Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB1431 Project Name Second Multisectoral HIV/AIDS project Region AFRICA Sector Other social services (65%); Health (35%) Project ID P090615 Borrower(s) REPUBLIC OF MADAGASCAR Implementing Agency MSPP UNITE DE GESTION (UGP) B.P. 248, Antananarivo, Madagascar Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared March 3, 2005 Estimated Date of Appraisal Authorization April 1, 2005 Estimated Date of Board Approval September 30, 2005 Key development issues and rationale for Bank involvement 1.1 Current dimensions of the HIV/AIDS Epidemic in Madagascar Until recently, Madagascar was considered an anomaly to the HIV/AIDS epidemic in Sub Saharan Africa: despite high STI prevalence (particularly among the sex workers active in approximately twenty “hot spot areas” countrywide) and risky sexual practices (including early sexual relations, multiple partners, and low rates of condom use), HIV/AIDS prevalence among blood donors, STI patients, and sex workers had remained remarkably low. 1 But infection rates have inexorably progressed (from 0.01% in 1996 to 0.15% in 1999 to 0.3% in 2001). The first nationally representative survey, conducted in 2003, indicates that 0,93% of pregnant women may be infected. 2 Despite such increases, Madagascar remains a low prevalence country and constitutes an opportunity to avert large numbers of future HIV infections (and related costs), provided that the country implements interventions that prevent and reduce HIV transmission in places where these activities could be particularly productive. 1.2 Implementation Arrangements 1 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 low HIV HIV/AIDS prevalence rate on the other hand, may be explained by (i) circumcision which is generalized; (ii) limited transport infrastructure and internal migration; and (iii) low herpes prevalence. 2 The 2003 sero-prevalence survey among pregnant women (Ministry of Health) gives a HIV/AIDS prevalence rate of 1.1%. However, this rate was not regionally weighted. It has recently (January 2005) just been corrected to 0.93%. HIV/AIDS prevalence in the general adult population of Madagascar is most probably lower than among pregnant women. Page 2 Over the past three years, the Government has taken the lead in mobilizing public opinion and in or ganizing the Government’s response to the epidemic. HIV/AIDS figures among the principal objectives of the Strategy for Poverty Reduction, a National Strategic Plan for HIV/AIDS (2001- 2006) has been adopted, and a National AIDS Commission (CNLS) and its Executive Secretariat have been established to coordinate the Government’s response. The CNLS ensures that all HIV/AIDS related activities undertaken by the various development partners (including the UN agencies, AfDB, the Global Fund, and other bilateral and NGO donors) are consistent with the National Plan. A UNAIDS theme group, made up of up representatives of most of the donors and development agencies, including the World Bank, was established under the auspices of UNAIDS (but with a rotating presidency) and staffed by CNLS. CNLS has begun to map out the availability and distribution of funds according to the priorities of the PSN. While there is currently no intention of formally harmonizing (or pooling) funds, MSPP II will seek to establish: (i) agreement on the annual work plan and outputs; and (ii) a detailed financing plan identifying specific activities to be funded by specific agencies, including the Government. Though individual partner financing will therefore be "earmarked" within the framework of the work plan agreed by all the parties, it is understood that IDA’s contribution will be flexible, based on the principles of justified need and donor of last resort. The National Secretariat is responsible for implementing the IDA-funded Multisectoral STI- HIV/AIDS Prevention Project (MSPP), which was approved in December 2001 and became effective on November 12, 2002. The project’s Development Objective is to support the efforts of the Government of Madagascar (GOM) to promote a national-scale, multi-sectoral response to HIV/AIDS and to STIs which contribute to the spread of HIV/AIDS. The proposed Second Multi-sectoral STI/HIV/AIDS Prevention Project (MSPP II) will build upon progress made under the MSPP I. 1.3 Lessons Learned Under First Madagascar Multi-Sectoral STI/HIV/AIDS Project A Mid-Term Review (MTR) was carried out jointly by the staff of the MSPP, the Bank and active donors in December 2004. Findings from the MTR were generally consistent with those of the Interim Review of the MAP Program For Africa (October 2004): (i) difficulties in implementing a sustainable public sector response, including from the health sector side; (ii) lack of a uniform system of monitoring indicators; and (iii) inadequate counterpart funding to