Page 1 Document of The World Bank Report No: 25264-DJI PROJECT APPRAISAL DOCUMENT ON A PROPOSED GRANT IN THE AMOUNT OF SDR 8.8 MILLION (US$12.0 MILLION EQUIVALENT) TO THE REPUBLIC OF DJIBOUTI FOR A €€IV/AIDS, MALARIA AND TUBERCULOSIS CONTROL PROJECT April 30,2003 Human Development Sector Middle East and North Africa Region Page 2 CURRENCY EQUIVALENTS (Exchange Rate Effective April 28,2003) Currency Unit = DJF (Djibouti Franc) DJF 175.0 = US$l.OO US$l.OO = DJF 175.0 ACP ADETIP AFU AIDS APL ARV CAMME CAS CAU CBC CBO CISU CIU CEDES csw DEPCI EA EMP ES FGC FMR GDP GFF GPA HCWMP HIV HSDP IC IDA IEC IGAD IMCI IMF KABP MAP FISCAL YEAR January - December ABBREVIATIONS AND ACRONYMS AIDS Control Program Agence Djiboutienne d 'exkution de travaux d 'intiret publiclSocia1 Fund and Public Works Program Administrative and Financial Unit Acquired Immunodeficiency Syndrome Adjustable Programme Lending Antiretroviral Centrale d 'Achats et de Matkriels EssentielslCentral Pharmaceutical Procurement Agency Country Assistance Strategy Credit Administration Unit Communication for Behavior Change Community-Based Organizations Community Intervention Support Unit Community Intervention Unit Centre de Recherches et d'Etudes pour le De'veloppement de la Santd Center for Research and Studies in Health Commercial Sex Worker Direction d'Etudes, PlaniJication et Coope'ration InternationaleDirectorate of Studies, Planning and Intemational Cooperation Environmental Assessment Environmental Management Plan Executive Secretariat Female Genital Cutting Financial Monitoring Report Gross Domestic Product Global Fund Facility Global Program for AIDS Health Care Waste Management Plan Human Immunodeficiency Virus Health Sector Development Project Interministerial Committee International Development Agency Information, Education and Communication Intergovernmental Authority on Development Integrated Management of Childhood Illnesses Intemational Monetary Fund Knowledge, Attitudes, Beliefs and Practices Multicountry AIDS Program-MAP Page 3 MAP2 MCH MENA M&E MOH MSrU NACP NGO 01 OPEC OPSISPO PAPFAM PHRD PLS PLWHA PMEU PMTCT PNLS POM PPF PVG scu STI TA TB TIC TOR UN UNAIDS UNFPA UNICEF USAID VCT WHO Second Multicountry AIDS Program Maternity Child Health Middle East and North Africa Monitoring and Evaluation Ministry of Health Multisectoral Intervention Unit National AIDS Control Program Non-Governmental Organization Opportunistic Infections Organization of the Petroleum Exporting Countries Organisme de la protection socialelSocia1 Protection Organization Pan-Arab Project for Family Health Policy and Human Resources Development Programme de Lutte contre le SIDAIProgram to control HIV/AIDS People Living with HIVIAIDS Planning, Monitoring and Evaluation Unit Prevention Mother-to-Child Transmission Programme National de Lutte contre le SIDAINational Program to control HIV/AIDS Project Operations Manual Project Preparation Facility Priority Vulnerable Groups Social Communication Unit Sexually Transmitted Infections Technical Assistance Tuberculosis Technical Interministerial Committee Terms of Reference United Nations United Nations AIDS United Nations Population Fund United Nations International Children's Emergency Fund United States Agency for International Development Voluntary Counseling and Testing World Health Organization Vice President: Jean-Louis Sarbib Sector Director: Jacques Baudouy Country Director: Mahmood Ayub Task Team Leader: Michkle Lioy -3- Page 4 Page 5 DJIBOUTI NATIONAL AIDS CONTROL PROJECT CONTENTS page 2 2 2 4 4 4 8 10 10 15 15 16 18 18 19 20 22 22 22 22 23 23 23 27 28 29 29 29 30 31 31 31 31 31 31 A. Project Development Objectives ................................................................ 1. Project development objective, ................................................................ 2. Key performance indicators.. .................................................................. B. Strategic Context ................................................................................... 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project.. .... 2. Main sector issues and government strategy., ............................................... 3. Sector issues to be addressed by the project and strategic choices.. ...................... C. Project Description Summary .................................................................... 1. Project components, ............................................................................. 2. Key policy and institutional reforms supported by the project.. .......................... 3. Benefits and target population.. ................................................................ 4. Institutional and implementation arrangements. ............................................ D. Project Rationale .................................................................................... 1. Project alternatives considered and reasons for rejection.. ................................. 2. Major related projects financed by the Bank and other development agencies.. ....... 3. Lessons learned and reflected in the project design.. ....................................... 4. Indications of Recipient commitment and 5. Value added of Bank support in this project.. ............................................... ownership. ....................................... E. Summary Project Analysis ........................................................................ 1. Economic.. ........................................................................................ 2. Financial.. ........................................................................................ 3. Technical.. ........................................................................................ 4. Institutional.. ..................................................................................... 5. Environmental.. .................................................................................. 6. Social.. ............................................................................................ 7. Safeguards Policies. ............................................................................. F. Sustainability and Risks ........................................................................... 2. Critical risks.. .................................................................................... 3. Possible controversial aspects. ................................................................. 1. Sustainability .................................................................................... G. Main Conditions.. .................................................................................. 1. Effectiveness Condition. ........................................................................ 2. Other.. .............................................................................................. H. Readiness for Implementation.. ................................................................. I. Compliance with Bank Policies.. ................................................................. -4- Page 6 Annexes Annex 1 . Annex 2 . Annex 3 . Annex 4 . Annex 5 . Annex 6 . Annex 7 . Annex 8 . Annex 9 . Project Design Summary .................................................................. Detailed Project Description ............................................................... Estimated Project Costs .................................................................... Economic Analysis ......................................................................... Financial Summary. ........................................................................ (A) Procurement Arrangements ........................................................... (B) Financial Management and Disbursement Arrangements ...................... Project Processing Schedule ............................................................... Documents in the Project File ............................................................. Statement of Loans and Credits ........................................................... Annex 10 . Country at a Glance ........................................................................ Annex 1 1 . Supervision Arrangements., .............................................................. Annex 12 . Environmental Management Plan ........................................................ Annex 13 . Social Assessment .......................................................................... 32 36 44 45 65 66 76 86 88 89 91 93 96 107 MWS) Djibouti map IBRD 29358 -5- Page 7 DJIBOUTI HIVIAIDS, Malaria, and Tuberculosis Control Project Project Appraisal Document Middle East and North Africa Region MNSHD Date: April 30,2003 Country Director: Mahmood Ayub Project ID: PO76183 Team Leader: Michkle Lioy Sector Director: Jacques Baudouy Sector(@: Other social services (60%), Health (30%), Central government administration ( 10%) Theme(s): Civic engagement, participation, and community-driven development (P), Gender (P), Fighting communicable diseases (P), Social analysis and monitoring (S) Lending Instrument: Specific Investment Loan (SIL) Project Financing Data [ ]Loan [ ] Credit [XI Grant [ ]Guarantee [ ]Other: For Loans/Credits/Others: Amount (US$m): 12.0 Financing Plan (US$m): 1 Source I Local I Foreign I Total BORROWEIURECPIENT 0.72 0.00 0.72 IDA GRANT FOR HIV/AIDS 8.60 3.40 12.00 FRANCE: MINISTRY OF FOREIGN 0.40 0.95 1.35 AFFAIRS (MOFA) UN CHILDREN'S FUND 0.10 0.20 0.30 UN DEVELOPMENT PROGRAM 0.08 0.20 0.28 UN FUND FOR POPULATION 0.02 0.08 0.10 ACTIVITIES WORLD HEALTH ORGANIZATION 0.05 0.20 0.25 Total: 9.97 5.03 15.00 Borrower/Recipient: REPUBLIC OF DJIBOUTI Responsible agency: HIV/AIDS, Malaria and Tuberculosis Control Interministerial Committee Address: Executive Secretariat, Centre Yonis Toussaint, Djibouti-Ville, Djibouti Contact Person: Mr. Omar Ali, Executive Secretary, Mr. Ali Sillaye Abdallah, Directeur des Projets santk Tel: 253.35.08.43 or 81.59.09 Fax: 253.35.21.38 Email: sillav fr@vahoo.fr; omarali @voila.fr Istimated Disbursements (Bank FY/US$m): FY 2004 2005 2006 2007 2008 Annual 1.50 2.90 3.30 2.30 2.00 Cumulative 1.50 4.40 7.70 10.00 12.00 Project implementation period: 09/15/2003 to 03/3 1/08 Expected effectiveness date: 09/30/2003 Expected closing date: 09/30/08 OCS PAD Fwm RBY. March. 2ooo Page 8 A. Project Development Objectives 1. Project development objectives: (see Annex 1) In accordance with the main goal of the Second Multicountry HIV/AIDS program (MAP2), the overall project objectives are to assist the Government of Djibouti in setting up and implementing a response against HIV/AIDS, sexually transmitted infections (STIs), malaria and tuberculosis (TB), of which the latter two are important risk cofactors. Djibouti meets the criteria for MAP2 eligibility; only the key features highlighted below are relevant to the HIV/AIDS epidemic in Djibouti and the Djibouti HIV/AIDS, Malaria and Tuberculosis Control Project. The proposed project will support the three National Strategic Plans to control HIV/AIDS, malaria, and tuberculosis (Plan stratdgique national de prdvention du VIHNDA, Plan stratdgique national de lutte contre le Paludisme, et Plan stratdgique national de lutte contre la Tuberculose) for the period 2003-2008. The development objective of the project is to contribute to the change in behavior of the Djiboutian population in order to contain or reduce the spread of the HIV/AIDS epidemic, to mitigate its impact on infected and affected persons, and to contribute to the control of malaria and tuberculosis. It will do so through a multisector approach: (i) preventing the spread of HIV/AIDS by reducing transmission, in particular among high-risk groups; (ii) expanding access to treatment of opportunistic illnesses, malaria, and tuberculosis, and providing care, support, and treatment to People Living with HIV/AIDS (PLWHA) in Djibouti; and (iii) supporting multisectoral, civil society, and community initiatives for HIV/AIDS prevention and care, and malaria and tuberculosis prevention. In the context of the above-mentioned strategic plans, the project will support and promote civil society and community initiatives, for prevention and care of HIV/AIDS, malaria, and tuberculosis developed by beneficiary groups selected on the basis of the technical quality, cost-effectiveness, and likely impact of their proposals. 2. Key performance indicators: (see Annex 1) With regard to HIV/AIDS, studies have been carried out to provide baseline data on the general population and on some specific groups. Given the nature of the HIV/AIDS epidemic and the experience gained from other countries, it is expected that the impact of project-supported activities, within the five-year implementation period, would be difficult to assess in terms of the reduction of HIV/AIDS prevalence in the overall population, or increased life expectancy. Measurable impact can be expected, however, among key target groups which will be reflected in the outcome indicators. A more extensive list of indicators is provided in Annex 1. In addition, some interim output/process indicators have been identified to assess early progress so that modifications to project design become a normal part of the implementatiodsupervision process (see Annex 1). Outcome indicators By project end: o Fifty percent of persons in high-risk groups (persons in uniform, commercial sex workers (CSW), and dockers) will have used a condom during their last non-union sexual encounter (present rate of use is 20 percent); Ninety percent of the population of Djibouti aged 15-49 will be able to identify at least three methods of protection against HIV/AIDS (at present 53 percent); Fifty percent of women attending prenatal consultations in centers offering Voluntary Counseling and Testing (VCT) will accept voluntary testing for HIV (at present voluntary testing has only just started being offered to pregnant women in end March 2003); HIV prevalence among pregnant women aged between 15-24 will be decreased from 2.7 percent to 2.0 percent; o o o -2- Page 9 o o o o STI prevalence rate among pregnant women decreased by 25 percent (baseline survey will be carried out in September 2003 in the sentinel sites); Rate of “lost cases” of tuberculosis will be reduced from 24 percent to 15 percent nationally; Hospital mortality due to malaria will be reduced by 50 percent (baseline data will be based on the National Malaria Program Report for 2002); and At least 15,000 households will be using impregnated bednets. Output/process indicators o By December 3 1, 2004, five of the eleven ministries represented in the Interministerial Committee, by December 3 1, 2006, eight of the ministries, and by the completion of the project, all eleven ministries, will be implementing the agreed HIV/AIDS action plan; By completion of the project, 12 of the 14 centers which currently provide prenatal consultations will be providing VCT services for HIV; By completion of the project, at least 2000 People Living with HIV/AIDS (PLWHAs) will be using counseling, testing, care and treatment services (in hospital andor on an ambulatory basis) delivered in accordance with established national protocols; By December 31, 2005 and by December 31, 2007, disbursement for community interventions will reach at least 50 percent and 85 percent of budgeted levels for these interventions, respectively; By completion of the project, 85 percent of the population of the vulnerable groups (commercial sex workers, dockers, youth, persons in uniform) will have been reached through Information, Education, and Communication (IEC)/Communication for Behavior Change (CBC) programs on HIV/AIDS; By completion of the project, 60 percent of households including declared infected persons who are under treatment, will be receiving socio-economic aid (social package); By December 3 1, 2004, at least five sentinel sites for the epidemiological surveillance of HIV/AIDS will be functional, and will remain so until the completion of the project; By December 3 1,2005, the services of tuberculosis screening, treatment and follow-up of cases, will be established in five centers at the periphery and these services will remain functional until the completion of the project; and By completion of the project, at least 20 community subprojects will include malaria- control aspects (Le., biological larva control and promotion and use of impregnated bednets, etc.). o o o o o o o o A Monitoring and Evaluation Plan which was developed using a participative approach, was reviewed and found to be satisfactory. Monitoring and Evaluation (M&E) will be subcontracted, and the Executive Secretariat (ES) will be the contractor’s counterpart. The ES will be responsible for following up with the different entities to ensure that data are collected on a regular basis and that they are available when analysis is scheduled. As specified in the M&E Plan, some data will be analyzed on a quarterly basis and others less frequently. The Terms of reference (TOR) of the long-term M&E consultant include capacity building and howledge transfer to strengthen and sustain the M&E system. Moreover, the firm, expected to start shortly after effectiveness, will assist the ES and its partners in strengthening the mechanisms for data collection and identifying the information that each partner will need to collect. Following an assessment during project implementation, a Planning, Monitoring and Evaluation Unit (PMEU) may be created if the ES cannot assume the role of counterpart to the contractor because of the workload generated by the project. -3- Page 10 B. Strategic Contextl. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1) Document number: 21414-DJI The project supports the third CAS objective of improving human development indicators by raising school enrollment, improving access to health services, and containing the spread of infectious diseases such as HIV/AIDS and TB, as well as improving access of the poor to basic services and to economic opportunities and targeting assistance to the most vulnerable. In particular, the project will address the issue of containing the spread of infectious diseases. By supporting services for the treatment of STIs, malaria, tuberculosis, opportunistic diseases, and, to a limited extent, AIDS through the pilot project on the use of ARVs (included in the Public Health Sector Response Component), the project will increase access to basic health services and to treatment of infectious diseases. Through its community intervention response and its information activities, the project will provide socio-economic assistance and referral information (promotion of available services) to the most vulnerable groups. Date of latest CAS discussion: 12/19/2000 2. Main sector issues and government strategy: Despite its relatively high nominal per capita income of US$780 (compared to an average of US$5 10 for Sub-Saharan Africa, US$320 for Yemen, and US$1 10 for Ethiopia), Djibouti has one of the poorest sets of social indicators in the world. Gross primary school enrollment is less than half the average for Africa (39 percent of the school-age population, compared to 78 percent for Sub-Saharan Africa). Health indicators are below regional averages. Approximately 33 percent of the population lacks access to potable water; sanitary conditions are often very precarious; and many are very poor. The incidence of infectious diseases such as HN/AIDS, malaria, and TB is high and rising. Nationwide, the HN/AIDS sero-prevalence rate is estimated at 3.0 percent for the whole population (3.1 percent for women and 2.9 percent for men), which is lower than expected. However, analysis of the data by age groups shows a prevalence higher than 5 percent among persons aged 20-35, indicating that early on HIV infects the economically productive and sexually active persons. Malaria has only been a problem in Djibouti since the late 1980s. Before 1973, when there was little urbanization, no irrigation, and an active attempt to control the vector during the rainy season, more than 80 percent of the notified cases migrated from neighboring countries. From 1973 to 1987, more Djiboutian cases appeared along the main transport axes linking Djibouti to neighboring countries, and after 1987 cases appeared in the urban areas. During this period, thousands of refugees resettled in Djibouti. Since 1988, the spread of malaria has increased steadily, reaching areas such as the northern districts of Tajourah and Obock where it was previously inexistent. Uncontrolled urbanization with inappropriate water supply, nonexistent wastewater evacuation system, settlement of nomad population in rural areas, increased irrigated areas, and frequent inundations contributed to the endemicity of malaria. Pro- active interventions are needed to prevent malaria from becoming more prevalent. With 588 cases of TB per 100,000 inhabitants, Djibouti has the second highest rate of TB in the world, after Swaziland. However, about 40 percent of the cases come fkom neighboring countries, in particular from Ethiopia, which inflates the rate. Foreigners come to Djibouti because it offers more and better-quality services (and free of charge). Nevertheless, TB patients are present in Djibouti and can infect people around them. As in other countries the link between HN and TB is apparent. Although the sero-prevalence rate in the general population is less than 3 percent, it is 23 percent among TB patients. In the last few years, two main factors contributed to the weakening of the national program. Although it remains one of the best in the region with 72 percent therapeutic success (treatment completed and patients cured) in 2000, an acute lack of personnel and the departure of the French Cooperation, which ceased all assistance (financial and technical) in June 2002, makes it difficult to maintain past performance levels. Over the next -4- Page 11 personnel and the departure of the French Cooperation, which ceased all assistance (financial and technical) in June 2002, makes it difficult to maintain past performance levels. Over the next three years, drugs are being supplied through the Global Fund Facility. The World Health Organization (WHO), and to a lesser extent, the Government of Djibouti (10 percent of the budgeted US$150,000) provide some financial assistance, but the prograq remains in increasing need of financial assistance. Infant mortality is 106 per thousand live births, compared to an average of 92 for Sub-Saharan Africa, 45 for the Middle East and North Africa, and 82 for Yemen. High maternal mortality (740 per 100,000 live births) can be largely attributed to high fertility rates, anemia caused by malnutrition, and poor health care facilities saturated with patients from neighboring Ethiopia and Somalia. Free health care contributes to the influx of patient-refugees seeking treatment in Djibouti, in particular for TB. Although the country spends about 7 percent of GDP on health, well above the regional average of 5 percent, service delivery is very poor. External assistance, notably from France, Italy, and Spain, accounts for 30 percent of health care expenditures; but external assistance has declined, putting additional pressure on an overtaxed and inefficient system. Indicators Life expectancy at birth HIVIAIDS infection among adults Infant mortality (per I, 000 live births) Unemployment Gross primary enrollment Male Female Mortality at delivery (per 100,000) Djibouti (percent) Sub-Saharan Africa 50 3.9 106 45 39 44 32 740 - 810 50 8 92 78 85 HIVIAID S . The first AIDS cases were reported in Djibouti in 1986. Since then the situation has been worsening steadily: at the end of 2000, there were 2,179 registered AIDS cases. Between 1994 and 2000 several surveys, including pregnant women and blood donors, showed that prevalence was particularly high in some groups (as early as 1994, it was 55 percent among commercial sex workers (CSWs), 24 percent among women working in bars, and 22.2 percent among STI patients; but information for the general population was discordant, varying from 4 to 6 percent in 1995 to 1.9 percent in 2000. However, none were as high as the 1999 UNAIDS estimate among Djiboutian adults aged 15-49 (1 1.9 percent). As the strategy was not to be the same if the rate was inferior or superior to 5 percent, it was decided to carry out a sero-prevalence survey during the preparation of the project. As mentioned above, the rate was found to be 2.9 percent following the results of the survey, and is still low. It should be underlined that the rate is more than 5 percent among persons aged 20-35, which confirms that the rate is on the increase, and that the critical threshold of 5 percent, (when the infection reaches the exponential growth rate), affects the most sexually active and economically productive age group. This situation is cause for concern and calls for a multisectoral response along with the full recognition of HIV/AIDS as a developmental issue. -5- Page 12 The analysis of the AIDS cases reported in 1998 and 1999 indicates that: 0 0 The transmission is mostly heterosexual (95.6 percent of declared cases among women and 91.6 percent among men). Persons aged 15-29 represent 47.4 percent of registered AIDS cases, which shows that people are infected at an early age and was confirmed by studies carried out in 2002. Women are infected at a younger age than men: women aged 15-29 represent 54.3 percent of declared cases, while men of the same age group represent only 42.7 percent. Risk factor specific to Djibouti Trade: Djibouti is a highly urbanized state (more than 80 percent of the population lives in urban areas) with economic activity centered around the port, which serves the Hom of Africa and services the French military bases. In addition, about a thousand transport trucks enter in and out of Djibouti's port on a daily basis to supply Ethiopia's needs (a country about 100 times larger in population according to the World Development Social Indicators Database). The prevalence rate of HIV/AIDS in the adult population of Ethiopia is 11 percent (end 1999). Djibouti is therefore highly susceptible to the spread of HIVIAIDS through the transport sector, and the disease is likely to spread to the whole subregion along the truck routes. In addition, taking into account that the city of Djibouti is a gravitational center for trade as well as the location of French military bases, prostitution is highly prevalent. Another factor contributing to the spread of the epidemic, STIs are frequent, with the number of infections being estimated at 25,000 per year. The population is young, and the age for first sexual contact is precocious. Finally, condoms are not readily available and are expensive. Migration: The situation is further complicated by the large influx of refugees and displaced persons. Cooperation with neighbors, such as Ethiopia, Somalia, and Eritrea, in assessing prevalence rates, in providing voluntary testing and counseling, in formulating consistent behavioral change communication messages, and in treating TB, is a strategic option that Djibouti and its neighbors need to explore to mutual benefit. This could be done through the Hom of Africa Regional HIV/AIDS project, which is being developed in the context of the MAP2, possibly in partnership with the Intergovernmental Authority on Development (IGAD), a regional development organization comprising seven countries (Djibouti, Ethiopia, Kenya, Somalia, Sudan, and Uganda) based in Djibouti. Such discussions could also be carried out through NGOs functioning inter-regionally, such as Save the Children, a US-NGO financed by USAID-Ethiopia that has carried out a Knowledge, Attitudes, Beliefs, and Practices (KAl3P) survey on the DjiboutiIAddis Ababa corridor. Gender Inequality: Women are the most vulnerable segment of the Djiboutian society. Economically, women have low participation rates, and low levels of education. (In the 20-29 age range, 60 percent of women, compared to 30 percent of men, have never attended school.) In terms of health, matemal mortality is 740 per 100,000 births (according to estimates of the Safe Motherhood project financed by UNFPA), one of the highest rates in the world. This is due to high fertility rates, anemia caused by malnutrition, and the widespread practice of female genital cutting (FGC). About 99 percent of women have been subjected to FGC (mostly infibulation, i.e., the most extreme type of female genital cutting), which tends to lead to other health problems. A law prohibiting the practice was adopted in 1995, but the private nature of the procedure makes it difficult to enforce. UNICEF, the Ministry of Health, CARITAS (a Catholic charity NGO), and UNFPA jointly initiated a project to reduce FGC in 1999. A multi-institutional professional team -6- Page 13 conducted awareness meetings with a number of decision-makers. In addition, sensitization meetings were conducted with religious leaders to address the problem of FGC and to identify ways to limit and/or eradicate it. The project approach, which emphasizes gender as a key issue, is consistent with one of the key levers of IDA's regional strategy. Government response to HIVIAIDS In the early 1990s, some HIV/AIDS prevention activities - mostly IEC activities - took place when financing from the Global Program for AIDS (GPA) was available. However, since the end of the GPA, the National AIDS Control Program (NACP) has been dormant. In 2001, the Government of Djibouti carried out a health sector study that was used to develop the governmentk health sector reform program, as well as a medium-term plan for the sector's development. In