the data in real-time project decision-making, which was not consistently done under the MSPP. To do so, data must be delivered to each level of CNLS or project management accurately and in a timely manner, and rapidly analyzed. The MSPPIIwill therefore place M&E specialists inthe project's Regional Coordination Bureaus to guide implementation o f the M&E system at the sub-regional level and ensure good-quality data collection. The project will finance revisions to its M I S and data entry processes to speed data collection. Each year, the MSPPII will also hire a consultant to collaborate with the CNLS to analyze the data generated each year and make programmatic recommendations based on the data analysis. Data analysis and recommendations will be summarized inan annual report, Results and Strategic Re-Orientations. 4. Lessonslearned and reflected in the project design The MSPPII will draw on a number of lessons learned, from intemational experience and from the first MSPP. The intemational lessons emerge from the first generation o f Multi-Country AIDS Programs (MAPs). Some of these lessons have beencompiled inthe Implementing Multi- Country HIUAIDS Programs (MAPS) in Africa report, while others have been highlighted through continued operational research on MAPs by the World Bank's Development Research Group. The MSPP lessons were outlined inthe Aide-Memoire for the MSPP Mid-Term Review Mission and inthe Aide-Memoire for the MSPPIIPre-Appraisal Mission. a) Internationallessonslearned Focus on high-risk zones in low prevalence countries. The first generation o f MAP projects provided broad-based funding for HIV/AIDS prevention and care-taking activities. This model was well suited to countries with a high level o f HIV prevalence where generalized prevention strategies were needed, and/or to creating a facilitating environment for highly targeted HIVIAIDS interventions. It is now recognized that HIV/AIDS response in low prevalence countries may be highly targeted to high-risk zones to reduce the risk o f HIV transmission inthe areas where that risk is greatest. To take this lesson into account, the MSPPII will change its coverage strategy to focus on core-transmitter groups inthe highest risk communes. An analysis o f existing epidemiological, behavioral and population-based data i s being financed under the MSPP to identify the high-risk communes. At least three-quarters o f the MSPPII's FAP will be invested inthese high-risk areas. A comprehensive approach in the fight against HIV/AIDS. When the World Bank first published Confronting AIDS in 1999, the annual cost o f ARV therapy for one person (inclusive o f medical costs) was estimated to be about USD10,OOO for a first-line ARV regimen. This cost was considered to be too highfor the vast majority o f developing countries to bear. Since 1999, however, the cost of ARV therapy has dropped considerably. Because the prices o f ARVs have 17 decreased substantially, and the regimens have become simpler to adhere to, it i s now feasible for more countries, including Madagascar, to support a comprehensive approach that includes offering prevention, care and treatment to those infected. The MSPPII will therefore make financing available to the health sector through its second component, for purchase o f ARVs and drugs for opportunistic diseases. This financing will compliment funding o f the purchase o f ARVs bythe Global Fund. b) MSPP lessons learned Stronger health sector involvement. The MSPP worked with sectors important to the prevention o f HIV/AIDS to develop sector strategies and action plans for management o f the epidemic. Though the project did emphasize a relationship with the health sector, its Mid-Term Review found that the Ministry o f Health's collaboration was strong, particularly on the STI kits, and highly complimentary to other MSPP activities. Given the strengtho fthis collaboration, there is now a need to expand MSPPII to support medical care o f PLWHAs. This support will be financed under a separateproject component. Stronger M&E system and more effective use of data. The MSPP financed a series o f national epidemiological and behavioral surveys, in fill or in part. However, these data are not sufficiently used to reorient the strategy and actions. To address these issues, the MSPPII will: (i) continue to co-finance epidemiological and behavioral surveys; (ii) support collection o f data in MSPPII project areas through sub-contracted Lot Quality Assurance Sampling (LQAS) to measure project-specific impact; (iii) finance annual analysis o f all survey and operational data, and (iv) finance the development of an annual report, ResuZts and Strategic Re-Orientations, in close collaboration with CNLS staff, that will present the summary data analysis and recommendations for re-orientation o f the National HIV/AIDS Program based on the data analysis. The report and its recommendations will be shared and discussed with development partners before implementation. 5. Alternatives considered and reasons for rejection Two alternatives to the MSPPII were considered and rejected, before determiningthat a repeater project was the best approach: 1. The alternative o f supplementinn the work done on HIVIAIDS under the on-noing Second Health Sector Support Proiect was not felt to be the most effective solution, given the closing date o f the health project (already extended once to 2006) and the multi- sectoral nature o f the HIV/AIDS problem. However, based on excellent previous collaboration between the two projects, MSPPII has developed an explicit health sector support component that involves the M o H inthe project directly. 2. The alternative of including HIVIAIDS inthe PRSC was rejected because o f the reduced amount o f PRSC2 financing made available for the key sectors o f education, health and nutrition, and because o f the need to earmark the use o f finds for STI/HIV/AIDS. 18 C. IMPLEMENTATION 1. Partnershiparrangements:Progresstowardsthe "Three Ones" Madagascar i s making good progress towards the "Three Ones" approach to management o f HIV/AIDS, which includes one national HIV/AIDS policy framework, one national coordinating authority, and one national M&E system. The country has one policy framework (2001-2006) and one national AIDS coordinating authority with reasonable technical capacity for coordination, M&E, resource mobilization, financial tracking and strategic information management. The CNLS has also developed a common M&E plan and a set o f performance indicators with UNAIDS support. The performance indicators were validated by the UNAIDS thematic group inApril 2005, and the MSPPII will use these indicators in its logical framework (Annex 2). To further support the "Three Ones", the project will: (i) the national strategic framework revise to incorporate the results o f the recent studies, include the proposed interventions o f the various partners, and serve as a consensus-based management tool for the period 2007-2010; (ii) maintain the institutional arrangements which were carehlly established during MSPP, but will revise the project's operational manuals to reflect improved capabilities and streamline existing procedures; and (iii) ensure that the M I S hnded by MSPP serves the needs o f the national M&E strategy as well as those o f all partners. The MSPPII will support revisions to the M I S system as needed. Under component 1, MSPPII will also provide funding to strengthen harmonization and donor coordination for HIV/AIDS interventions. The CNLS has begun to map out the availability and distribution o f funds according to the priorities o f the NSP. While there is currently no intention of formally harmonizing or pooling funds, the MSPPII will seek to establish: (i) agreement on the annual work plan and outputs; and (ii) a detailed financing plan identifyingspecific activities to be funded by specific agencies and the GoM. Individual partners' financing will be "earmarked" in the annual work plan. However, it is understood that the IDA contribution will be flexible, andusedas funding o f last resort. Finally, the MSPPIIwill continue to submit bi-annual program monitoring reports for review by the CNLS and its financing partners. Reporting formats (including summary reports on activity outputs, financial statements, and procurement) will reinforce the "Three Ones" and will be agreed on by CNLS and its partners. Adjustments to the annual work plan will bejointly agreed upon at bi-annual reviews. 2. Institutionaland implementationarrangements The institutional arrangements for the National HIV/AIDS Program and the MSPPII are similar to those used under the MSPP.' The responsibility for the oversight o f the National H N / A I D S Program rests with the CNLS at the central level; the Regional HIV/AIDS Prevention Committee (CRLS) at the regional level; and the Local HIV/AIDS Prevention Committee (CLLS) at the A detailed description ofthe differences between the MSPPand MSPPII institutional arrangements is provided in Annex VI. 19 commune level. These committees are made up o f HIV/AIDS stakeholders, including representatives from Government, PLWHAs, NGOs, the private sector, and religious and CBOs. At the central level, the CNLS was created by Government decree in October 2002. The mandate o f the CNLS i s to: (i)coordinate the national fight against HN/AIDS; and (ii) the guide implementation o f the NSP. The CNLS i s made up o f an Executive Secretariat (SE) and a plenary committee. Inaddition to the day-to-day management o f national HIV/AIDS prevention activities, the SE provides political and strategic support to the Govemment's fight against HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection o f rights. The SE also oversees implementation o f the MSPP, with the Executive Secretary serving as project director. Implementation o f the national HIV/AIDS program i s coordinated at the regional level by the CRLS, which i s responsible for (i) supervising and coordinating HIV/AIDS interventions; (ii) guiding implementation o f the NSP; and (iii) between the CNLS, the Local CLLS, and liaising other STI/HIV/AIDS prevention actors in the region. At the commune level, the CLLS i s responsible for: (i)developing the local plan in the fight against HN/AIDS; (ii) guidinglcoordinating implementation o f the plan; and (iii) mobilizing the local population in the fight against HIV/AIDS. Project Implementation Arrangements. The UGP i s responsible for day-to-day management o f the project. Itsresponsibilities include: (i) development o f the annual work program andbudget; (ii)management o f project activities, financial management, procurement, administration and logistics; (iii)oversight o f monitoring and evaluation (contracted to the Monitoring and Evaluation Organization or OSE); and (iv) periodic reporting to the World Bank. The UGP also serves as the Secretary o f the MSPP Council, which provides oversight o f the project as a whole. The Council reports directly to the President o f the Republic and is made up o f fifteen permanent members, including one representative from each of the following: the Office o f the President o f the Republic; the Ministry o f Finance; the Ordre des Experts ComptabZes de Madagascar; the NGO sector; the private sector; beneficiaries' associations; and key sectors such as health, education, security and youth. The UGP is supported by the OSE and the Technical Review Organization (ORT). The OSE i s responsible for carrying out periodic project monitoring surveys and for supporting MSPP management to use data in project decision-making and strategic re-orientations. The ORT, under the auspices of the UNAIDS thematic group "dargie", consists o f designated partners within the group who review for technical quality all proposals over USD25,OOO and a sub-set o f proposals over USDlO0,OOO submittedto the FAP. At the regional level, the Regional Coordination Bureau (BCR) is responsible for MSPPII implementation. Each B C R covers one to three administrative regions, and i s staffed by a Director and a Technical Coordinator. M&E Consultants will be assigned to each office to ensure high-quality regional data collection. Each region also has a Facilitating Organization (OF). The OF is an NGOcontractedbythe project to assist: (i) communes inthe development o f their local plans in the fight Against HIV/AIDS; and (ii)CBOs in the development and implementationo fthe technical aspects o f their applications for Fundfinancing. 20 Lastly, a Financial Management Agency (AGF) i s responsible for: (i) evaluating the financial viability o f CBO applications to the Fund; (ii) returningfinancially weak proposals to the CBOs for revision; (iii)forwarding suitable proposals to the OF for technical review; and (iv) making payments to the CBOs for approved sub-projects. The AGF i s also responsible for maintaining a database o f unit costs for the range o f activities eligible under the Fund. 3. Monitoring and evaluation of outcomes/results Though MSPP generally adhered to the arrangements described in the annex to the original PAD, two M&E specialists were insufficient to carry out the range o f responsibilities described. Specific problems included: (i) the coherent functioning o f the computerized MIS. The M I S i s in place and operational at the UGP and AGF but, while some parts o f the system work individually, only one (sub-projects) i s fully automated and the parts do not function together as a whole; (ii) the lack o f use o f monitoring data in national programming or project decision- making; and (iii) the lack o f impact evaluation(s) o f project activities. The MSPPII M&E subcomponent will also ensure that the national M&E system used by all donors is inplace and operational. a) Monitoring The MSPPII Monitoring Plan contains five parts. First, a monitoring framework identifies the key performance indicators associated with MSPP project inputs (Annex 2). Second, outcomes (i.e., behaviors and knowledge) in the project's at-risk zones (as well as in a limited number o f control areas) will be measured using LQAS for recurrent behavioral surveillance. Third, key performance indicators as well as financial, input and operational data will be consolidated inthe project MIS, which will be improved to form a single, coherent system. Fourth, sub-project quality will be monitored more closely byplacing M&E staff inthe BCRs, verify the accuracy o f monitoring data; monitor sub-project quality through periodic site visits; and share relevant data with regional partners. Fifth, monitoring data will be regularlyreleased to development partners and the public, primarilyinthe form o f quarterly, biannual and annual reports. b) Epidemiological data collection and special studies The MSPPII will continue to contribute to the financing o f a second generation surveillance system and other population-based surveys and large-scale studies. These include bi-annual behavioral surveys among high-risk groups (sex workers, sex workers' clients, truck drivers, military and youth) and annual sentinel biological surveillance surveys o f clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). The latter includes the cross-sectional HIV prevalence study (Enqugte Nationale de Sero-prevalence Auprks des Femmes Enceintes) first conducted in 2003; the 2008/09 Demographic and Health Survey; and the annual "PLACES" studyo fhigh-risk sites andrisk behaviors there. c) Impact studies The MSPPII will support one or more (pending the availability o f funding) impact studies to measure, for example, changes in HIV/AIDS prevalence and incidence, changes inAIDS related mortality, social norms, coping capacity in the community, and economic impact. These impact 21 studies will be launched only after technical review confirms that the study design has sufficient statistical power to test the study hypothesis. The study methodology will be reviewed by the Global HIV/AIDS Monitoringand Evaluation Support Team. d) Consolidatedanalysis to reorient the strategy The project will also finance a consolidated annual report, ResuZts and Strategic Re-Orientations. The report will present: (i) analysis o f data generated and studies camed out inthe course o f an the year, and (ii) recommendations on re-direction o f the National HN/AIDS Program or the MSPPII. The report will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based on this analysis. The reports will then be disseminated to and discussed with the UNAIDS thematic group, with a view to regularly using monitoring and evaluation information in program decision-making. 4. Sustainability Though perhaps less so in Madagascar than in neighboring countries, HIV/AIDS constitutes a pending natural disaster, to which response i s well beyond the Government's financial means. For the foreseeable fiture, there is general agreement within the international community that an effective and sufficient response to the epidemic is largely dependent upon the continued financial support o f multilateral and bilateral donors. However, the project will try to build sustainability by measures such as advocating for budget lines for HIV/AIDS or assigning civil servants filltime to the fight against the epidemic. 5. Critical risks and possible controversial aspects Risk Risk Rating Risk-MitigatingMeasures For equity reasons, the UGP may not be able M The project will allocate 75 percent o f sub-project to focus the majority o f its resources on high- funds to identified "hot," or high-risk, communes. riskareas, despite the pressing The Fund's procedures manual will be revised epidemiological case for doing so. accordingly. Despite Government's efforts to mobilize M The MSPP has invested considerable resources in public opinion, some religious organizations reaching both religious and traditional leaders. The may continue to speak out against condom MSPPIIwill continue to do so, with an emphasis on use andor encourage stigmatization. continuing the dialogue with opposing groups. Within the project, communication regarding condoms will be less aggressive inmass media campaigns but intensified incommunications with high-riskgroups. Inaddition, the project will try to better leverage the President's commitment to HIV/AIDS prevention to involve other national leaders inthe promotion o f condoms and the reduction o f stigma. 