support project activities. However, the MSPP was particularly successful in terms of its: (i) flexible response to evolving conditions (including development of a national communications strategy, reorganization and strengthening of project implementation; and shifting of resources to high priority zones); (ii) effective outreach to the community level, first through financing of local NGOs, facilitated by a consortium of International NGOs, and subsequently through financing of authorities at the commune level; and (iii) contribution to the implementation of a number of important studies on the HIV/AIDS situation in the country (including the fist annual national HIV/syphilis survey among pregnant women, the DHS, and cultural and behavioral surveys). The MTR also documented that MSPP, which has been rated Satisfactory since April 2003, (i) had disbursed US$ 12.2 million (54% of the credit) by November 30, 2004; (ii) has committed US$ 5.0 million; and (iii) plans to disburse the balance of the credit by before December 2005. The CNLS has already prepared a draft concept note which the Government of Madagascar (GOM) has submitted to IDA for consideration. Page 3 1.4 Rationale for World Bank Involvement The CNLS has undertaken a mapping exercise (comparing estimated financial requirements with available resources) and concluded that even with important contributions from the Global Fund (USD16 millions in 2004-06, with a possible addition of USD6 million in 2007) and the expected contribution from the AfDB (USD 9 million in 2005-07), there is a funding shortfall of approximately US$ 31 million until 2007. There is, however, no clarity yet on the financial gap beyond that date. No other partner is currently capable of making up this funding shortfall, and the shortfall will have the sharpest impact in areas where the MSPP has already invested significant resources. Continued IDA support will therefore be necessary to continue to make progress towards Madagascar’s Poverty Reduction Strategy objectives, and the Millennium Development Goal to prevent the spread of the disease. Proposed Objectives The development objectives of the MSPP II are: (i) to support the Government of Madagascar’s efforts to promote a multisectoral response to the HIV/AIDS crisis, and (ii) to contain the spread of HIV/AIDS on its territory. To do so, the project will build capacity and scale-up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread of HIV/AIDS. In addition, the MSPP II will also seek to improve the quality of life of persons living with HIV/AIDS through increased accessibility to quality medical care and non-medical support services. Preliminary Description: Project Overview and Components To work towards the project development objectives, the project will build capacity and scale-up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread of HIV/AIDS. In addition, the MSPP II will also seek to improve the quality of life of persons living with HIV/AIDS through increased accessibility 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 in high prevalence areas 3 , while gradually expanding services to other affected groups (e.g., orphans and other vulnerable children). The project will maintain its support the three “ones” principles of one national HIV/AIDS policy framework, one national coordinating authority, and one national M&E system. The project will: (i) revise the national strategic framework to incorporate the results of the recent studies, include the proposed interventions of the various partners, and serve as a consensus- based management tool for the period 2007-2010; (ii) maintain the institutional arrangements 3 Madagascar has experimented with the "PLACE" method, which uses local ethnographic and contextual data rather than blood testing in order to identify sites where HIV prevention activities could be particularly productive. A PLACE pilot study was carried out in May, 2003 in 7 towns judged at high risk for sexual transmitted infections because of their activities (e.g. mines, large cattle markets, tourism, ports.) Preparation of a 2005 PLACE study is ongoing. Page 4 which were carefully established during MSPP I, but will revise the different operational manuals to reflect improved capabilities and to streamline existing procedures; and (iii) ensure that the management information system (MIS) funded by MSPP I serves the needs of the national monitoring and evaluation strategy as well as those of all partners. As needed, the MSPP II will support revisions to the MIS system. The project will include five components, with sub-components: (i) Harmonization and Donor Coordination, and Support of Key Sector Strategies and Action Plans, with the following five activities emphasized: a. Harmonization and Donor Coordination b. Updating of the National Strategic Plan c. Updating and