the context of this reform program, and in order to respond more equitably to the needs of the population, it was decided to reinvigorate the NACP and the treatment for STIs. In October 2001, the president of the Republic himself endorsed the control of HIV/AIDS when he inaugurated the new NACP and treatment of STIs facility, which energized the control of HIV/AIDS. About a year ago, the HN/AIDS program was reorganized: a new director was nominated; the program moved to newly renovated offices (with the assistance of the French Cooperation); and certain staff were trained in counseling. Some timid awareness campaigns were conducted. Outreach programs remained very limited and mainly involved some newly created NGOs in scattered activities, which were, for the most part, conducted in the context of International AIDS day in December 2001 and 2002. The Ministry of Social Affairs and Promotion of Women is carrying out some HIV/AIDS IEC activities. The Ministry of Defense distributes a certain amount of condoms. During the appraisal of the Health Sector Development Project (HSDP), in May 2002, HIV/AIDS was identified as an emergency situation; and the government, through the president and the minister of Health, who strongly and publicly back the control of HIV/AIDS, subsequently requested IDA's assistance to address the problem. A National HIV/AIDS Strategic plan, using a participative approach, was initiated. The Plan was completed and approved during a consensus seminar in December 2002. The government recently created an Interministerial Committee against HIV/AIDS, malaria and TB (IC), as required in its National HIV/AIDS Strategic Plan, which will have a policy role (see section C4 on institutional arrangements for more details), and a Technical Interministerial Committee (TIC), which will be the technical arm of the IC, to manage the response to HIV/AIDS. These two entities are to be assisted by an Executive Secretariat (ES). The Ministry of Health hired a consulting firm to assist with the preparation of the National HIV/AIDS Strategic Plan. The prevalence surveys carried out during project preparation provide baseline data for the general population, STI patients, military personnel, and CSWs. The prevalence surveys made it possible to identify the Priority Vulnerable Groups (PVG). Also during project preparation, KABP studies were carried out among the general population, school children, military personnel, and dockers in addition to the survey being carried out by Save the Children mentioned above. UNICEF is implementing a Mother-to-Child Transmission (MTCT) pilot program which started at the end of March 2003. The UNAIDS Thematic Group has also been reinvigorated. It has prepared a work plan that made it possible to coordinate activities while the National Strategic Plan was being developed, and the coordinating bodies were being created so as to avoid duplication. During the identification mission, it was decided that all documents and minutes produced by the Thematic Group would be sent to IDA, which is to be considered a "virtuall' member of the Thematic Group, because the World Bank Group does not have a Country Office in Djibouti. In addition, the Thematic Group is informed of all visits planned by the country director or the sector director. The country director and sector director will be informed of the planned Thematic Group meeting dates so that they may participate in the meetings whenever possible in order to raise the level of attention among donors and UN -7- Page 14 agencies. Whenever the IDA mission comes to Djibouti, the Thematic Group organizes meetings; and there is regular communication between the president of the Thematic Group (the UNICEF resident representative) and the team. In light of the creation of the institutional structure for the control of HIV/AIDS, malaria and tuberculosis, the mandate of the National Program for AIDS Control (NPAC) changed. The NPAC has been renamed the Program for AIDS Control (PLS). The PLS of the Ministry of Health (MOH) will limit its coordinating and planning role to the Ministry of Health. A new director has been nominated, and a new organigram for the PLS has been developed. The mandate of the Center Yonis Toussaint has also been redefined. It will be a reference center for ambulatory treatment of STIs and of opportunistic diseases, and later, when the ARV pilot program is put in place, as an Ambulatory Treatment Center for the MOH. New job descriptions are being prepared, and the MOH is planning to staff the Center so that it is completely functional when the project becomes effective. 3. Sector issues to be addressed by the project and strategic choices: The basic issue is how to prevent the spread of HIV/AIDS, malaria and tuberculosis, in a multisectoral manner. With regard to HIVIAIDS, the Multicountry HIV/AIDS Program for the Africa Region (MAP) provides the requisite framework and is the concept upon which is based the Djibouti HIVIAIDS, Malaria and Tuberculosis Control Project. Djibouti is eligible for MAP funding, because it has satisfied the four MAP eligibility criteria, namely: Satisfactory evidence of a strategic approach to HIVIAIDS. Djibouti has the basic ingredients for a strategic approach with which to build upon, including a situation analysis and an HIV/AIDS strategic plan. These have been prepared through a participatory process. A high-level HIV/AIDS coordinating body. The Interministerial Committee (IC) was established under the presidency of the prime minister. The vice president is the minister of Health. In addition to the Ministry of Health, the Interministerial Committee includes eleven ministries: National Education; Economy, Finance and Plan; Interior and Decentralization; Defense; Justice and Penitentiary and Religious Affairs; Ministry of Wakfs and Islamic Affairs; Employment and Solidarity; Equipment and Transport; Communication, Telecommunications and Culture; Women Promotion Social Affairs and Family Welfare; and Youth and Sport. The IC will have the responsibility to set national policies for the control of HIV/AIDS, malaria and tuberculosis, and will stimulate the multisectoral approach. A Technical Intersectoral Committee (TIC) was established, and it includes civil society, as well as representatives of the IC ministries. The TIC will have a technical role, and the responsibility, with the assistance of the ES, to review the annual work plans and budgets and to ensure that they are implemented in accordance with the National Strategic Plan. In addition, the ES will have the responsibility to manage the project (see below, section C4 “Institutional Arrangements”). Government agreement to use appropriate implementation arrangements. The govemment has indicated, in principle, its willingness to accelerate project implementation by channeling funds to communities, civil society, and the private sector. Government agreement to use and fund multiple implementation agencies. The govemment has agreed to progressively expand HIV/AIDS activities to cover a broad range of ministries, districts, and local entities as well as to fund activities undertaken by nongovernmental organizations, community-based organizations, and the private sector. This will be done as capacities are being strengthened and, in some cases, created. -8- Page 15 Other sector issues to be addressed by the project and strategic choices: Weak institutional capacity and limited partnership with civil society. The intensification of the prevention effort and the introduction of care will require significant strengthening and coordination of the concerned institutions, services, and systems, notably: Systems and procedures to channel funds more efficiently and on a large scale to the grassroots level. Developing capacity at the district level through accelerated training of health personnel in the areas of Voluntary Counseling and Testing (VCT) (especially for pregnant women), treatment of opportunistic infections (01) and STIs, and procedures to ensure safe blood supplies and the safe handling of medical waste. Partnerships within the civil society to strengthen and develop local capacity to deliver prevention and care. Monitoring and Evaluation, which will become more complex as a result of greater grassroots involvement. Procurement of drugs, testing kits, and related services to ensure that district services are supplied efficiently and on time. Assessing the feasibility of a social marketing program. Training of multilevel health services. Prevention at the grassroot level. Although there is now broad agreement on prevention as a national priority, much work is still to be done, particularly with regard to: Youth (aged 15-19) must be educated about the means of disease transmission and protection, and encouraged to postpone first sexual contacts. This gropp must be reached in the last years of primary school, before sexual activity begins. Truck drivers and dockers (Ethiopia-Djibouti corridor personnel), who are major carriers and spreaders of the disease. Specific activities need to be set up at all major truck stops and in the port. CSWs and high HIV-prevalence women who work in bars, will be provided with peer education, special STI/HIV prevention measures, and condoms (free and/or at the least possible cost). Persons in uniform need to be informed about prevention and have condoms available at all times. There is a need to decentralize TB screening to treat patients in the districts and periphery near country borders and to avoid a greater influx of TB patients into Djibouti-Ville. This measure should decrease the risk of infection to the Djiboutian population. As mentioned in section B2, malaria in Djibouti is mainly caused by human factors: urbanization and settlement of nomads. It is therefore necessary to involve communities in malaria control in order that they improve their environment, protect themselves, and control the vector. Health sector issues. The current health system needs a significant input of human and financial resources to ensure the provision of services and drugs on a regular basis at the national level. However, many of the issues concerning the health sector are being addressed within the context of the HSDP mentioned above. In February 2002, a Round Table was held in Djibouti-Ville and development partners. Significant financial resources have been pledged in support of the health -9- Page 16 sector, comprising allocations for the control of HIV/AIDS, malaria and tuberculosis. In this context, the HSDP, financed by IDA and effective since November 2002, provides support to the pharmaceutical sector, by establishing a Centrale d'Achats pour les MCdicaments et MatCriels Essentiels (CAMME), to the reproductive health system (including the reduction of female genital cutting), to the Integrated Management of Childhood Illnesses (IMCI) Program, and to training of healthcare personnel. Its specific objectives are to: (i) improve maternal and child health services to deal with the low quality of care and the poor management of healthcare facilities; (ii) address emergency drug needs as well as long-term drug supply to remedy the existing shortage of drugs in health facilities and the current high cost of drugs in the private sector; (iii) support malaria programs given the resurgence of malaria in the country; (iv) support vaccination programs suffering from inadequate resources; (v) increase the capacity to train more para-medics by strengthening the national health training center to provide up-to-date and quality training, and (vi) support the ministry's capacity to monitor health conditions and the progress of the reform program, through the establishment of sound Monitoring and Evaluation procedures. It should be underlined that for the present project to be effective, it is essential that the HSDP be carried out and that services and medical supplies to be provided to the sector be made readily available. There are numerous links between the two projects. The HSDP is presently buying a one-year STI drug supply to be used in the context of the STI subcomponent of the present project, i.e., these drugs will be available when the project becomes effective. In addition, included in the emergency drug procurement, are needed drugs, including drugs for the treatment of 01s and ARV, for the AIDS global treatment pilot project to be put in place when the project becomes effective. Finally, in the pharmaceutical sector, the CAMME will have a critical role to play to ensure that drugs are available on a regular basis for the present project as well as for the HSDP to function. Some malaria-related activities have been included in the HSDP, because they needed immediate financing; but the second-year activities and onward will be financed under the present project once it becomes effective. As mentioned earlier, one of the main goals of the MAP projects is to reinforce capacities. It is expected that the National Training Center, being strengthened under the HSDP, will play a major role in the project's capacity-building activities. The creation of new courses of studies, such as counseling, and the proper use of ARVs, are being envisaged in two to three years once the center is fully functioning. C. Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): The project will support the implementation of Djibouti's HN/AIDS National Strategic Plan, the National Malaria Strategic Plan, and the National Tuberculosis Strategic Plan through a wide variety of public sector agencies, private and non-governmental organizations, and community- based organizations. The project will include four major components as follows: (1) capacity building and policy development; (2) public health sector responses to HNIAIDS, management including prevention, treatment, and care of STIs and TB, and prevention, control and treatment of malaria; (3) multisector response to HIV/AIDS prevention and care; and (4) support to community-based initiatives for the three diseases. These activities will take into account the existing conditions and Djibouti's capacity both at the central and the district levels, recognizing that at present capacity is weak at both levels. Presented below are the main subcomponents of each component (for more details, see Annex 2). Component 1. Capacity Building and Policy Development (total cost US$4.9 million) This component would aim at strengthening Djibouti's capacity to control the spread of HIV/AIDS, malaria and tuberculosis by supporting: (i) the work of the IC, the TIC, and the - 10- Page 17 ES,including project coordination and facilitation; (ii) the updating of the National Strategic Plans (for each of the three diseases) and annual action plans; and (iii) strengthening of public, private, and nongovemmental institutions in preparing and implementing prevention, care, and treatment interventions. Human resources are very limited both in number and in quality. The acute shortage of human resources remains the most important constraint to the success of the project. For instance in the MOH the number of qualified persons is not only limited but most are already engaged in the launching of the HSDP and/or in implementing the ministry’s programs. In order to address this problem, it has been agreed with the government that: (a) some tasks would be contracted out (Monitoring and Evaluation); (b) some Djiboutian experts will be recruited on the basis of a competitive process and hired with one-year contracts renewable on the basis of performance; (c) training will be organized, in particular, for specialized tasks and for NGOs and community- based organizations (CBOs) before they are awarded financing to implement a project; and (d) two long-term international technical assistants (a procurementhmplementation specialist and a social communication expert) and some short-term experts for specialized tasks (for example, training in counseling or development of a condom distribution strategy) will be recruited. All the terms of reference of the technical assistants specify that one of their tasks is to transfer competencies. Each technical assistant (TA) will have an official counterpart named or recruited by the Djiboutian authorities. This component will also include training activities, under contract with local institutions, for the NGOs and governmental institutions responsible for supervising and training local NGOs and CBOs and for the ministries’ PLS unit, local NGOs, and associations implementing activities. Some study tours may be included as part of this training as well as for selected members of the IC, TIC, and ES. Finally, the construction of a reference laboratory at the Peltier General Hospital, and the rehabilitation of the building next to the offices of the AIDS Control Program of the MOH and the Center Yonis Toussaint, will be included in this component. The laboratory equipment is being financed under the HSDP, but the laboratory building itself is presently located in unsafe or temporary buildings that need to be replaced as soon as possible. The rehabilitation work being envisaged will provide space for expanding the role of Yonis Toussaint Center as a reference center for counseling, voluntary testing, and care and treatment of sero-positive persons. It will also provide a space where information is available and where NGOs and associations can meet. This will be one of the centers in the AIDS treatment pilot project included in the public health component (see next section and Annex 2 for more details). Component 2. Public Health Sector Response to HIV/AIDS, STIs, Malaria and Tuberculosis (total cost US$3.8 million) The Ministry of Health (MOH) and more broadly the health community, have special responsibilities for the prevention and management of HIV/AIDS/STIs, malaria, and opportunistic infections (malaria and TB). This sector therefore warrants a separate component, to provide prevention, care, and treatment from a health sector perspective. This component will aim at expanding access to preventive measures such as condoms; to treatment of STIs, OIs, malaria and tuberculosis; and to care, support, and treat People Living with HIV/AIDS (PLWHA) in Djibouti. In addition, a subcomponent’s objective is to increase clinical safety and to ameliorate the treatment of solid medical waste. - 11 - Page 18 Under this component, the project will include: (a) development of Voluntary Counseling and Testing (VCT) protocols as well as a significant role in training counselors and in carrying out VCT activities and follow-up; (b) implementation of syndromic algorithms for diagnosis and case management of STIs; (c) strengthening of the health system for the treatment of HIV/AIDS, STIs, malaria, and OIs, in particular TB; (d) setting up measures to prevent the transmission of the HIV in clinical settings; (e) procurement of condoms and a significant role in their distribution; (f) scaling-up of activities targeting vulnerable/potentially high-transmitter groups in collaboration with other sector partners; (g) support to the decentralization program for TB screening and treatment; (h) strengthening of the detection, prevention, and response to malaria; and (i) financing drugs, test kits, and medical consumables, all of which may be bought from the CAMME once it is established. It was also decided that WHO would enter into a partnership agreement with the ES to supervise some of the above-mentioned activities, which will be discussed in detail with the MOH, the ES, and the government, during the post-appraisal mission of May 2003. The Bank has also been working closely with its UNAIDS partners, drug companies, and developing-country governments on access to ARV therapy. This is an evolving situation that progressively allows for low-cost choices and alternative options. The project intends to support the development of guidelines and the strengthening of health infrastructure to allow ARV therapy drugs to be used in a safe, effective, and sustainable manner. It will assist the MOH, in collaboration with other partners (e.g., the French Cooperation, WHO, and UNICEF) in implementing a one-year pilot project, including the treatment with ARV of sero-positive persons, in the three public health systems of the country (Ministry of Health, Ministry of Defense, and Ministry of EmploymentlOuganisme de Protection Sociale [OPS]). This pilot project will be used to assess the feasibility and cost of extending the treatment program to the whole country. The drugs for the pilot project are being included in the first purchase procured under the HSDP. Moreover, the Government of Djibouti is now eligible to apply to the Global Fund and is preparing a proposal for the next round. It is hoped that in the future, at least part of the drugs for the program can be bought with Global Fund financing. The prevention of mother-to-child transmission (PMTCT) of HIV is not included in the project, because UNICEF is presently establishing a PMTCT pilot program in two Djiboutian health centers (one in a public maternity center and the other in the Maternal Child Health (MCH) Center of OPS). As the pilot program may be scaled up, the project will contribute to the training of counselors and to providing artificial milk for mothers who decide not to breast-feed, as well as psycho-social support. Finally, regarding condoms, a consultant may be recruited either under the PPF or at the outset of the project launch, to develop a condom distribution strategy. Condoms will be provided free of charge to STI patients, but condoms also must be made available outside of the health system as needed (based on the strategy developed). Component 3. Multisector Responses for HIV/AIDS Prevention and Care (total cost US$3.7 million) As has been demonstrated in other countries, and in order for the control of HIV/AIDS to be effective, it is necessary to have a multisectoral approach to better target Priority Vulnerable Groups. Although the multisectoral response is presently very limited, the Ministries of Social Affairs and Women Promotion, and Defense, already carry out some IEC and condom distribution activities. The project will reinforce on-going activities and provide support to the following key ministries outside of the MOH: the ministries of (a) Economy, Finances, and - 12- Page 19 Planning, (b) Youth and Sport, (c) National Education, Women Promotion, (d) Social Affairs and Family Welfare, (e) Defense (army), (0 Employment and National Solidarity, (g) Communication, Telecommunication and Culture, (h) Justice, Penitentiary, and Religious Affairs, (i) Ministry of Wakfs and Islamic Affairs, 6) Interior and Decentralization (police), and (k) Equipment and Transport. This component will provide these ministries with resources and training to improve their capacity to respond to the HIV/AIDS epidemic, emphasizing prevention and care. Most of the above-mentioned ministries are finalizing their action plans, which include performance indicators and define monitoring systems and budgets. The action plans are targeted at line ministry staff and focus on training peer educators on issues of HIV/AIDS and STIs, the importance of condoms in the control of these diseases, including other support mechanisms to encourage a change in behavior. These plans will be integrated into the ministries' ongoing operations. At this point, there are no plans for the project to assist the Ministry of Transport, because Save the Children, financed by USAID/Ethiopia, is providing such support and could also receive additional support through the Regional Project for the Horn of Africa being developed by ActAfrica in the context of the MAP2. The Ministry of Communication will have a special role to play: at the beginning of the project, it will assist the international specialist and the Djiboutian counterpart in communication and in developing a national communication strategy for the control of HN/AIDS, Malaria and Tuberculosis. At this stage, the Ministry of Communication's role in the strategy will be defined. At a later stage, it is expected that the Ministry of Communication will disseminate audio-visual and written materials prepared in the context of the communication strategy. The preparation of these materials will be contracted out. Activities in the ministries will be financed on the basis of an annual work plan and budget. The ministries will receive a first tranche which it will have to justify in order to receive the second tranche. The administrative and financial manager of each ministry, who will manage these funds, will receive training if necessary. Component 4. Support to community-based initiatives (total cost US2.6 million) In order to enlist communities in the control of HIV/AIDS and to provide them with the means to mitigate the impact of the epidemic, it is necessary to provide resources at the local level. The objectives of this component are to: (a) strengthen communities and Djiboutian associations and NGOs so that they can implement essential activities for the reduction of the vulnerability to HIV/AIDS, malaria and tuberculosis; and (b) strengthen institutional capacities of Djiboutian NGOs and associations so that they can deliver essential services needed to the most vulnerable groups. Project support will be provided in such a way as to ensure that community interventions are complementary and in synergy with interventions carried out by governmental services and other potential partners. In order to ensure that this component takes into account Djiboutian realities, a pilot project will be developed, with the assistance of an NGO, to provide nutritional support to PLWHA in Djibouti-Ville and the Hospital Paul Faure (TB Hospital). This will be done during the preparation phase of the project so as to fine tune the mechanisms of interventions and define an acceptable and reasonably priced social package (which could also include assistance for disabled HN/AIDS persons). Essential activities identified for community interventions can be classified in three categories: (i) prevention of HIV, malaria, and tuberculosis transmission; (ii) reduction of the impact of HIV/AIDS (including psycho-medico-social support and care to PLWHA and their families; social/economic support, including food, to PLWHA and their families; and income-generating activities for the families of PLWHA); and (iii) legal support (see Annex 2 for more details on activities). - 13 - Page 20 In order to implement the above activities, it will be necessary for the project to finance support activities to strengthen the institutional capacities of the Djiboutian NGOs. In order to do so, NGO personnel will be trained in the following areas: (a) management and development of social projects; (b) basic information on HIV/AIDS, malaria and tuberculosis; (c) analysis of vulnerability and identification of appropriate solutions; (d) quality control for activities being financed at the community level; (e) mobilization and promotion of community participation; and (0 supervision and evaluation of services. The modalities of this training would require prior government approval. However, there are options for training to be contracted out either to local institutions, or based on government approval, to the UNDP in the context of their 2003-2006 program, (through cost-sharing or other arrangements). The need for training and supervision of local NGOs and associations was assessed during the development of the HIV/AIDS National Strategic Plan. Support to local NGOs and associations will be provided by the governmental and non-governmental institutions responsible for training and supervision (called NGO Supporting Organizations). The preparation team is conscious of the fact that even the capacities of these organizations will need to be strengthened. At the end of the training, an evaluation will identify the best 5 to 10 organizations, taking into account the criteria defined during a consensus workshop on training and supervision. During project preparation, the ES will prepare the Procedures Manual for Community Interventions. It will be finalized through a consensus workshop organized in collaboration with the UN agencies and attended by all ministries that are involved in the control of HN/AIDS, civil society, and other partners. The consultant being recruited under the HSDP to prepare the project Procedures Manual will be requested to prepare the Project Operations Manual (POM) (the Procedures Manual for Community Interventions has been prepared and needs fine tuning), on the basis of the model elaborated by the ActAfrica team (to be financed under the PPF). With regard to the identification of local projects for community interventions for the first year of the project, it will be done in a realistic manner. It will prioritize learning and the development of capacities of the personnel involved as well as quality control. Coverage will be gradually increased. On the basis of the response analysis carried out in 2002, it was agreed that about 30 community projects will be developed for 2004. These projects will be implemented by 25-30 local NGOs and associations assisted by 5-10 supporting organizations and by the ministry dealing with the same vulnerable groups and the Community Intervention Support Unit (CISU) of the ES. The preparation and selection process of community subprojects to be financed under the project will be an annual process carried out in each district (or neighborhood) under the auspices of the regional HIV/AIDS Councils. The subprojects will be identified and selected takmg into account the essential activities necessary to reduce the vulnerability of priority groups in each district of the country and neighborhood of Djibouti-Ville as well as governmental interventions identified in the sectoral plans. The implementation of these subprojects will be monitored and supervised at the central level by the CISU in close collaboration with the person responsible for sectoral response in the ES and at the regional level with the supporting organizations, the HIV/AIDS regional committees, and the M&E consultant, who will be contracted out. The modalities of these arrangements are defined in the M&E Plan. Community project and supporting organizations’ contract financing will be carried out by the CISU in agreement with the Procedures Manual for Community Intervention, which will need to be finalized prior to project effectiveness. The mechanisms to channel funds from the CISU to communities was agreed upon during the appraisal mission. The selection - 14- Page 21 process of the projects will be carried out by an independent committee, civil society, and donor representatives. The selection modalities will be stipulated in the Procedure Manual for Community Interventions. Indicative Percent Bank Percent Component costs of Financing of Bank- (US$M) Total (US$M) Financing Capacity Building and Policy Development 4.9** 33% 4.6 38%"" Public Health Sector Response to HIV/AIDS/IST, malaria and tuberculosis 3.8 25% 2.3 19% Multi-sector Responses for HN/AIDS Prevention and Care 3.7 25% 2.6 22% Support to community-based initiatives 2.6 17% 2.5 21% Total Project Costs 15.0 100.0 12.0 100.0 Total Financing Required 15.0 100.0 12.0 100.0 ** The cost of this component is high, because it includes civil works and two long-term technical assistants, a procurement specialist for 5 years and a social communication specialist for two years. 