22 The capacity o f the health care system to S The project description allows the project to be provide basic services for treatment o f STI flexible inits support to the health sector, intervene and HIV positive patients (opportunistic where it sees that it will have the greatest impact, and infections, MTCT, ARVs), and for voluntary act in compliment to the CRESANII Project and counseling andtestingis too weak to enable health-related activities supported by the PRSCs. the project to meet its health sector-related For example, it may finance the training o fhealth objectives. staff. NationalNGOs may not have the expertise to M At least twenty percent o fthe regional OFcontracts successfully assist CBOs inimplementing will be awarded to internationalNGOswith a proven more technically sophisticated or socially track record. challenging sub-projects, such as home- based care or support to orphans and vulnerable children or PLWHAs. 6. Loadcredit conditions and covenants (i)Conditionsfor effectiveness 0 Recruitmentof auditors acceptable to IDA. (ii)Covenants 0 Submission o f the updated Project Implementation Manual, including updated administrative, accounting and financial Parts (with new Chart o f accounts and Financial Monitoring Reports) to IDAby August 31,2005; 0 Submissiono f the updatedFAPprocedures manual to IDAby September 30,2005; 0 Finalization o f revised National M&E Plan and validation by all stakeholders by June 30, 2005; and 0 Completion o f a technical audit o fFAP sub-projects by October 31,2005. D. APPRAISAL SUMMARY 1. Economic and financial analyses Detailed economic analysis on HIV/AIDS has been carried out under the Multi-Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR, paragraphs 76-78). The analysis demonstrates the impact o f the epidemic on economic development and poverty as well as the cost-benefit o f fHIV/AIDS interventions. The fiscal impact of the project is expected to be modest. Counterpart funds are not required and will therefore not impose a financial burdenon the GoM. Civil works will be minimal and will be primarily restricted to the renovation o f voluntary counseling and testing (VCT) facilities in existing health centers. The recurrent cost o f maintenance for infrastructure built under the project i s thus expected to be negligible. Finally, the MPPPII will finance expansion, staffing and operating costs o f the BCRs. This will involve some supplemental costs relative to the original project. As detailed in the "sustainability" section above, however, the international community i s expected to finance the response to the HIV/AIDS epidemic for the foreseeable 23 future. The slight additional costs o f new BCRs should therefore not create any additional fiscal burden on the GoM. 2. Technical The design o f the MSPPII is based on the MSPP. The MSPP, in turn, relied on existing knowledge and experience gained inMadagascar and inother African and Asian countries. The preparation team relied heavily on the UNAIDS Thematic Group inMadagascar for the project's technical content. The design follows the MAP principles and the NSP, which reflects a consensus among all stakeholders. Inaddition for MSPPII, UNICEFprovided technical support for communication and on orphans and vulnerable children (OVC) activities. The design o f the new health component is based on IDA'Sexperience with the health sector in Madagascar through successive health support projects, and from international experience in the financing o f care and treatment for PLWHAs. The M&E component has been strengthened through the collaboration o f the World Bank and USAID. The M&E sub-committee o f the UNAIDS Thematic Group will continue to advise the CNLS and UGP during implementation. The UGP will also continue to rely heavily on its partners for technical support on the Fund implementation. For example, before approval by the AGF, all sub-project proposals to the FAP above USD25,OOO will be reviewed by designated partners o f the UNAIDS Thematic Group with comparative advantage in the type o f activity proposed (Annex IV provides details). The UGP can at all times apply for technical support from the partners to the UNAIDS Thematic Group and/or from the UNAIDS Secretariat. Annual technical audits will be undertaken by independent consultants. 3. Fiduciary Procurement. The third Country Procurement Assessment Review (CPAR) for Madagascar was conducted inNovember 2002. It was followed by a workshop inJune 2003 that validated ajoint CPAR/ Country Profile o f Financial Accountability (CPFA) action plan to ensure rapid implementation o f procurement reforms. K e y elements o f the intended procurement reforms are: (i) revision o f the draft procurement code to ensure transparency, simplify procedures, and comply with international standards; (ii) establishment o f effective procurement institutions to ensure that the new regulations will be adequately applied, provide sufficient oversight and control, and improve efficiency through adequate delegation of responsibilities; and (iii) implementation o f adequate training and capacity building to ensure the sustainability o f the procurement reforms. A new procurement code was enacted inJuly 2004. Since the texts for regulatory application are still under preparation, however, the existing Procurement Code o f 1998 will continue to be applied. The World Bank ascertained that deficient features identified in the 1995 CPAR have been properly addressed. IDA standardbidding documents are widely used. An area o f concern, however, i s the cumbersome and overly bureaucratic approval process for contract signingby the Government, which causes unnecessary delays. In addition, insufficient programming and procurement planning contribute to delays in project implementation resulting in slow disbursement. To mitigate risks o f delays for the proposed project, proper prerequisites for the 24 use o f Bank standard bidding documents, including evaluation reports for national competitive bidding procedures, have been agreed upon with Government duringnegotiations. The Project Implementation Manualwill be updated. A procurement capacity assessmento fthe UGP, including training needs and arrangements, was conducted as part o f project preparation. On the basis o f the initial assessment, an action plan was drafted to address areas where the UGP needs to be strengthened. The action plan includes: (i)specific sectiononprocurement intheProjectImplementationManualtobeupdatedby a August 31, 2005; (ii) improvement o f organization o f the filing o f procurement-related the documents, including within the regional offices; (iii) procurement training sessions for project staff; and (v) the financing o f independentprocurement and technical audits to be carried out on a regular basis. Financial management (FM). In accordance with Bank policy and procedures, the financial management arrangements o f the UGP responsible for the implementation o f the MSPPII have been reviewed to determine whether they are acceptable to the Bank. This review is an update, since the FM system o f this entity has already been assessed in the context o f the MSSP. The conclusion o f this review rated the project FM system "globally satisfactory". However, the following measures need to be taken to ensure adequate recording o f project transactions and timely production o f financial reports required for managing and monitoring MSPPII activities: i)review oftheprojectChart ofaccountsto reflect components andactivitiestobefinanced under MSPPII credit; ii)determination o f the format and contents o f the financial and physical progress reports to be agreed by August 31,2005; and iii)recruitment, on a competitive basis, o f an accounting assistant to better handle the high volume o f transactions and activity, and ensure appropriate segregation o f duties. All these recommendations should be implemented by early July 2005. The project financial statements will be audited annually by independent and qualified auditors acceptable to IDA, in accordance with International Standards o f Auditing. The auditors should be recruited prior to effectiveness. The audit report will be submitted to IDA not later than six months after the end of each fiscal year. The content and format o f the new financial management reports (FMRs) will be agreed before effectiveness. No significant problems have been encountered interms o f audit covenants: the MSPP and all other Bank-financed projects in Madagascar have consistently submitted their audit reports indue time. 4. Social 4.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes. Madagascar i s still at an early stage in the epidemic and is therefore in the fortunate position to be able to curb its spread. The project is designed to reach the most at-risk groups, which include sex workers and their clients, migratory workers, youth, etc. It will empower these groups to undertake HIV/AIDS activities, reduce transmission and ultimately avoid the severe socio-economic impact of HIV/AIDS that i s seen incountries with highprevalence rates. Recent 25 studies on sexual and socio-cultural behavior will be used to fine-tune project-financed activities for STI/HIV/AIDS prevention and treatment. 4.2 Participatory Approach: How are key stakeholders participating in the project? The original project was developed on the basis o f the government's NSP and in close consultation with key government, NGO and elected representatives as well as international stakeholders. Different focus group discussions were conducted at the central level and local levels. In addition, several regional meetings were carried out with the participation o f local development actors and potential beneficiaries to develop regional and sectoral HIV/AIDS strategies. Technical assistance was provided to assist the government in empowering the communities and NGOs to actively participate in designing and implementing the national HIV/AIDS program through the PRSP process. During the pre-appraisal mission (March 2005), the proposedrepeater project was discussed with the Partners Forum. The project design reflects inputfrom its members. Finally, representatives of FIFAFI, Madagascar's only association o f PLWHAs, are members o f the MSPP Council, the CNLS, and the Country Coordinating Mechanism (CCM). Four PLWHAs are currently working inthe CNLS and the UGP. 4.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? To date, 850 sub-projects requested by NGOs and CBOs have benefited from funding from the Fund. A consortium o f three international NGOs was also hiredto provide technical support to the NGOs or CBOs that submitted sub-project proposals under USD25,OOO. With the increase in volume o f component 3 (the FAP), NGOs and CBOs will continue to be eligible to request sub- project funding. Those NGOs with specialized capacity and experience in the fight against HIV/AIDS will be contracted as OF to assist: (i)communes in the development o f their local plans in the fight against HIV/AIDS; and (ii)CBOs or NGOs in the development and implementation of the technical aspects o f their applications for Fund financing. There will be 22 OF contracts, one for each region o f Madagascar. Up to 80 percent o f the contracts may be won bynationalNGOs. 4.4 What institutional arrangements have been provided to ensure that the project achieves its social development outcomes? At the central level, the CNLS oversees the national, multi-sectoral HIV/AIDS prevention efforts. The mandate o f the CNLS includes attention to social development objectives and the involvement o f PLWHAs in the National HIV/AIDS Program and MSPP in particular. At the regional and local levels, the project facilitates achievement o f social development outcomes through its Fund, which seeks to empower local communities by allowing them to apply for funds for and implement their own STI/HIV/AIDS activities. On the supply side, as above, the MSPPII provides the opportunity for national NGOs to develop their ability to facilitate STI/HN/AIDS prevention and care-taking activities by acting as OFs. 26 4.5 How will the project monitor performance in terms of social development outcomes? The MSPP is a social development project. Its M&E arrangements are described inbrief inthe "Monitoring and Evaluation o f Outcomes and Results" section, M&E indicators are listed in Annex 2, and in detail in Additional Annex 14 on Detailed Monitoring and Evaluation Arrangements. 5. Environment The proposed project has been classified as category B )) for environmental screening purposes, given the risks associatedwith the handling and disposal o fmedical wastes. 6. Safeguard policies The only safeguard triggered i s the environmental assessment, because a medical waste managementplan (MWMP) is required. A full environmental assessment of the health sector, which included HIV/AIDS, was also carried out as part of the preparation of the IDA-financed Second Health Sector Support Project (CRESANII). A MWMP was developed for the MSPP, andhas beenimplemented since May 2004. Since that date, the MoH has installed 200 small-scale burners to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that burners are used at the sites supervised (district hospitals o f Ankazobe, Antanifotsy and Faratsiho). The construction o f full incinerators at district level is underway; some o f them should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out inMadagascar's different types o fhealth facilities. The MoHhas demonstrated the ability to plan for and prepare these activities. Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [x 1 [I Natural Habitats (OPBP 4.04) [I [X I Pest Management (OP 4.09) [I [X I Cultural Property (OPN 11.03, beingrevised as OP 4.11) [I [I [X I Involuntary Resettlement (OP/BP 4.12) [X I Indigenous Peoples (OD 4.20, beingrevised as OP 4.10) 11 [X I Forests (OP/BP 4.36) [I [X I Safety o f Dams (OP/BP 4.37) [I [X I Projects inDisputed Areas (OP/BP/GP 7.60)* [I [X I Projects on InternationalWaterways (OP/BP/GP 7.50) [I [I 7. Policy Exceptions and Readiness The proposed project does not require any exceptions from Bankpolicies onrepeater projects. * By supporting theproposedproject, the Bank does not intend to prejudice thefinal determination of the parties' claims on the disputed areas 27 Annex 1: Country and Sector or ProgramBackground MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project 1. CurrentDimensionsof the HIV/AIDSEpidemicinMadagascar HIV was first diagnosed inMadagascar in 1984. In 1998, 37 AIDS cases and 233 HIV positive cases were reported to the World Health Organization (WHO). While sparse study results indicated that HIV had more than doubled in three years, from 0.07 percent (1996) to 0.15 percent (1999), it i s only in 2003 that the first national representative survey showed that HIV prevalence was 0.95 percent.6 Based on the HIV rate differential between pregnant women and the general population observed in other country studies, HIV prevalence in the general adult population o f Madagascar i s probably lower than among pregnant women. The estimated number o f reported deaths due to AIDS in2003 was 24, and the number o f people known to be living with AIDS was 68.7 Current estimates suggest that there are at least 35,000 HIV positive people in Madagascar. Studies conducted in 2001 estimated that 96 percent o f HN infections were acquired through sexual transmission. 2. Risk andVulnerability Factors Extremely high STZ rates. Rates o f sexually transmitted infections (STI) are extremely highin Madagascar. Because ulcerative genital disease, such as herpes genitalis and syphilis, increases the risk o f HIV transmission by 50 to 300 times (male to female), control o f STIs through condom use with irregular partners and the availability o f prompt and affordable STI treatment is particularly critical inthe fight against HIV/AIDS inMadagascar. Syphilis and gonorrhea rates, in particular, are among the highest in the world. In 1998, active syphilis in pregnant women was as high as 14.8 percent, and was over 35 percent among sex workers in some regions. In a May 2000 study o f approximately 1,000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. The first nationally representative survey carried out in 2003 found that active syphilis was 8 percent among pregnant women.* Recent analysis o f a sample of 2003104 DHS showed syphilis prevalence at 6.3 percent among adults aged 15-49. The 2003/04 DHS confirmed most o f the findings of the national survey o f pregnantwomen, and provided more insight into the variations in syphilis prevalence: (i) highlands (Antananarivo the and Fianarantsoa) are less affected than the coastal areas; (ii) the capital city has a very while low prevalence rate, the other cities have a slightly lower prevalence than the rural areas which are the most affected; and (iii) i s a clear inverse relationship between syphilis prevalence there and welfare (the poorest being 5.9 times more likely to be positive than the richest), and syphilis prevalence and education (those with no education are 3.5 and 5.7. times more likely to be infected than those who have had some primary and secondary education, respectively). 6 The previous national prevalence figure of 1.1% was subsequently corrected to take into account the proper weighting of the different provinces. 'Projectdata. The analysis on the raw data however ignored the different weight attached to the sample groups. For example, young rural women were not weighted inrelation with their representation inthe actual population. 