piloting of the MSPP II communications strategy d. Implementation support of a limited number of sector strategies and action plans e. Support to local authorities (ii) Support for Health Sector Response, with three types of activities emphasized: a. Support for STI control b. Support for care and treatment of PLWHA c. Other health sector response activities (iii) Fund for STI/HIV/AIDS Prevention and Care-taking Activities (iv) Monitoring and Evaluation System (v) Project Management, and Strengthening of Institutional Capacity Building. A detailed description of project components can be found in Annex 1. Safeguard Policies that Might Apply The only safeguard which could be triggered under this project is the Environmental Assessment, because the project involves risks associated with the handling and disposal of HIV-infected materials. These risks potentially affect personnel in hospitals, health centers and municipalities who handle waste; families whose income derives from the triage of waste; and also the general public, to the extent that waste is not disposed of on-site nor safely contained in protected areas. To manage these risks, a Medical Waste Management Plan is required. It is the only safeguard- related study required for this project. The MWMP was prepared for the first Multisectoral STI/HIV/AIDS Prevention Project, and was approved. The MWMP will be disclosed under the MSPP II prior to project appraisal, in-country and in the InfoShop. The existing MWMP includes proper disposal of hazardous bio-medical waste and a bio-safety training program for the staff of all hospital, health centers and community-based programs, including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and treatment. Though not required for HIV/AIDS projects, an Environmental Assessment of the Health Sector (which included HIV/AIDS) was also carried out as part of the preparation of the IDA financed Health Sector Support Project (CRESAN 2). Page 5 Tentative Financing Total (US$M): BORROWER 1.5 IDA 30.0 LOCAL COMMUNITIES 0.0 Total Project Cost 31.5 Sustainability The project is not expected to be financially sustainable in the short-term. The Bank will therefore waive the country co-financing requirements. In the medium to long-term, financial sustainability will be dependent upon (i) improvement of Madagascar’s economic performance, which will allow the Government to take on an increasingly important role in co-financing the project (the Bank is supporting Madagascar’s long-term economic development through the remainder of its lending portfolio); and (ii) donors’ commitment to continue funding the fight against the epidemic. Contact Point Task Manager Nadine Poupart The World Bank 1818 H Street, NW Washington D.C. 20433 npoupart@worldbank.org Telephone: 202 458 2590 Fax: 202 473 8107 Page 6 Annex 1: Detailed Description of Project Components Component 1: Harmonization, Donor Coordination and Strategies. Under MSPP I, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This component will be revised to include donor coordination, the updating of the national strategy, and a more selected support to sectors. This component will emphasize five activities: (i) Harmonization and Donor Coordination : This activity will support practical mechanisms of coordination among donors to ensure better impact and cost- efficiency of HIV/AIDS interventions. Although Madagascar has achieved two of “Three One principles” (one national authority for HIV/AIDS, and one strategic framework) donor coordination needs to be intensified, particularly on the M&E system. (ii) Updating of the National Strategic Plan . The current Plan covers the period through the end of 2006, and will need to be updated and re-validated thereafter. (iii) Updating and piloting of the MSPP II communications strategy . Though knowledge of HIV and information on prevention is now relatively widespread, 4 actual sexual practices remain risky, 5 and stigma strong. The MSPP II will update the communications strategy that will maintain mass media campaigns, but will place more emphasis on grassroots communication (small groups, peer to peer education, etc.) for behavioral change, particularly in the most at risk places, and reduction of stigma. (iv) Support for Implementation for a limited number of sector strategies and action plans (two to three) . The health sector and sectors which focus on high risk groups (e.g. Education for the youth, Defense for the militaries etc.) will receive priority. If implementation progresses satisfactorily, the number or sectors may be expanded during the course of the project. (v) Support to local authorities . MSPP II will increase the number of commune- level AIDS councils (CLLS), particularly in the most affected areas, and will provide technical support for planning the communal response ( Plans Stratégiques Locaux ). Component 2: Support for Health Sector Response . Under the MSPP I, the Ministry of Health was involved only in the implementation of a major STI program, and the implementation of the medical waste management plan. The involvement of the health sector will be strengthened under the MSPPII. This component will provide funding to the Ministry of Health to fight HIV/AIDS, complementing general funding to the sector provided through the Second 4 The DHS 2003-04 showed that knowledge of HIV/AIDS satisfactorily progressed since 1997 from 69% to 79% for women and it is at 88% for men in 2003. 