2. Key policy and institutional reforms supported by the project: The project is not designed to support policy reform in any sector. The Project will assist in carrying out the comprehensive National Strategic Plans (HIV/AIDS, malaria, and tuberculosis) that will bring together, in a coordinated manner, various initiatives. By supporting the IC in the prime minister's office, the TIC, and the ES, it will encourage deepening recognition that HIV/AIDS, in particular, is a multisectoral, development issue, and that the highest levels of government, with an enhanced inter-ministerial coordination, have taken the lead. In addition, the project will build up the capacity of line ministries and of local communities and allow them to address their developmental challenges, including HIV/AIDS, malaria and tuberculosis. To prepare and implement projects, the capacity of local communities, associations, NGOs, and more generally civil-society organizations will be enhanced. 3. Benefits and target population: Economic Bene$&: Preliminary analysis of potential macroeconomic impacts of the epidemic in Djibouti suggest that, in the absence of policy interventions, the HIV/AIDS epidemic will continue to spread rapidly, with devastating consequences on the size and composition of the labor force, productivity, health expenditures, and growth. It is estimated that the GDP growth rate would be reduced on average by 1.6 percent per year and that HIV/AIDS-related expenditures could surpass 5 percent of GDP, even under conservative assumptions about access to treatment. Through cost-effective interventions and strong community participation, the project is expected to reduce these costs. It is expected that the project will help reduce the number and frequency of sick-days and that, by increasing the use of community-based programs, the project would also help reduce the unit costs of caring for HIV/AIDS patients. Cost savings are expected from the decrease in future needs for treatment, care, and support. Social Benefits: The entire population will benefit from the project. Care will be taken during project implementation that communities are not left behind, and, on the other hand, that high- powered groups do not receive disproportionate support from the project. As specified in the HIV/AIDS National Strategic Plan, some interventions will be targeted to those who are vulnerable to AIDS such as pregnant women, commercial sex workers, persons in uniform, and the young in general and orphans of HIV/AIDS in particular. Because of Djibouti's position as a - 15 - Page 22 transport hub, truck drivers and others passing through the port and the Djibouti/Addis corridor would be targeted by specific interventions to help reduce the spread of the disease. Project interventions targeted to widows, women, persons in uniform, and transporters will mitigate the economic and social impact of HIV/AIDS. It will strengthen the capacity of local communities to provide support to groups affected by HIV/AIDS. It will promote the establishment of a social support system, such as counseling services, support groups for patients and their families or caregivers, which should help reduce the economic and social burden on the affected families (i.e., assisting orphans through education, providing support to community clinics, assisting in revenue-generating activities, etc.). It will streamline the procedures for transferring resources to local communities. Institutional Benefits: Capacity building of key stakeholders including community groups to coordinate, manage, and implement the proposed interventions. Development of an improved national system for monitoring HIV/AIDS that would exchange information with subregional information systems such as those in Ethiopia and Eritrea. Health Benefits: The project will contribute to lowering Djibouti's burden of diseases due to infections such as STIs, malaria and tuberculosis through targeting these and other 01s. Early disease detection and interventions should help reduce transmission. The risk of an even higher child mortality rate will be lowered by reducing the number of HIV-infected newborns. 4. Institutional and implementation arrangements: The implementation arrangements of the project will follow general MAP guidelines, with the establishment of an IC under the auspices of the prime minister, and a TIC to be assisted by an ES. This was deemed as the most appropriate mechanism for implementing the project given the multisectoral nature of the activities being proposed, and the coordination efforts needed to ensure efficient use of funds and impact of project activities. The IC is chaired by the prime minister, with the vice-presidency held by the Minister of Health. The IC serves as the policy focal point and will be made up of representatives from sectoral ministries. The IC will have responsibility for coordinating the implementation of the National Strategic Plans (HIV/AIDS, malaria, and tuberculosis), increasing awareness and mobilizing civil society in the promotion of prevention measures regarding HIV infection, malaria and tuberculosis, and providing guidance to the project. The IC will meet at least twice a year. The TIC is the technical arm of the IC and will oversee the preparation of annual action plans and budgets and the implementation of the project activities. The TIC will have responsibility for ensuring that the integration of activities (HIV/AIDS, malaria and tuberculosis) are executed in the public, para-public, and private sectors to promote the multisectoral impact of the actions being carried out, and will validate and supervise the execution of the multisectoral action plans and associated budgets through its executing arm, the ES. The TIC will meet at least four times a year and will have representatives from the concerned ministries, civil society, and the private sector. The TIC will need to coordinate closely its efforts with the UNAIDS Thematic Group. Project funds will be budgeted in the prime minister's office and delegated to the ES, which will be responsible for day-to-day implementation of the three National Strategic Plans (HIV/AIDS, malaria, and tuberculosis). To do so, the ES will be comprised of about ten full time professionals (including two international technical assistants); it will include an Administrative and Financial Unit (AFU), a Multisectoral Unit, a Community Intervention Support Unit (CISU), and a Social Communication Unit (SCU). In addition, if necessary, a Planning, Monitoring and Evaluation Unit (PMEU) will be created. At the beginning of the project, these tasks will be contracted out under the supervision of the ES. The technical assistance will include a specialist in procurement and project implementation for five years and a social communication specialist who will be hired to transfer competencies to the staff of the ES. The ES will be responsible for - 16- Page 23 project execution, coordination, follow-up, and monitoring of project interventions. The ES will coordinate the activities of the proposed action plans presented by the MOH (through the Public Hygiene Prevention Department), ministerial focal points, and the communities. The ES will also need to closely liaise with the MOH's Planning Unit, the Direction of Primary Health Care, as well as other national technical experts, who may be called upon to provide assistance, either as TAs or as specialist trainers. The ES will also need to collaborate with the Regional Counsels, who should be in place once the decentralization efforts take place early in 2003. The ES will prepare all documentation for the TIC (meeting documents, minutes, progress reports on the national program, inter-ministerial project activities, and community interventions) and the IC. It is expected that the relationship between the new structure (IC, TIC, and ES) and the MOH will be satisfactory for the following reasons: (a) the MOH has been the architect of the new structure and has defended it so that it could be ratified; (b) the Minister of Health is the vice president of the IC; (c) the president of the TIC is the General Secretary of the MOH; and (d) the Executive Secretary has been selected among the key health civil servants. The organization still designates an important role to the MOH, which is closely involved in the new structure. The different stakeholders will need to prepare annual action plans with associated estimated budgets. These action plans will be submitted to the ES who will need to ascertain whether the plans match the actions to be undertaken under the National Strategic Plans. The CrU will play a particular role within the ES to ensure that the activities submitted by the communities respond to the targeted populations, and fall within the predefined criteria established in the POM. The selection of community subprojects will be handled out by a tripartite committee (government, donors, and civil society). Given the shortage of existing capacity in the country, and the complexity of the project that requires in-depth follow-up, the responsibilities under the PMEU for M&E will be subcontracted out, and part of the civil works activities may be subcontracted out to the Agence Djiboutienne &Execution de Travaux d'IntCr&t Public (ADETP) pending an assessment of their capacity to undertake this type of civil works management. In addition, as mentioned above, two long-term technical advisors will be hired to assist with procurement and social communication. Finally, a partnership with WHO has been agreed upon and other partnerships are envisaged with other UN agencies as well as the French Cooperation, which are present in the field and may be able to assist in supervision of activities. Until such time as the above arrangements are running and functional, the Credit Administration Unit (CAU) of the MOH will be responsible for project activities in the "transition" phase, and with oversight and executive responsibility for the project's Project Preparation Facility (PPF). The financial management and procurement capacities of the CAU were partially evaluated during the appraisal mission and were found to be satisfactory. Partnership. Project preparation has been carried out in close collaboration with UN agencies, in particular those represented in the UNAJDS Thematic Group, the bilateral donors, and the NGOs. Interventions to be financed by the project have been selected after discussion of the National Strategic Plans with the various partners. As mentioned above in the section C4 on 'Institutional Arrangements', it will be the role the TIC and the ES to coordinate donor interventions and ensure that they are in agreement with the objectives of the strategic plans as well as complementary. In addition, PPF funds were used to contribute to the financing of the PAPFAM study, which will provide baseline data needed for the M&E of the HIV/AIDS activities, being carried out by the UNFPA. During project implementation, it is envisaged to continue this close collaboration (see above on institutional arrangements for supervision). These partnerships (including WHO), would make it possible for them to participate in specific areas, and allow the Bank to delegate certain aspects of program supervision thereby fi-eeing up supervision funds. - 17- Page 24 However, these partnerships still need to be discussed in detail with the ES and the MOH. This could be undertaken during the post-appraisal mission, and in particular, at the time of the donor’s conference that the Djiboutian authorities will organize in mid-May 2003. If the Global Fund proposal results in additional resources for Djibouti, it may free up some project funds which could be reallocated to other needs and which could not be included at the time of preparation. If the funds were to be allocated to HIV/AIDS, they could contribute to increasing the number of persons treated with ARVs after the end of the pilot project. D. Project Rationale 1. Project alternatives considered and reasons for rejection: Originally, a small-scale component on HIV/AIDS and related diseases was considered under the proposed Health Sector Development Project (HSDP). However, given the magnitude of the problem, the inter-linkages with other country HIV/AIDS programs (namely Ethiopia and Eritrea at this time), and the cross-sectoral dimension needed to combat the pandemic, the proposal was rejected in favor of a stand-alone project. It is also to be noted that the HSDP will focus primarily on restructuring the health system as a whole and improving the state of the current health system. All of this leads to a very large intervention, where the focus on HIV/AIDS may be lost. IDA considered and discussed whether it would be feasible to include the Djibouti HIV/AIDS project in a regional funding program; it was rejected as the surrounding countries have already launched their own program at this stage. In addition, it made more sense in a stand-alone project to include a M&E system that could be linked to a wider regional database in the future. Another alternative was to limit the project to HIV/AIDS. However, there is a high prevalence of TB in Djibouti, in part because many people from neighboring countries come to Djibouti to be treated. Their presence on Djiboutian soil can infect others. The National Tuberculosis Program received assistance (financial and technical) fi-om the French Cooperation until June 2002. Since then it has received financing from the Global Drug Facility funds, which covers TB drugs for three years; but the program does not receive much additional support. Because TB and AIDS are linked, it was decided that support to the TB program should be included in the present project. With regard to the National Malaria Program, the program will receive support under the- HSDP project for the first year, namely treatment and prophylaxis to fill in the gap until the present project is effective. Given that malaria in Djibouti is largely man-made, i.e., poor sanitation in growing urban areas and settlement of nomads who build ponds and cultivate irrigated areas, it is necessary to develop a large community education program in order to reduce larva habitat, to work with community to enforce vector control measures, and to encourage them to use impregnated bed-nets. Because of this community dimension to malaria control, it was decided that it would be more appropriate to include support to the National Malaria Control in the present project, as it has a large community-intervention component. It is expected that these prevention measures would be quite cost-effective, as they could significantly reduce morbidity and mortality rates due to malaria. At the beginning of project preparation, it was decided that procurement would be subcontracted. However, after preliminary examination, it became apparent that it would be difficult and very expensive to contract out procurement to a firm; because Djibouti is situated primarily in an Anglophone region (language being the main barrier), and there are no firms with the necessary expertise in Djibouti. It was then decided that a long-term technical assistant, who was a specialist in procurement and project implementation, might be better suited to assist with this task provided that (a) she would have a Djiboutian counterpart; and (b) it be specified in the terms of reference that transfer of competencies and capacity building would be a large part of herhis duty and would weigh heavily on the annual performance review of hidher assistance. - 18- Page 25 Finally, the consultant could play the role of “facilitator” and assist with the launching of project activities. The project team was guided by the work done under the first phase of the Multicountry HIV/AIDS Program for the Africa Region (MAP) and the lessons learnt from those projects and contained in the Memorandum and Recommendation of the President for MAP2 (Report No. P 7497 AFR of December 20, 2001). In addition, the team drew upon field experience from other African countries (particularly Senegal and Chad) to ensure that the program would be truly multisectoral and would focus heavily on the empowennent of communities in the control of HIV/AIDS. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing, and planned). Although it is not included in the list below, because the financing has not yet been granted, it should be mentioned that Djibouti applied to the Global Fund against HIV/AIDS, malaria and tuberculosis in support of the programs for malaria and tuberculosis. When it applied, it was not yet eligible to apply for HIVIAIDS, because its National Strategic Plan had not yet been completed. Sector Issue Ban k-financed Integrated Health Sector Investment Project Small health sector infrastructure rehabilitation Health Education Other development agencies UNICEF with UNAIDS Financing UNFPA BAD BAD French Cooperation French Cooperation Global Drug Facility Spain French Cooperation UNICEF French Cooperation Islamic Development Bank (commitment at donor meeting) Saudi Fund for Development (commitment at donor meeting) African Development Bank Project Health Sector Development Project Public worksISocia1 Development (ADETIP) School Access and Improvement - APL Prevention of Mother-to-Child Transmission of HIVIAIDS Reproductive HealthiSafe Mother Pilot Project Social Funds and Microfinance Promotion of Women Pharmaceutical Sector reform Training of Health Professionals Drugs for TB Some rehabilitation of the General Hospital Peltier HIV/AIDS Basic Immunization, IMCI Pilot Rehabilitation central drug facilities Support for Health Infrastructure Support for Health Infrastructure Support to infrastructure in the north and Latest Supervision (PSR) Ratings (Bank-financed projects only) Implementation Development Progress (IP) Objective (DO) S S S S S S - 19- Page 26 also pharmaceuticals included in AfDB funded social fund. Future Support for Rural Health African Development BaaOPEC Fund - commitment at donor meeting IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: Lessons learned from HIV/AIDS program development and implementation in other countries show that preventive measures, e.g. IEC/CBC interventions designed to bring about behavior change, condom use, treatment of STIs and 01s (such as TB), VCT, improvement in blood supply, and preventing mother-to-child transmission, have all proven highly effective in reducing HIV transmission. Community-based programs have been especially effective in enhancing prevention, care, support, and treatment for those infected and affected by HIV/AIDS. Lessons learned during the implementation of effective HN/AIDS programs in various countries will be integrated into the project as appropriate. Specific lessons taken into account and learned from international experience with HIV/AIDS programs (MAP) include: Importance of political leadership and commitment. Experience showed that strong commitment from the top political and religious leadership in the country is important for the success of HIV/AIDS efforts. In recent months the president of the Republic of Djibouti, including several ministers, has demonstrated strong support for the program. Need for a multisectoral approach. Experience in many countries in Africa has shown that HIV/AIDS control activities start in the health sector but need to be expanded to other sectors. However, past experience has demonstrated difficulties in implementing projects across multiple ministries. Obviously a multisectoral HIV/AIDS project must engage a number of line ministries and other govemment/public sector mechanisms. The risks inherent in this arrangement will be mitigated by the fact that the project is to be “coordinated” by the IC, placed under the prime minister’s office. Social Assessments: Experience in previous projects has shown the importance of conducting social assessments, and MAP guidelines also reinforce that which has benefited project preparation. A qualitative social assessment of the impact of AIDS on people infected and affected by the disease was conducted; the study found nutrition, poor medical and counseling services, and financial constraints to be primary problems (see Annex 13 on Social Assessment). PLWHA were actively involved in the study, and based on the study’s findings a pilot nutritional program was put in place during preparation. Stakeholder Consultation. Key stakeholders, particularly those with an important role in implementation, should be involved as early in the process as possible. Project identification has been done in consultation with line ministries, including that of Religious Affairs, NGOs (including the NGO “Oui u la vie” which includes PLWHA), UNAIDS and UN agencies, other IDA projects, OPS, and donor agencies. Several workshops have taken place in the five districts and in Djibouti-Ville to contribute to the finalization of the HIV/AIDS National Strategic Plan and to discuss the KABP studies. The HIV/AIDS National Strategic Plan was approved during a consensus seminar that included all the partners consulted for project identification. Additional regional workshops will be held annually to set community- and district- - 20 - Page 27 level priorities and activities planned for the year. It should also be noted that PLWHA have been very much involved in project preparation, and in the design and implementation of the social assessment of the impact of AIDS on families and individuals (carried out in December, 2002). Need for community participation. Local communities have a key role to play in the prevention of HIV/AIDS, the care of infected people, and the support to affected groups. They also have a role to play in sanitation and controlling malaria. The spread of infectious diseases and of HIV/AIDS in particular results in a heavy burden on local communities. They need support to cope and to be able to express their needs. Appropriate mechanisms must be put in place to facilitate the provision of support and resources to communities (such as education of communities to better engage them in the process, and so that adequate controls on financing mechanisms are put in place). It is recognized that experience with NGOs has been difficult in Djibouti. An NGO institutional analysis carried out during preparation indicated that NGOs were very weak, lacked expertise, professionalism, and know how. These finding suggests that in-depth systematic institutional capacity building is necessary. Consequently it was decided to have capacity-building activities up front before launching community interventions (see annex 2 section 4, for further details). In addition, the project intends to select 5 to 10 NGOs or other institutions with recognized capacities to train; and, on the basis of a competition, select 5 of them as supporting organizations. These will have the responsibility of training local NGOs and associations, assist them with subproject preparation, and supervise and control the quality of their activities. This two-tier system should ensure close supervision. Finally, a pilot project to provide support to sero-positive persons and their families is being carried out during project preparation. At the end of this project, the following will be identified: (1) mechanisms to better work with NGOs and local associations; and (2) means to avoid some of the past constraints. This pilot project will also assist in defining the social package to be provided to infected and affected persons. MAPprojects tended to lose momentum after Board approval. A PPF was requested and approved to sensitize representatives of public sector and civil society organizations, to establish program coordination and implementation mechanisms, to start pilot operations as soon as possible, and to carry KABP studies. Funds available under a PHRD grant were used to provide technical assistance to assist in the development of a strategic plan and the carrying out of a sero-prevalence survey, dissemination workshops, and establish a monitoring and evaluation system. Importance of monitoring and evaluation. The design of the M&E system should focus on who will use the indicators and how they will influence the decision-making process. Baseline data are essential for proper monitoring and have been collected during the preparation phase (see the above point). The Monitoring and Evaluation Plan was prepared; this task will be subcontracted out to ensure that it is carried out by qualified experts. Capacity building and transfer of competences will be a big part of the contractor’s TOR. e Overall implementation experience in the education sector has shown that by having the project implemented by a unit within the Ministry of Education, there is better coordination among the different partners (government, civil society, stakeholders) within the framework of a sectoral committee established at that level, as well as better coordination between the donors. The Implementation Unit has a better grasp of the reform process and how the different interventions fit in. There are now regular meetings between the donors and the Ministry of Education, and these have led to better synergy in impact interventions. -21 - Page 28 4. Indications of recipient commitment and ownership Over the years the government has urgently requested IDA support for the health sector and reiterated its request during high-level meetings between the government and IDA’s top management. In addition, the government specifically indicated its interest in IDA support for an HIV/AIDS control project. Concrete evidence of recipient commitment is further manifested by the creation of the IC, the TIC, and the ES under the prime minister’s presidency, outside of the MOH. 5. Value added of Bank support in this project: The Multicountry HIV/AIDS Program for the Africa Region places HIV/AIDS at the center of the development agenda for work in the region. The deceleration of the spread of HIV is pivotal if human development and overall development goals are to be achieved in Djibouti and in neighboring countries. In addition, IDA’s comparative advantage is its past and present involvement in the sector, and its flexibility to work across sectors, which will facilitate the proposed multisectoral approach being considered here. Furthermore, there are clear links with other IDA-funded projects, such as the Social Fund and Public Works Project, the School Access Improvement Project and the proposed HSDP, and the possibility of using these entry points to disseminate the message on HIV/AIDS. Given the potential macroeconomic impact of HIV/AIDS in Djibouti, IDA’s involvement with structural adjustment, public sector reform and close working partnership with the International Monetary Fund (IMF) will help reduce expenditures on nonpriority areas, thereby freeing up resources for the health and education sectors primarily. IDA’s involvement will also be key in: (i) ensuring better coordination among key stakeholders; (ii) preventing duplication of efforts; and (iii) exploiting the complementary aspects of the different projects currently being financed by IDA. As IDA is a key partner in the global “STOP TB” initiative in collaboration with UNAIDS and in the “Roll back Malaria” initative, the ability to play a facilitating role in identifying expertise and possible partners is also an asset. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): Other (specify) NPV=US$ million; ERR = % (see Annex 4) The Economic Analysis of HIV/AIDS contained in the Multicountry HIV/AIDS Program for the Africa Region (MAP) Project Appraisal Document (Report No. 20727 AFT, Annex 5) and the Second Multicountly HIVIAIDS Program (MAP2) (APL) for the Africa Region (Report No. P7497 AFR), provides the economic justification for projects implemented in the context of the MAP Program. As it indicates, HIV/AIDS undermines the three major determinants of economic growth, namely physical, human, and social capital. Due to its long incubation period (7-10 years), the impact of the HIV/AIDS epidemic is likely to be drawn over time with the rate of growth of physical and human capital and the efficiency of social capital declining slowly in parallel with the maturing of the HIVIAIDS epidemic. Over time, the GDP movement would reflect a similar gradual downward reduction of the rate of growth (or increased rate of contraction), rather than a sudden fall in GDP per capita. Available data indicate that Djibouti represents the classic case of a country in which the rapid spread of the virus is likely. Poverty, refugees, high levels of sexually transmitted infections and opportunistic infections, inequality, gender inequality are all part of the mosaic. Once HIV levels reach 5 percent, the infection spreads exponentially with the prevalence rate sometimes increasing by 50 percent every year. Should the epidemic not be checked, it will prevent an increasing share of the population from participating in the economy and result in the reduced economic growth and increased poverty, thereby accelerating the vicious cycle. - 22 - Page 29 An economic analysis and simulation model on the effect of HIV/AIDS on the economy of Djibouti has been undertaken (see annex 4), primarily as Djibouti is small in size, mostly an urban country, and heavily dependent on services (unlike most other African countries). The analysis clearly shows that the economic impact of HIV/AIDS on Djibouti would be devastating if the epidemic were not checked. It also shows the importance of prevention interventions such as reducing the number of nonunion sexual partners, increasing the use of condoms, especially during sexual contacts with nonregular partners, and treating STIs. 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) A large amount of resources (about 20 percent of resources, excluding civil works and long-term TA), will be directed at community interventions. The project will rely on civil society organizations. Mechanisms on how to provide project resources to NGOs and community groups were identified during preparation. The fiscal burden of the program is expected to be low. The need for additional recurrent costs will be limited and consist mainly, besides the costs of drug test kits, of condoms (some of which will be covered by the HSDP and other donors such as UNFPA, WHO, and the French Cooperation) and the costs related to the coordination of program implementation, financial management, and M&E. The financial analysis will compare annual recurrent costs with ongoing expenditures in key sectors. However, given Djibouti's level of resources and the long-term nature of the epidemic, financial sustainability can only be assured with the assistance of the donor community. 3. Technical: The project will incorporate accepted practices for HIV/AIDS responses as defined by the MAP and by UNAIDS pamers taken into account experiences in other African countries. The project will tailor these general principles to the specific Djibouti situation and will follow best accepted and applicable practices in technical standards for the handling of medical supplies, medical tests, and medical waste to minimize any environmental impact. Protocols for the effective care of STIs have been revised to be adapted to the Djiboutian epidemiological situation. Messages will be tailored to their respective audiences and take into account Djibouti's cultural realities. Target groups have been identified. Line ministries will prepare their annual action plans in keeping with national technical standards and in agreement with the National Strategic Plan. Technical personnel at the national and district levels will receive adequate training and will ensure that proposals are technically sound and cost effective. Most components will include training programs to ensure that staff involved in implementation have the capacity to deliver services as expected. 4. Institutional: Success in implementation will depend in great part on the effective collaboration between the IC, the TIC, and the ES, and their collaboration with their partners, in particular with the MOH and the UNAIDS Thematic Group. Both Committees have been created, and the TIC and the ES are in the process of being established. The IC is chaired by the prime minister, with the minister of Health holding the vice-presidential chair. The IC has ultimate responsibility for sensitizing and mobilizing civil society, promoting prevention measures against HIV/AIDS, and seeking support from and ensuring a smooth coordination among donors. The TIC is the technical arm of the IC and has oversight responsibility for project planning activities and integration between the HIV/AIDS, malaria and tuberculosis programs, and for ensuring a more effective multisectoral approach. The ES is responsible for the day-to-day implementation of activities included in the annual plan and manages the project. Long- and short-term technical assistance will focus on - 23 - Page 30 procurement and project implementation issues and communication efforts and would facilitate project execution. During preparation, and until the ES is completely functional, the CAU of the MOH will ensure the transition. The CAU has the capacity to carry out preparation activities, such as recruitment of experts, management of the PPF, etc. (see section C4 above for more details). The IC will be responsible for coordinating policy issues concerning HIV/AIDS, malaria and tuberculosis. The IC will have the authority to make recommendations for improving project implementation, if necessary. Lastly, it will be responsible for organizing consultations with the different partners, in particular through biannual activity reviews. To that end, the IC will be assisted by the ES. Project activities may be adjusted at those times to accommodate changes in the sectors andor the pace of implementation and to coordinate with the implementing agencies and other partners (donors/co-financiers, private sector, civil society, and NGOs). A procurement and financial assessment was partially carried out during the appraisal mission. Since the Administrative and Financial Unit of the ES was not in place, the assessment focused on the CAU’s ability to manage the transition phase. The assessment found the CAU’s capacity to undertake the transition phase of managing project activities to be satisfactory. It is to be noted that the CAU has been managing the PHRD grant and the PPF for this project since the start of project preparation. The Executive Secretary of the ES has been nominated. The Chief of the Administrative and Financial Unit (AFU) and the accountant have been recruited, which fulfills the condition of Board presentation. The recruitment of additional staff is underway, which will lead to a functioning ES prior to Board presentation. A second assessment will take place in mid- May 2003, once the AFU of the ES is fully staffed; and an action plan will be established to ensure sound project implementation, A draft procurement plan was reviewed at the time of negotiations. 4.1 Executing agencies: The ES, as Secretariat to the IC and to the TIC, will be responsible for overall management, implementation, and coordination activities. Ministries, public agencies, and civil society organizations will implement project activities with support from the ES. The IC and TIC will coordinate efforts in their respective areas of responsibilities. A POM, satisfactory to IDA, will be developed using previous experience in the MAP program. It will delineate processes and responsibilities for general management, procurement activities, and financial management and control, including TORS for internal (community fund) and external audits acceptable to the Bank. The POM will take into account lessons learned from other countries that are implementing or have implemented a MAP project. The POM will be adopted by the Recipient before December 31,2003. 4.2 Project management: The day-to-day coordination of project activities will be carried out by the ES under the aegis of the TIC, to be chaired by the Secretary General of the MOH. The ES will ensure that the action plans of the sectorial ministries involved in the project are in line with the National Strategy and carried out within the allocated budget. It will also be responsible for supervising community interventions and the subcontractors. In addition, the ES will need to ensure good coordination with the regional councils, which will be established as part of the government’s decentralization efforts. As mentioned above, the procurement functions of the AFU/ES will be carried out with the assistance of a long-term technical assistant, due to lack of capacity to manage complex procurement procedures. In addition, the planning, monitoring, and evaluation tasks will be - 24 - Page 31 subcontracted out to a private firm. A community intervention specialist and an accountant for the CISU, and an administrator responsible for following up with sectoral line ministry activities will be hired on a competitive basis. The recruitment of the accountant is a condition of project effectiveness. Although the role of the ES will be mainly coordination, it will also play an administrative role. It will be responsible for managing project funds, preparing disbursement requests, supervising contractors, ensuring the liaison with the Project Task Team and IDA in general, preparing and submitting semi-annual progress reports to IDA. The ES will work in close collaboration with the entities responsible for implementing the project components. 4.3 Procurement issues: 4.3 Procurement Issues A review of the national procurement policies and procedures was carried out under the HSDP. Certain wealmesses were highlighted (see HSDP PAD for further details). Regardless, the procurement for all IDA-financed activities will be carried out in accordance with the Bank's Guidelines for procurement under IBRD loans and IDA credits (January 1995, revised in January and August 1996, September 1997, January 1999 and May 2002), in particular, section 3.15, "Community participation in procurement." Consulting services will be awarded in accordance with the Bank's Guidelines: Selection and employment of consultants by World Bank borrowers (January 1997, revised in September 1997 and January 1999). A procurement assessment was partially carried out during the appraisal mission. A second assessment will take place in May 2003 (see section E, paragraph 2). It was agreed that an international expert in procurement with project management skills will be hired no later than June 15, 2003. Advertisement for Expression of Interest was launched in the UNDB on March 14, 2003 and expressions are to be received by April 4, 2003. The expert would be responsible for setting up the procurement unit in the ES (within the AFU) and guiding all procurement activities for smooth implementation of the project. Procurement performance will be assessed on an annual basis in the form of random audits by an external agency as well as by the supervision missions. UN agencies may be used for the procurement of certain goods, such as condoms, essential medicines, and vehicles. The HSDP is in the process of setting up a CAMME. When the CAMME is functional, and if it has procurement procedures satisfactory to IDA, the possibility of buying essential drugs and medical and consumables under the project will be explored and the Development Grant Agreement amended accordingly. 4.4 Financial management issues: The AFU within the Secretariat will be responsible for the overall coordination of the financial management of project activities, accounting and reporting consolidation of all project activities, and annual external auditing arrangements. The Unit is not yet operational, but the Chief of the AFU and the accountant have been recruited. Discussions were held during the pre-appraisal and appraisal missions and agreement reached with the Djiboutian authorities regarding the financial management function, its structure, and the flow of funds. Also, to ensure that satisfactory financial management arrangements are in place prior to project effectiveness, a set of actions were discussed and agreed with the authorities during the pre-appraisal mission and progress reviewed during the appraisal mission. An updated implementation schedule of these actions is summarized below and detailed in annex 6. As stated above, the final institutional arrangements to carry out the project activities are being established, The appraisal mission reported a slow implementation of the agreed actions to - 25 - Page 32 establish minimum financial management arrangements. As such, there were no institutional arrangements to be assessed during the appraisal mission at the ES level. However, the mission had discussions with various other implementing ministries and parties regarding the implementation arrangements and the financial management capacity. The various implementing agencies will rely on their existing structures to implement the activities including accounting for the grant proceeds; they will designate a small team as the vis-&vis of the ES in implementing the activities at each level. This core team will include a person with some accounting background to ensure that the funds are properly used and accounted for during the implementation of the activities under their agency's responsibility. Most of the agencies seemed to have the structure in place and are willing to meet the requirements. The financial management function of the project at the AFU level will be managed by the AFU Chief and an accountant. These two positions are currently being evaluated and will be filled shortly. Given the small size and high number of community transactions, on one hand, and the low management capacity at the community level, on the other hand, an additional accountant to follow-up on the accounting and disbursement of such community development activities will also be recruited. Two special accounts will be managed by the AFU, one for the community-based activities and one for the rest of the activities. As is the case for all the project activities, the financial management function will rely on the various partners' existing structures with a coordination at the AFU level. The various working relationships and reporting requirements will be defined and will be part of the Procedures Manual for the financial management section of the POM as well as the Procedure Manual for Community Interventions. The AFU will be in charge of the consolidation of all the financial information including that of the disbursement and accounting records. It will have the responsibility of submitting to IDA the periodic Financial Monitoring Reports (FMRs). The flow of funds will be channeled through advance accounts at each of the implementing agencies. Accounts will be opened in commercial banks. The two special accounts will be maintained by the AFU and will receive transfers from the grant proceeds. Initially advances will be made by the AFU to the various partners' advance accounts based on an agreement to be signed between the ES and the implementing partners for their respective activities. Each implementing agency will receive a 90-day advance from the main special account, calculated on the basis of actual needs to finance their activities over a 90-day period. Once an initial advance is made, no further advances will be permitted, unless and until, the concemed implementing agency submits a replenishment request and the documentation justifying the use of the advance funds. Replenishments will be based on the cost of the activities included in the annual work plan for the next 90 days. These procedures will be specified in the POM. In order to properly handle the financial management functions and meet IDA'S financial management requirements, the format and the content of the Financial Monitoring Reports (FMRs) need to be submitted to IDA for approval prior to project effectiveness. In addition, an accounting system, in accordance with international standards and acceptable reporting will be adopted and put in place before December 31, 2003 (dated covenant). In particular, the regular FMRs (including project financial statements, procurement, and physical progress reports) will be designed and generated by the system in place, and external independent auditors acceptable to IDA will be appointed annually, and their audit reports transmitted in a timely manner to IDA. These requirements will be spelled out in the POM. - 26 - Page 33 A consulting firm will be appointed to assist the AFU in the establishment of a financial management system and procedures, the selection of an adequate accounting software, and the training of personnel on the established system. All these steps and requirements were discussed and agreed with the Djibouti authorities. A detailed timetable is included in annex 6.b. The lack of preparedness in the implementation and financial management arrangements is due to the delay in the establishment of the ES. However, it is not expected that this will cause delays in project implementation, primarily because the CAU, which is presently managing the PPF, is doing so in a manner satisfactory to IDA, and will be able to ensure project management responsibilities until the ES is in place. 5. Environmental: Environmental Category: B (Partial Assessment) 5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The program is not expected to have a major environmental impact. The handling and disposal of clinical and in particular of HIV/AIDS-infected materials is the most significant issue. Although an environmental plan was prepared for the HSDP, a more substantive assessment on medical solid waste was prepared and submitted to the Infoshop on February 27,2003. The plan includes recommendations for improvements to the legal text on sanitary waste management, training on how to safely dispose of contaminated blood and other materials, wider dissemination of information to the general population, health supplies such as gloves, waste disposal canisters, incinerators, etc., and M&E. Health facilities benefiting from proceeds of the grant will be required to demonstrate that they have safe methods of waste disposal and that the training provided to their staff includes precautions in handling sensitive materials. 5.2 What are the main features of the EMP and are they adequate? The main features of the EMP are as follows: development of a national policy on waste management, and the appropriate guides and legal texts; training of key personnel in all health facilities; dissemination to the wider population through different means of media coverage; improvements to waste collection methods and purchase of needed supplies toward that end; and M&E of activities undertaken. 5.3 For Category A and B projects, timeline and status of EA: Date of receipt of final draft: February 27,2003 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? Health personnel were consulted, as well as reference hospitals. In addition, interviews were held with local communities that suffer the effects of having waste disposal sites located in their vicinity and with NGOs involved in the health sector. 5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? - 27 - Page 34 Impact of the project on the environment and the recommendations of the EMP will be monitored during supervision missions. 6. Social: 6.1 Summarize key social issues relevant to the project objectives and specify the project’s social development outcomes. See paragraph 83 of the Multicountry HIV/’DS Program for the Africa Region (Report No. 20727 AFR) and paragraph 106 of the MAP2 (Report No. P7497 AFR). Six key desired social development outcomes for the project are: (i) ensuring access to HIV/AIDS-related information, prevention, treatment, and psychosocial support regardless of gender, age, occupation, ethnicity, or nationality; (ii) reducing the taboos surrounding AIDS and the stigmatization of PLWHA so that they may seek treatment and reduce cross-infection; (iii) ensuring communities are better able to protect themselves from HIV infection and to care for those among them who are affected by AIDS; (iv) reducing the rate of increase of AIDS infection among the general population; (v) improving life expectancy and productivity of PLWHA and ensuring better livelihood prospects for AIDS orphans, widows, or other dependents; (vi) improving the knowledge and understanding of opinion leaders. The project will strengthen community-based organizations which will have a beneficial impact on other development initiatives. 6.2 Participatory Approach: How are key stakeholders participating in the project? Stakeholders were extensively consulted during the preparation of the project, through participatory workshops held to formulate the National Strategic Plan for the Control of HN/AIDS. Workshop participants consisted of local community leaders (traditional and religious), elected officials, and representatives of civil society, women’s groups, and youth. The workshops were held in all districts and Djibouti-Ville. In addition, focus group discussions were conducted with specific vulnerable groups such as CSW and dockers to identify attitudes and practices exposing them to infection. PLWHA (especially the only NGO directly representing their interests, “Oui a la Vie”) were extensively consulted so that their needs and priorities are integrated into project design. A social assessment of PLWHA was conducted in partnership with “Oui a la Vie,” and its findings were discussed with key stakeholders (service providers, civil society, PLWHA etc) (see Annex 13 on Social Assessment). The Ministry of Waqfs and Islamic Affairs is among the ministries that have developed a plan for the control of HIV/AIDS. In addition, there was extensive coordination with various donors financing surveys targeting vulnerable groups, and information was shared through dissemination and consensus workshops. During project implementation, regional priorities will be set annually through participatory regional workshops. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? NGOs and other civil society organizations have been engaged in the formulation of the National HIV/AIDS strategy. NGOs and CBOs, among other civil society organizations, have already been consulted and involved in project design, and are expected to play an active role in project implementation. CBO and NGO activities will consist of (i) providing care and support for PLWHA and their dependents (e.g., nutrition for AIDS patients, income-generating activities); (ii) information and CBC activities for prevention (e.g., peer and gender-based sex education) and destigmatization of PLWHA; (iii) distribution of condoms; and (iv) integration of traditional healers in counseling. Resources will be provided to NGOs and CBOs using simple contractual agreements to enable them to conduct specific subprojects on a larger scale covering their work in - 28 - Page 35 evaluation and research. Capacity-building initiatives, including training for budgeting, management, and proposal writing, and implementing specific actions, will be provided by the project. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? The participatory approach used in project preparation will be continued during project implementation. The project will ensure that community initiatives are identified and selected in a transparent manner by establishing clear criteria of participation and the establishment of a broad- based selection committee. At the national level, the TIC and the ES will oversee project-funded initiatives; the ES will also be assigned a TA in communications to support all communication activities related to HIV/AIDS, malaria and tuberculosis. The CISU, which will train, support, and supervise CBOs and NGOs, will be established. The project will also provide tools (such as counseling and peer education guides) in order to harmonize all messages. 6.5 How will the project monitor performance in terms of social development outcomes? Two beneficiary assessments will be conducted, one at project mid-term and again at the end of the project (the KABP will be the baseline). The Interministerial Committee will provide regular oversight of the Action Plan. The MOH, and subsequently the ES, will review progress in meeting key indicators. Indicators of beneficiary satisfaction are included in project design and will be regularly monitored during project implementation. 7. Safeguard Policies: 7.1 Are any of the following safeguard policies triggered by the project? Policy Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) Natural Habitats (OP 4.04, BP 4.04, GP 4.04) Forestry (OP 4.36, GP 4.36) Pest Management (OP 4.09) Cultural Property (OPN 11.03) Indigenous Peoples (OD 4.20) Involuntary Resettlement (OPBP 4.12) Safety of Dams (OP 4.37, BP 4.37) Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60)* Triggered Yes No No No No No No No No No 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. The only potential environmental issue relates to medical solid waste management. A waste management plan has been prepared (along standardized guidelines of other MAP projects). F. Sustainability and Risks 1. Sustainability: The sustainability of the project will depend on the degree to which the strategy and activities become fully owned by the various partners at national, district, and local levels. It will hinge on - 29 - Page 36 improved capacity at all levels to develop and implement action plans and proposals that are effective in changing behaviors and providing care and support to affected groups. 2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1): Risk From Outputs to Objective Political support is not maintained at all levels of government to address the problem. Younger people do not accept behavior changes which reduce risk. The highly porous nature of Djibouti's borders and the volume of transit trucks contributes to increasing infections. TB infections are not properly detected or in a timely manner to be adequately treated. From Components to Outputs Data collection is not systematic and representative. Qualified human resources will not be available to carry out the planned activities. Knowledge of safe behavior is not translated into action. Population is not willing to visit diagnosidtreatment centers. Stigma against HIV/AIDS and AIDS victims impede community action. Government objects to financing community activities. Capacities of NGOs and local organizations do not improve. ES is slow and does not solve problems. Transfer of funds to local organizations is not smooth nor efficient. Overall Risk Rating Risk Rating M S S M S H S S H S S S H H Risk Mitigation Measure Consultations with the highest level during project preparation. Repeated messages in media and through the education system. Include truck-drivers using the port among target population. Conduct awareness campaigns in border towns. Awareness campaigns. Location of testing facilities at all health centers. Proper follow- up of patients by medical staff. International expertise will be brought in to design a simple but effective system that can be implemented and conduct intensive training of the users. Training of counselors, physicians, midwives, nurses, and NGOs is planned early in the project . Peer Education and CBC campaigns down to the community level. Good monitoring and evaluation mechanisms put in place. Social awareness campaigns to reduce stigma. Enlist help of community leaders including religious leaders. Discuss and prepare up-front grant conditions. Intensify local training. Review procedures in light of experience and modify if necessary. Review personnel qualifications. Do random checks during each supervision mission at local level to identify problem. Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N (Negligible or Low Risk) The project is rated as a "high risk" because of the social stigma associated with the disease, the burdening poverty faced by the majority of the population, Djibouti's highly porous borders, and the high volume of transit traffic through the port of Djibouti and its subsequent impact. It is also and foremost a high-risk project because of the shortage of human resources and the limited - 30- Page 37 capacities available in Djibouti. Finally, NGOs and CBOs are weak, and past experiences have been mixed. One way of mitigating this risk has been to put added emphasis on capacity building and strengthening at the start of the project. 3. Possible Controversial Aspects: Some religious leaders may object to condom promotion and sexual education of young people. In order to prevent this, the preparation team met with religious groups. The prime minister and the president are also playing a role to inform religious leaders and to moderate their opinions. G. Main Loan Conditions 1. Effectiveness Condition 1. Procedure Manual for Community Interventions is submitted in form and substance satisfactory to IDA. 2. The appointment of an accountant for the Community Intervention Support Unit (CISU), with terms of reference acceptable to IDA. 3. Finalization of the form and content of the FMR. 2. Other [classify according to covenant types used in the Legal Agreements.] Conditions of Nepotiations which have been met 1. Nomination of the director of the AIDS Control Program of the Ministry of Health. 