28 High-risk sexual behavior and misconceptions. The median age at first sex in women has remained constant at around 17.5 years over the past years.' Fifty one percent o f women and 61 percent o f menknow that condom protect against HIV. But this proportion is lower among the youngest: only 44 percent of young girls who knew about HIV/AIDS and were sexually active, know that condoms protect against HIV (DHS 2003/04). Sixty percent o f women and 73 percent o f men knew that limiting the number o f sexual partners could protect against HIV. This knowledge has dramatically increased, especially among women, compared to DHS 1997 (38 percent o f women). Nevertheless, when it comes to the behavior, 17 percent o f women and 38.1 percent of men said they had high-risk sexual behavior during the past 12 months. There is a great variation o f behavior depending on social, demographic and geographical characteristics: men in general and single women tend to have more high-risksexual behavior. InAntsiranana and Toliara, multiple sexual partners are more common. Risky behavior i s particularly high among the youngest (43 percent among the 15-19 year old girls, and 89.2 percent among the 15-19 year old boys). The use o f condom also remains very low (5.4 percent for girls, 12.2 percent for boys). Moreover, there are still about 25 percent o f menandwomen who have had an STI and who did not look for treatment or counseling.lo Misconceptions regarding STI/HIV/AIDS are consistently reported, including among youth (15- 19 years o f age). This includes the beliefthat HlV/AIDS can be transmitted by insect bites, and by sharing dishes with someone with AIDS, as well as that a person looking healthy cannot be HIVpositive. Cultural bamers andmisconceptions about transmissionmay help to explain why condom use remains very low. A large proportion o f those interviewed stated that they know what a condom is but would not propose the use o f one duringoccasional sex. Condoms are also source o f misconceptions such as causing uterine cancer and leading to infertility and people often consider that condoms are less important than fidelity. Qualitative research shows that talking about sex remains taboo. The influence o f parents seems to remain very high in Madagascar (53 percent o f interviewees stated that they are mostly influenced in their behavior by their parents), but most parents are reluctant to discuss sexuality with their children. On the other hand, virginity i s considered less important now throughout most o f the country and there i s a strong link between material or financial compensation and sex. This link has led, in some instances, to an easy transition to commercial sex. Despite the strength o f religion as reflected in the level o f churchgoers, the clergy seem to have little influence on sexual behavior' . * 3. Strategic Axes Communication. The project will support a reorientation o f communication activities from top- down mass communication (which will be reduced) to grassroots communication using participatory methods (which will be intensified). Even in mass communication, it will be important to introduce interactivity though televised debates, hot lines, etc. Efforts to involve D H S 2003. Nevertheless there i s a general opinion that DHS overestimated the median age which could be closer to 13. lo D H S 2003 11 Synthesis Report : Society, culture and HIV-AIDS inMadagascar. M e i Zegers. April, 2003. 29 PLWHAs in prevention efforts will also be intensified. The use o f radio will be favored over print and television media, givenradio's relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement o f influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers' associations). The project will support training and capacity building o f these different groups. Local response. The MSPPII will continue to finance the Fund created under MSPP to support the local response, and the Fund will continue to be managed by an independent AGF. During the MSPP, nearly 850 sub-projects run by local NGOs and CBOs have contributed to the implementation o f prevention programs across the country. Under the MSPPII, CBOs will take over o f the local response to HIV/AIDS from the NGOs, under the leadership o f the CLLS. The local response will include: (i)condom distribution in identified high-risk communes; (ii) HIV/AIDS peer education and training o f community counselors, with a special emphasis on communication for behavior change; (iii) home delivery o f treatment and non-medical care- taking services to PLWHAs (activities could include psycho-social and nutritional support); (iv) orphans and vulnerable children activities; (v) awareness-raising inhigh-risk groups and areas to increase the demand for HIV/AIDS services; (vi) reinforced communication to reduce stigma and discrimination towards PLWHAs, including greater focus on elimination o f misperceptions about PLWHAs; and (vii) HIV/AIDS in workplace programs both in the public and the private sector. Technical coordinators at the regional level, assisted by OFs, will supervise the preparation of the local plans to fight against HIV/AIDS and the implementation o f the plans by CBOs (in the form o f local response activities). There will be up to twelve regional coordinators in Regional Coordination Offices, and twenty-two OF contracts, one for each o f Madagascar's regions. The OF will be local or international NGOs. Twenty percent of the regional contracts will be awardedto international NGOs. Several steps will be taken to enhance the effectiveness o f local response activities. The terms o f reference o f the AGF and the OF will be revised in order to enhance the coordination between them. As a result, the AGF (whose number o f regional offices is likely to grow inthe future) will start keeping a database o f unit costs and will adapt the latter to the regional contexts, as needed. The menu o f standard sub-projects will also be revised and tailored to CBO capacities. In addition, a second menuwill be elaborated to address the needs in the lower risk areas. Finally, the Fund's procedures manual will be modified in order to improve CBO selection criteria, and encourage a sub-program approach (long-term) versus a sub-project approach (short-term) at the commune level. Sexually transmitted infections (STIs). A broad national STI control program was launched in 2003. The strategy i s based on the syndromic approach,12 which promotes the subsidized sale of two standardized STI treatment kits through the public and private sectors (the latter through '' STIsare classified by syndrome. Each syndrome is madeup of a combination of symptoms and clinical signs identified upon examination. The four main symptoms are (i) urethraldischarge for men; (ii) lower abdominal pain for women; (iii) vaginal discharge for women; and (iv) genital ulcers for both men and women. 30 social marketing in pharmacies and pharmaceutical wholesalers; see Box 1.l).13 The high prevalence o f STIs, combined with the highpercentage o f the poor who cannot afford to pay for STI treatment, provides the argument for subsidizing STI treatment andor making treatment available at no cost to the very poor ("indigents'y. Inaddition, PSI has established a network of franchised clinics run by general practitioners (GPs) in several towns (Antananarivo, Diego, Mahajanga, Tamatave). The GPs are specially trained in providing STI treatment and other health care to youth. A recent Government decree allows GPs to provide their STI patients with STI treatment kits directly. Finally, as syphilis treatment for pregnant women has been shown to be highly cost-effe~tive,'~a syphilis campaign for pregnant women will start in regional and district hospitals as well as inabout 350 rural health centers. Box 1.1: STI TreatmentKits While HIV prevalence in Madagascar i s still low compared with other Sub-Saharan African countries, rates o f chlamydia, gonorrhea and syphilis are high. Studies in Tanzania and Uganda have demonstrated that improved STI treatment can reduce HIV transmission by up to 40 percent in countries or areas where, like Madagascar, HIV prevalence is l o w and STI prevalence i s high. Because STI treatment not only prevents but lowers the risk o f HIV infection, such treatment has strong, positive spillover effects whichjustify focused public attention and subsidy. Since the public sector alone cannot fill the need for the STI treatment nationwide, Population Services International (PSI) has set up a program to distribute subsidized pre-packaged STI kits in the public and private sectors, with assistance from U S A I D and the World Bank-financed CRESANII and MSPP project. STI kit distribution is coupled withpromotional and educational activities, andtraining for healthprofessionals. I The pre-packaged therapy contains antibiotics to treat the STI; sufficient condoms for the duration o f treatment; partner referral cards; and educational and informational leaflets. In the last two years, 360,000 CURA 7 kits (to treat infections with genital discharge symptoms) and 78,000 Genicure kits (to treat ulcerative infections) have been sold. The luts have provento be the preferred treatment option for STIs, with CURA 7 kits selling at 135 percent o f projected volume for the period and Genicure luts selling at 205 percent of projectedvolume. (Source: Preventing HIV through Social Marketing of Pre-Packaged Sexually transmitted Illness treatment kits, 2004, as cited in"Performance o f the Madagascar health sector: Current situation, constraints and policy recommendations," under preparation by the World BanWAFTH3). Condom promotion. Awareness o f the importance o f condoms in protecting individuals from HIVhas increased considerably since 1997. The 2003/04 DHS shows a 30 point increase inthe percentage o f women who know that condom use can protect against the virus (from 27.2 percent in 1997 to 50.8 percent in2003). Increased awareness o f the importance o f condoms has not been matched by increased condom use, however. Condom use inthe general population is low (2.2 percent of women and 4 percent o f men used a condom the last time that they had sex). Although it i s consistently higher among populations with non-regular sex partners, condom use inthis populationvaries widely by region: condom use bywomen with non-regular sex partners varies between a high o f 71 percent in Mahajanga to a low o f 24 percent in Ilakaka, a "Wild West" type miningarea. l3Cura-7, a kit combining ciprofloxacin and doxycyclin for genital discharge and Genicure combining ciprofloxacin and penicillin. Both kits are fitted with ad hoc information, simple instructions for usingthe drugs, illustrations showing several pictures o fthe respective syndromes including genital diseasesthat are not cored by the kits as well as waming cards for the sexual partner(s). For detailed information see box "STI kits". l4I s antenatal syphilis screening still cost effective in sub-Saharan Africa. Sex Transm Infect. 2003 Oct; 79(5):375-81. Terris- Prestholt F. et al. 31 Social marketing has facilitated condom access: over 32 million units were distributed from 2000 to 2004 through more than 25,000 retail points nationwide, at the cost o f almost USD0.20 each. Nonetheless, gaps in condom access persist in the general and in high-risk areas. To address these gaps, a new brand o f luxury condom will be launched, with a projected distribution o f five million the next few years, and 15 million basic quality condoms will be distributed for free in high-risk areas. Voluntary counseling and testing (VCT), prevention of mother-to-child transmission (MTCT), and safe blood transfusion. The country currently has 49 VCT centers for a population o f 17 million, mostly located in the province o f Antananarivo (22 VCT). The other provinces respectively have 3 to 8 VCT centers (8 in Toliara, 7 in Antsiranana, 5 in Fianantsoa, 4 in Toamasina, 3 in Majunga province). Nevertheless free testing is the rule in only three provinces (Fianarantsoa, Toamasina, Mahajunga). Inthe province o f Antananarivo, only 11out o f 22 VCT centers provide free testing. Comparedto 6 to 7 inAntsiranana, and 6 to 8 inToliara). UNICEF finances HIV screening for pregnant women and the prevention o f MTCT in 11 Hospitals and 14 health centers. With the support o f UNICEF and the Global Fund (USD13.4 million), the Government i s planningto significantly expand the number o f V C T centers over the next few years. The MSPPII will complement these efforts where necessary. Currently, given the overall low prevalence and the fear o f stigmatization, few people actually use these services. It is expected that the utilization rate o f the VCT services will be boosted once ARV and adequate lab testing for ARV follow-up will be made available as planned by the M o H and coordinated by the CNLS, and as communication campaigns help to reduce stigmatization. Properly tested blood transfusions are available on demand, using family relatives as donors in all hospitals practicing surgery. Outside Antananarivo and a few other cities, blood banks are not yet functional. The ADB i s launching a U S D l1 million project to strengthen the safety of blood transfusion and implementation o f universal precautions countrywide. Finally, the M o His currently organizing a circuit to collect medical waste inperipheral health centers and is building "Montfort" incinerators at the district hospital level to properly to manage medical waste. Again, the project will complement these efforts where necessary. Anti-retroviral treatment. Currently, treatment o f AIDS cases i s fully supported by the Association Rive from the Reunion. The association i s providing technical and laboratory assistance, as well as generic and brand name ARV drugs. However, the ARVs are prescribed according to French treatment protocols, which are not adapted to a developing country environment. Moreover, drugs that will be ordered shortly are mostly not fixed-dose combinations o f ARV. This choice increases the risk o f prescription errors, poor adherence to treatment (too many pills to take, mono or bi-therapy, increase in drug resistance) and drug management risk (drug forecasting, expiration date, stock out)." All these factors are likely to hamper health services quality and prevent from a rapid scaling up o f antiretroviral therapy all over the country o f Madagascar. Moreover, while the current cost o f treatment under these protocols remains affordable due to the very limited numbero f patients served, it will be beyond l5Sources: (i) 2003; (ii) "two pills to save lives, fixed-dose combinations o fARVs", February, 2004. OMS, MSF 32 Madagascar's financial means to treat AIDS patients under these protocols as the number o f patients seeking treatment increases.16 Treatment guidelines. In 2004, the M o H developed PLWHA treatment guidelines, including treatment protocols for opportunistic infections at the different levels o f the health system (primary health care centers, district hospitals, referral centers). However, these protocols did not take into account the limited laboratory infrastructure o f the health facilities (testing equipment, laboratory monitoring). The M o H recently developed draft treatment guidelines that are closer to WHO recommendations. The draft guidelines were partially approved by the Partners' Forumwhich requestedthat these also addressissues such as the use o f standardized first and second line regimen^,'^ the use o f Fixed Dose Combinations o f ARVs," when to start ARV therapy and when to change regimen, clinical and laboratory monitoring, drug resistance monitoring, management o f the medicine supply cycle, lab analysis and ihfrastructure management (taking into account the existing capacity in health facilities), capacity building program including counseling and treatment adherence, and strategy for setting up o f the ARV prescribing sites. These guidelines are expected to follow international recommendations for countries with limited resource^.'^ Monitoring and evaluation of ARV treatment would be carried out by the treating doctor who would track: (i)treatment tolerance andtoxicity; (ii)clinical andimmunologic responseto treatment; and (iii) treatment adherence. This last point could be promoted by the use o f Fixed Dose Combinations but will also require strong education campaigns carried out by treating doctors, counselors, health workers, and voluntary organizations working close to patients' home. Patient follows-up should also be put into place to evaluate the treatment efficiency, and monitor toxicity and emergence o f drugresistance. Medical and management expert committee. In January 2003, the GoM established a technical committee on drug management, which includes laboratory analysis experts, representatives o f the National Referral Laboratory, and some health partners. A national coordinator for drug procurement planning and distribution was recently appointed. A sub-committee including experts from technical and financial partners has been asked to finalize the guidelines taking into account international recommendations as soon as possible. However, there is no formal l6It i s expected that approximately 3,000 new patients will need ARV therapy each year, which will quickly increase the financial burden o f providing such treatment. In2003, the WHO recommends for the first lineregimens: d4T/3TC/NVP or ZDV/3TC/NVP or d4TI3TCIEFV or ZDV/3TC/EFZ. EFV should not be given to pregnant women and ZDV requires haematologic monitoring. 2e line regimen: TDF or ABC+ddI+LPV/r or SQV/r or NFV ifno cold-chain available. InAnnex D of the WHO document, 2003, there is a list o f FixedDose combination o f ARVs that are available and pre-qualified by the WHO. The list o f WHO pre-qualified manufacturers is continuously updated and i s available at :~~~W.Who.iiit,:"edicines. l9 2003.Scalingupantiretroviraltherapyinresource-limitedsettings:treatmentguidelinesforapublichealth WHO approach. WHO recommendations for initiating antiretroviral treatment therapy are the following ones: (i) ifCD4 testing available, offer ARV to patients with either WHO stage IV disease irrespective of CD4 cell count, or WHO stage I11disease and CD4 cell count below 350/mm3, or WHO stage 1 or I1disease with CD4 cell count below 200/mm3;(ii) CD4 testing unavailable, offer treatment to patients with WHO stage IV or I11disease, irrespective if of total lymphocyte count, or WHO stage I1with a total lymphocyte count below 1200/mm3. 33 committee o f national medical and management experts in charge o f the development o f the national treatment guidelines. Consequently, the GoM will need to establish a national committee consisting o f medical experts on the one hand, and drug and laboratory monitoring management on the other hand. The medical sub-committee would consist o f two or three referring physicians specialized in HIV/AIDS treatment, and who have an expertise in public health in developing countries. This committee would act as a medical reference for prescribing physicians all over the country, especially regarding more complex clinical cases, and could provide counseling to the CNLS and the MoH on national medical issues linked with diagnosis, treatment and follow up o f AIDS patients. The sub-committee for drug and laboratory monitoring management should include experts with strong knowledge of the national health system capacity to better address logistical bottlenecks. This committee should work in close collaboration with the medical expert sub-committee. The project will strengthen the capacities o f this sub-committee through technical support provided by organisms with background indeveloping countries with a similar epidemiologic and socio- economic profile or through periodic clinical training seminars that follow international recommendations for resource-limited settings. Orphans and vulnerable children (OVC). According to the latest UNICEF estimates,20 100,000 orphans live in Madagascar, and 30,000 o f them are A I D S orphans. About 2,400 orphans are estimated to be orphans o f both parents. In an effort to avoid further discrimination and stigmatization vis-&vis AIDS orphans, the implementation and respect o f all OVC rights will needto be assured throughout the country. Inorder to develop appropriate programming for orphans OVC, aneeds assessmentofMalagasy orphans and other vulnerable children will be undertaken. The needs assessment will: (i) identify different categories o f OVC; (ii) compile an inventory o f formal and informal services that currently address these children's needs; (iii)develop profiles o f the types o f families most likely to become foster or adoptive families at present; and (iv) analyze the challenges particular to OVC care in community settings. The needs assessment will be usedto identify the policies and programs that are most urgently needed for OVC children. Interms o f program options, the "extended family" model should be preferred to programs involving the creation o f children's homes or the identification o f non-family-related foster parents. The extended family model has consistently been shown to be the most effective and cost-effective intervention in terms o f children's welfare. Inaddition, anetworkoftechnical assistancefor allnationalOVC support programsandservices should be established (the creation o f a National Steering Committee for OVC i s currently underway). Finally, existing norms and guidelines regulating public and private institutions for orphans and abandoned children will be revised, and minimum standards o f services concerning early childhood care and development are likely to be developed. 