5 The 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 of 71% (Mahajanga) and lows of 24% (Ilakaka). Page 7 Health Support Project ($40 million for the original credit and $22 million for a supplemental credit that will be submitted to the Board in early FY06). 6 It will target high risk places, persons living with AIDS (PLWHA), and their families and care-takers. Examples of activities to be financed under this component are provided below. (i) Support for STI control . MSPP I made a significant effort to control STIs by financing a) training based on the Syndromic Approach and b) the sale of two STI treatment kits at subsidized prices in both the public and in private sectors 7 . MSPP II will expand these activities. (ii) Support for care and treatment of PLWHA . Based on the preliminary experience of the IDA-financed Regional Treatment Acceleration Program (TAP), and on the Interim Review of the MAP Program in Africa, MSPP II will help the Ministry of Health establish a range of complementary services such as: (a) expansion of the VCT centers in all district hospitals and in health centers in high- risk areas 8 ; (b) psycho-social, nutritional, and other support for persons infected and affected by HIV/AIDS, including home-base care; and (c) treatment of PLWHA, including PMTCT, and treatment of opportunistic infections. (iii) Other health sector response activities. MSPPII will provide complementary funding as needed to activities supported by other donors such as laboratories and ARVs (mainly supported by the Global Fund), and blood transfusion (mainly supported by the African Development Bank). It may also finance some human resource development. Component 3: Fund for STI/HIV/AIDS Prevention and Care-taking Activities . Under MSPP I, some 850 NGO, CBO, and association-sponsored sub-projects have contributed to a range of preventive interventions in higher prevalence areas. These activities will be pursued but with a stronger effort to identify the places where the population is at greatest risk of being infected or of transmitting the infection. Under MSPP II, sub-projects will continue to include condom distribution. Communication activities will shift from general knowledge (the traditional Information Education and Communication (IEC) to Behavioral Communication for Change (BCC). NGOs and CBOs will be encouraged to engage more heavily in care-related activities such as VCT, home-base care, community support for PLWHA and associations of PLWHAs, and programs for orphans and vulnerable children. NGOs and CBOs will be encouraged to work with at risk groups to increase their demand for HIV/AIDS services, to implement outreach programs, training of peer educators, training of counselors, reducing stigma and discrimination against PLWA. The MSPP I developed standardized activities to increase the 6 The objective of this project is to contribute to the improvement of the health status of the population through more accessible and better quality health services. 7 More than 400,000 STI kits for genital discharge were sold in 2004 at approximately $0.5 through social marketing in the private sector and at $0.35 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. 8 Along with the reconstruction/rehabilitation of 300 health centers, a comprehensive needs assessment was recently performed at district (first-referral) level providing the needed information to prioritize the creation of VCT centers and the strengthening of lab facilities. Page 8 Fund’s effectiveness and methods of avoiding over-programming for geographic areas and target populations. These tools will be updated, and used under the proposed project. The update may be based on an assessment of the Fund impact 9 , and on an ex ante cost-effectiveness analysis of the Fund’s interventions, using the “Allocation By Cost-effectiveness” model 10 . Component 4: Monitoring and Evaluation System . A Monitoring Plan will be built upon the management information system (MIS) which is already operational at the MSPPI. This existing MIS is composed of 4 sub-systems (sectors, Fund sub-projects, structures and PIU operations). Although the system is in place, it will need to be strengthened to allow for a more detailed analysis of data (below the province