2. Preparation of all the position descriptions for the AIDS Control Program of the Ministry of Health and for the Center Yonis Toussaint. Conditions of Board presentation which have been met 1. Selection under a competitive basis of two long-term national consultants who will constitute the Administration and Financial Unit (Chief of the financial unit and the accountant). H. Readiness for Implementation The Project Implementation Plan has been appraised and was found to be realistic and of The following items are under preparation and are discussed under loan conditions (Section G): satisfactory quality. Project Operations Manual (POM) and Procedure Manual for Community Interventions I. Compliance with Bank Policies 1. This project complies with all applicable Bank policies. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. i- - Jacques Baudouy {dMahmood Ayub Task Team Leader Sector Director Country Director - 31 - Page 38 Annex 1 : Project Design Summary DJlI Hierarchy of Objectives Sector-related CAS Goal: Improve human development indicators by mitigating the socioeconomic impact of HIViAIDS epidemic on development and on the level of poverty Jroject Development 3bjective: To contribute to the change in behavior of the Djiboutian population in order to contain or reduce the spread of the HIV/AIDS epidemic and to mitigate its impact on infected and affected persons OUT1 : H lV/Al DS , M alaria,-an Key Performance Indicators Sector Indicators: Human Development indicators HIViAIDS new infections, STI and TB rates Outcome / Impact Indicators: By the end of the project, 50% of high-risk groups (men in uniform, dockers and CSWs) used condoms during their last nonunion sexual encounter By the end of the project, 90% of Djiboutians aged 15 to 49 identified at least 3 methods of protection against HIViAIDS By the end of the project, 50% of pregnant women attending prenatal consultations in the centers offering VCT, accepted voluntary testing for HIV By the end of the project, HIV prevalence rate among 15-24 year-old pregnant women reduced from 2.7% to 2.0%. By the end of the project, the rate of “lost cases” of TB reduced from 24% to 15% nationallv. By the end of the project, hospital mortality rate due to malaria reduced by 50%. By the end of the project, at least 15,000 households will be using impregnated bednets. Tuberculosis Contro Data Collection Strategy Sector/ Country Reports : UNDP Annual Report Health Statistical Reports Data from Sentinel sites1 Epidemiological surveillance Project reports: KABP Studies KABP Studies Analysis of Services Statistics Prevalence surveys Prevalence Surveys Sentinel Sites, Service Statistics Malaria Program Report Project Critical Assumptions (from Goal to IDA Mission) Political commitment to make the HIViAIDS Committee fimction Adoption of the National HIViAIDS Strategic Plan Public Finance and Public sector management constraints do not impede action (from Objective to Goal) Political support maintained at all levels of Government to address the problem. Knowledge of safe behavior is translated into action. The highly porous nature of Djibouti borders and the volume of transit trucks do not increase infections. - 32 - Page 39 Hierarchy of Objectives Output from each Component: Capacity Building and Policy Development (a) National Strategic Plan and Action Plans (b) Project Coordination and Administration (c) Capacity Building and Training, which would include on-the-job training for health personnel, advocacy, and social communication training (e) Monitoring and Evaluation Health Sector Responses to HIV/AIDS, STIs, Malaria, and TB a) the strengthening of the national sentinel surveillance system and sero-prevalence surveys Key Performance Indicators Output Indicators: National HIV/AIDS Strategic Plan is implemented IC established and operational Coordination mechanisms establilshed and operating satisfactorily Satisfactory MIS At least 80% of annual plan executed 150 peer educators trained each year 50% of health personnel adequately trained to provide care of sexually transmitted infections (STIs) and opportunistic infections (01s) by 2006 and 75% by end of the project. 85% of Djiboutians in vulnerable groups reached by a message on HIV/AID S/STI At least 14 messages on HIV/AIDS, Malaria and TB diffused on radio per week 50% of Djiboutians know 2 methods to protect themselves against malaria Data for monitoring of outcome and impact indicators are collected regularly By the end of 2005, at least five sentinel sites for the epidemiological surveillance of HIV/AIDS will be functional, and will remain operational until the end of the project Data Collection Strategy Project reports: Project Reports, Work Plans Intersectoral Committee Reports Interministerial Committee Progress Reports Project data Intersectoral Committee Progress Reports Project data Monitoring reports MOH/PLS data Critical Assumptions [from Outputs to Objective) Personnel may not be available to carry out planned tasks Population visits centers for diagnosis and treatment. - 33 - Page 40 Hierarchy of Objectives Output from each Component: c) the strengthening of the health system for the treatment of HIVIAIDSISTIs, and other opportunistic infections, and particularly TB d) the procurement of condoms and a significant role in the distribution of condoms: Multisector Responses for HIV/AIDS Prevention and Care The different sectors have developed HIVIAIDS action plans Support to community- based initiatives CBC strengthened Mechanisms in place to finnel funds to communities Key Performance Indicators Output Indicators: By the end of the project, 90% of health training include training for STI By the end of 2005, the services of TB screening, treatment and follow up will be established in five centers at the periphery and these services will remain fimctional until the end of the project By the end of the project, at least 2000 PLWHAs will be using counseling, testing, care and treatment services (in hospital andor on ambulatory basis), delivered in accordance with established national protocols. To be determined once the strategy is developed 5, 8, and 11 ministries implemented the agreed action plans for HIVIAIDS by the end of 2004,2006, and end of project, respectively. 150 peer educators trained each year By the end of the project, 85% of Djiboutians in vulnerable groups reached by a message on HIV/AIDS/STI By the end of 2005 and 2007, the rate of disbursement for the community initiatives reached at least 50% and 85%, respectively, 60% of households where persons declared infected by HIViAIDS live, received psycho-social support (social package) Data Collection aroject reports: viOH reports Vational TB program .eports To be determined once the strategy is developed nterministerial :ommitteeProgress teports Interministerial Committee Progress Reports KABP Surveys Interministerial Committee Progress Reports from Outputs to Ibjective) Communities are willing to take up the responsibilities and Government is willing to transfer resources to the communities. - 34 - Page 41 Subcomponents: Capacity Building and Policy Development Public Health Sector Response to HIVIAIDS, STIs, Malaria, and TB Multisector Responses for HIV/AIDS Prevention and ~ Care 1 Communities empowered Support to community-based initiatives Key Performance Indicators Inputs: (budget for each component) -Total project cost (of which IDA Grant) 30 and 110 communities implementing an HIV/AIDS preventiodcare action plan at the end of 2004 and 1 10 by the end of the project By the end of the project, 10 truck rest sites benefit from m HIV prevention intervention By the end of the project, at least 20 community sub- projects integrated some interventions to control malaria US$4.9 million (US$4.6) US$3.8 million (US$2.3) US$3.7 million (US$2.6) US$2.6 million (US$2.5) Data Collection Strategy Project reports: Interministerial Committee Progress Reports Reports of the National Malaria Control Program Critical Assumptions (from Components to Outputs) Capacities of NGOs and local organizations improve The impregnated bednets and the chemical and biological means to control malaria are available ES is rapid and solves problems Health services will improve Human resources are made available and encouraged by the heads of the sectoral ministries Transfer of funds to local organizations is smooth and efficient - 35 - Page 42 Annex 2: Detailed Project Description DJIBOUTI: HIV/AIDS, Malaria, and Tuberculosis Control Project By Component: Project Component 1 - US$4.9 million total cost This component would aim at strengthening Djibouti’s capacity to cope with the spread of HIV/AIDS and to control malaria and tuberculosis by supporting: (i) the work of the Interministerial Committee, the Technical Intersectoral Committee, and the Executive Secretariat-including project coordination and facilitation; (ii) the updating of the National Strategic and Annual Action Plans for HIV/AIDS, malaria, and tuberculosis; (iii) the development of capacities of governmental and non-governmental organizations responsible for controlling the quality of essential activities (supporting organizations/agencies d’encadrement); and (iv) strengthening of public, private, and non-governmental institutions in preparing and implementing HIV/AIDS prevention and care interventions. Four subcomponents would address the following areas: (a) National Strategic Plans and Action Plans; (b) project coordination and administration, which will be carried out by the Executive Secretariat; (c) capacity building and training, which would include on-the-job training for health personnel, advocacy, and communication training as well as support to existing institutions (public and non-governmental) to develop and implement interventions aimed at controlling HIV/AIDS, malaria, and tuberculosis; and (d) Monitoring and Evaluation (M&E), i.e., including behavioral surveillance, operational research and pilot testing, and other M&E activities. It was decided during the appraisal mission that M&E activities would be subcontracted out under the supervision of the Executive Secretariat. Training, institutional development, and quality-control activities will be given a high priority during the first year of the project. These activities are necessary to ensure increased quality coverage of vulnerable groups. Capacity Building and Policy Development Project Component 2 - US$3.8 million total cost The Ministry of Health (MOH) and more broadly the health community have special responsibilities for the prevention and management of HIV/AIDS/STIs, malaria, and other opportunistic infections - including malaria and tuberculosis. This sector therefore warrants a separate component, making provision for prevention, treatment, and care from a health-sector perspective, whether public or private. To this effect, this component will provide the resources to the health sector through the MOH to strengthen its key programs such as HIV/AIDS, reproductive health, control of communicable diseases, STIs, malaria, and tuberculosis. It will also complement the Health Sector Reform Project (HSDP) financed by IDA and the programs that are currently implemented or to be financed by the MOH and its health development partners. The implementation of this component will be guided by the HIV/AIDS, Malaria, and Tuberculosis National Strategic Plans in terms of priority interventions and which aspects of its HIV/AIDS/STIs, malaria, and tuberculosis activities can be scaled UP. Health Sector Responses to HIV/AIDS/STIs, Malaria, and Tuberculosis Under this component, the project will include: (a) development of Voluntary Counseling and Testing (VCT) protocols for HIV/AIDS as well as implementing VCT activities and follow-up; (b) strengthening the health system for the comprehensive treatment of HIV/AIDS, STIs (using the syndromic algorithm for diagnosis and case management), and opportunistic infections - including TB; (c) development of measures to prevent the transmission of HN in clinical settings; (d) the dissemination of information and the scaling-up of activities targeting vulnerable groups in collaboration with other sector partners; (e) strengthening of the TB program including screening and treatment as well as program decentralization; (0 strengthening of the malaria program in terms of detection, prevention, and treatment; (g) the procurement and distribution of condoms; and h) the financing of drugs, test kits, and medical supplies, which may be bought from the CAMME once it is set up (see section on goods, Procurement, Annex 6A). The activities included under this component have been identified in the context of the National Strategic Plans and take into account the interventions to be financed by the other development partners (for example, blood transfusion is being supported by the French Cooperation and prevention of mother-to-child transmission is being supported by UNICEF). - 36 - Page 43 IDA has also been working closely with its UNAIDS partners, drug companies, and developing-country governments on improving access to antiretroviral (ARV) therapy in order to allow for low-cost choices and alternative options for comprehensive care of AIDS patients. The project will therefore support the development of guidelines and the strengthening of health infrasmcture to pilot the use of ARV therapy in a safe, effective, and sustainable manner. It will assist the MOH, in collaboration with other partners (e.g., the French Cooperation, WHO, and UNICEF) in putting in place a one-year pilot project including the treatment with ARV of sero-positive persons in the three public health systems of the country (Ministry of Health, Ministry of Defense, and Ministry of EmploymentBocial Protection Organization [SPO]). (This organization is a parastatal institution providing basic health services to private sector employees [Organisation de la protection sociale (OPS)]. This pilot project will be used to assess the feasibility and cost of extending the treatment program to the whole country. The drugs for the pilot project (including ARV) will be procured under the HSDP. The Government of Djibouti is now eligible to apply to the Global Fund and is preparing a proposal for the next round. It is hoped that in the future at least part of the drugs for the program can be bought with Global Fund financing. The prevention of mother-to-child transmission of HIV (PMTCT) is not included in the project, because UNICEF is presently establishing a PMTCT pilot program in two Dijboutian health centers (one in a public maternity center and the other in the Maternity Child Health (MCH) Center of the SPO). However, as the pilot program may be scaled up, the project will contribute to the training of counselors and provision of artificial milk for mothers who decide not to breast-feed, as well as psycho-social support. Finally, regarding condoms, a consultant may be recruited either under the PPF or at the outset of the project launch to develop a condom distribution strategy. Condoms will be provided free of charge to STI patients, but condoms should also be made available outside of the health system as needed (based on the strategy developed). This component would be primarily implemented by the MOH, its Directorates, and its Programs. However, it has been decided that WHO, in the context of an Agreement with the ES, will provide technical assistance to the MOH. The details of this Agreement will be finalized during the post-appraisal mission. Moreover, the other existing health systems, namely, the Army, Police and SPO would also participate in specialized training programs in areas such as counseling and the use of the syndromic algorithm for the treatment of STIs and receiving (or in the case of SPO, purchasing) condoms and drugs for the treatment of opportunistic diseases and STIs. The PLS will work under the auspices of the Interministerial Committee and will be represented in the Intersectoral Technical Committee. Project Component 3 - US$3.7 million total cost As demonstrated in other countries, in order for the control of HIV/AIDS to be effective, it is necessary to have a multisectoral approach to better target Priority Vulnerable Groups. The preparation process of the National Strategic Plan has demonstrated that the MOH could not by itself deliver all the essential prevention- and impact-reduction activities and cover all the vulnerable groups identified. Although the multi-sectoral response is presently very weak, the ministries of Social Affairs and Women Promotion, of Interior, and of Defense, already carry out some IEC and condom-distribution activities. The objectives of these component are to: (i) strengthen the management quality control capacities of the ministries participating in the control of HN/AIDS; (ii) support these ministries so that they can implement essential activities aimed at preventing HIV infection and reducing the impact of AIDS on their own personnel and on the vulnerable groups for which they are responsible. Multisector Responses for HIV/AIDS Prevention and Care The 11 ministries, other than the Ministry of Health that are included in the Interministerial Committee are the following: (i) Ministry of Economy, Finances and Planification; (ii) the Ministry of Youth and Sports; (iii) Ministry of National and Higher Education; (iv) the Ministry of Women Promotion, Social Affairs and Family Welfare; (v) Ministry of Defense (Forces armies Djiboutiennes - FAD);(vi) Ministry of Employment and National Solidarity (through the Organisme de Protection sociale-OPS); (vii) the Ministry of Communication, Telecommunications and Culture; (viii) Ministry of Justice and Penitentiary and Religious Affairs; (ix) Ministry - 37 - Page 44 of Wakfs and of Muslim Affairs; (x) Ministry of the Interior and of Decentralization (Force nationale de Police- FNP); and (xi) Ministry of Equipment and Transport. Most the above-mentioned ministries have already developed action plans that include performance indicators and define monitoring systems and budgets. The action plans are targeted to the staff of line ministries and focus on the development of reference guides for the essential activities they plan to carry out, social communication, and peer education activities. They include activities such as training peer educators on issues of HIV/AIDS/STIs, the importance of condoms in the control of these diseases, including other support mechanisms to encourage a change in behavior practices. These plans will be integrated into the ministries' ongoing operations. In addition, training will be provided to staff to transfer knowledge to their partners and to groups for which they are responsible (e.g., student-parent associations, dockers' associations, truckers, women's groups, health committees, CSWs), so as to promote effective HIV/AIDS/STI prevention, and how best to access health care facilities, care, and treatment. At this point it is not planned that the project assists the Ministry of Transport because Save the Children, financed by USAID/Ethiopia, is providing support to that ministry, which could in addition receive additional support through the Regional Project for the Horn of Africa being developed in the context of the MAP2. The Ministry of Communication will have a special role to play: at the beginning of the project, it will assist the international specialist in communication and the Djiboutian counterpart in the Executive Secretariat, in developing a national communication strategy for the control of HIV/AIDS, malaria, and tuberculosis, in particular in the areas of advocacy and use of modem media. During this process, its role in the strategy will be defined. At a later stage, it is expected that it will disseminate audio- visual and written materials prepared in the context of the communication strategy. The preparation of these materials will be contracted out. The activities implemented by these ministries will be integrated in the local plans developed by the districts and city neighborhoods of Djibouti-Ville. The operational process will be coordinated by the regional committees for the control of against transmissible diseases, and activities will be implemented in a formal partnership with local NGOs and ABCs. The mandate of each of the ministries in the control of HIV/AIDS and the respective support to be provided by the Project are specified below. Each ministry will have to supervise and ensure the quality of the activities which will be under their responsibility. 0 Ministry of National Education: Its mandate will include formal education of students about HIV/AIDS, social communication with teachers, and peer education in the context of health clubs for youth in and out of school. Project support for this ministry will include: (a) logistical support and equipment for the focal point; (b) training of inspectors, teachers, and peer educators; (c) preparation of a Guide for Peer Educators; (d) production of educational materials; (e) strengthening of social communication capacities; (0 implementation of peer education; and (8) implementation of social communication activities through theater. 0 Ministry of Justice, Penitentiary, and Religious Affairs and Ministry of Wakfs and Muslim Affairs: Their mandate will include the promotion of legal practices in favor of victims of sexual violence and the human and social rights of persons infected or affected by HIV/AIDS. This will be done in the areas of penal, social, and religious (Charia) law. The ministries will also implement social communication activities for all the social groups concerned and HIV/AIDS-prevention activities in the prisons and jails of the country. Project support to these ministries will include: (a) implementation of social communication activities on the rights of PLWHA and of persons affected by HIV/AIDS; (b) preparation of three booklets on HIV/AIDS in the context of, respectively, the penal, social, and charian law; (c) training of lawyers, officers, and policemen; (d) organization of debatedworkshops with religious leaders; and (e) logistical support for the focal points of each of the ministries. - 38 - Page 45 e e e e e Ministry of Interior and Decentralization: Its mandate will include promoting the prevention of HIV infection as well as reducing the impact of AIDS on police persons and their families. Project support will include: (a) diagnostic and treatment of STIs; (b) promotion of and access to condoms for policemen; (c) counseling and psychological support to infected police persons and their families; (d) social communication for the police force and their families in the military barracks; (e) peer education training to the police force; (f) medical care for infected police persons; (8) social support to infected persons and their families; (h) training of physicians and paramedical FNP medical service personnel in the clinical aspect of AIDS and in counseling; (i) advocacy for the high ranking officers; and (j) logistical support for the focal point. Ministry of Defense (FAD): Its mandate will be to promote the prevention of the HIV infection to as well as to reduce the impact of AIDS on soldiers and their families Project support will include : (a) diagnostic and treatment of STIs among soldiers; (b) promotion of and access to condoms for the military; (c) counseling and psychological support to infected soldiers and their families; (d) social communication for the military and their families in the casemes; (e) peer education training to the military; (f) medical care for infected soldiers; (g) social support to infected persons and their families; (h) training of army medical service physicians and paramedical personnel in the clinical aspect of AIDS and in counseling; (i) advocacy for the high ranlung officers; (j) logistical support for the focal point. Ministry of Employment and National Solidarity (OPS): The mandate of OPS, which provides medical services, family allowances, and pension for private sector workers, will be to promote the prevention of the HIV infection as well as the reduction of the impact of AIDS on private sector workers and their families. Project support will include: (a) social communication activities; (b) peer education activities for private sector workers; (c) supply of condoms; (d) medical care, including with ARV when requested by the selection committee, of infected workers and of their families; (e) advocacy for employers, in particular in regard to the social rights linked to the HIV/AIDS; (f) production of educational materials for the workers; and (g) training for peer educators. Ministry of Youth and Sports: Its mandate is to promote, through social communication and peer education, the prevention of the transmission of the HIV and the mobilization of adolescents who do not attend school. Project support to this ministry will include: (a) peer education for youth of both genders who do not attend school; (b) social communication through theater, debates between adolescents of the same gender, and cultural events both in urban and rural settings; (c) youth mobilization, especially in urban settings; (d) professional training for the youth who are engaged in peer education; (e) training of peer educators; (0 capacity strengthening in IEC/HIV/AIDS in the Youth Directorate; (g) logistical support (audio-visual materials and leisure equipment for community centers; (h) training of heads of sports organization in IEC/HIV/AIDS; and (i) recruiting of personnel for the Points Information-Jeunesse - PIJ (Youth Information Points). Ministry of Communication, Telecommunications, and Culture: Its mandate will be to assist the Executive Secretariat in developing and implementing the National Communication Strategy for the control of HIV/AIDS, malaria, and tuberculosis by using modern communication channels and to promote services available through the national media. Preparation of audio-visual materials prepared in the context of the implementation of the National Strategy will be contracted out. It should be noted that the Ministry of Communication will have a special role to play: at the beginning of the project, the ministry will collaborate with the international specialist in communication and the Djiboutian counterpart to develop a national communication strategy for the control of HIV/AIDS, malaria, and tuberculosis. During this process, its role in the strategy will be better defined. At a later stage, it is expected that it will disseminate audio-visual and written materials prepared in the context of the communication strategy. - 39 - Page 46 Project support to this ministry will include: (a) training of national cadres in social communication through the media; (b) development of community and rural radios; (c) production of informative and educational shows on the HN/AIDS, malaria, and tuberculosis, with a focus on vulnerable groups; and (d) logistical support for the focal points. 