2oUNICEF Childrenon The Brink2004 : 26 34 Annex 2: Major RelatedProjectsFinancedby the Bank and/or other Agencies MADAGASCAR: SecondMultisectoral STI/HIV/AIDSPreventionProject The MultisectoralSTI/ HIV/AIDS Project (WorldBank,USD20millioncredit). This project was approved in November 2001, and is expected to close around December 2005, i.e. a year ahead o f time. Its development objective is to support the Government o f Madagascar's efforts to promote a multi-sectoral response to the HIV/AIDS crisis and contain the spread o f HIV/AIDS on its territory. To do so, the project builds capacity and scales up the national response to HIV/AIDS and STIs, a key risk factor and contributor to the spread o f HIV/AIDS. The project has financed, inter alia, sector strategies and pilot projects, including communication campaigns, the implementation o f the local response, and M&E activities. It i s rated satisfactory on both IP and DO ratings. The SecondHealthSector SupportProject (WorldBank,USD40millioncredit). The project was approved in November 1999, and a supplemental credit (USD22 Million) i s under preparation. Health services are provided at approximately 2,500 health facilities nationwide (public sector andNGOs). Approximately 60 percent o f the population i s estimated to live within a five-kilometer radius o f a public facility. An emerging but limited private health sector operates essentially in urban and suburban centers. Quality o f services i s below standard and the supply o f basic medicines and supplies has been poor. The project objective is to contribute to the improvement o f the health status o f the population through more accessible andbetter quality health services. The project i s rated satisfactory onboth IP andDO ratings. Intensification of the fight against HIV/AIDS: (Global Fund, USD13.4 million grant). The goal o f this project (November 04 - October 06) i s to maintain a low level o f HIV infection in20 high-riskdistricts by: (i) increasing access to VCT services in 20 high-risk areas; (ii) improving access to prevention opportunities o f transmission from mother to child in healthcare facilities; (iii)reinforcing existing prevention measures by the application of universal precaution measures, reinforcing transfusion safety and free access to condoms in public healthcare facilities; (iv) assuring proper care o f persons suffering from H N through the establishment o f a technical platform inthree regions, the supply o f tests for biological examinations, andthe social and community care; and (v) improving the care o f orphans o f AIDS, reinforcing the capacity o f associations o f persons living with HIV, and host families and by assuring the care o f basic needs o fthe orphans. Project to Support the Control of Communicable Diseases (STI/HIV/AIDS/Tuberculosis (African Development Fund, OPEP, UNAIDS, USDll million). The project is under preparation and i s expected to be approved shortly. It will be implemented over a five-year period. The specific objective is to ensure safe blood transfusion and improve the population's access to preventive and curative care with respect to communicable diseases, notably HIV/AIDS, STI and tuberculosis. The project includes: (i) the establishment o f an operational blood transfusion network; (ii) improving the populations' access to services for the prevention, diagnosis and treatment o f communicable diseases (STI/HIV/AIDS, tuberculosis and hepatitis); (iii)national capacity building for epidemiological surveillance; and (iv) capacity building for the management o f the project. 35 Annex 3: ResultsFramework and Monitoring MADAGASCAR:SecondMultisectoralSTI/HIV/AIDS PreventionProject ResultsFramework To SUDDO~~ Govemment the ,f Madagascar'seffortsto commercial sex workers Icommunication strategy is effective romote a multi-sectoral or needs modification. esponseto the HIVIAIDS :risis, and to contain the Determineiftargetingstrategy (both :preadof HN/AIDS on its high-risk groups and communes) emtory needs to bechanged. 2. Percentage ofrespondentswho canbothcorrectly identify ways of preventingthe sexual transmissionof Providedata for impact evaluation HIVand reject majormisconceptionsabout HN studies. transmissionand prevention(by age group and gender) 3. Percentageof peoplein high-risk groups (commercialsex workers, truck drivers, military), who can cite three methodsof HN/AIDS prevention. 4. Percentof youth 15-24 exposed to STI/HIV/AIDS communicationactivities/products inthe previous6 months (by source of information) dtitude Indicator 5. Percentage of populationaged 15-49who do not expressdiscriminatory attitudes towards PLWHA (by age and gender) lehavior Indicators 6. Percentageof youth aged 15-24reportingthe use of acondom in their last act of sexualintercoursewith a non-regular partner inthe last 12months 7. Percentageofmenand women aged 15-49who report having sex with anon regularpartner 8. Percentage of menand women aged 15-49 reporting the use of a condomintheir last act of sexual intercoursewith anon-regular sexual partner in the last 12months 9. Percentage of commercialsex workers reporting the use of a condom in their last act of sexualintercourse with a client 10. Percentage of truck drivers and military reporting the use of a condom intheir last act of sexual intercourse with anon-regular sexualpartner in the last 12 months 36 IntermediateResults Oneper Component Component One: Component One: Component One: 1, Coordinationamong donors and 1.1. The National Strategic Plan for HIV/AIDS i s 3ighlights donor duplication of 3artners on contribution to the revised and disseminated by the end o f 2006 :fforts and identify gaps. iational HIVIAIDS strategy 1.2. Annual reporting allows identification o f donor Racks coherencebetween strategies contributions to the program in a coherent manner md activities. 1.3. The national communication plan is updated according to recommendations of the midterm evaluation ComponentTwo: Component Two : ComponentTwo: 2. Strengthened the capacity of the 2.1 Number of STI treatment kits distributed to Tracks availability o fcondoms and health sector to effectively provide M O Hper year and sold inpublic and private sectors STI kits to determine adequacy of :are and support to PLWHA. per year nesponse 2.2. Number of condoms distributed and sold Ensure adequacy o f treatment through the public sector andNGOprograms per year 2.3. ARV Treatment Guidelines are adequate and implemented Component Three: Component Three: ComponentThree: 3. Sub-projects promote behavior 3.1. Seventy five percent o f the FAP resources are Flags problemswith increased change and implement support and allocated to hot places commune-level activities. Tracks care activities mainly in at-risk targeting o fmost at-risk zones areas. 3.2. Number o f CLLS implementingand monitoring their PLLS on a monthly basis 3.3. Number o f interpersonal communication activities camed out per year in hot spots 3.4. Number o fbeneficiaries reached by group 3.5. Number o fCBOsreceivingcapacity building in STVHIV/AIDS by OFs Component Four: Component Four: Component Four: 4. The MSPPIImonitoring and 4.1. Annual operational plan reflects Provides data to MSPPIImanagement evaluation system provides data recommendations o f ConsolidatedAnnual Report for decision making. that i s used to orient programming and funding decisions. Component Five: Component Five: Component Five: 5. Capacity o f regional 5.1. Capacity buildingplan is produced and Highlights project staffweaknesses so coordinatingstaff to manage implementedannually as to improve skills at the regional MSPPIIactivities i s increased. level. 37 8 e, F, ....................................... m - t- 2 % N 00 M E ...................................... .I h 0 t- 2 2 2 g g z 0 .3 Y cl E 0 .......... ......................... 00 " 3 Y v1 a m a A o m w W W Z Z m o v1 CJ h h W (El t- .~ ! Y v1 m m > o m m m m t - wm r - o w a - M E 2E ..r. s .............. 0 In 2 ? m - r w r . r . o m 2 g $ 2 $0 c g 3 : . $ -- r9 s g z 2 c 0 $ 5 U P B -4 .-E I M E Y 10 S ?? B - sK N .-S c e, n BaE .R Y I _ 1 - 8 W Do E .I L ---k-t- 8 .I *0 I- H YVI a M a2 L 8L YVI : E Q) Do 22 E -r- h s m S I Annex 4: DetailedProjectDescription MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject PROJECT COMPONENT 1: Harmonization,donor coordination, and strategies(USD1.5 million equivalent). Under MSPP, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This was generally due to the low priority given by the sectors which did not see muchbenefit indeveloping sector plans, given the limited resources provided to implement pilot activities. This component will be revised to include donor coordination, the updating o f the national strategy, and a more selective support to sectors. This component will emphasize four activities: Harmonization and donor coordination: This activity will support practical mechanisms o f coordination among donors to ensure better impact and cost-efficiency o f HIV/AIDS interventions. Although Madagascar has achieved two o f "Three One principles" (one national authority for HIVIAIDS, and one strategic framework) donor coordination needs to be intensified, particularly on the M&E system. Updatingof the NSP. The current plan covers the period through the end o f 2006, andwill need to be updated and re-validated thereafter, based on recent knowledge about the disease and the evaluation o fpast activities. Implementing the STI/HIV/AIDS communications strategy and action plan. Though knowledge o f HIV and information on prevention i s now relatively ~ i d e s p r e a d ,actual ~ ~ sexual practices remain risky,25 and stigma strong. The project will maintain mass media campaigns, but will place more emphasis on activities that facilitate dialogue and action on prevention and stigma reduction at the grassroots level. This sub-component will finance mass communication activities initiated by the UGP and communication materials and toolkits for NGOs and CBOs that will implement grassroots communication sub-projects under the Fund. Ifneeded, the existing communications strategy (October 2004) may be updatedbased on the evaluation o f communication activities. Support for the developmentof sector strategies and action plans. This sub-component will finance an assessment o f "impact effectiveness" o f the support received by key line ministries and public sector agencies fiom the MSPP. It will also finance sector strategies and/or action plans for a limited number o f sectors (two to three) which focus on high-risk groups (e.g. education for the youth, security for the solders, prisoners, police personnel etc.), and which has been found to be most effective. If implementation o f the public sector response progresses satisfactorily, the number or sectors may be expanded during the course o f the project. To address the limitations found in the public sector response under the MSPP, the project will try to institutionalize the relationships with the sectors (e.g. periodic 24The DHS 2003-04 showed that knowledge o f HIViAIDS satisfactorily progressed since 1997 from 69% to 79% for women and it is at 88% for men in 2003. 25The 2004 pilot PLACE survey among risk groups in certain hot spot areas showed that condom use by women with non- regular partners varies between highs o f 71% (Mahajanga) and lows o f 24% (Ilakaka). 41 working groups, participation o f these groups in strategic decisions such as the revision o f the NSP etc.) PROJECT COMPONENT 2: Support for health sector response (USD3.5 million equivalent). Under the MSPP, the M o H was involved in the implementation o f a major STI program, and o f the medical waste management plan. The involvement o f the health sector in the fight against STI/HIV/AIDS will be strengthenedunder the MSPPII, which will complement general funding to the sector provided by CRESANII (USD40 million for the original credit and USD22 million for a supplemental credit that will be submitted to the Board in early FY06).26 This component will finance a range o f activities, including the revision o f the health strategy for the prevention o f HIVIAIDS. The UGP and the M o H may decide together to sub-contract some o f these activities to NGOs and the private sector. a) Support for STI control. MSPP made a significant effort to control STIs by financing (a) training based on the syndromic approach, and (b) the sale o f two STI treatment kits at subsidized prices in both the public and in private sectors.27 MSPPII will expand these activities in high-risks places or groups, particularly for pregnant women by supporting a program o f syphilis elimination. b) Support for care and treatment of PLWHAs. Based on the preliminary experience o fthe IDA-financed Regional Treatment Acceleration Program, and on the interim review o f the MAPPrograminAfrica, MSPPIIwill help the M o Hestablish arange ofcomplementaryser- vices such as: (a) expansion o f the VCT centers in all 111 district hospitals and in health centers inhigh-risk areas28. These VCT will be staffed by one nurse or laboratory technician and one counselor; (b) psycho-social, nutritional, and other support for persons infected and affected by HIVIAIDS; and (c) treatment o f PLWHAs (ARVs, CD4 count), prevention o f MTCT, and treatment o f opportunistic infections (diagnosis tools and pharmaceutical products). This financing will compliment financing by the Global Fund. c) Other health sector response activities. MSPPII will provide complementary funding for other activities as needed, such as laboratories (mainly supported by the Global Fund) or blood transfusion (mainly supported by the AfDB), training o f health staff, and medical waste management. PROJECT COMPONENT 3: Fund for STI/HIV/AIDS prevention and care-taking activities (USD16.5 millionequivalent). Under MSPP, some 850 NGO, CBO, and association- sponsored sub-projects have contributed to a range o f preventive interventions. These local response activities will be scaled up with a stronger focus on places where the population i s at greatest risk o f being infected or o f transmitting the infection. Seventy five percent o f the Fund 26The objective o f this project is to contribute to the improvement o f the health status o f the population through more accessible andbetter quality health services. 27More than 400,000 STI kits for genital discharge were sold in 2004 at approximately USDO.5 through social marketing in the private sector and at USD0.35 in the public sector. STI kits for genital ulcer are being commercialized through social marketing and will soon be available in the public sector at the same price. However, this activity has not been evaluated. 28Along with the reconstructionirehabilitation o f 300 health centers, a comprehensive needs assessment was recently performed at district (first-referral) level providing the needed information to prioritize the creation o f VCT centers and the strengthening o f lab facilities. 