level), and to include the new project activities. In addition to supporting ongoing collection of comprehensive data on financial and physical inputs, the project will monitor key project outputs by carefully and rigorously sampling selected performance indicators over time. In order to achieve the necessary rigor at minimum cost, the project will apply the techniques of Lot Quality Assurance Sampling (LQAS) and other sampling techniques as deemed appropriate during project implementation. Key project indicators subject to sampling by LQAS methods (Annex 1) will continue to include: (i) increases in the proportion of the population knowledgeable about STIs/HIV/AIDS; (ii) increases in condom use; (iii) reduction of the population with more than one regular sex partner over a year’s time; and (iv) decreases in the rate of STIs. Since some key indicators from MSPP I were too ambitious (particularly attitudinal and behavior change regarding prevention within a four-year timeframe) or inappropriate (e.g., the measurement of gonorrhea rather than syphilis to measure STI Levels) or unavailable (because they were not part of the national M&E plan), these will be dropped and a small number of other indicators will be agreed on at appraisal with the GOM and its partners (within the framework of the "Three Ones"). Among the criteria for choosing these additional indicators will be whether they can be feasibly collected, whether they are likely to vary in the population over the project horizon, and whether they are more than just measures of inputs. To monitor changes in knowledge, risk behavior and in the epidemiology of the virus, the project will continue to support a systematic "second-generation" surveillance system by contributing to the conduct of large-scale surveys and studies. This will include biannual behavioral surveillance surveys among high risk groups (sex workers, truck drivers, military, and youth) 11 , and annual biological surveillance surveys (sex workers, pregnant women, and IST patients) 12 . The Evaluation Plan will contain an evaluation framework which identifies the strategic linkages between AIDS-related government inputs (whether or not they are supported by Bank financing) and outcomes and then proposes additional specific data collection efforts which will permit the Malagasies and the Bank to evaluate the impact of the inputs on these outcomes and ultimately to maximize the cost-effectiveness of their intervention strategy . The additional data collection will extend in two key ways what would be collected for monitoring alone. First, data would be collected in areas where project implementation has either not started or is less advanced as well 9 Requested during the MSPP I Mid-Term Review (December 2004) 10 The « Allocation By Cost-effectiveness » or ABC model will determine the resource allocation that will prevent the maximum number of new HIV infections at any given budget level. 11 The baseline survey was completed in 2004 12 The baseline survey is under preparation and will be carried out in 2005. Page 9 as in areas where project implementation is proceeding rapidly. For example, LQAS techniques will be applied to assess the difference in indicator values in areas that have undertaken community initiatives in comparison with those that have not yet done so. This comparison should lead to inferences about the conditions under which the value-added of the community initiatives can be maximized. Second, LQAS and other appropriate sampling techniques will be used to focus measurement of changes in knowledge, behavior and STI incidence tightly at the site(s) of the intervention. Building on the results of the PLACE surveys, the evaluation component will sample the people who can be found at the social meeting spots to track reductions in risk behavior that occur after interventions are introduced at those sites. Similarly, focused sampling will be used to evaluate the efficacy of the current practice of distributing STI treatment kits over the counter rather than by prescription. The appraisal document will contain a small prototype cost-effectiveness analysis of the government's HIV prevention and treatment interventions as an example of the kind of analysis that will be possible with much more precision based on the project's implementation of the monitoring and evaluation framework. Component 5: Project Management and Strengthening of Institutional Capacity Building. MSPP II will support the institutional arrangements and operational modalities established under MSPP I, at the central level (CNLS, the PMPS Council, and UGP), at the provincial level (BCP), and at the regional level (UCL). This component will finance part of each level’s staff, equipment and operating costs; periodic technical assistance; and some training based on annual capacity building plans.