0 Ministry for the Promotion of Women, Social Affairs, and Family Welfare (MPWSAFW): Its mandate will include the implementation of HIV/AIDS prevention activities for young women who are attending the professional training institution under the authority of this ministry and the development of the social package for persons infected and affected by the HIV/AIDS. A pilot project will be implemented during the preparation of the project to identify the best strategy to ensure access to the social package by the persons infected and affected by the HIV/AIDS. The ES and the MPWSAFW will follow up this project and coordinate the results analysis. This Ministry will then be in charge of implementing the strategies identified thanks to the pilot project. Project support to this ministry will include: (a) social communication activities; (b) peer education; (c) training of cadres of the ministry and professional training centers for young women; and (d) logistical support to the focal point. At this point it is not planned that the project assist the Ministry of Transport, because Save the Children, financed by USAID/Ethiopia, is providing support to that Ministry, which could, in addition, receive additional support through the Regional Project for the Horn of Africa being developed in the context of the MAP2. This approach will be revisited at the end of the first year of the project, The Ministry of Finance has nominated a focal point who follows activities related to the project and will be kept informed. Activities in the ministries will be financed on the basis of an agreed annual workplan and budget. Each ministry will receive advances. The first advance will have to be justified by the concerned ministry (invoice, receipts, reports, etc.) before receiving the second advance. The Administrative and Financial Manager of each ministry, who will manage these funds, will receive training as necessary. Project Component 4 - US$2.6 million total cost In order to enlist communities in controlling HIV/AIDS, malaria, and tuberculosis, and to provide them with the means to mitigate the impact of these diseases, it is necessary to provide resources at the local level. This component will be implemented by local NGOs and CBAs. The NGOs and CBAs will submit projects for financing to the ES on an annual basis. These projects will be developed taking into account criteria for eligibility and will be implemented in such a way as to complement governmental services identified in the multi-sectoral component. Support to Community-Based Initiatives The objectives of this community intervention component are : (a) to strengthen communities with the assistance of Djiboutian associations and NGOs so that they can implement essential activities for the reduction of the vulnerability to HIV/AIDS, malaria, and tuberculosis; and (b) to strengthen institutional capacities of Djiboutian NGOs and associations so that they can deliver essential services to the neediest vulnerable groups. Project support will be provided to ensure that community interventions are complementary and in synergy with interventions carried out by governmental services and other potential partners. Essential activities identified for community interventions can be classified in three categories: (a) prevention aimed at reducing vulnerability to the infection by HIV, malaria, and tuberculosis; (b) essential activities aimed at reducing the impact of HIVIAIDS on infected and affected persons, including adults and children of affected families; and (c) legal essential activities aimed at supporting persons affected by the HIV/AIDS and victims of sexual violence. The essential prevention activities identified during project preparation are the following : (a) information and promotion of the various activities and services provided by the public sector as well as those provided at the community level; (b) social communication on HIV/AIDS and feminine genital cutting, through theater and other traditional communication means; (c) sexual education carried out by peers of the same gender; (d) - 40 - Page 47 revenue-generating activities for infected and affected persons; and (e) condom distribution or sale, according to the strategy that will be defined. Essential activities related to impact reduction as identified are the following: (a) social and nutritional support to affected persons, in particular orphans; and (b) revenue-generating activities for families of PLWHA. Because of cultural specificities (to be identified as a PLWHA or to be related to a PLWHA is still very stigmatizing), psychological support activities will not be developed at the community level during the first years of the project. Essential legal activities at the community level are: (a) information and education to strengthen the defense and negotiation capacity of women, young boys, and young girls; and (b) legal counseling and assistance for victims of sexual violence and persons living in affected families and whose social rights are threatened or violated. The implementation of essential activities will require the development of several support activities in order to strengthen the institutional capacities of Djiboutian NGOs and associations. Project support will include training of the cadres of NGOs and associations in the following areas: (a) management and development of social projects; (b) analysis of vulnerability situation and identification of appropriate solutions; (c) implementation of the essential activities mentioned above; (d) mobilization and promotion of community participation; and (e) supervision and quality control of services being provided. The needs for training and supervision of local NGOs and associations were assessed during the development of the HIV/AIDS National Strategic Plan. Support to local NGOs and associations will be provided by govemmental and non-govemmental institutions which will be responsible for training and supervision (supporting organizations). A very important step for this component will be to identify, in a consensual and participative manner, 9-10 institutions/NGOs that have the potential to train and supervise local NGOs and associations that will be responsible for carrying out community interventions. IDA is conscious of the fact that even the capacities of these supporting organizations need to be strengthened. In particular, the personnel who conduct the training and supervision will need to be trained in accordance with the guides prepared for each essential activity, and those who are responsible for quality control of the delivered services will need to be trained in accordance with established protocols. At the end of the training, an exam will identify the best 5-10 institutions to serve as supporting organizations, taking into account the criteria defined during a consensus workshop on training and supervision. This selection will be based on three dimensions: (a) a technical dimension related to the essential or support activities the NGO will be concerned with; (b) a social dimension related to the priority vulnerable groups which need to be covered; and (c) a geographical dimension to ensure that all the neighborhoods of Djibouti-Ville and the districts of the country are covered. One supporting organization can cover several technical areas, or several vulnerable groups, or several districts, depending on its real capacities. Prior to effectiveness, the ES will prepare the Procedure Manual for Community Interventions. This manual will include procedures on programmatic and financial management for the interventions carried out by civil society and on project selection. The institutions wishing to apply to become supporting organizations, will need to submit to the ES projects which take into account the prerequisites stipulated in the Procedure Manual for Community Interventions. These prerequisites will concern: programmatic and financial management capacities; qualified human resources; and agreements of the local NGOs and associations with whom they intend to work with. The Procedure Manual for Community Interventions should be finalized in a consensus workshop organized in collaboration with the UN Agencies and in which all the ministries concerned with the control of HIV/AIDS, civil society, and other partners would participate. With regard to the identification of local sub-projects for community interventions for the first year of the project, it will be done in a realistic manner that will prioritize leaming and the capacity development of the personnel involved and quality control aspects. Coverage, which will be gradually increased, will not be a priority during the first year. On the basis of the analysis of the response carried out in 2002 and of the advice of the ES, it was agreed that about 30 community sub-projects will be formulated for 2004. These sub-projects will be implemented by 25 to 30 local NGOs and associations assisted by 5-10 supporting organizations, the -41 - Page 48 ministry dealing with the same vulnerable group and the Community Intervention Support Unit (CISU) of the ES . The preparation and selection process of community sub-projects to be financed by the project will be an annual process that will be carried out in each district (or neighborhood) under the responsibility and in close collaboration with the regional HIV/AIDS Councils. The sub-project will be identified and selected taking into account the essential activities necessary to reduce the vulnerability of priority groups in each neighborhood of Djibouti-Ville and district of the country. Annual regional workshops will be held by groups in each district of the country and neighborhood of Djibouti- Ville in order to identify portfolio of priority projects taking into account governmental interventions identified in sectoral plans. The “partnership tables” will underline the complementarity of the actions proposed by the local actors for each vulnerable group. The first regional workshops will be organized after the supporting organizations for the training and supervision of local NGOs and associations have been selected. The management staff of the supporting organizations, be they governmental or non-governmental, will participate as facilitators in the regional workshops. On the basis of the initial analysis of local NGOs and association capacity, the ES estimates that the following number of sub-projects could be developed per vulnerable group: (a) in the Addis-Djibouti corridor, 4 sub- projects for truckers, 3 sub-project for CSWs, 2 sub-projects for Nomads living along the corridor; (b) 2 sub- project for the dockers; (c) 2 sub-projects for other private sector workers; (d) 4 sub-projects for out of school youth; (e) 2 sub-projects for youth in school; 5 sub-projects for young women in difficulty; (0 2 sub-projects for young Khat users; (g) 3 sub-projects for immigrants/refugees; and one sub-project for street children. It has been agreed that these community sub-projects will cover about 14,000 vulnerable persons the first year. These sub-projects will also be complementary and in synergy with the sectoral interventions and that of the SPO. The implementation of these sub-projects will be monitored and supervised at the central level by the CISU in close collaboration with the person responsible for sectoral response within the ES and at the regional level with the supporting organizations, the HIV/AIDS regional committees, and the consultant to which M&E will be contracted out. The modalities of these arrangements will be defined in the Monitoring and Evaluation Plan. The financing of community sub-projects and contracts with supporting organizations will be carried out by the CISU in agreement with the Procedure Manual for Community Interventions. The mechanisms to channel finds from the CISU to communities were agreed upon during the appraisal mission. The selection of sub-projects will be carried out by an independent committee including an equal number of representatives of government, civil society, and donors. The selection modalities will be stipulated in the Procedure Manual for Community Interventions. Community response will be coordinated between associations and between the associations and the government in a partnership framework at the central level, the level of the neighborhoods, and the district level through the HIV/AIDS Regional Committees and the ES. Legal texts and simple partnership agreement letters will stipulate the right and duties of all the actors as required by the Procedure Manual for Community Interventions. - 42 - Page 49 I m d I 1 Page 50 Annex 3: Estimated Project Costs DJIBOUTI: HIV/AIDS, Malaria, and Tuberculosis Control Project Local US $million Project Cost By Component Foreign Total US $million US $million Capacity Building and Policy Development Public Health Sector Response to HIV/AIDS/STIs, Malaria, and Tuberculosis Multi-sector Responses for HIV/AIDS Prevention and Care Support to Community-Based Initiatives To .AI Project Corsl Total Financing Required Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs1 9.65 5.35 15.00 9.65 5.35 15.00 Total Financing Required Local US$ million 3 .OO 1.30 3.55 1.70 9.55 0.03 0.05 9.63 9.63 Foreign US$ million 1.90 2.20 0.18 0.88 5.16 0.12 0.09 5.37 5.37 Total US$ million 4.90 3.50 3.73 2.58 14.71 0.15 0.14 15.00 15.00 Project Cost By Category Goods Medical products Works Multisectoral Subprojects Community Subgrants Serviceslauditsltraining 0.80 0.00 0.25 3.20 1.30 4.10 1.70 0.20 0.75 0.00 0.40 2.30 2.50 0.20 1 .oo 3.20 1.70 6.40 Identifiable taxes and duties are 0 (USSm) and the total project cost, net of taxes, is 15 (US$m). Therefore, the project cost sharing ratio is 0% of total project cost net of taxes (the project is tax exempt). - 44 - Page 51 Annex 4: Economic Analysis DJIBOUTI: HIVIAIDS, Malaria, and Tuberculosis Control Project This Annex presents the main results of the economic analysis of the Djibouti HIVIAIDS project. We show that the project is likely to bring considerable benefits to the Djiboutian society by contributing to reduce HIV/AIDS prevalence rates and the associated economic costs. Conservative estimates put the net benefits of the project during the next 25 years between USD 50 and 60 million or close to 10 percent of today’s GDP’. The intemal rate of retum of the project is most likely in the 40-60 percent range. No large recurrent costs are expected. On the contrary, the project will reduce the pressure over the health budget. Indeed, the analysis estimates that in the absence of the project health expenditures related to HIV/AIDS could surpass 6 percent of GDP by year 2010. No large recurrent costs are expected from the project, and therefore there are no negative fiscal impacts. On the contrary, by reducing the HIV/AIDS prevalence rate the project will reduce the future pressure on the health sector budget. Nonetheless, the sustainability of the various interventions and therefore the full realization of the project’s benefits require progress in two areas. First, identifying appropriate mechanisms to supply and price condoms, ensuring that the public absorbs a fair share of the costs. Second, and more importantly, advancing the reform of the health sector. Financing mechanisms, budget process, and delivery systems need to be reviewed to improve the allocation of resources, reduce costs, and bring higher quality and access. In the absence of these reforms the health sector will not be able to sustain the public interventions necessary to keep the HIV/AIDS epidemic under control. The Annex is organized in four sections. Section 1 discusses the main channels through which the HIV epidemic can affect the economy. Section 2 briefly summarizes the rationale for public financing of the current project. Section 3 presents estimates of the economic costs of inaction. Section 4 illustrates how alternative project interventions could contribute to reduce HIV/AIDS prevalence rates, estimates associated benefits, and computes intemal rates of retum. Section 5 proffers the conclusion. 1. The economic impact of HIV/AIDS The economics of HIV/AIDS have been a fertile area of research during the last two decades. Several papers have attempted to provide estimates of the microeconomic and macroeconomic implications of the epidemic in various countries (see Robalino et al. 2002a and World Bank 2001 for a review). In general, there are three main channels through which the epidemic affects the economy. First, through higher mortality and morbidity among young adults in their most productive ages, HIV/AIDS reduces the productive capacity of a country. Premature deaths imply a reduction in the size of the labor force. Higher morbidity often implies lower productivity of the labor force, for instance, given higher labor tumover. Second, in the absence of appropriate risk management instruments, HIV/AIDS can hrther compromise the accumulation of human capital by increasing the number of Assumes a 10 percent discount rate. 1 - 45 - Page 52 orphans who are less likely to develop fully their physical and intellectual capacities2, and by forcing households to recur to welfare-decreasing coping mechanisms (e.g., reduction in food consumption, sending children to work). Third, the need to finance additional health expenditures and reallocate resources towards curative and preventive measures reduces economic efficiency and can slow the accumulation of produced capital. 0 Regarding the last point, the impact of the epidemics on the health system can vary widely from one country to another, depending on the type of technologies and services provided to HIV/AIDS patients. In general, however, the epidemic brings higher demand for health services, higher prices, and therefore higher expenditures. The macroeconomic consequences depend, in part, on how additional expenditures are financed. In the case of public expenditures, governments have the choice between increasing taxes, issuing debt, or simply reducing other types of expenditures (consumption or investment). For instance, higher expenditures in HIV/AIDS curative interventions could crowd-out other health or education expenditures (see Figure 1). Higher private expenditures could also be financed either by reducing savings3 or substituting consumption. If lower savings dominate, then new investments and growth would be compromised. In all cases, necessary adjustment to finance additional health expenditures are likely to be welfare decreasing. Efficiency losses may also result as private and public resources used to supply HIV/AIDS-related services are reallocated away from other more productive uses. Figure 1: Annual cost of treating an AIDS patient Vs. Annual cost of primary education by countries’ level of income 7000 L 6000 % 5000 4000 3000 h m & 2000 m 1000 0 400 1400 2400 3400 4400 Income per Capita ($) HIV/AIDS expenditures are a function of income per capita in $ (Y) are given by: Primary education expenditures as a function of income per capita in $ (Y) are given by: Source: Cyril10 et al. (2001), Floyd and Gilks (2001), World Bank (2002a). In Ea,dr = 0.6393 1 + 0.95 In Y In E,, = -3.3554 + 1.1589 In Y A recent analysis of the macroeconomic impact of the epidemic in countries in the Middle East and North Africa (MENA) region showed that the costs could be considerable, even if most countries, excluding Djibouti, still have low HIV/AIDS prevalence rates (World Bank, 2002~). The GDP growth rate for the period 2000-2025 could be reduced, on average by 0.27 percent per Research has shown that beyond the psychological impact, among low-income populations, the death of one parent is associated with a deterioration of nutritional status can lower school enrollment rates. (Ainsworth and Koda, 1993). See also Bell et al. 2002. Private savings can also be reduced if HIViAIDS increases discount rates, thus favoring present consumption. 3 - 46 - Page 53 year in Yemen and Jordan, to 0.36 percent in Lebanon, and over 1 percent in Djibouti. Lower economic growth would result in output losses for the period 2002-2025 equivalent to 31.4 percent of today’s GDP in Yemen, 36 percent in Algeria, 44.3 percent in Egypt, and over 100 percent in Djibouti. In year 201 5, HIV/AIDS-related health expenditures could average 1.2 percent of GDP. By year 2025, the labor force could be reduced by 2.5 percent in Yemen to 4 percent in Algeria and 22 percent in Djibouti. Thus, regardless of the distribution factors that affect the different countries’ vulnerability (differences in unemployment rates, the share of labor in total inputs, the growth rate of labor productivity), HIV/AIDS poses a serious threat. In low-income countries such as Djibouti, the epidemic is likely to severely jeopardize current strategies to reduce poverty. First, lower economic growth will reduce the number of people lifted out of poverty. Second, the economic impact of the epidemic is likely to be more severe among the poor. The non-poor can hedge their losses in wage income due to AIDS with other assets, but for the poor the main or only source of revenue is their labor force. Coping mechanisms for the poor are more limited and usually involve changes in consumption patterns (e.g., reducing education, food, and health expenditures) or sending children to work. These mechanisms result in human capital loss as a result, among others, of high child malnutrition or lower school enrollment rates. While in MENA countries informal coping mechanisms to manage risks are diverse - ranging from family support and kinship ties to religious charitable organizations - research has shown that they are usually insufficient to hedge against adverse shocks (World Bank 2002b). Studies show that reductions in consumption in low-income households following the death of an adult household member would reduce food expenditures by 32 percent and food consumption by 15 percent (Over et al., 2001). This occurs not only as household income is lost and funeral expenditures need to be financed (on average households spend 50 percent more, or $800-$900, on funerals than they do for medical care), but also because households that experience a death cut back on the number of hours they work for wages (Beegle, 1996). In most MENA countries the poor already face problems of access to health services. As health systems become financially constrained, these problems can be exacerbated. At the same time, the poor are more exposed to infectious diseases, and, complicated with under- nutrition, are more vulnerable to the deterioration of their immune system. 2. The role of the government Governments have a key role in developing and financing the implementation of policies to confront HIV/AIDS. Indeed, individuals alone cannot devise appropriate mechanisms to contain the epidemic. First, individuals do not take into account the social costs of the risks they take, or the social benefits of the preventive measure they adopt. In an unregulated market we would observe an excess of risky behavior and too little prevention from a social point of view. A second reason is information-related problems. Individuals may not have enough information about the risks of HIV and may lack knowledge and skills related to preventive behaviors. Finally, culturalheligious values may constrain individuals’ actions in ways that render them, and society, more vulnerable to HIV/AIDS. The role of governments in providing information and subsidizing interventions to reduce risky behaviors is therefore critical. Governments can only intervene, however, if there are cost-effective interventions at their disposal. Fortunately, international experience has demonstrated that this is the case with HIV/AIDS. Recent studies show that interventions that focus on reducing risks (through information and preventive behaviors and services) in those population groups most likely to contract and spread HIV can be highly cost-effective (Jenkins et al., 2001a, Kahn, 1996). Interventions such as reproductive health and HIVIAIDS education in schools, targeted treatment - 47 - Page 54 of sexually transmitted infections (STIs) for highly vulnerable groups, and reduction of infection by intravenous drug use (IDU) have also proved to be cost-effective (Jenkins et al., 2001b). As discussed intensively in Kremer (1996a, 1996b), the social benefits from obtaining treatment for sexually transmitted diseases, condom distribution, are likely to be many times the private benefits. To implement these interventions several instruments are available including direct provision of services and of information, subsidies, taxes, and regulatory power. In general, early interventions bring higher benefits and lower costs, both economic and social. Previous MENA Country studies have looked at the impact of increasing condom use by 30 percent and expanding access to safe needles for IDUs by 20 percent (World Bank, 2002~). The results showed that these two interventions can considerably reduce GDP losses for the period 2002-2025 from an average of 5 percent of today’s GDP in the case of Yemen to over 70 percent in the case of Djibouti. Across all MENA countries savings (net of the costs of the interventions) could average 20 percent of today’s GDP. On average, this translates to an increase of 0.2 percentage points in the yearly GDP growth rate. Not surprisingly, waiting to intervene can cost countries an average of 6 percent of today’s GDP (20 percent in the case of Djibouti). Hence, the Government of Djibouti is taking an important step forward by preparing the current HIV/AIDS project. In the following sections we discuss the costs for the Djiboutian society of not implementing the project, as well as the net benefits from its implementation. 3. The costs of inaction in Djibouti A nationally representative zero-prevalence survey conducted in March 2002 as part of the preparation of this project reveals an HIV/AIDS prevalence rate of 2.9 percent (CREDES, 2002). In the city of Djibouti the prevalence rate is higher (3.4 percent), while in the remainder of the country it is close to one percent. In the city of Djibouti the prevalence rate among men (3.1 percent) is slightly lower than among women (3.4 percent). Risks are higher among young adults in their most productive years (age 25 to 34). The probability of infection among this group is three to four times higher than that of individuals younger than 20 or older than 35. Four important risk factors for the development of a major epidemic are present: 1. Large population flows are observed between Djibouti and Ethiopia, where the adult prevalence rate is close to 11 percent, as a result of migration and transportation activities (close to 1,000 trucks enter and exit Djibouti port on a daily basis). 2. Prostitution is widespread, and the use of condoms is rare. A survey conducted in 1994 among men suffering STIs showed that 57 percent of men did not know their partners and that 53.8 percent had had rapports with sexual workers (see Ministry of Health, 2002). Yet, only 2.5 percent of them had used condoms. The strong foreign military presence contributes to the development of night-bars where the majority of sex workers operate. Condoms are not readily available and are expensive. 3. While an exact estimate is not currently available, there is evidence that the prevalence of STIs is high. Close to 8,500 new STI cases are reported each year (Ministry of Health, 2002). However, most patients suffering from STIs, particularly women, do not consult a health professional. Hence, it is estimated that there are currently 25,000 STI cases. Assuming that these occur in the population 15-49, the implied prevalence rate is close to 10 percent. 4. High poverty rates combined with income and gender inequality create an ideal environment for the diffusion of the epidemic. Indeed, two studies (Over, 1997 and World Bank 2002c) have shown that other things being equal, HIV/AIDS prevalence rates increase when income per capita decreases, and when income and gender inequality - 48 - Page 55 (proxied by the gap between male and female literacy) increase. In Djibouti, despite a relatively high GDP per capita (US$800) compared to countries such as Yemen (US$320) and Ethiopia (US$1 lo), 40 percent of the population is considered poor. With a Gini coefficient of 39, Djibouti is one of the countries with the highest concentration of income in the MENA region. Gender inequalities also seem to be pervasive. Women have a low participation rate in the labor force and a lower level of education than men (60 percent of women aged 20-29 never attended school compared to 30 percent for men). Population group Children and youth To evaluate the economic costs related to HIV/AIDS in Djibouti, we use a modified version of the model developed in Robalino et al. (2002a) to generate plausible diffusion scenarios for the HIV/AIDS epidemic in Djibouti and estimate associated costs. The original model simulates the diffusion of the epidemic through two channels: sexual intercourse (which takes into account the prevalence of sexually transmitted diseases) and exchange of infected needles among injecting drug users. While the model is highly stylized, it is able to capture key features of the diffusion process. In the version used here we have ignored transmission through needle exchange, which is irrelevant in the case of Djibouti, and added mother-to-child transmission as an additional mechanism. We have also left out the macroeconomic module of the original model. Thus, the analysis presented here is not a general equilibrium analysis. We focus on estimating three categories of costs: i) treatment of AIDS patients (public and private costs); ii) costs of antiretroviral drugs; iii) other costs faced by households foregone revenue from higher morbidity and funeral costs); and iv) costs related to the years of life lost due to premature deaths. We do not assess how alternative financing mechanisms affect the dynamics of the economy and social welfare (see Robalino et al., 2002a and Robalino et al., 2002b). We also ignore the effects of the epidemic on total factor productivity, the accumulation of human capital, and economic growth. Hence, our estimates of costs can be considered as a lower bound (see World Bank 2000, for a similar approach). Share in Prevalence 2002 rate 47.3% 0.25% Methods and assumptions We divide the Djiboutian population into four groups: (1) children and youth-age 0 to 14; (2) males-age 15 to 49; (3) women who do not engage in sexual work-age 15 to 59, and (4) women who engage in sexual work-age 15 to 40. The share of each population group is given in Table 1. The total population evolves on the basis of age- and sex-specific fertility and mortality rates, which have been projected by the World Bank Health, Nutrition, and Population group (see Figure 2). The total population in year 2002 is estimated at 658,000. In the absence of HIV/AIDS, fertility rates and mortality rates would be expected to decline, thus increasing the share of the population over age 23 (see Figure 3). From the projections of the total population by age and sex, the composition of our four subgroups follows naturally if we assume a constant share of sex workers in the female population. This share is more or less arbitrary, since surveys of sex workers have not been conducted yet. We estimate that there are close to 4,000 sex workers in Djibouti, which seems a conservative number given the large number of night-clubs in the city of Djibouti and the important foreign military presence4. Keeping the demand constant, a small population of sex workers speeds-up the diffusion of the epidemic. - 49 - Page 56 Males (15-49) Sex workers Females (14-49) Figure 2: Fertility and Mortality Rates by Year 25.49% 3.1% 26.51% 3.4% 0.67% 10% ~ 0 IO 20 30 40 50 60 70 go// 0 IO 20 30 40 50 60 70 84 Source: World Bank 2002. Figure 3: Population dynamics in the absence of the HIV/AIDS I 13 8 fitrentage2 7 12 Souiw: Atitlior's calculations. The model tracks prevalence rates in each of the four population groups. The diffusion of the epidemic depends on four sets of parameters5: 0 the heterogeneity and frequency of sexual interactions between groups 2-3 and 3-4 0 the prevalence of STIs (only considered for the population as a whole) 0 the probability of transmission of the virus with and without STIs the prevalence of condom use and the effectiveness of condoms in preventing the transmission 0 the probability of transmission from mother-to-child in the absence of any intervention. To distribute new infections by age we take into account CREDES' (2002) estimates of risk (see Table 2). Hence, total new infections within group i, at time t attributed to age a are given by: " ... f pop,", .risk" 'i newInA; = newInji,, e .