42 resources will be allocated to these places, which will be identified using the PLACE methodology (already piloted) and the LQAS. This component will finance the following activities: a) Sub-projects. Sub-projects will include: (i) condom distribution through social marketing and promotional distribution; (ii)grassroots communication activities that shift the focus from general knowledge about the epidemic to behavioral communication for change; (iii) home-base care and other support for PLWHAs and associations o f PLWHAs; (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for HIV/AIDS services; (vi) training o f peer educators and community-based counselors; (vii) activities that aim at reducing stigma and discrimination against PLWHAs; and (viii) workplace HIV/AIDS plansfor the public sector. b) Fund Management. This component will finance fund management by the AGF, the OFs and the ORT. The AGF reviews sub-project proposals for the strength of financial management arrangements, and transfers funds from the project to organizations who have received approval for the sub-project proposal. The OFs will i)support the CLLS in incorporating STI/HIV/AIDS activities into their Communal Development Plans in the highest risk areas; and (ii) strengthen CBO capacity to develop and implement sub-projects. This sub-component will also finance the updating o f the list o f the standardized activities eligible under the Fund and developed under the MSPP. Under the MSPP, the list o f the standardized activities was usedto increase the effectiveness of Fund-financed activities and to avoid over-programming o f geographic areas and/or target populations. The updating will refine this instrument and its mode d'emploi so that it can be used as effectively as possible inthe MSPPII's high-riskcommunes. Operation ofthe fund. As under the original project, the management o f the Fund will be contracted out by the UGP to an AGF using a performance-based contract. The AGF will have representatives in each province and will be responsible for (i)processing requests for financing; (ii)approving requests underUSD100,000 usingselectioncriteria; (iii)submitting requests above USD100,OOO to the Conseil for approval; (iv) notifying applicants o f financing decisions; (v) disbursing approved financing; and (vi) providingnecessary data and informationto auditors for annual technical and financial reports, and to UGP on a regular basis. The AGF will receive training on HIV/AIDS. Proposals under USD100,OOO will be automatically approved by the regional office o f the AGF according to agreed upon criteria, as outlined in the procedures manual. Proposals over USD100,OOO will be submitted by the regional office o f the AGF to the Conseil for approval after technical review by the technical sub-committee o f the UNAIDS Thematic group. In all cases, the regional office o f the AGF i s responsible for contracting the implementation o f the approved project and disbursing approved financing. All proposals over USD25,OOO and a sub- set o f proposals over USD10,000 will be submitted for technical review to designatedpartners o f the UNAIDS Thematic Group. A beneficiary contribution will be requestedin-kindor in-cash for sub-project costingmore than USD10,OOO. This contribution will amount to 3 percent of sub-project cost (for proposals costing 43 between USD10,OOO and USD25,000), 5 percent (for proposal costing between USD25,OOOO to USD100,000), and 10 percent for proposals costingbetween more than USDlO0,OOOO). PROJECT COMPONENT 4: Monitoring and evaluation system (USD3.0 million equivalent). Inaccordance with the "Three Ones" principle, the MSPPIIproject will support the national M&E plan to which all HIV/AIDS partners in the country adhere. This component provides support to a single M&E system, and has four objectives: (i) ensure that the national M&E system is operational; (ii) develop a functional monitoring system (including MIS) to measure andmanage the performance o f the MSPPIIproject; (iii) track the evolving status o f the HIV/AIDS epidemic in Madagascar; and (iv) learn how government policy can slow the epidemic and mitigate its consequences, drawing from the Malagasy experience. The M&E component will have three parts: monitoring; epidemiological studies; impact studies and consolidated annual report. More details on this component are provided in Additional Annex Monitoring: The project will support implementation o f a five-part monitoring plan. The monitoring plan is designed to generate and/or collect key performance indicators, financial, input and operational data for the project; consolidate this data in a fully functional MIS; and use the data collected in project decision-making. LQAS will be used for quality data collection o f a sub-set o f key performance indicators. Epidemiologicalsurveys: The component will continue to finance a series o f second generation surveillance surveys and other population based surveys. These include bi- annual behavioral surveys among high-risk groups (sex workers, truck drivers, military and youth); annual sentinel surveillance surveys o f clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). The latter includes the cross- sectional HIV-prevalence study (Enqugte Nationale de Sero-prevalence Aupr2.s des Femmes Enceintes) first conducted in 2003; the 2008/09 DHS; and the annual "PLACES" study o f high-risk sites and risk behaviors. Impact studies and consolidatedannualreport:The MSPPII will support one or more impact studies. The project will also develop a consolidated annual report, in close collaboration with the CNLS. The report will provide a summary analysis o f data collected inthe course o f the year and recommendations on re-orientation o f the national HIV/AIDS program, based on the data analysis. The study methodology will be reviewed by the Global HIV/AIDS Monitoring and Evaluation Support Team. COMPONENT 5: Project management and capacity building (USD2.5 million). MSPPII will support the institutional arrangements and operational modalities established under MSPP, at the central level (CNLS, MSPPII Council, andUGP), and the new structures established at the regional level (BCR), following the creation o f regions mid-2004.29 This component will finance part o f each level's staff, equipment and operating costs, vehicles, periodic technical assistance, and some training based on annual capacity buildingplans. 29Under MSPPI, UGP had an office in each o f the six provinces. Under the MSPPII, this arrangement will be replaced b y an office in each o f the 22 regons. 44 Annex 5: Project Costs MADAGASCAR:Second Multisectoral STI/HIV/AIDS PreventionProject Table 5.1: Project Costsby Component Local Foreign Total Project Costs By Component or Activity USM USM Component 1: Harmonization, donor coordination and strategies 1.45 0.05 Component 2: Support for health sector response 2.50 1.oo Component 3: Fundfor STI/HIV/AIDS prevention and care-taking activities 16.50 0.00 16.50 Component 4: Monitoringand evaluation 2.25 0.65 Component 5: Project management and capacity building 2.00 0.50 2.50 Total Baseline Cost 24.7 2.2 Physical Contingencies 0.7 0,1 Price Contingencies 0.1 2.2 Total Project Costs 25.5 4.5 30.0 1 Interest duringConstruction Front-end Fee Total Financing Required 25.5 4.5 30.01 'Identifiable taxes and duties are USDO, and the total project cost, including taxes, is USD30 million. Therefore, the share of project cost including taxes i s 100percent. Table 5.2: Disbursement Schedule (in USD million) IDA FY 2006 2007 2008 2009 Annual 6 8 8 8 Cumulative 6 14 22 30 45 Annex 6: ImplementationArrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject 1. Institutionalandimplementationarrangements The institutional arrangements for the National HIV/AIDS Program and the MSPPII remain similar to those used under the MSPP, and are charted in Figure 6.1. Generally speaking, the institutional arrangements for the National HIV/AIDS Program and the MSPPII Project are complimentary. This i s consistent with the "Three Ones" approach to management o f the HIV/AIDS epidemic, inwhich a common approach to management o f the epidemic i s seen as the most coherent, cost-effective means o f containing the virus. Figure6.1:NationalHIV/AIDS Programand MSPPII ProjectInstitutionalArrangements MSPPII Operational I I NationalHIV/AIDS I Arrangements I I PropramArrangements Council ......................... .........I........................................ However, there will be four significant institutional changes between the MSPP and the MSPPII. First, the National3 Coordinating Committee (Comitk de Coordination Nationale, CCN) was a temporary committee mandated to guide definition o f national HIV/AIDS priorities in the lead- up to the MSPP, and was described as such in the MSPP project appraisal document. The committee was formalized as the National HIV/AIDS Prevention Committee (Cumitk National de Lutte contre le VIH/SIDA, CNLS) during the MSPP and i s now consistently referred to as the CNLS. Second, the UGP was moved under the under the direction o f the Executive Secretary o f 46 the CNLS in December 2003. This has allowed an improvement in coordination and a more steady response o f actions. Third, Madagascar is in the process of decentralizing and has recently created 22 regions, between the province and district levels. To accommodate regionalization, the MSPPII will increase the number o f Provincial HIV/AIDS Prevention Committees (Comitks Provinciaux de Lutte contre le VIH/SIDA, CPLS) from six to up to twelve; the name o f these committees will be changed to the Regional HIV/AIDSPrevention Committee (Comitks Rkgionaux de Lutte contre le VIH/SIDA, CRLS); and the CRLS will be expected to cover a set o f regions rather than provinces. Fourth, the project adds contracting o f a monitoring and evaluation organization (Organisation de Suivi et Evaluation, OSE). The OSE i s responsible for carrying out periodic project monitoring surveys and for working with the CNLS and MSPP management to use data inproject decision-making and strategic re-orientations. a) Institutional arrangements for the national HIV/AIDS program The institutional arrangements for the National HIV/AIDS Program include the CNLS at the central level; the CRLS at the regional level; and the Local HIV/AIDS Prevention Committee (CLLS) at the commune level. Central level. The CNLS was created by Government decree in October 2002. The mandate o f the CNLS i s to (i)coordinate the national fight against HIV/AIDS and (ii)guide the implementation ofthe National Strategic Plan. The CNLS is made up o f an Executive Secretariat (SE) and a plenary committee. The SE has day-to-day management o f national HIV/AIDS prevention activities and provides political and strategic support to the Government's fight against HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection o f rights. The SE also oversees implementation o f the MSPP, with the CNLS Executive Secretary serving as project director. The plenary committee is responsible for overseeing implementation o f the NSP. It is made up o f eighty stakeholders, including representatives from Government, PLWHAs, NGOs, the private sector, andreligious andCBOs. The Partners' Forum (Forum des Partenaires) enhances the dialogue between the CNLS and the major bilateral and multilateral donors andNGOs. Coordinated by the Executive Secretary o f the CNLS, Partners' Forum provides the CNLS a venue to monthly inform all major donors on its current and future activities. Donors participating insuch periodic reunions have the opportunity to offer their feed-back to the CNLS and express their possible concerns over existing issues identifiedwithin the scope o fthe project implementation. The Country Coordinating Mechanism (CCM) was recently added at the Global Fund's request. The mandate of the C C M i s to submit, monitor, and evaluate activities on AIDS, Tuberculosis and Malaria to be financed by the Global Fund. The CCM is coordinated by the CNLS, and includes representatives o f major donors, Government, NGOs, CBOs, Academia, the private sector, and PLWHAs. The C C M meets on a monthly basis andhas become very active. The CNLS also houses a UNAIDS Thematic Group, which is made up o f representatives o f UN agencies and the World Bank. The group meets on a monthly basis to provide support and 47 advice to the Government on HIViAIDS. The group has prepared an Inter-Agency Program to support the Government's NSP, inwhich eachUNagency outlines their support to the NSP. Regional level. Implementation o f the national HIV/AIDS program is coordinated at the regional level by the CRLS. Up to twelve CRLS will be formed during the MSPPII implementation period.30 The CRLS i s responsible for (i)supervising and coordinating HIV/AIDS interventions; (ii) implementation o f the NSP; and (iii) between the guiding liaising CNLS, the CLLS, and other STI/HIV/AIDS prevention actors inthe region. As with the CNLS, CRLS members include representatives from a range o f public, private and non-governmental organizations implicated inthe fight against HIV/AIDS. Local level. At the commune level, a CLLS i s responsible for: (i) developing the local plan in the fight against HIV/AIDS; (ii)guidingcoordinating implementation o f the plan; and (iii) mobilizing the local population in the fight against HIV/AID.S. Again, as with the CNLS, the CLLS i s made up o f representatives from a range o f public, private and NGOs implicated inthe fight against HIV/AIDS. b) Projectimplementationarrangements The implementation arrangements for the MSPPII include the UGP, the Technical Review Organization (ORT), the Monitoring and Evaluation Organization (OSE), and the MSPPII Council at the central level, as well as the Regional Coordination Bureau (BCR), the Facilitating Organization (OF) and the Financial Management Agency (AGF) at the regional level. Given the Government long-term commitment to the fight against HIV/AIDS, the option o f eliminating the UPG and merging its functions under a Multi-Sectoral Response Unit o f the CNLS will be explored duringproject implementation. Central level. The UGP is responsible for day-to-day management o f the project. Its responsibilities include: (i)development o f the annual work program and budget; (ii) management o f project activities, financial management, procurement, administration and logistics; (iii) oversight o f monitoring and evaluation (contracted to the OSE); and (iv) periodic reporting to the World Bank, and integration o f data into project decision-making. The UGP also serves as the Secretary o fthe MSPP Council. An MSPP Council provides oversight o f the project as a whole. Its responsibilities are to: (i) approve the UGP's annual work program and budget; (ii) approve requests to the Fund over USD100,000; (iii)ensure that the project-financed activities achieve the project development objective; (iv) approve annual technical and financial audits; (v) adopt and approve the procedures manual o f the Fund and the Project Implementation Manual, and approve modifications to them; (vi) evaluate the perfonnance o f the UGP based on performance indicators, inconsultation with IDA; and (vii) approve the recruitment o f the AGF. The Council also includes an audit committee, whose role is to facilitate the work o f external project auditors, review auditors' findings, and ensure the implementationo f such recommendations. 30Prior to the recent creation o f Madagascar's regions, responsibility for coordination and oversight o f HIV/AIDS prevention efforts at the sub-national level fell to the Comitb Provincial de Lutte contre le VIHSIDA (CPLS). 48 The Council reports directly to the President o f the Republic. It is made up o f fifteen permanent members, including one representative from each o f the following: the Office o f the President o f the Republic; the Ministry o f Finance; the Ordre des Experts Comptables de Madagascar; the NGO sector; the private sector; beneficiaries' associations; and key sectors such as education, security and youth. The UGP i s also supported by the ORT, under the auspices o f the UNAIDS Thematic Group. The ORT, made up o f designated partners, undertakes a technical review o f all proposals over USD25,OOO and a sub-set o f proposals over USD100,OOO submitted to the FAP to ensure quality and provide recommendations for improvement, as necessary. Regional level. In addition to its responsibilities within the CNLS, the B C R is responsible for ensuring MSPPII implementation at the regional level. Each BCR covers one to three administrative regions, and i s staffed by a Director and a Technical Coordinator. The Director (i)coordinates project implementation by component; (ii)liaises with development partners across sectors inorder to ensure effective project implementation andmaximum complimentarity with other STI/HIV/AIDS activities in the region; and (iii) supervises the work o f the OF and AGF in his or her region(s). The Technical Coordinator i s responsible for supervising the development o f local plans inthe fight against HIV/AIDS, with the assistance o f the OF, and the technical quality o f the work performed by the OFs. The Technical Coordinator also plays an active role inimplementation o f quality activities under the project's other components. Each region also has an OF. The OF i s anNGO contracted by the project to assist: (i) communes in the development of their local plans in the fight Against HIV/AIDS; and (ii) in the CBOs development and implementation o f the technical aspects o f their applications for Fund financing. Particular emphasis will be placed on the use o f key messages focusing on all three means o f preventing HIV transmission- abstinence, fidelity and condom use - andnot a sub-set of those messages. There will be 22 contracts available under the MSPPII, one for each o f Madagascar's 22 regions. An OF may hold a single contract to cover one region, or may hold several contracts. In order to ensure the continued transfer o f technical expertise to national NGOs and CBOs, 20 percent o f regional contracts will be awarded to international NGOs for at least the first two years o f the project. Finally, an AGF i s responsible for: (i) evaluating the financial viability of CBO applications to the Fund; (ii) returning weak proposals to CBOs for revision; (iii) forwarding suitable proposals to the OF for technical review; and (iv) making payments to CBOs for approved sub-projects. The AGF i s also responsible for maintaining a database o f unit costs for the range o f activities eligible under the Fund. A single AGF i s engaged by the project; it i s expected to have eight regional offices. c) Implementationarrangementsfor monitoring& evaluation The UGP i s responsible for monitoring project performance and contracting out the impact evaluation studies. The M&E Unit i s currently staffed by two M&E specialists; a third staff member (or long term consultant) will be hired to perform spatial analyses o f data using a Geographic Information System. Funds are budgeted to contract consultant services 49 internationally and nationally to provide the necessary support to the team's approach to M&E and its instruments. Additional M&E staff will be contracted and placed in eight regional MSPPII offices to perform periodic spot checks o f subprojects and to monitor the data collected and compiled at the local level. These staff will report to the UGP M&E team and will be technically qualified to provide continuous M&E presence in the field to supplement the intermittent site visits bythe UGP M&E staff. 50 Annex 7: Financial Management and DisbursementArrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project Country issues Several diagnostic works carried over the last two years31 confirmed the weak capacity o f the country public financial management system. To increase the quality and success o f MSPPII, it is more efficient to entrust the implementation o f this project to the UGP which had already a strong experience inmanaging World Bank funds. The CPFA (Country Profile o f Financial Accountability) carried out in September 1998 established also the weak capacity o f the accounting profession in Madagascar: a number o f accounting firms were operating below the international standards due to the lack o f regulatory framework, proper auditing standards, clearly defined guidelines and procedures for systematic peer reviews, continuing education requirements, quality control mechanisms to harmonize methodology. To improve the capacity and the competitiveness o f the local auditing firms, the following measures have been taken: (i) obligation for local auditors to enter into partnership with international accounting firms while auditing Bank/IDA financed projects in order to improve the quality of audit reports and ensure practical training and real transfer o f methodology in the areas o f organization and execution o f audit assignments; (ii)effective participation o f the international accounting firm while carrying out audit works in the field and submissiono f audit reportjointly signed by the local and international audit firms. Table 7.1: I; sk Analysis Risks Risk RiskMitigationMeasures rating Implementing Enti@ Low Stafflng Low NIA Funds Flow.Rsk of delays in Moderate Establishment of a bank account in the name of the payment ofNGOs, CBOs each regional AGF, with an initial deposit covering and other partners (associations, three months of expenditures (Special Account 90- communes) working at the day advance procedure). regional. Maintain good liquidity level both at central and regional levels by: (i)a close monitoring o f cash forecast prepared on a quarterly basis; (ii)regular submission (at least on a monthly basis) of withdrawal application to replenish regional bank accounts and project special accounts. Accounting Policies Low NIA and Procedures 31 Country FinancialAccountability Assessment (CFAA), Country Procurement Assessment Report (CPAR), HIPC-Assessmentand Action Plan, IMF Technical Assistance Report, EuropeanUnionFinancial Audit and Public Expenditure Review. 51 I nterna1Audit Low NIA External Audit: The CPFA Substantial Local auditors who intend to audit the financial (Country Profile of Financial statements o f Bank financed projects should Accountability) carried out in enter into partnership with international auditing September 1998 established the firmto strengthentheir capacity. weak capacity o f the accounting profession in Madagascar. The Effective participation o f the international C F A A conducted in 2003 auditing firm inthe fieldwork. confirmed that the country public financial management Reinforcement o f the accounting profession after poses a major fiduciary risk. the completion o f the ROSC mission. Monitoring and Reporting NIA Information Systems NIA Implementingentities The UGP i s responsible for coordinating project implementation, and managing procurement, financial management, disbursement, project monitoring, reporting and evaluation. It will assure the record-keeping o f transactions under the components 1, 2, 4 and 5 as well as the consolidation o f project accounts and the production o f quarterly Financial Monitoring Reports (FMRs) in compliance with international accounting standards and IDA requirements. Implementation o f project activities under the component 3 will be sub-contracted to existing structures such as NGOs, CBOs and other associations whereas the financial management o f funds financing these activities will be contracted to the existing AGF. Procedures and modalities for selection and contracting o f these executing agencies are described indetails inthe operation manuals. The AGF will keep an accounting system satisfactory to IDA and will prepare its own financial statements as well as other financial and technical reports as required by the UGP. Each o f the AGF's regional offices has an accountant responsible for regional accounts as well as the electronic transmission o f regional accounts to the central level, using the existing computerized accounting and financial management system. Strengthsandweaknesses The UGP has strong experience in managing World Bank funds for being in charge o f the implementation o f MSPP. The accounting/budgeting system is adequate and the internal control procedures appropriate. It has also qualified and trained accounting staff who are very knowledgeable about Bank procedures. However, to further strengthen the project financial management system, some measures need to be taken. The following table provides relevant measures to address main deficiencies identified inthe UGP financial management system. 52 Table 7.2: Measuresto address deficiencies of financial managementsvstem Significant Weaknesses Resolutions Chart o f accounts not reflecting yet the new components Review o f the chart o f accounts to reflect new and activities to be executed under MSPPIIproject components/activities eligible under MSPPII credit to satisfy reporting requirements Accounting manual of procedures not beingupdated to Update of the accounting manual o f procedures include the new chart of accounts and the models o f to facilitate adequate record keeping o f MSPPII financial and physical progress reports required for transactions, and satisfy reporting requirements managing and monitoring MSPPII activities Inadequate number o f accountant commensurate with the Recruitment o f a qualified and skilled accounting volume o f tasks to be coped with. assistant inconformity with the Bank procedures Auditors incharge o f the review o f MSPPII accounts Recruitment o f an accounting firm acceptable to have not been recruited yet IDAto carry out the audit o fMSPPIIaccounts FundsFlow T h e flow o f funds from IDA i s presented as follows: World Bank (Credit) l - 7 (Special Account A) CentralAGF (Special Account B) I I I RegionalAGF (Special sub-account) Grants to recipients (NGOs, CBOs, other associations) for provision o f goods and services I I Suppliers of goods and services I 53 Staffing The UGP's accounting staff i s qualified. However due to the volume o f project transactions and activities and to ensure appropriate segregation o f duties infinancial management area, the Bank recommended to recruit an accounting assistant in conformity with the Bank procedures. The recruitment o f this second accountant has been completed prior to negotiations. Accountingpoliciesandprocedures The accounting system in place is in compliance with generally accounting standards and IDA requirements and capable o f producing timely financial information required for managing and monitoring project activities. The project accounting manual o f procedures needs to be updated to include the new Chart o f accounts as well as the models o f financial and physical progress reports to be produced. Internalaudit To ensure consistent application o f the procedures and efficient use o f finds by executing agencies, the accounting firm Delta Audit Deloitte and Touche in collaboration with the UGP M&E staff will continue to play the role o f internal auditors. All issues identified duringinternal audit should be addressed quickly to improve the project performance. Externalaudit The project financial statements will be audited annually by an international private accounting firm acceptable to IDA, in accordance with International Standards o f Auditing and the new Guidelines describing Audit Policy and Practices for World Bank-financed Activities. The auditors will provide a single opinion on the annual financial statements, stating whether the financial statements fairly present the financial transactions and balances associated with the implementation o f the project, and if the expenditures financed by the credit were appropriate. The auditors will be also required to carry out a comprehensive review o f the internal control procedures and provide a management report outlining any recommendations for their improvement. The audit report will be submitted to IDA not later than six months after the end o f each fiscal year. The auditors should berecruitedprior to effectiveness. Reportingand monitoring. To monitor project implementation, the UGP will produce the following reports that should be prepared incompliance with international accounting standards: Annualfinancial statements comprising: a) Summary o f sources and uses o f funds (by components/project activitiedcredit category and showing all sources o f finds); b) Project Balance Sheet; 54 0 QuarterZy FMRs: The FMRs includes financial reports, physical progress reports and procurement reports to facilitate project monitoring. The FMRs should be submitted to IDA within 45 days o fthe end ofthe reporting period (quarter). The form and content of FMRs has been determined as part o f project appraisal and will be agreed at negotiations. Models of these reports will be presented inthe project accounting manual o f procedures. Informationsystems The UGP and AGF are using an integrated financial management system capable o f recording and producing in a timely manner all financial reports required for managing and monitoring project activities. Impactof procurementarrangements Procurement arrangements do not present substantial risk. Actionplan The present action plan agreed with the borrower describes main actions to be taken to strengthen the MSPPII financial management system. Table7.3: Action planfor strengtheningMSP: 11financialmanag ment system Actions Datedue by Responsible 1 Update o f the project Chart o f accounts to reflect 06/15/05 UGP/AGF new components and activities to be financed under MSPPII; 2 Submission o f the content o f FMRs to be agreed at 06131/05 UGPIAGF negotiations. Recruitment of auditors in charge o f the audit o f UGP MSPPII accounts: 0 Agreement on Terms ofreference 0 Submission o f the technical and financial 06/15/05 proposal to the VPM; 07130105 0 Negotiations Submission o f contract to IDA for non 08/06/05 objection 081lolo5 Award of the contract to the auditors. 08/20/05 Production of the first FMRs and submit them to the 07106105 Bank. 55 Disbursementfrom IDA credit For the implementation o f MSPPII the following bank accounts will be opened in local commercial banks under conditions satisfactory to IDA: 0 Special Account A: Denominated in USD, disbursements from the IDA credit will be deposited on this account to finance MSPPII activities under expenditure categories 1 (Goods and Works), 2 (Consultant Services, Training and Workshops), and 4 (Operating Costs) inaccordance with the disbursementpercentages indicated inthe DCA. 0 Special Account B: Denominated in USD, disbursements from the IDA credit will be deposited on this account to finance MSPPII activities under expenditure category 3 (Grants to Sub-Projects) in accordance with the disbursement percentages indicated in the DCA. Funds deposited in these accounts will be used to ensure timely payments o f (i) suppliers o f goods and services, and (ii) contractors (NGOs, CBOs, other organizations) in conformity with the terms o f the contract signed by the parties concerned. The project implementation and accounting manuals describe in details all procedural aspects regarding financial management (payments, replenishment, reporting, internal control) and reference to the procedures outlined in these manuals will be indicated inthe DCA. Disbursementarrangements Method of Disbursement. The project would follow the transaction-based disbursements procedures (traditional mode) outlined inthe Bank's Disbursement Handbook. The use o f report- based disbursements could be possible thereafter if requested by the borrower and if the following criteria are met: (i)the FMrating has been maintained at satisfactory level; and (ii) the submission o f at least three quarterly satisfactory FMRsthat could be relied upon for purposes o f disbursement. Detailed disbursement procedures will be described in the project accounting manual o fprocedures. Minimum of Application Size. The minimum application size for direct payments, to be withdrawn directly from the Credit Account, and special commitments is 20 percent o f the amount advanced to the related special account. Use of Statements of Expenses (SOEs). Withdrawals are to be made on the basis o f SOEs for the following cases: 0 Contracts for equipments and goods inan amount inferior to USD150,OOO; 0 Contracts for works in an amount inferior to USD200,OOO; 0 Contracts for consulting services, training by firms o f less than USD100,000; 0 Contracts for consulting services, training by individual o f less than USDl00,OOO; 0 All incrementaloperatingexpenses; and 0 Miscellaneous training expenditures (ie., those not subject to contract) Special Accounts. To ensure that funds will be available when needed, two special accounts in USDwill be established in a local commercial bank under conditions satisfactory to IDA. The special account A, in the amount o f U S D l.O million, will be opened in the name o f the UGP, 56 whereas the special account B in the amount o f USD1.25 million will be in the name o f AGF. The amounts have been estimated to cover about four months o f expenditures and would be withdrawn from the credit account after effectiveness. The special accounts would be replenishedon the basis of documentary evidence o f payments required by IDA, made from the special accounts, eligible for financing under IDA Credit. All SOEs supporting documentation will be kept by the executing agencies and made available for reviewby bank supervision missions and external auditors. Allocation of Credit Proceeds I Amountin Financing 4. OPERATINGCOSTS 2.1 100%foreign UNALLOCATED 3.1 Total Project Costs 30.0 57 Annex 8: ProcurementArrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDSPrevention Project A. General Procurement for the proposedproject would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers'' dated May 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Credit, the different procurement methods or consultant selection methods, the need for pre- qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank inthe Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. Procurementof Works: Works procured under this project would include: the rehabilitationo f VCT centers and incinerator construction. The procurement will be done using the Bank's Standard Bidding Documents (SBD) for all International Competitive Bidding (ICB) and National SBD agreed with or satisfactory to the Bank. Since no major works are expected for this Project, for contract estimated to cost less than USD200,OOO equivalent per contract, civil work procurement may be carried out through National Competitive Bidding (NCB) and contracts for small works, estimated to cost less than USD50,000, will be procured through quotations procedures. Nevertheless, for minor works to be procured under sub-projects, specific procedures details can be found inthe Manual o f Procedures for the FAP (Annex 7). Procurement of Goods: Goods procured under this project would include: print media furniture, reproduction o f movies, fmiture for STI control, medical treatment for PLWHA, equipment for VCT centers, vehicles, office equipment, and IT and software. The procurement will be done usingthe Bank's SBD for all ICB and National SBD agreed with or satisfactory to the Bank. To the extent practicable, contracts shall be grouped into bid packages estimated to cost the equivalent o f USDl50,OOO or more and would be procured through I C B procedures. For contract estimated to cost less than USD150,000 equivalent per contract, procurement o f goods may be carried out through N C B procedures and purchase o f small furniture estimated to cost less than USD30,OOO will be conducted through prudent shopping procedures. Vehicles, ARV and medical treatment may be procured from UN agencies. STI kits may be procured from SALAMA, Madagascar Central Purchasing Agency for Essential Medicines and Medical Material. SALAMA procurement procedures have been assessed by the Bank and found to be acceptable. Procurement of non-consulting services: distribution o f kits for CBOs, and TV and radio broadcast. The project will contract NGOs and TV and radio usingDirect Contracting methods. Selection of Consultants: technical assistance, training and workshops, operationalization o f cinemobiles, films production, financial management agency (AGF), data collection and surveys, financial and technical audits, and capacity building. Short lists o f consultants for services 58 estimated to cost less than USD100,OOO equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines if a minimum o f three qualified ones are available. Wherever applicable, public training institutions such as INSPC and INSTAT, and NGOs may be hired for capacity building and surveys. Firms will be recruited on the basis o f the Quality and Cost Based Selection (QCBS) method, using the Bank's Standard Request for Proposals. Selection based on consultants' qualifications (CQ) can be used for the recruitment o f training institutions and for assignments that meet criteria set out in para. 3.7 o f the Consultant Guidelines. Single source selection can be used to contract firms for assignment that meet criteria set out in para. 3.9 to 3.13 o f the Consultant Guidelines and for contract which amount do not exceed USD100,OOO. Operating Costs: The project will finance project management unit and regional office management salaries, incremental costs, CNLS salaries, and capacity building for project staff. All staff selection within this category shall be done according Section V o f Consultant Guidelines. Others:The Manualo fProcedures o fthe FAPwill govern sub-project financing inhigh-riskand rionhigh-risk communes. The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented in the Project Implementation Manual B. Assessment of the agency's capacityto implementprocurement Procurement activities will be carried out by the UGP which includes a Procurement Officer and a Procurement Assistant. An assessment of the capacity o f the UGP to implement procurement actions for the project has been carried out by Sylvain Rambeloson (Sr. Procurement Specialist) in April 2005. The assessment reviewed the organizational structure for implementing the project andthe interactionbetween the project's Procurement Officer and the Ministry's relevant central unit for administration and finance. The key issues and risks concerning procurement for implementation o f the project have been identified and include the phasing o f activities to be undertaken and possible emerging o f emergency cases. The corrective measures which have been agreed are the close follow-up o f the agreed procurement plan and activity scheduling. A procurement action plan will be fine-tuned quarterly and the mainprocurement planwill be up-dated accordingly. The overall project risk for procurement is Average. C. ProcurementPlan The Borrower, at appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan has been agreed between the Borrower and the Project Team on M a y 23, 2005 and is available at UGP. It will also be available inthe project's database and inthe Bank's external website. The Procurement Plan will 59 be updated in agreement with the Project Team annually or as required to reflect the actual project implementationneeds and improvementsininstitutional capacity. D. Frequencyof ProcurementSupervision In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment o f the ImplementingAgency has recommended annual supervision missions to visit the field to carry out post review ofprocurement actions. E. Detailsofthe ProcurementArrangements InvolvingInternationalCompetition 1. Goods,Works, andNonConsultingServices (a) List o f contract packages to beprocured following ICB and direct contracting: 1 2 13 4 5 6 9 Ref. Contract Estimated Procurement P- Domestic Expected Comments No. (Description) cost Method Q Preference by Bank Bid- (yes/no) (Prior/ Post) Opening I.3.3.1 Billboard 144,000 Direct No No Prior Oct 07 production contracting installation t.1.1 Social 1,400,000 ICB No No Prior Feb06 0.35KUSD marketing of peryear for STItreatment four years luts (purchase distribution) - L2.1 Medical Direct No No Progressive treatment for 990,100 contracting andw/UN PLWHA - agencies L3.1 Incinerator 250,000 Direct No No Construction Contracting - 5.1.3.1 Vehicles Direct No No IAPSO gL 175,000 contracting 5.3.2.1 (b) ICB contracts estimated to cost above USD200,OOO for works andUSD150,OOO for goods per contract and all direct contracting will be subject to prior review by the Bank. 60 2. ConsultingServices (a) List o f consulting assignments with short-list o f international firms. 