>. IF pop:, .risk" where newInA.,, are the total number of new infections in group i at time t, and popz:, is the total population of age a, in group i at time t. See Robalino et al. 2002a for a formal description of the model. 5 -50- Page 57 Table 2: Risk factors >34 25-29 3.32 1 Non-STIs STIs -GUD STIs non-GUD Both [85%,90%,95%,100%] 25% 50% 25% Transmission probabilities Non-STIs STIs -GUD STIs non-GUD Both Male-to-Female 0.2% 4% 2% 4 % Female-to-Male 0.1% 2 Yo 1% 2% (Yo STIS) (Yo STIS) Prevalence STIs (percent population 15-49) (% STIs) Mother-to-Child 30% 30% 3 0% 3 0% Level and heterogeneity of sexual activity. Given scant information about sexual behaviors, the parameters determining the level and heterogeneity of sexual activity have been calibrated on the basis of Rehle et al., (1998) and anecdotal facts. Table 3 presents the average number of partners across population groups and the average number of sex acts per year. It is assumed that, on average, males have two female partners who are not sex workers, with an average of 30 sex acts per year with each partner. Moreover, the average male frequents eight to ten sex workers per year with an average number of sex acts of two to three per year with each partner. Quat consumption stimulates the demand for commercial sex. Table 3: Average number of partners and sexual intercourse per year Partners Males F e m a 1 e s Sex workers Males 0 2 iS,lOl Females endogenous 0 0 Sex workers endogenous 0 0 Males 0 30 12731 Females 30 0 0 Sex workers [2,31 0 0 Contacts Males Females Sex workers Parameters labeled endogenous are calculated to ensure intemal consistency. Basically that the total number of sexual acts by males is equal to the total number of sexual acts by females. Source: Based on Rehle et al. (1998). Prevalence of STIs and transmission probabilities. As previously discussed, there are no good data regarding the prevalence of STIs. To illustrate the importance of this variable on the diffusion of the epidemic we work with four values: 0 percent, 5 percent, 10 percent, and 15 percent. The current estimate is closer to 10 percent of the population aged 15 to 49. Transmission probabilities by sex are based on Rehle et al. (1998). The values of the different parameters are summarized in Table 4. Source: Based on Rehle et al. (1998) and discussion with technical staff at the Ministry of Health in Djibouti Use of condoms and effectiveness. We differentiate between the utilization of condoms in groups 2-3 (men having sex with non-sex workers) and 2-4 (men having sex with sex workers). - 51 - Page 58 The data on utilization are also weak, but it is very unlikely that condoms are being used between spouses, and the utilization of condoms with sex workers or unknown partners seems to be considerably low (below 2.5 percent according to Ministry of Health, 2002). Nonetheless, we take a conservative approach and consider the following three cases for the prevalence of condom use between groups 2-3 and 2-4: low-case (2.5 percent and 5 percent), base-case (5 percent and 7.5 percent), and high-case (5 percent and 10 percent). The effectiveness of a condom is assumed to be 98 percent (Le., the probabilities of transmission presented in Table 4 are reduced by 98 percent). Costs. The final ingredient for the analysis is the cost of various factors associated with the epidemic. As previously discussed, we look at four types of costs: costs of treatment excluding antiretroviral drugs (public and private); cost of antiretroviral drugs; other costs for households (foregone revenue and funerals); and the cost of years of life lost. The various assumptions are summarized in Table 5. Costs of treatment excluding Antiretroviral (AR y) drugs. In terms of treatment, no reliable data are available in the case of Djibouti, although it is known that expenditures focus on opportunistic diseases. A 1996 report of the Ministry of Health states that 12 percent of infectious diseases in the Peltier Hospital were attributed to AIDS. Furthermore, eight percent of registered deaths were caused by the AIDS6. However, there are no data regarding the operational costs of the hospital. Thus, in our analysis we rely on estimates from the literature. The average cost of treatment estimated from cross-country studies ranges between two and three times GDP per capita (see Floyd and Gilks, 2001). The economic analysis of the Chad Second Population and AIDS Project suggests an average annual cost of US$560 for Chad, and cites an average cost of US$125 for Cote d’Ivoire (see World Bank, 2000). Here we consider three plausible values for the annual cost of treatment: US$lOO, US$300, and US$500. Costs of Antiretroviral (ARV) drugs. ARVs are almost nonexistent in Djibouti at the moment. A few AIDS patient are buying ARVs privately and a few others, no more than 100 patients, are treated with extemal funds. Hence, roughly 0.5-1 percent of all patients have access to ARVs. The cost of antiretroviral drugs is estimated at US$80-100 per month per patient, including the tests necessary to follow-up the patient. In our analysis we use a conservative figure of US$l,OOO per year per patient. We assume that individuals receiving ARVs face mortality rates equal to those of individuals who are not infected with HIV. The simulation program keeps track of the number of individuals by age and sex who are receiving ARVs at a particular point in time. This is like to be a underestimation given that most many deaths are registered are caused by opportunistic 6 infectious, even though the primary cause is AIDS. - 52 - Page 59 Treatment Antiretroviral drugs Forgone revenue for households Funerals cost (US$) [100,300,500] 1,000 [50,150,250] 200 Costs to households in foregone revenue and funeral expenditures. Another source of uncertainty regarding costs relates to the level of foregone revenue due to sickness and the cost of funerals. The economic analysis of the Chad's Second Population and AIDS project (see World Bank, 2002) reports that AIDS patients loose on average 17.4 days of work per month, compared to 2.1 days for non-AIDS patients (more than a 50 percent loss). Expenditures for funerals represented twice the monthly income. In the case of Tanzania, Over et al., (2001) reports funeral expenditures of US$800-900. In this analysis we use three values for the foregone revenue: 10 percent, 20 percent, and 50 percent of average income in the formal sector (US$500 per year according to the databases of contributors of private workers pension funds). The cost of funeral expenditures has been fixed at US$200. Memo item GDP per capita (USD) Total GDP growth (percent per year) Discount rate Cost related to the years of life lost due to premature death. We compute these costs under the assumption that individuals work only until age 50 and that each year is valued by GDP per capita (our proxy for the marginal product of labor). We have: 860 1 % (real) 10% (real) 2 49 49 CostYOL, = AIDSdeathsp" .y, .E (1 - m::(k-al s=l a=l k=a where t is time, a is the age of the individual when dying at time t, s is the sex of the individual, y is the marginal product of labor, m: is the mortality rate of an individual of age k and sex s at time t, g is the growth rate of GDP per capita (one percent per year), and r is the discount rate (10 percent per year). Projections of the HIV/AIDS prevalence rate Our assumptions about the parameters determining the difhsion of the epidemic outline 48 scenarios: four combinations of parameters determining the heterogeneity and frequency of sexual acts (Table 3); four values for the prevalence of STIs (Table 4), and three cases for the prevalence of condom use (see paragraph use of condoms and effectiveness). All the other parameters determining the diffusion of the epidemic (e.g., the probabilities of transmission) are kept constant across scenarios. Not all of the scenarios resulting from the various combinations of parameters are equally likely. For instance, the prevalence of STIs in Djibouti is definitely higher than zero. Nonetheless, by exploring this wide range of scenarios we are able to illustrate the importance of the different parameters in determining the dynamics of the epidemic. Below we present the main messages from the analysis. In what we consider the baseline scenario, the HIV/AIDS prevalence rate in Djibouti could attain 10 percent of the population aged 15 to 49 by year 2010. In this scenario, the average number of sexual partners who are sex workers is set to eight per year and the average number of sexual acts to two per year per partner. The prevalence of STIs is set at 10 percent (close to current estimates), and the prevalence of condom use at 2.5 percent among groups 2 and 3, and 5 percent among groups 2 and 4. All the other parameters - 53 - Page 60 are set at the values indicated in Tables 2 to 3. Under this scenario, the HIV/AIDS prevalence among sex workers could reach 60 percent by year 2012 (see Figure 4). New infections per year could grow from close to 3,000 per year today to 10,000 in year 2010. Figure 4: Prevalence rate and new infections in baseline scenario i ___--- no D' 2001 2008 2012 2016 2020 2024 2028 IE YeOI Yeor Average number of sexual workers partners is set to 8. Average number of contacts per partner (sex worker) is set to 2 per year. Prevalence of STIs is set at 10 percent. Prevalence of condom use is set at 2.5 percent among groups 2 and 3, and at 5 percent among groups 2 and 4 (men with sex workers). Source: Authors' calculations. A key factor determining the evolution of the epidemic is the prevalence of STIs. If in the previous scenario the prevalence rate was 0 percent instead of 10 percent, the HIVIAIDS prevalence rate would remain below 10 percent of the population aged 15-49 (see Figure 5). The prevalence rate among sex workers would decrease slightly. This occurs because the probability of infection in the presence of an STI is 10 to 30 times higher than without an STI. These results show the importance of treating STIs, particularly among sex workers (see next Section). Small changes in the use of condoms have little incidence in the dynamics of the epidemic. For instance, if in the first scenario the prevalence of condom use increased from 2.5 percent to 5 percent among groups 2 and 3, and from 5 percent to 7.5 percent among groups 2 and 4, the prevalence rate in year 2010 would be reduced by less than one percentage point (see Figure 6). Hence, our current uncertainty regarding the use of condoms, 0 to 5 percent, does not affect considerably our estimates of future prevalence rates. This being said, however, larger changes (in the order of 20 percentage points) in the prevalence of condom use can have dramatic impacts on the diffusion of the epidemic (see next Section). The heterogeneity and frequency of sexual acts are also key factors influencing the dynamics of the epidemic. If in the first scenario the average number of partners who are sexual workers increased from eight to ten and the average number of contacts from two to three per partner, then the HIV/AIDS prevalence in year 2010 could attain 20 percent (see Figure 7). Thus, as discussed in the next section, interventions that promote changes in sexual behaviors are essential components of a strategy to fight the epidemic. - 54 - Page 61 Figure 5: Prevalence rate and new infections with no STIs. _-------.?-__-_______ 0 200' 2008 2012 2015 2020 2024 2028 Yeor Average number of sexual workers partners is set to 8. Average number of contacts per partner (sex worker) is set to 2 per year per partner. Prevalence of STIs is set at 0 percent. Prevalence of condom use is set at 2.5 percent among groups 2 and 3, and at 5 percent among groups 2 and 4 (men with sex workers). Source: Authors' calculations. Figure 6: Prevalence rate and new infections with Spercent and 7.5percent prevalence of condom use among groups 2 and 3, and 3 and 4 respectively Year Yeor Average number of sexual workers partners is set to 8. Average number of contacts per partner (sex worker) is set to 2 per year. Prevalence of STIs is set at 10 percent . Prevalence of condom use is set at 5 percent among groups 2 and 3, and at 7.5 percent among groups 2 and 4 (men with sex workers). Source: Authors' calculations. Figure 7: Prevalence rate and new infections with higher heterogeneity and frequency in sexual acts , 2004 2008 2012 2016 2020 2024 2028 .c 0 It ,_---- "I ci , D / 2004 2008 2012 2016 2020 2024 2028 ___---- __.._---__._ __._..--.__. 0-q' " - ' Year Year Average number of sexual workers partners is set to 10. Average number of contacts per partner (sex worker) is set to 3 per year. Prevalence of STIs is set at 10 percent. Prevalence of condom use is set at 2.5 percent among groups 2 and 3, and at 5 percent among groups 2 and 4 (men with sex workers). Source: Authors' calculations. In conclusion, the combination of an already important HIV/AIDS prevalence rate, the high prevalence of STIs, widespread commercial sex, and virtually no condom use sets the ideal conditions for the development of a major epidemic in Djibouti. In the next section we look at the potential costs of this epidemic. - 55 - Page 62 Potential costs To illustrate the magnitude and dynamics of various costs, we use the baseline scenario discussed in the previous section7. We look at nine costs scenarios combining three values for the cost of treatment (mostly treatment of opportunistic diseases) and three values for the level of foregone revenue of HIV/AIDS patients. We keep constant across scenarios the cost of funerals. Given that the use of ARVs is marginal the associate costs are not included in this part of the analysis. We find that even in the case of the most conservative scenario (cost of treatment excluding ARVs equal to USD 100 per year and forgone revenue equal to USD 50 per year), the total costs of the epidemic, excluding the years of life lost, would approximate two percent of GDP per year. In addition, the costs of years of life lost could represent 10 percent of GDP by year 2010 and exceed 20 percent by year 2020 (see Figure 8). With more realistic assumptions about costs (Le., treatment costs USD 300 per year and HIV/AIDS patients forego USD 150 per year), the costs of the epidemic (excluding years of lost life) could surpass four percent of GDP by year 2010, and peak at six percent of GDP by year 2015 (see Figure 9). If the cost of treatment approximated USD 500 per year and the revenue foregone due to the disease was closer to USD 250 year, then costs by year 2010 would surpass eight percent of GDP (see Figure 10). Our calculations of internal rates of return presented in the next section, however, look at the universe of 7 epidemiological scenarios. - 56 - Page 63 Figure 8: Total costs under low unit cost 0 - 5 a 0. 0 -: 0" -. a- x- 0 28 - Tola0 CO4, 1 rico,mcn, __ --- ~ :y,,---? r I I / , Cost of treatment excluding ARVs (mostly opportunistic infections) set equal to USD 100 per year. Forgone revenue set at USD 50 per year. Source: Authors' calculations. Figure 9: Total costs under average unit costs Figure 10: Total costs under high unit costs i D 5' z00n ' 2008 ' 2012 ' 20'6 ' 2020 ' 2024 ' ,,!, Yea- Cost of treatment excluding ARVs (mostly opportunistic infections) set equal to USD 500 per year. Forgone revenue set at USD 250 per year. Source: Authors' calculations. In summary, the epidemic will impose large costs on the Djiboutian society. The cumulative costs of treatment and foregone revenue for the period 2002-2028 could range between 12 and 57 percent of current GDP (see Table 6). The 12 percent figure corresponds to very conservative assumptions about unit costs. Most likely, the average cost of treatment and the average foregone revenue will be above USD 300 and USD 150, respectively. Cumulative costs then would be over 30 percent of current GDP. If on top of that we add the cost of years of life lost due to premature deaths (22.4 percent in year 2015), the present value of aggregate costs could represent several times today's GDP. -57- Page 64 Table 6: Summary of the costs of the epidemic under the status-quo Treatment Forgone Total Costs of Present value ARVs (USD (USD per (YO GDP (YO GDP and funeral Years of life lost (YO today's per year) year) 2015) 2015) (Yo GDP 2015) (Yo GDP 2015) GDP) 100 50 1.7% 1 .O% 0.7% 22.4% 12.6% 100 150 2.7% 1 .O% 1.7% 22.4% 20.1% 100 250 3.7% 1 .O% 2.7% 22.4% 27.5% excluding revenue costs treatment Forgone revenue costs 2002-202s 250 50 3.7% 2.9% 0.7% 22.4% 27.5% 250 150 4.6% 2.9% 1.7% 22.4% 34.9% 250 250 5.6% 2.9% 2.7% 22.4% 42.4% 500 50 5.6% 4.9% 0.7% 22.4% 42.4% 500 150 6.6% 4.9% 1.7% 22.4% 49.8% 500 250 7.6% 4.9% 2.7% 22.4% 57.2% The cost of treatment in the table reflects mostly expenditures related to the treatment of opportunistic diseases. Source: Authors' calculations. 4. The net benefits of the project Not all the interventions supported by the project can be easily evaluated in monetary terms; for instance those related to community projects. Here we focus on three core preventive interventions: i) increasing the prevalence of condom use; ii) treating STIs; and iii) changing sexual behaviors. In addition we assess the economic and epidemiological consequences of providing access to ARVs. To illustrate economic costs and benefits, we have defined a few conservative targets for the various interventions. Given the project budget, USD 12 million, we compute internal rates of return (IRR) across a large number of epidemiological and economic scenarios. It is expected that this analysis will guide the allocation of project resources. Impact of selected interventions Increasing condom use to 50 percent of sexual acts with sex workers and to 25 percent of sexual acts with non-sex workers. If these targets are achieved, the number of new infections each year could be reduced by 30 to 60 percent from the baseline (see Table 7). In the case of the baseline scenario 2,300 infections could be averted in 2005 and over 10,000 infections by 2025. These targets imply that additional 3 to 4.3 million condoms will be consumed each year, costing US$2.2 to 3.2 million. The project will finance initially (Le., during the first four years) part of these costs, but mechanisms for a more sustainable delivery of condoms are necessary. Further analyses are required, for instance, to establish the viability of social marketing in Djibouti. - 58 - Page 65 Table 7: Impact of alternative project interventions 2002 2005 2010 2015 2020 2025 Status-quo Prevalence 3.3% 5.8% 12.2% 17.9% 22.8% 26.4% New Infections 3,176 5,264 10,069 13,240 15,155 15,640 Deaths due to HIViAIDS 1,108 5,104 8,332 12,048 14,681 1. Infections averted from condom intervention (increase use to 25% among non-sex workers and 50% among sex workers) - Prevalence with intervention 3.3% 4.5% 6.4% 6.7% 7.1% New infections with intervention 2,181 2,920 4,181 4,577 5,088 Number of condoms 3,105,000 3,316,648 3,654,138 3,959,239 4,202,566 Cost of condoms (USD) 2,328,750 2,487,486 2,740,604 2,969,429 3,15 1,924 Infections averted 995 2,344 5,888 8,663 10,067 Condoms per infection 3,121 1,415 62 1 457 417 Direct cost per infection (USD) 2,34 1 1,06 1 465 343 313 Deaths due to HIViAIDS 1,108 3,658 3,783 4,286 Lives saved 1,447 4,549 7,762 Cost per life saved (USD) 1,895 653 406 2. Infections averted from change in sexual behavior (halve the number of partners who are sexual workers) Prevalence with the intervention 3.3% 4.8% 7.5% 8.7% New infections with the intervention 2,393 3,078 5,065 6,050 Infections averted 783 2,187 5,004 7,190 Deaths due to HIViAIDS 1,108 3,562 4,190 Lives saved 1,542 4,142 3. Infections averted by reducing the prevalence of STIs by 2/3 Prevalence with the intervention 3.3% 4.6% 6.7% 7.2% New infections with the intervention 2,224 3,012 4,425 4,966 Infections averted 952 2,252 5,643 8,274 Deaths due to HIViAIDS 1,108 3,710 3,963 Lives saved 1,395 4,368 4. Effects of the distribution of anti-retrovirus to 20% of new infected HIV patients Prevalence rate New infections Costs ARVs (USD) Deaths due to HIV/AIDS Lives saved Cost per life saved (USD) 5. Interventions 1 to 4 together Prevalence with the intervention New infections with the intervention Infections averted Deaths due to HIViAIDS Lives saved 6. Interventions 1 to 3 together Prevalence with the intervention New infections with the intervention Infections averted Deaths due to HIViAIDS 3.3% 3,176 3.3% 1,27 1 1,904 3.3% 1,271 1,904 5.8% 5,264 4103 13 1,108 3.5% 1,367 3,897 1,108 3.5% 1,367 3,897 1,108 12.4% 10,179 884,677 4,305 799 1,107 3.0% 1,234 8,835 2,204 2,901 3.0% 1,213 8,856 2,478 19.7% 14,25 1 1,402,525 6,670 1,66 1 844 1.9% 839 12,401 1,05 1 7,280 1.5% 665 12,575 1,311 10.2% 7,321 7,834 5,630 6,417 7.8% 5,588 9,567 4,625 7,423 27.9% 17,3 82 1,978,894 10,157 1,891 1,047 1.6% 768 14,386 694 11,354 0.0% 15,155 308 1 1.740 7.6% 5,604 4,378,856 3,284,142 10,036 436 3 27 4,897 9,783 336 11.8% 8,5 17 7,122 6,883 7,791 8.5% 6,157 9,483 5,363 9,318 36.0% 18,770 2,626,340 13,223 1,457 1,802 1.6% 816 14,824 622 14,059 0.0% 15,640 ILives saved 2,627 7,021 14,681 Source: Authors’ calculations. Reducing by half the average number of sexual partners who are sexual workers. This intervention could avert 2,100 new infections in year 2005 and up to 7,000 infections by year 2025. To achieve this target, the project will allocate resources to support community development to provide other income-generating activities to sex workers and to carry out information campaigns about the risks of engaging in sex work. While the effectiveness of these interventions remains unknown, the importance of the demand for commercial sex in determining the dynamics of the epidemic justifies allocating project resources on a pilot basis. - 59 - Page 66 Reducing by two-thirds current prevalence of STIs. This intervention could also avert 3,000 infections in year 2005 and close to 7,000 new infections by year 2025. At this stage, the costs of treatment of various STIs in Djibouti are not available. Nonetheless, in other countries, studies have demonstrated the cost-effectiveness of this intervention (see Jenkins et al., 2002 for a discussion). Thus, this project will allocate an important share of resources to increase access to treatment and ensure the availability of the necessary medical inputs and drugs. Providing access to antiretroviral drugs. While the demand for antiretroviral drugs in Djibouti is high, our analysis suggests that the costs of the intervention would not be affordable. The current annual cost of ARV drugs (US$l,OOO) is over 10 times the current level of per-capita expenditures in health. As an illustration, providing access to ARVs to 50 percent of current HIV/AIDS infected individuals would initially cost USD 5.5 million. Hence, the project could finance roughly two years of drugs. We have simulated the economic and epidemiological impacts of providing access to ARVs to 20 percent of newly infected patients. Our results show that, due to the fact that individuals receiving ARVs continue to be infective, in the absence of other interventions, providing access to ARVs could increase the prevalence rate (see Table 7). This relatively modest intervention in terms of outreach, would still cost over US$1 million per year. More importantly, the cost of each life saved using this strategy would increase over time reaching 1,800 per life saved in year 2025. This is in contrast to the expansion in the prevalence of condom use, where the cost per life saved decreases over time reaching US$336 in year 2025. With this consideration, the current project will minimize the level of resources that are allocated to ARV. Instead, the focus in the area of treatment will be in enforcing institutional capacity of the health centers receiving HIV/AIDS patients. Implementing simultaneously the three preventive interventions. Our results show that the combined preventive interventions could significantly reduce, and almost eliminate, the HIV/AIDS prevalence rate over the next 25 years. The number of new infections averted could increase from 1,300 in year 2005 to over 15,000 in year 2025 (see Table 7). We notice that when combining the preventive interventions with the provisions of ARVs, the HIV/AIDS prevalence rate over the long-run remains at 1.6 percent of the population aged 15-49. Again, this is because of individuals who continue to display risky behaviors can be infective over longer periods of time. Inevitably therefore, to the benefits of the years of life gained through the use of ARVs, policy makers need to subtract not only the costs of the treatment itself, but also the costs associated with a potentially higher HIV/AIDS prevalence rate. To minimize these costs, when ARVs are used patients should be carefully monitored and counseling used to promote safe sexual behaviors. The potential net benefits of the project and its financial sustainability. The project has a total cost of US$12 million, over a period of four years. If the project is able to achieve simultaneously the targets defined in the previous section (except for the distribution of ARV drugs), the present value of net benefits for the period 2003-2027 would approximate 10 percent of today’s GDP. The project generates high intemal rates of return (IRR) across a large number of scenarios (see Figure 11). In the two panels of Figure 1 1 each bar is associated with a given intemal rate of return (IRR). The height of the bar represents the number of explored scenarios that generate that particular IRR. We observe that even as early as year 2008 the IRR of the project would be positive in most cases. The few instances where internal rates of return are negative refer to scenarios with low unit costs and low levels of sexual interaction. By year 2025, none of the scenarios would generate negative IRRs and in most cases the IRRs would be above 30 percent. Hence, the economic rationale for the project is very strong. - 60 - Page 67 Figure 11: Project Internal Rates of Return in Years 2008 and 2025 for various epidemiological and economic scenarios 0, I 0, I IRR year 2008 Source: Authors’ calculations. IRR yeor 2025 Clearly, the financial sustainability of the various interventions is today at risk. While the government should not aim at subsidizing in full condoms and ARVs, a minimum budget is necessary to sustain community interventions, screening and monitoring systems, and information campaigns. Given the current financial crisis of the health sector, the necessary resources are not likely to be available over the medium-term without donor support. The financial crisis of the health sector reflects not only inappropriate financing mechanisms, but also low levels of technical and allocative efficiency. The very high costs of medical inputs and in particular drugs, is an illustration of the problem (see CREDES 2002). It is expected that the Health Sector Reform Project will address these problems. The project will not only to review financing mechanisms, but also seeks to rationalize the budget process to improve the allocation of resources across levels and types of interventions. Introducing these reforms is a pre- condition for the success of the current project. 5. Conclusions This short note presents the results of the economic analysis of the Djibouti HIV/AIDS project. The note discusses the mechanisms through which the epidemic can affect the economy and provides justifications for government intervention. Projections of the HIV/AIDS prevalence rate in the absence of changes in the sexual behaviors are developed. These projections are based on a model that simulates the diffusion of the epidemic through two channels: sexual intercourse and mother-to-child transmission. Given limited epidemiological and behavioral data, the analysis explores large regions of the parameter space. We find that even under conservative assumptions about the heterogeneity and frequency of sexual acts, the prevalence of STIs, and the use of condoms, Djibouti could experience a major HIV/AIDS epidemic. In the baseline scenario the HIV/AIDS prevalence rate could attain 10 percent of the population aged 15-49 by year 2010. In more pessimistic scenarios the prevalence rate could attain 20 percent. The economic costs of the epidemic are considerable. In the baseline scenario, the costs of treatment (excluding ARVs) and the foregone revenue of individuals affected by the epidemic could surpass six percent of GDP by year 2010. The cost of the years of life lost due to premature deaths could exceed 30 percent by year 2010. These are considered low-end estimates as the analysis ignores the impact that the epidemic can have on the accumulation of human capital, total factor productivity, and through this channel economic growth. Indeed, previous analyses have shown that the HIV/AIDS epidemic could reduce the growth rate of GDP in Djibouti by at least one percentage point. - 61 - Page 68 In a second part the note discusses the impact of three core interventions targeted by this program: increasing the use of condoms; reducing the prevalence of STIs; and changing sexual behaviors to reduce the demand for commercial sex. The results of the analysis show that these interventions can have dramatic effects on the dynamics of the epidemic. Individually, each of these interventions has the potential to reduce new infections by 30-60 percent per year. The project can be of great benefit to the Djiboutian society. If the targets of the project are achieved, the present value of net benefits for the period 2002-2028 can surpass 10 percent of today’s GDP. Across a large number of scenarios the internal rates of retum of the project are positive starting in year 2008. By year 2025 internal rates of retum surpass 30 percent in most cases. No large recurrent costs are expected, and therefore there are no negative fiscal impacts. On the contrary, by reducing the HIV/AIDS prevalence rate the project will reduce the pressure on the public health budget. Nonetheless, the sustainability of the various interventions and therefore the full realization of the project’s benefits require progress in two areas. First, identifying appropriate mechanisms to supply and price condoms, ensuring that the public absorbs a fair share of the costs. Second, and more importantly, advancing the reform of the health sector. Financing mechanisms, budget process, and delivery systems need to be reviewed to improve the allocation of resources, reduce costs, and bring higher quality and access. In the absence of these reforms the health sector will not be able to sustain the public interventions necessary to keep the HIV/AIDS epidemic under control. - 62 - Page 69 References: Ainsworth, M. and Koda, G. 1993. The impact of adult deaths from AIDS and other causes on school enrollment in Tanzania. Paper presented at the Annual Meetings of the Population Association of America. Cincinnati, Ohio. Beegle, Kathleen. 