1 2 13 14 15 5 7 Ref. No. Description of Estimate Selection Review Expected Comments Assignment d Method by Bank Proposals cost (Prior I Submission Date 1.32 Production o fradio To be h e contract programming determined with phases 1 1 (programs, spots and :client flashes) satisfaction) 3.1.1 Agence de Gestion 663,000 QCBS Prior Dec 05 The actual Financiere 4GF will 3perateto Jun 36 I 3.1.2 Organization o f ____ 1,084,0001 QCBS Prior Sept 05 Annual facilitation 4.1.2 LQASbaseline, mid- 588,000 CQS/QCBS Prior Feb06 point and final surveys, analysis and dissemination 4.1.3.1 Technical audit 92,000 IC Prior JulO5 4.2.1 ImDact studies (TBD) I 500.000 I OCBS I Prior Oct 05 4.3.2.1 HIV/AIDS Prior To be Year 1will be Epidemiological IC I determined coveredby Situation report I 5.4.1 Financial Audit 104,600 LCS Prior Dec 05 5.4.2 CNLS capacity 105,000 CQS Prior Feb06 buildingand workshop on M&E data use (b) Consultancy services estimated to cost above USD100,000 per contract and single source selection o f consultants (firms) and for individual consultants assignments estimated to cost above USD50,OOO will be subject to prior review by the Bank. (c) Short lists composed entirely o f national consultants: Short lists o f consultants for services estimated to cost less than USD100,OOO equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines. 61 Annex 9: SafeguardPolicy Issues MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject The project i s rated as category B. The Borrower has demonstrated the capacity to properly develop and implement a medical waste management plan (MWMP). The MWMP i s the only safeguard-related study requiredfor this project. A MWMP was developed for the MSPP, approved and has beenimplemented since May 2004. Itwas disclosedunderthe MSPPIIprior to project appraisal, in-country andinthe Infoshop. The existing MWMP includes proper disposal o f hazardous bio-medical waste and a bio-safety training program for the staff o f all hospital, health centers and community-based programs, including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and treatment. Under the MSPP, three different agencies were responsible for, respectively: (i)ensuring development and implementation o f the MWMP; (ii)implementing the plan; and (iii) supervising implementation o fthe plan at the provincial and district levels. Ensuring development and implementation of the plan. The UGP has been responsible for ensuring development and implementation o f the MWMP. The UGP has satisfactorily hlfilled this role, supervising implementation o f the MWMP according to the agreed-upon calendar and undertaking additional activities in support o f implementation o f the plan (national kick-off ceremony, annual evaluations o fthe plan). Implementing theplan. The M o H has been responsible for implementation o f the MWMP, and has demonstrated capacity to properly implement the plan. Since M a y 2004, the M o H has installed 200 small-scale bumers to bum medical wastes. in all 200 health centers rehabilitated under the CRESANII Project. Recent supervision found that burners are being used at the CHD of Ankazobe, Antanifotsy and Faratsiho. The construction o f full incinerators at district level is underway, and some o f them should be functional by June 2005. The Plan also includes specific medical waste disposal and management actions, to be carried out in Madagascar's different types o f health facilities. The M o H has demonstrated the ability to plan for and prepare these activities, as well. Supervising implementation of theplan: The Office for the Environment o f the Ministry o f the Environment (MINENV) has been responsible for supervising its implementation at the provincial and district level. It has performed this role satisfactorily. 62 Annex 10: Project Preparation and Supervision M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project Planned Actual PCN review 01/12/05 01112/05 Initial PID to PIC 02/01/05 02101/05 Initial ISDS to PIC 03/07/05 03/07/05 Appraisal 05/06/05 03114/05 Negotiations 05123IO5 06/02/2004 BoardRVP approval 07/07/07 Planned date o f effectiveness 10118/05 Planned date of mid-term review 07/07/07 K e y institutions responsible for preparation o fthe project: - inGovernment : CNLS, MSPPUGP, Ministryo fHealth - Donor partners included: UNICEF, and USAID Bank staff and consultants who worked on the project included: Name ____ Title Unit Nadine Poupart Sr. Economist, TTL AFTH3 Jean-Pierre Manshande Sr. Health Specialist AFTH3 Hope Neighbor ETConsultant AFTH3 Mead Over Lead Health Economist DECRG Joseph Valadez Sr. Monitoring and Evaluation Specialist HDNGA Nancy Lemay Monitoring USAID Michele Tarsilla Consultant AFTH3 Anne-Claire Haye Consultant AFTH3 Peter Bachrach Consultant AFTH3 EtiennePoirot Orphans and vulnerable children UNICEF Diane Coury Orphans and vulnerable children UNICEF Farellia Venance Tahina Communication UNICEF ManuellaVarasso Communication UNICEF Gervais Rakotoarimanana Sr. FinancialManagement Specialist AFTFM SylvainRambeloson Sr. Procurement SpeciaIist AFTPC Hisham A. Abdo Kahin ETConsultant LEGAF Sameena Dost Counsel LEGAF Michael Fowler Sr. Finance Officer LOAG2 Maryanne Sharp Operations Officer AFTH3 Astania Kamau Team Assistant AFTH3 Andrianina Nor0 Rafamatanantsoa Team Assistant AFTH3 Joan MacNeil Sr. HIVIAIDS Specialist & Peer Reviewer HDNGA John May Sr. Population Specialist & Peer Reviewer AFTH2 Patricio Marauez Lead Health Specialist & Peer Reviewer ECSHD ~ 63 Bank funds expended to date on project preparation: 1. Bank resources: USD95,OOO 2. Trust funds: USDO 3. Total: USD95,OOO Estimated Approval and Supervisioncosts: 1. Remaining costs to approval: USD30,OOO 2. Estimated annual supervisioncost: USDl80,OOO 64 Annex 11:Documentsin the ProjectFile MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project Inaddition to the documentsmentioned inthe PAD ofthe original project, the following documents are available inthe project file: A. ProjectDocuments Manuel d 'exe'cutiondu Projet, Septembre 2002 e Manuel deproce'dures pour lefinancement des organismes communautaires de base, DCcembre 2003 e Vers une compe'tencelocale en matiBre de VIH/SIDA :Les Principes Gkne'raux,2004 . Vers une compktence locale en matikre de VIH/SIDA :Guidepratique a 1'usage des institutions et organismes chargks d 'appuyer les communes dans la Eutte contre le VIH/SID, Septembre2004 Prbparer la rbponse locale face aux IST/VIH/SIDA Ci Madagascar, Madagascar, Octobre 2003 e c&feilleures pratiques )) pour la lutte contre les IST/VIH/SIDA et de'termination de leur niveau optimum par zone d 'intervention, Madagascar, Juin 2003 B. BankStaffAssessments BanWGovernment Aide Memoires: Mid-Term Review December 2004 Project Concept Note January 2005 Pre-Appraisal MissionMarch2005 C.Other Madagascar National HN/AIDS Strategies: Plan Stratkgique National de Lutte contre le VIH/SIDA 2001-2006, Madagascar 2001 Politique nationale deprise en charge des personnes vivant avec le VIH/SIDA, Ministkre de la SantC, Madagascar, Mars 2003 Strate'gieNationale de Communication face aux IST/VIH/SIDA, Madagascar 2004-2006 Mise en oeuvre de la Stratkgie Nationale de Communicationface aux IST/VIH/SIDA, Pre'sidence de la Rkpublique, CNLS, 2004 Plans Stratkgiques Locaux des CLLS, USAID, Madagascar, Novembre 2004 Notes de prksentation sur le programme PTME relative aux besoins d'extension des sites pour 1'annbe 2004, Madagascar, Septembre 2004 Prioritiesfor Local AIDS Control Efforts (PLACE),USAID, May 2004 Document de Programme Conjoint d'Appui a la Lutte contre le VIH/SIDA Ci Madagascar, Groupe Thkmatique Nations Unies pour le V W S I D A , Madagascar, Avril2005 StratbgieNationale de la PlaniJication du PrbsewatiJ; Madagascar,' DCcembre 2003 Madagascar HN/AIDS related studies and activities o fNGO and civil society e Etude sur les problkmes des relations sociales des personnes vivant avec le VIH/SIDA, Madagascar, Octobre 2002 65 Une se'rie d 'outilspour lafacilitation de discussions participatives sur les IST curables et le VIHSIDA, International HIV/AIDS Alliance, M a i 2005 e Integrating Service Delivery and Behavior Change Communication to Improve Adolescent Reproductive Health in Madagascar, PSIMadagascar, Decembre 2004 National HIV/AIDSSurveys EnquZte De'mographique de Sante' 2003-2004, Madagascar, Avril2005 Enqukte de Surveillance Comportementale sur les Camionneurs h Madagascar, Madagascar 2004 EnquZte de Surveillance Comportementale sur les Travailleuses du Sexe a Madagascar, Madagascar 2004 e EnquZte de Surveillance Comportementale sur les Jeunes h Madagascar, Madagascar 2004 e Enqukte de Surveillance Comportementale sur Ies Militaires h Madagascar, Madagascar 2004 Annuaire des Statistiques du Secteur Sa&, Ministhe de la Sant6 de Madagascar 2002 General Documents Assessing Community Health Programs: Using LQAS for baseline surveys and regular monitoring, USAID January 2003 Activite's PTME re'alise'es au niveau des formations sanitaires, Ministere de l a Sante, Madagascar, Mars 2005 Access des Personnes vivant avec l'infection h VIH/SIDA aux ARV h Madagascar, Madagascar, Fevrier 2005 The Guttmacher Report on Public Policy :A policy Analysis for the ABC Approach to HIV Prevention, Washington DC, December 2003 Guidepour la prise en charge de l'infection h VIH chez 1'adulte et l'enfant h Madagascar, Ministbre de la Sant6, 2004 AIDS in Africa: ThreeScenarios to 2025, UNAIDS, March2005 Madagascar: epidemiological fact sheets on HIV/AIDS and sexually transmitted infections, UNAIDS, September 2004 Report on the GlobalAIDSpandemic, UNAIDS, 2004 Reaching out to African Orphans, A framework for public action, African Region Human Development Series, World Bank 2004 66 Annex 12: Statementof Loans andCredits MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject Difference between expected and actual Original Amount in USDMillions disbursements ProjectID F Y Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm.Rev'd PO74236 2004 MG-GEFEnvironmentProgram3 (FY04) 0.00 0.00 0.00 9.00 0.00 8.70 0.83 0.00 PO74448 2004 MG-Govemance & Inst Dev T A L (FY04) 0.00 30.00 0.00 0.00 0.00 29.84 3.21 0.00 PO74235 2004 MG-Environment Program 3 (FY04) 0.00 0.00 0.00 0.00 0.00 37.92 -0.98 0.00 PO82806 2004 MG-Transport Infrastr Invest P i (FY04) 0.00 150.00 0.00 0.00 0.00 146.71 27.96 0.00 PO73689 2003 MG-Rural TransportAPL 2 (FY03) 0.00 80.00 0.00 0.00 0.00 61.39 -1.27 0.00 PO76245 2003 MINERALRESOURCESGOVERNANCE 0.00 32.00 0.00 0.00 0.00 28.39 0.38 0.00 PROJECT PO72160 2002 M G - PSD 2 0.00 23.80 0.00 0.00 0.00 19.48 9.20 0.00 PO72987 2002 MG-MultiSec STI/HIV/AIDS Prev APL 0.00 20.00 0.00 0.00 0.00 10.49 -5.95 0.00 (FY02) PO55166 2001 MG-Community Development Fund SIL 0.00 110.00 0.00 0.00 0.00 37.41 -74.04 -23.15 (FYOl) PO51922 2001 MG-Rural Development Support SIL 0.00 89.05 0.00 0.00 0.00 64.42 -38.47 -6.08 (FYOl) PO51741 2000 2nd Health Sector Support 0.00 40.00 0.00 0.00 0.00 6.72 0.03 0.00 PO52208 2000 M G Transp Sector Reform& Rehab 0.00 65.00 0.00 0.00 0.00 9.63 4.55 0.00 PO52186 1999 MICRO FINANCE 0.00 16.40 0.00 0.00 0.00 5.30 4.22 0.00 PO01559 1998 Educ. Sector Dev. 0.00 65.00 0.00 0.00 0.00 7.48 6.27 0.16 PO01564 1998 RURALWATER SEC.PIL0 0.00 17.30 0.00 0.00 0.00 6.05 5.46 0.00 PO01568 1998 2nd Community Nutrition 0.00 27.60 0.00 0.00 0.00 6.89 -3.92 0.00 PO48697 1997 URBANINFRASTRUCTURE 0.00 35.00 0.00 0.00 0.00 3.44 3.06 3.16 PO01533 1996 MG-Energy Sec Dev Prj (FY05) 0.00 46.00 0.00 0.00 0.00 6.95 9.69 9.68 Total: 0.00 847.15 0.00 9.00 0.00 497.21 - 49.77 - 16.23 MADAGASCAR STATEMENT OF IFC's HeldandDisbursedPortfolio InMillions ofUS Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1997 AEF GHM 0.73 0.00 0.00 0.00 0.73 0.00 0.00 0.00 1995 AEF Karibotel 0.20 0.00 0.00 0.00 0.20 0.00 0.00 0.00 1992 Aqualma 0.00 0.61 0.00 0.00 0.00 0.61 0.00 0.00 1991 BNI 0.00 2.61 0.00 0.00 0.00 2.61 0.00 0.00 2000 BOA-M 0.00 0.82 0.77 0.00 0.00 0.82 0.77 0.00 2004 Cottonline 5.00 0.00 0.00 0.00 1S O 0.00 0.00 0.00 1983189 Nossi-Be 0.00 0.14 0.00 0.00 0.00 0.14 0.00 0.00 Total portfolio: 5.93 4.18 0.77 0.00 2.43 4.18 0.77 0.00 67 ~ Approvals PendingCommitment FY Approval Company Loan Equity Quasi Partic 2004 BPMadagascar 0.00 0.00 0.00 0.00 2001 Besalampy 0.02 0.00 0.00 0.00 2001 COTONA 111 0.01 0.00 0.00 0.00 2004 LGA 0.01 0.00 0.00 0.00 Total pendingcommitment: 0.04 0.00 0.00 0.00 68 Annex 13: Country at a Glance MADAGASCAR SECONDMULTISECTORAL STI/HIV/AIDS PREVENTIONPROJECT Sub- POVERTY and SOCIAL Saharan Low- Madagascar Africa income Development diamond' 2003 Population,mid-year(mi//ions) 6.9 703 2,30 Lifeexpectancy GNIpercapita (Atlas method, US$) 290 490 450 GNI (Atlas method, US$ billions) 4.9 347 1038 - Average annual growth, 1997-03 Population (%$ 3.0 2.3 19 Laborforce(%) 3.2 2.4 2.3 GNI Gross M o s t recent estimate (latest year available, 1997-03) per primary capita nrollment Poverty(%of populationbelownationalpovertyline) 71 '/' Urbanpopulation(%oftotalpopulation) 27 36 30 Life expectancyat birth (years) 55 46 58 1 Infantmortality(per 1,OOOlive births) 84 a 3 82 Child malnutrition (%of childrenunder5) 33 44 Access to improvedwater source Access to an improvedwtersource (%ofpopulation) 47 58 75 Illiteracy(%ofpopu/ation age 159 35 39 Gross primaryenrollment (%of school-age population) 0 4 87 92 -(-Madagascar Male 0 6 94 99 - Low-incomegroup Female 0 2 80 85 KEY ECONOMIC RATIOS and LONG-TERM TRENDS I 1983 1993 2002 2003 Economic ratios* GDP (US$ billions) 3.5 3.4 4.4 5.5 Gross domestic investmentlGDP 8.4 114 14.3 n.9 Exports of goods and services/GDP 0.6 15.3 16.0 215 Gross domestic savings/GDP 14 2.1 7.7 7.8 Gross nationalsavings/GDP -14 3.6 8.4 119 Currentaccount balancelGDP -7.1 -7.4 -6.2 -6.0 InterestpaymentslGDP 0.9 0.8 0.7 16 Total debt/GDP 58.1 tT2.9 02.7 83.8 Total debt serviceiexports 20.9 Q.3 9.6 Q.O Present valueof debWGDP 318 43A Present value of debtlexports 184.8 2002 Indebtedness 1983-93 1993.03 2002 2003 2003-07 (average annualgroMh) GDP 14 2.5 -Q.7 9.8 6.7 -Madagascar GDP oercaoita -13 -0.5 -15.2 6.8 4.1 Lowincome group STRUCTURE o f the ECONOMY 1983 1993 2002 2003 (%of GDP) Agriculture 35.8 28.7 317 29.2 I Industry 13.5 119 14.4 15.4 Manufacturing .. 9.9 Q.5 13.7 Services 50.7 59.4 53.8 55.4 Privateconsumption 69.0 90.0 84.1 83.0 Generalgovernment consumption 9.6 7.9 8.2 9.2 Imports of goods and services V.5 24.6 22.6 316 1983-93 1993-03 2002 2003 (average annualgrovdh) Growth o f exports and imports (%) Agriculture 2.5 19 -16 13 Industry 2.1 2.4 -20.8 14.5 P Manufacturing 0.5 2.9 -18.3 P.8 50 Services 11 2.9 -15.4 9.5 0 Private consumption 0.3 2.9 -6.9 8.6 -50 3 General government consumption -0.3 2.7 -13.5 28.8 -100 Gross domestic investment 5.1 7.1 -314 57.2 imports of goods andservices -0.8 7.6 -310 129.8 -*--Exports --O--lrrQOrtS 69 PRICES and GOVERNMENT FINANCE 1983 1993 2002 2003 Domestic prices Inflation (%) (%change) I20 T 20 j 1I Consumer prices 9.2 15.8 -0.8 15 Implicit GDP deflator 215 P.1 25.3 2.8 10 Government finance 5 (%of GDP, includes current grants) 0 Current revenue 116 8.8 13.1 -5 Current budget balance -16 -15 17 Overallsurplus/deficit -0.1 -6.8 -6.5 I ----GDPdeilator -e-CPI I TRADE 1983 1993 2002 2003 (US$ millions) Export and import levels (US$ mill.) Total exports (fob) 3 0 332 499 852 1,500T Coffee 113 40 3 4 Vanilla 62 34 P O 8 5 Manufactures I75 227 551 Total imports (cif) 4% 599 729 1,300 Food 73 51 61 16 Fuel and energy 98 85 217 184 I Capital goods 90 140 92 217 Export price index (895-WO) 90 77 0 2 0 9 97 98 99 00 01 02 Import price index(895=WO) 89 92 113 %ports Q lTQ0rtS Terms of trade (895=x]O) 87 ni 96 O3 BALANCE of PAYMENTS 1983 1993 2002 2003 (US$ millions) Current account balance t o GDP ( O h ) Exports of goods and services 368 5 6 730 1l71 Imports of goods and services 509 8 6 1029 1,720 Resource balance -121 -300 -299 -549 Net income -118 -134 -71 -80 Net current transfers -0 184 99 302 Current account balance -249 -250 -272 -327 Financingitems (net) 228 270 218 344 Changesin net reserves 21 -20 53 -n Memo: Reserves includinggold (US$ millions) 81 363 397 Conversion rate (DEC,/oca//US$j 430.4 2914.3 6.832.0 6.816 EXTERNAL DEBT and RESOURCE FLOWS 1983 1993 2002 2003 (US$ millions) Composition o f 2003 debt (US$ mill.) Total debt outstanding anddisbursed 2,041 3,805 4,518 4,590 IBRD 30 l7 0 0 G 231 IDA 223 932 1,652 1,804 Total debt service 83 78 73 142 IBRD 3 4 0 0 IDA 2 12 6 34 Compositionof net resourcefiows Official grants 77 257 66 Official credit0rs 218 97 149 P8 Private creditors 74 -8 0 -8 Foreign direct investment 4 15 8 Portfolio equity 0 0 0 World Bank program Commitments 62 85 130 222 4 IBRD - E- Bilateral Disbursements 37 47 6 3 174 3-IDA D-Otkmltilatetal F-Rivate Principal repayments 2 8 6 22 3-IMF G- Shart-term 70 AdditionalAnnex 14: DetailedMonitoringand EvaluationArrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject Subcomponent4.1 Monitoring The MSPPII Monitoring and Evaluation (M&E) subcomponent will ensure that the national M&E system usedby all donors is inplace and operational. The subcomponent will finance the following five activities: (i) set ofproposed indicators to measure project performance and to a track the epidemiology o f the virus; (ii) introduction o f LQAS to collect a subset o f the project's key performance indicators; (iii) revision o f the project's M I S to effectively organize indicators o f output, outcome and impact as well as financial, input and operational data; (iv) monitoring o f sub-project quality; and (v) reporting and use o f monitoring data. Proposed indicators. The proposed MSPPII indicators include several o f the performance indicators used during the MSPP project (Annex 1). The other indicators from the original project were dropped because they were either inappropriate, or data was not available. All proposed outcome indicators for MSPPII are aligned with the national M&E plan and with indicators used inprimary data sources to ensure that data will be available. An important difference in the indicators proposed for MSPPII is that they provide a comprehensive picture o f the outputs and outcomes associated with knowledge, attitude and behavior change inhigh-risk groups (commercial sex workers, truck drivers and miners) and in the population as a whole. The indicators also include indicators on youth (girls 10-14years old andboydgirls 15-24 years old) andon risk groups, neither o fwhich were included inthe MSPPI M&E plan. This change reflects the need to monitor HIV/AIDS knowledge, behavior and ultimately prevalence among the specific population groups where the epidemic is currently concentrated. Lot Quality Assurance Sampling (LQAS). Under this sub-component, the MSPPII will support the collection o f outcome and impact level, inpart using LQAS methodology. According to the MSPPII intervention strategy, a limited number o f at-risk areas will be selected where HIV transmission i s suspected, or documented, to be high. These will be the priority intervention zones for the project where the project will measure outcomes using LQAS. Data will be collected at an aggregate level among intervention zones rather than at the commune level. Because MSPPII will provide a small amount o f funding for general behavior change for communication activities innon target areas, a set o f these communes will be selected as control areas for the measurement o f outcomes. The control areas will be sampled to ensure that the data can be aggregated to represent the national catchments area. Data sources for all outcome indicators are displayed inAnnex 1. Management Information System (MIS). The M I S will build on the project's existing MIS, which is in place at the UGP but not fully operational. There are two main problems with the project's existing MIS system. The first is the process for collecting data to input to the system: regional data is collected by the AGF, which takes extensive time to verify data quality, and which then provides monthly, quarterly and annual reports to the project. The data collected by the AGF is outside o f the MIS. The project M&E team then manually inputs the AGF data into 71 the UGP central MIS. This process is laborious and time-consuming. The second problem i s that the M I S is not fully functional. While some parts o f the systemwork individually, none are fully automated and the parts do not function together as a whole (see footnote).32 As a result, information does not flow effectively, there i s incomplete data at the central level, and there are delays inproducing reports. A series o f changes will be made to the MIS to allow it to function more effectively under the MSPPII. These include: 0 Dataflow. The MSPPII will correct the database problems in order to address most o f the problems associated with the lack o f full automation o f the M I S and the lack o f a single, functioning system. The MSPPII will also address related problems in data flow, including delays in submission o f data (particularly the operational planmodule) and inadequate use o f data at all levels o f the system. 0 Financial, input and Operational datu. The current MSPP project will finance strengthening o f its existing MIS to allow for a more detailed analysis o f data below the province level, and to permit the consolidation of,all data at the MSPP central office. Through this process, the M I S sub-systems will be adapted to include the new project activities and indicators in MSPPII and to eliminate its duplication o f the accounting system. The M I S will also be modified to include health center and VCT data to monitor access to HIV/AIDS services - acquisition o f these data will be coordinated with the Global Fund. 0 Outcome and impact datu. The introduction o f LQASwill allow the project to collect key outcome and impact data for its intervention areas. Use of LQAS will allow the MSPPII to rigorously collect these indicators at minimum cost. A separate database will be developed to hold outcome and impact level data33that can be exported and merged with the existing MIS. Monitoring of sub-project quaZity. Much effort i s currently placed on monitoring the cost and completion o f sub-project activities, but not much emphasis i s placed on monitoring the quality o fthese activities. At the most basic level, becausemost output data have not beenentered inthe system at the level o f the MSPP, the M I S i s currently used mainly to track inputs. Inthe MSPPII, the MSPP team will focus on using their output data to better manage the project. Inaddition, a technical M&E staff member will be hired and placed in eight o f the regional offices to serve as an extension o f the UGP M&E office. These staff will be responsible for: (i) verifying the accuracy o f the data submittedby promoters and CBOs; (ii) monitoring the quality o f subprojects through periodic site visits and formative supervision; and (iii) sharing relevant data with partners inthe region. 32The main issues are related to problems with the database design and functions and problems with the flow o f information within the system. The MIS currently consists o f four sub-systems: 1) sector plans - well designed subsystem with very little data because, except for the labor sector, sector plans have only recently been finalized; 2) sub-projects - data exist and are current at the central AGF but are not yet consolidated at the MSPP level due to numerous problems with the design o f this subsystem; 3) program operations - this subsystem could work well except for problems assigning the correct timeframe to the annual operational plans; for now the M&E team performs systematic tracking o f annual plans by hand; and 4) structures - detailed financial data are available on the AGF, NGOs, subproject technical review organism; the subsystem functions well except that the monetary unit i s still inFmgrather than Ariary. 33Impact level indicators will be monitored based on epidemiological and behavioral data coming from other surveys. 72 Reporting and use of data. The M&E unit will ensure that monitoring data are routinely reported to the public and to partners o f the HIV/AIDS program through regular dissemination workshops and distribution of trimester, 6six month and annual monitoring reports. Regional UGP M&E staff will be responsible for conducting regular (six monthly) sessions with regional coordination staff to promote the use o f project output data for management decisions. To ensure that outcome and process data are used for decision making by the UGP, annual operational plans will be supported from data assembled from the M I S and associated databases. Similarly, MIS data will form the basis of quarterly and annual reviews o f project activities and progress. Monitoring data will also be used in the annual "situation analysis" and policy recommendations, described inthe following section. Subcomponent 4.2 Epidemiologicaldata collection special studies, and situation analysis This sub-component includes two parts. The first is the project's contribution to a second- generation surveillance system as well as other population-basedsurveys and large-scale studies; the second ,is the development of an annual "Results and Strategic Re-Orientations" report, which will compile data from the year's surveys and make programmatic recommendations based upon analysis o fthat data. Second generation surveillance; other population-based surveys and large-scale studies. Madagascar's second generation surveillance system includes biannual behavioral surveillance surveys among high-risk groups (commercial sex workers, truck drivers, military, and youth) and the annual sentinel surveillance surveys o f clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). Its population-based surveys and other large-scale studies include the cross-sectional HIV prevalence study ("Enquete Nationale de Sero- prevalance azipris des Femmes Enceintes") first conducted in 2003, the DHS planned for 2008/2009, and the annual replication o f the "PLACES" study, which maps high-risk sites and monitors risk behaviors in Madagascar's at-risk communes. The MSPPII will finance a portion of each o f these studies. The project will also support the inclusion o f an HIV/AIDS module in the survey instruments o f large scale surveys and studies undertaken by agencies external to the MSPP.34 Report on "Results and Strategic Re-orientations ". This sub-component will also support the development o f annual CNLS reports which will provide: (i) a consolidated technical analysis of data generated and studies carried out in the course o f the year; and (ii) recommendations on policy re-directions based on the technical analysis. Each report will address the following issues: 1) estimates o f H N and STI prevalence in Madagascar and their variation by age, sex, risk group, location and educational status; 2) best estimates and description o f the trends inthe prevalence data; 3) summary information from sub-component 4.1 M I S data and national M I S data on the intensity o f prevention interventions in the identified risk groups; 4) a judgment regarding the success or lack o f success o f prevention programs inthe various demographic and 34The first application of the MSPPiHIViAIDS module was included in the 2003/4 DHS. However, the questions proposed by CNLS and MSPP were not compatible with MacroDHS survey formats. It is strongly recommended that future auxiliary survey instruments and methodologies be reviewed in collaboration with Macro or other agencies specializing in large-scale surveys, and that they are complimentary to the main survey instead of overlapping with it. 73 risk groups and inthe various parts of the country; and 5) implications for reorienting HIV/AIDS policy and programs. The entire report, and in particular the last section, will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based on this analysis. The reports will then be disseminated to and discussed with development partners, with a view to implementationo fthe report's recommendations. Subcomponent4.3 Impactstudies For the benefit of the national fight against HIV/AIDS, as well as for global knowledge creation, the MSPPIIproject will support one or more (pendingthe availability o f fhding) impact studies. Theses studies will measure, for example, changes in HIV/AIDS prevalence and incidence, changes in AIDS related mortality, social norms, coping capacity in the community, or the economic impact. The study will be awarded only after technical review confirms that the study design has sufficient statistical power to test the studyhypothesis. 74 AdditionalAnnex 15: SupervisionPlan MADAGASCAR: Second Multisectoral STI/HIV/AIDS PreventionProject GeneralSupervisionStrategy The project will require intensive supervision. A budget o f USD180,OOO is allocated to supervise the project during the first 12 months o f project implementation. It i s multisectoral, with multiple players operating at the national and decentralized levels. At the decentralized level, it will be implemented largely by many entities only recently established and whose capacity will need strengthening. The skills required for supervision are varied, given the multisectoral nature o f the project and the diversity o f issues surrounding HIVIAIDS. It is, therefore, proposed to establish a core supervision team, enhanced by specialists and other inputs on an as needed basis. The core supervision team will be in the field twice a year and would rely on UNAIDS Thematic Group partners for supervision o f activities during and between missions. A supervision mission would take, on average, three weeks, andinclude about five people. Specialized inputs will be provided as required. Task team leaders o f related sectoral projects (mostly education and health) will be asked to devote at least half a day during each o f their supervision mission on the MSPPII. At the same time, the core supervision team will rely heavily on the technical inputs and collaboration o f its partners inthe UNAIDS Thematic group and the team may tap into UNAIDS expertise for the specialized inputs. Project progress reviews will be held annually to assess the performance of the project and its contribution to the national effort to reduce the spread and impact o f HIV/AIDS. They will be held jointly with the Conseil du PMPS and the UNAIDS thematic group. M&E information and conclusions o f site visits conducted by the supervision team will form the basis o f the discussions. Progress reviews would include a presentation by the UGP on progress attained, problems encountered, and hture steps. A progress report will be prepared for annual review attendees to be distributed at least one week prior to the meetings. The presentationwill employ data derived from the project MIS and observations made during site visits. Other information available at the time, including studies conductedby the project or other donors will be employed to complement M I S data. Progress reviews will culminate in stakeholder meetings that will form a basis for re- planningfor the next two years. These meetings will be usedto share information on trends, best practices and to provide general technical information. Given the key role that M o H activities have on the success o f the government's efforts to reduce the spread o f HIVIAIDS, supervision missions will coordinate closely with the MoH's ongoing CRESANII Project. SupervisionObjectives The core team will be primarilyresponsible for the review of: (i) o f project management quality and implementation, and adherence to the procedures and implementation manuals; (ii) monitoring and evaluation results; (iii)financial management, including AGF performance, 75 procurement procedures, and technical and financial audits; (iv) spot-check quality, relevance and location o f sub-projects financed under the Fund component; (v) adherence to ARV treatment and STI treatment guidelines; (v) adherence o f health sector activities with health sector policy; and (vi) progress on NSP update, communication action plan, and sector strategies and actionplans. SupervisionRequirements Core team: The core team would consist o f staff from the Washington office and from the country office. The following skills would be included: (i)task team leader; (ii) a health specialist; (iii)a procurement specialist; (iv) a financial management/private sector specialist; and (v) team counterpart in country. A health specialist based in the field will participate in missions, and will focus year-round on the collaboration with the MoH. During the first two years, a monitoring and evaluation specialist should be part o f the core team. For the first and second years, 24 Washington-based staff weeks and 18 country office staff weeks are planned for the core team; to be gradually reduced inthe third and fourth year. Enhanced specialists and additional support: The core team will be enhanced by other specialists on a needed basis and at the discretion o f the task team leader. These specialists would be responsible for the following: (i) provide strategic support to the revision o f the NSP; (ii) ofcommunicationactivitiesasawhole;(iii) quality occasional in-depthreview of particular subprojects focusing on specific target groups; and (iv) impact evaluations. For the first year, seven Washington-based staff weeks and six country office staff weeks are planned on an ad-hoc basis. Collaboration will be sought with the team leaders of relevant sectoral projects to provide time on MSPP duringeach supervision mission inthe field. 76 44° 46° 48° 50° MADAGASCAR SECOND STI/HIV/AIDS PREVENTION PROJECT 12° 12° ANTSIRANANA PAVED ROADS ALL-WEATHER ROADS DIANA RAILROADS RIVERS Ambilobe Iharana SELECTED CITIES Mahavavy Vohimarina REGION CAPITALS PROVINCE CAPITALS Ambanja NATIONAL CAPITAL A N T S I R A N A N A 14° REGION BOUNDARIES 14° PROVINCE BOUNDARIES SAVA Sambava Bealanana Analalava Andapa Antsohihy Antalaha SOFIA Befandriana Maroantsetra Boriziny Sofia MAHAJANGA Mandritsara M A H A J A N G AAnjombony 16° Mitsinjo Marovoay Mampikony 16° Soalala Bemarivo Mahajamba Mananara BOENY Ambato Boeni Besalampy ANALANJIROFO Boinakely Tsaratanana Soanierana- Andilamena Ivongo Maevatanana Ambodifotatra Mozambique Vohitraivo MELAKY Kandreho Betsiboka Vavatenina Andriamena Manambaho BETSIBOKA Fenoarivo-Atsinanana Amparafaravola Lake Ambatomainty Alaotra Channel Morafenobe Ambatondrazaka Vohidiala 18° Maintirano Bemahatazana ALAOTRA 18° Ankazobe Mahavavy MANGORO Fenoarivo be ANALAMANGA TOAMASINA Fanandrana BONGOLAVA Anjozorobe T O A M A S I N A Antsalova A N TA N A N A R I V O Tsiroanomandidy ANTANANARIVO Miarinarivo Perinet Manja- Ampasimanolotra Moramanga Manambolo ITASY kandriana ATSINANANA Andramasin Faratsiho Anosibe Miandrivazo Vatomandry Belo Canal Tsiribihina Mandoto Antanambao-Manampotsy Antanifotsy Tsiribihina VAKINANKARATRA Antsirabe Mangoro 20° MENABE Mahanoro 20° Morondava Marolambo Mahabo Fandriana Morondava Malaimbandy AMORON' MANIA Ambatofinandrahana Ambositra Manandriana VATOVAVY Nosy Varika INDIAN FITOVINANI Vohilava Ambohimahasoa Pangalanes Ikalamavony Vohiparara Alakamisin' Manja OCEAN Ambohimaha Mananjary FIANARANTSOA Ifanadiana Irondro Beroroha HAUTE MATSIATRA Morombe Mangoky F I A N A R A N T S O A Ambalavao 22° T O L I A R A IHOROMBE Ankarmena Ikongo 22° Ankazoabo Manakara atm. Ihosy Ivohibe Vohipeno ATSIMO ANDREFANA Vondrozo Sakaraha Farafangana Iakora ATSIMO TOLIARA Fiherechana Betroka Benenitra ATSINANANA Vangaindrano Midongy-du-Sud Onilahy Betioky ANOSY Befotaka 50° 24° 24° TANZANIA Berakete 45° 50° Bekily COMOROS Antsiranana Manantenina Mayotte (Fr) Ampanihy Mandrave 15° ANDROY 15° Mahajanga Amboasary- Sud MOZAMBIQUE Toamasina Beloha Tolagnaro Channel ANTANANARIVO Ambovombe 20° 20° Tsihombe Androy ozambique This map was produced by the Map Design Unit of The World Bank. M IBRD The boundaries, colors, denominations and any other information 0 50 100 150 200 Toliara ADAGASCARFianarantsoa JUNE shown on this map do not imply, on the part of The World Bank M Group, any judgment on the legal status of any territory, or any KILOMETERS 34097 2005 endorsement or acceptance of such boundaries. 25° 25° 44° 46° 48° 40° 45° 50°