1996. The impact of prime-age adult mortalitv on labor suuuly. Michigan State University, East Lansing. Bell Clive, Devarajan Shanta, and Gersbach Hans. 2002. The Economic Impact of Health Shocks on Growth. Washington DC. CREDES.2002, RCsultats Enqdte Nationale seroprCvalence VM en RCpublique de Diibouti. CREDES. Cyrillo, D., Paulina, L. and Aguirre, B. 2001 Direct Costs of AIDS Treatments in Brazil: A Methodological Comuaraison. Mimeo. UNAIDS Home Page. Floyd, K. and Gilks, C. 2001 Cost and Financing Aspects of Providing Anti-Retroviral Therapy: A Background Paper. Mimeo. UNAIDS Home Page. Jenkins, C., Ahmed, Shale, Rahman, Habibur, and Faisal, M.M. 2001a Male prostitutes in Dhaka: risk reduction through effective intervention. Paper presented at Intemational Conference on AIDS in the Asia-Pacific, Melbourne. Jenkins, C., Rahman, H., Saidel, T., Jana, S., and Hussain, A.M.Z. 2001b Measuring the impact of needle exchange programs among iniecting drug users though the National Behavioral Surveillance in Bangladesh. AIDS Education and Prevention. Kahn, J. 1996 The cost-effectiveness of HIV-prevention targeting: how much more bang for the buck? Amer J Public Health. Kremer M. 1996a. AIDS: The Economic Rationale for Public Intervention. World Bank, Washington DC. Kremer M. 1996b. Optimal Subsidies for AIDS Prevention. World Bank, Washington DC. Ministry of Health. 200 1. Processus de Planification StratCgique de la rkponse Nationale contre le VIH/SIDA en RCpublique de Diibouti. Ministkre de la SantC de Djibouti, RCpublique de Djibouti. Over, M. 1992. The Macroeconomic Impact of AIDS in Sub-Saharan Afi-ica. Working Paper, Population and Human Resources Department, World Bank. Over M. 1997. The Effects of Societal Variables on Urban Rates of HIV Infection in Developing Countries: an explanatory analysis. European Commission. Over, M., Mujinja, P., Dorsainvil, D. and Gupta I. 2001. Impact of Adult Death on Household Expenditures in Kagera. Tanzania. Working Paper, Policy Research Department, World Bank, Washington, DC. Rehle, T., Saidel, T., Hassig, S., Bouey, P., Gaillard, E. and Sokal, D. 1998. AVERT: A User-friendly Model to Estimate the Impact of HIV/Sexuallv Transmitted Disease Prevention Interventions on HIV Transmission. AIDS, Robalino David, Carol Jenkins, and Karim El Maroufi. 2002a The Risks and Macroeconomic Impact of HIV/AIDS in the Middle East and North Africa. Middle East and North Africa Region Human Development Group. Working Paper# 2874. World Bank, Washington, DC. - 63 - Page 70 Robalino A. David, Voetberg Albertus and Oscar Picazo, 2002b. The Macroeconomic Impacts of AIDS in Kenya Estimating Optimal Reduction Targets for the HIV/AIDS Incidence Rate, North Holland; Journal of Policy Modeling. World Bank. 1997. Confronting AIDS: Public Priorities in a Global Epidemic. New York: Oxford University Press. World Bank. 2000. Economic Analysis of High Fertility and HIV/AIDS in Chad. World Bank, Washington DC. World Bank. 2002a. World Development Indicators. Data Base (SIMA). World Bank. 2002b. Social Protection Strategy in the Middle East and North Africa. Middle East and North Africa Human Development, World Bank, Washington, DC. World Bank. 2002c. Overview of the HIV/ AIDS Situation in the Middle East and North Africa and Eastern Mediterranean Region. World Bank, Middle East and North Africa Human Development; World Health Organization, Regional Office for the Eastern Mediterranean; UNAIDS. Washington, DC. - 64 - Page 71 Annex 5: Financial Summary DJIBOUTI: HIVIAIDS, Malaria, and Tuberculosis Control Project Years Ending 2008 IMPLEMENTATION PERIOD Total Financing Required Project Costs investment Costs Recurrent Costs Total Project Costs Total Financing Financing I BRDll DA Government Central Provincial Co-financiers User FeeslBeneficiaries Other Total Project Financing Year 1 2.66 0.20 2.86 2.86 2.36 0.50 0.0 0.0 0.0 0.0 0.0 2.86 Year2 Year3 Year4 Year5 Year6 Year7 3.35 3.95 2.74 1.80 0.08 0.08 0.09 0.05 3.43 4.03 2.83 1.85 3.43 4.03 2.83 1.85 2.52 3.18 2.40 1.55 0.91 0.85 0.43 0.30 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 3.43 4.03 2.83 1.85 - 65 - Page 72 Annex 6(A): Procurement Arrangements DJIBOUTI: HlVlAlDS, Malaria, and Tuberculosis Control Project Procurement General 1. Public procurement in Djibouti is regulated by the National Procurement Decree of 1995. The “Commission des March& is the national agency that evaluates all bids for amounts which exceed FDJ 5,000,000 (roughly US$28,000). The Commission includes 13 permanent members from different govemment offices and is headed by the Secretary General of the Govemment. While preparation of technical drawings and bidding documents for civil works and goods, and RFPs for consultant services are decentralized to the line ministries, evaluation of bids and proposals are conducted with the Commission. For each contract higher than the above-mentioned threshold, the Commission assigns the evaluation subcommittee with a representative from the ministry concerned. This subcommittee conducts the evaluation of bids/proposals and submits its report with an award recommendation to the “Commission” for approval. An evaluation of the “Code des marchis” was carried out during the preparation of the Health Sector Development Project (HSDP) (see Project Appraisal Document). A Country Procurement Assessment Report (CPAR) has not been carried out to date. However, the first CPAR for Djibouti is scheduled for delivery to the authorities in early FY04, with a set of findings of weaknesses in the current legal framework as well actionable recommendations to a phased-manner reform (given Djibouti’s institutional capacity constraints) of current public sector procurement in the country. 2. Djiboutian procurement laws and regulations acceptable to IDA, provided that: National Competitive Bidding (NCB), advertised locally, would be carried out in accordance with (a) all bidders are given sufficient time to submit bids (four weeks); (b) bid evaluation and bidder qualification criteria are clearly specified in bidding documents; (c) a margin of preference is granted only to local manufactured goods and not to locally (d) no bid is rejected during bid opening; (e) eligible firms are not precluded from participation; (0 award is made to the lowest evaluated bidder who meets the appropriate standards of capability and resources in accordance with predetermined criteria specified in the bidding documents. Standard bidding documents for the procurement of goods and works prepared by the project and found acceptable to IDA will be used during project implementation for NCB; (g) government-owned enterprises in the Recipient’s country may participate only if they can establish that they: procured works; i. are legally and financially autonomous, and ii. operate under commercial law. No dependent agency of the Recipient or Subrecipient of the project or their employees shall be permitted to submit or participate in a proposal for the provision of consulting services under the project; (h) bids are allowed to be submitted by mail or directly to the Client before bid submission deadline; (i) bid envelopes are opened in public, opening time being the same as the bid submission deadline, or immediately thereafter, and time and place of bid opening being clearly announced in the bidding documents; and (j) in the case that a two-envelope system is applied, the two envelops shall be opened simultaneously. - 66 - Page 73 Use of Bank Guidelines and Standard Documents 3. Procurement of works and goods will be carried out in accordance with the guidelines for Procurement under IBRD Loans and IDA Credits (January 1995, Revised January and August 1996, September 1997, and January 1999). Bank’s Standard Bidding Documents (SBD) and Standard Evaluation Forms would be used where practicable, particularly for ICB procurement of works and goods. The CAU will use the pre-approved National Competitive Bidding (NCB) document for works and goods which are currently being used under both the Education (Cr. 3445-DJI) and the ADETIP projects. Simplified NCB documents for use by community subprojects in accordance with paragraph 3.15 of the guidelines (Community Participation in Procurement) would also be prepared under the proposed Grant and apply to relatively low-value works contracts. These would be described in a specific chapter of the Project Operations Manual (POM). All procurement of consultant services by firms or individuals for award of contract will be done in accordance with the guidelines for the Selection and Employment of Consultants (World Bank Borrowers, January 1997, revised September 1997, January 1999, and May 2002). The Banks Standard Request for Proposals (RFP) for the Selection of Consultants (July 1997, Revised April 1998 and July 1999) and the Standard Form of Contracts (with some adaptation to fit special requirements as applicable) would be used for contracts above US$ 100,000 equivalent. Simplified request for proposals and contract forms will be used for short-term consultants assignments - simple assignments of standard nature (i.e. those not exceeding six months) carried out by firms or individual consultants. Advertising 4. A General Procurement Notice (GPN) will be published in the United Nations Development Business (UNDB) and in at least two local newspapers, soon after project negotiations. The GPN would be updated annually for all outstanding ICB goods procurement and International Consulting Services. Expressions of Interest will be placed in newspapers and the UNDB for all consultant contracts greater than US$lOO,OOO, and a short-list would be submitted for IDA’S no objection. Specific Procurement Notices (SPN) for certain key contracts estimated to cost US$lOO,OOO (i.e. drugs, medical equipment, etc.) will be published in the UNDB and in at least two national newspapers of wide circulation. Procurement Capacity Assessment 5. A first phase procurement capacity assessment was carried out during the February 2003 mission. As the Executive Secretariat was not fully staffed or fully functional, the assessment focused on the Credit Administration Unit (CAU) of the Ministry of Health. The CAU is currently responsible for the HSDP and has also been responsible for the management of the PPF and the Japanese Grant accorded to the AIDS project. The main conclusions of this first assessment is that the CAU will need to be strengthened first by a procurement assistant given that the procurement unit in the CAU is at present only staffed with one person (the Procurement Officer). As the HSDP is currently underway, the management of the transitory phase will put added pressure on the CAU and the Procurement Officer. To follow up on management capacity, the Procurement Officer will participate in a procurement course on goods in Dakar, Senegal in AprilMay 2003 (to be financed under the HSDP). The second recommendation is that technical assistance, in the form of a consultant specialized in procurement and project management, be recruited under the AIDS-PPF financing, who can assist the CAU in the execution of the present project (HIV/AIDS). Such technical assistance, particularly in procurement planning and administration aspect, as well as carrying out a serious skills transfer program to the existing CAU procurement staff and the Procurement Unit to be established in the Executive Secretariat (ES), as the agency ultimately responsible for implementing the project. It is expected that the TA be recruited by mid-June 2003. In addition, the CAU is currently in the process of selecting a firm to prepare the operations manual for the HSDP. It is recommended that the same firm’s TOR be extended to include the preparation of the Project Operational Manual and the Community Intervention Manual for the HIV/AIDS project. - 67 - Page 74 6. A second evaluation to assess the ES will be carried out before the end of May 2003. In summary, the timeline is as follows: a) Evaluate Expressions of Interest received for the position of the International Procurement Specialist b) Prepare first draft of the Procurement Plan (prior to Negotiations) c) Procurement Officer to attend training (Dakar) d) Finalize Procurement Plan for the first year of the project e) Adapt standard POM and Community Intervention Manual f) Recruit the International Procurement Specialist g) Recruit a Procurement assistant for the CAU April 3,2003 (done) April 4,2003 (done) AprilMay 2003 May 3 1,2003 June 15,2003 June 15,2003 June 30,2003 Procurement Plan 7. Draft procurement plans were to be prepared during appraisal, however, the lone Procurement Specialist in the CAU had only made a start on the contract packaging and scheduling for items to be procured under the PPF. A first working draft was subsequently presented at negotiations and found to be satisfactory. The National Strategic Plan, which was prepared with the assistance of consultants funded under a PHRD grant, has been validated. This comprises the basic elements for the procurement activities to be financed under the project, as well as by other donors. The overall activities, budget cost, and responsibility matrix have been approved by the stakeholders concerned. As this is a multi-sector project, the exact mix of procurement will be determined on an annual basis during joint reviews between the ES, line ministries, IDA, and other partners where a draft procurement plan as well as multi-sectoral work for the following financial year will be presented and agreed upon. Procurement Implementation Arrangements 8. The overall coordination of program implementation would be carried out by the ES, with each participating line ministry and community group responsible for implementation of their relevant work programs or sub-projects. Procurement by the line ministries would be limited to expenditures of US$20,000. The project will recruit an international procurement expert to assist the ES for at least the first two years of the project, to be extended following an assessment of project performance. 9. As the project has a community subproject component, the procurement undertaken for this activity will be governed by the Project Operational Manual (POM), and paragraph 3.15 of the guidelines will apply. The ES will oversee procurement management and will ensure that procurement procedures, funding, and eligibility criteria for subprojects agreed with IDA, and described in the POM, are satisfactorily compliance with. As there are a limited number of NGOs capable of handling the procurement requirements, the ES will carry out all procurement activities until such time as the NGOs and associations are trained in the procurement requirements for the project. Once the NGOs/associations are fully trained, the bidding process will be undertaken by them using simpler documentation (to be part of the POM). Community subprojects will be small in general, averaging $2,000 to $5,000. Procurement Methods 10. Civil Works: Civil works estimated to cost approximately US$l .O million under the project will comprise mainly the renovation of the biology laboratory of the Peltier General Hospital and the renovatiodnew construction of the Centre Yonis Toussaint. It is foreseen that this would concern predominantly local enterprises that have the capacity to undertake this type of construction; at least 2-3 construction companies have the capacity to undertake large construction jobs. In addition, ADETP may be sought for certain renovation activities, which would be evaluated at the time of the request. The contracts being considered are too small to attract the interest of foreign construction companies outside Djibouti; therefore, all civil works contracts will likely be awarded under NCB procedures. The technical drawings and bidding documents for activities to be financed for the first year of the project are being developed. IDA will review all architectural drawings as well as the bidding documents for all civil works contracts. - 68 - Page 75 1 1. Goods: The total cost of goods is estimated at US$2.1 million and would comprise: (a) drugs, testing kits, condoms, and medical consumables; (b) furniture, computers, information systems, vehicles, documentatiodguides, and general equipment; and (c) food supplies (World Food Program). With regard to medicines and medical supplies, due to existing shortages (and because the HSDP covers only an emergency purchase for the first year, as well as the first stock for the still to be established Centrale d ’Achats de Mddicaments et de Matbriels Essentiels (CAMME)), the current project will purchase needed medicine at least for the first two years of the project for the pilot project, STIs, ARVs, as well as condoms. Condoms may be purchased through the UNFPA program, which is currently providing condoms for national health projects. Once the CAMME is functional, and if it has developed procedures acceptable to IDA, the possibility of purchasing drugs and medicine from the CAMME will be explored as needed, and the Development Grant Agreement may be amended once the evaluation is satisfactory. 12. Procurement of goods will be bulked where feasible into packages valued at US$55,000 equivalent or more and will be procured through ICB. Goods with an estimated contract value equal to or below US$lOO,OOO equivalent, and up to an aggregate amount of US$800,000 equivalent, may be procured through National Competitive Bidding (NCB) procedures with advertisements in at least two national newspapers. Goods with an estimated contract value equal to or below US$40,000 equivalent, up to an aggregate amount of US$400,000 equivalent, may be procured through International Shopping (IS)/National Shopping (NS) procedures, by soliciting at least three competitive quotations from suppliers. Standard request forms and establishment of guidelines for using shopping methods will be in accordance with the Bank’s memorandum of June 8, 2000 on “guidance procurement note on handling procurement under Shopping Method” and will be included in the procurement section of the POM. Pharmaceutical products, condoms, medical equipment, impregnated bednets, World Health Organization (WHO) approved insecticides and sprayers, vehicle, and food supplies, up to an aggregate amount of US$500,000 may be procured through the United Nations agencies (Inter-Agency Procurement Services Office (IAPSO), United Nations International Children’s Emergency Fund (UNICEF), United Nations World Food Program (WFP), and the WHO. 13. Consultant Services. Under consulting services, the project will finance several consultant services to carry out the various activities under the project, such as setting up sound surveillance systems, training on counseling, revising treatment algorithms, reinforcing M&E systems, communication strategy, social marketing, hygiene and prevention measures, implementing the medical waste management plan, training on sexual education, revenue-generating activities, studies and surveys, etc. In addition, the project will finance the audit fees for the project. 14. Services to be contracted include long-term and short-term international and national consultants. Quality-Cost-Based Selection (QCBS) will be the preferred method to be used for the employment of firms. However, and as deemed necessary, consultant firms equal to or below US$50,000 equivalent per contract, up to an aggregate amount of US$500,000 equivalent, may be selected using Consultant’s Qualifications (CQ) procedures, as well as for the selection of training institutes (for contract amounts not exceeding US50,OOO). Single-source selection (SS) would be accorded, on a prior-review basis, for very small assignments below US$5,000. Single-source selection (SS) is also accorded for managing works under component 1 of the project for an amount not exceeding US$150,000 based on the assessment of the firm by IDA prior to award, and the WHO for managing parts of components 1 and 2 for an amount not exceeding US$400,000. Individual consultants would be procured in accordance with Section V of the consultant guidelines. 15. Multisectoral sub-projects would comprise the purchase of small quantities of goods, consultant services for small assignments, dissemination seminars, etc. Purchases that require grouping for cost- efficiency, and consultant services which would cover larger targeted groups would be hired by the ES. The modalities for the operation of the multisectoral subprojects would be defined in the POM. Community sub-grants would comprise the purchase of small quantities of goods and services to be paid for as grants for community-based sub-projects by the approving authority, in accordance with - 69 - Page 76 procedures set out in the POM. In addition, the use of Non-governmental Organizations (NGOs) would be procured according to paragraph 3.14 of the guidelines on selection of consultants. 16. following: incremental staff salaries which will have been selected and hired on a competitive and contractual basis for the Executive Secretariat, office supplies, office rental, printing and utilities for rented offices, and communication costs, costs for the maintenance of vehicles and equipment, and costs incurred on account of the supervision of the Project, including fuel for supervision and per diem while away on mission. Incremental Operating Costs will be financed under the project and will be comprised of the Prior-review 17. Table B provides the prior-review thresholds. During the first year of the project, all contracts issued during the first year will be reviewed and cleared with IDA on a prior-review basis, as the ES is a new institution. Based on performance, the second year’s prior-review will be assessed. In general, all ICB, all works contracts, and the first three NCB contracts for goods regardless of value for the first year, and subsequently all contracts for goods estimated to cost the equivalent of $80,000 or more will follow the procedures set forth in paragraphs 2 and 3 of appendix 1 of the guidelines. All other contracts would be subject to post-review in accordance with paragraph 4 appendix I of the guidelines. All TORS for consultant contracts (firms and individuals) will be subject to prior-review by IDA. All consulting contracts costing US$lOO,OOO equivalent or more for firms would be subject to IDA prior-review. For consulting contracts costing less than US$lOO,OOO, but more than US$50,000, the Recipient will notify IDA of the results of the technical evaluation prior to opening the financial offers. With respect to each contract for employment of individual consultants estimated to cost the equivalent of US$50,000 or more, the qualifications, experience, terms of reference, and terms of employment of the consultants shall be furnished to IDA for its prior-review. Any amendments to existing contracts raising their values to levels equivalent or above the prior-review thresholds are subject to IDA review. - 70 - Page 77 Table A: Project Costs by Procurement Arrangements (US$ million equivalent) Procurement NCB 1. Works 0.90 (0.50) 2. Goods 0.80 0.22 (0.64) (0.18) 3. Services Expenditure Category ICB 4. Subprojects multisectoral 5. Grants for Community Subprojects Methodl Other2 0.10 (0.06) 1.12 (0.81) 6.5 1 (5.61) 3.18 1.68 (1.68) (2.22) NBF Total Cost 1 .oo (0.56) 2.14 (1.63) 0.16 6.67 (0.00) (5.61) 3.18 1.68 (1.68) (2.22) 6. Training 0.5 1 0.5 1 (0.35) (0.35) 7. Incremental Operating Costs 0.33 0.02 0.33 (0.30) (0.00) (0.30) Total 0.80 1.12 12.92 0.16 15 .OO (0.64) (0.68) ( 10.68) (0.00) ( 1 2.00) Figures in parenthesis are the amounts to be financed by the IDA Grant. All costs include contingencies. Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to managing the project. In addition, drugs will be purchased either through IS procedures or through UN agencies. 21 Table A1 : Consultant Selection Arrangements (optional) (includes Training) (US$ million equivalent) Consultant Services Expenditure Category QCBS A. Firms 3.21 (2.85) B. Individuals 1.61 (1.35) Total 4.82 (4.20) Selection Method QBS SFB LCS CQ Other 0.70 0.56 (0.5 1) (0.50) 0.15 0.32 (0.10) (0.30) 0.85 0.88 (0.61) (0.80) Total 4.47 (3.86) 0.12 2.20 (0.00) (1.75) 0.12 6.67 (0.00) (5.61) NBF. Cost1 li Including contingencies Note: QCBS = Quality- and Cost-based Selection QBS = Quality-based Selection SFB = Selection under a Fixed Budget LCS = Least-Cost Selection CQ = Selection Based on Consultants' Qualifications Other = Selection of individual consultants (per Section V of Consultants guidelines), Commercial Practices, etc. N.B.F. = Not IDA-financed Figures in parenthesis are the amounts to be financed by the IDA Grant. - 71 - Page 78 Modalities for IDA prior-review and post-review 18. For the first year of the project, IDA will review all contracts, regardless of value, for conformity with procedures, including all architectural drawings and bidding documents for civil works planned under the project. Before the second year of the project, IDA will review whether the threshold for prior review in the DGA based on performance and actual values of procurement implemented. Monitoring and Evaluation of procurement performance at all levels (national and community) would be carried out during supervision missions for contracts above prior-review threshold, and through annual ex-post procurement reviews. This will involve two out of 10 contracts in the ES and one out of 3 contracts managed by the line ministries and participating agencies. Table B: Thresholds for Procurement Methods and Prior-review Expenditure Category 1. Works 1. Goods 3. Services Firms Individuals Training 4. Intersectoral subprojects and Community subgrants Contract Value Threshold (US$’) All => 100,000 < 100,000 <40,000 =>100,000 < 100,000 =>50,000 <50,000 < 5,000 >50,000 NA Procurement Method NCB ICB NCB Isms QCBSISS QCB SICQIS S Section V of the Consultant guidelines CQ ss Para. 3.15 of guidelines Contracts Subject to Prior-review (US$) All civil works contracts regardless of value. (Appendix 1, para. 2-3 of guidelines) All ICB contracts and first 3 contracts regardless of value for the first year. All NCB contracts above US$80,000 (Appendix 1, para. 2-3 of guidelines) Post-review. All QCBS contracts. All contracts above us$loo,ooo. First 3 contracts regardless of value for the first year. All SS contracts (others post-review) All TORS and prior-review TOR; Post-review All +TORS Post-review of annual training plans NA - 72 - Page 79 Total value of contracts subject to prior-review: $4.8 million Overall Procurement Risk Assessment High 19. IDA was unable to conduct a full assessment of the Executive Secretariat (ES) at the time of appraisal, as the ES was not fully functional at that time, The assessment focused on the CAU who is currently managing the HSDP, and which also manages the PPF for the HIV/AIDS project. The CAU was found to be satisfactory. The ES is currently recruiting key staff, and a second IDA assessment will be carried out in May 2003 to complete the evaluation of the ES and to provide conclusions. The Risk Assessment is rated as High, mainly because the CAU has pressure to deliver the HSDP, and is understaffed to do so, and the added burden of a new project may stretch it's limits, without additional assistance as related above in the para. on Capacity Assessment. 20. Frequency of procurement supervision missions proposed: One every 6 months (includes special procurement supervision for post-review/audits). The first year will require intensive supervision missions to ensure proper implementation start-up and ES's familiarity with IDA procedures. Thresholds generally differ by country and project. Consult OD 1 1.04 "Review of Procurement Documentation" and contact the Regional Procurement Adviser for guidance. - 73 - Page 80 Disbursement Amount in SDR 600,000 1,050,000 200,000 2,950,000 1,100,000 1,300,000 750,000 550,000 300,000 8,800,000 21, years in accordance with Table C. All project activities are expected to be completed by March 3 1,2008, and the grant will close on September 30,2008. The grant of SDR 8.8 million (US$12.0 million equivalent) will be disbursed over a period of 5 Amount in US$ equivalent 800,000 1,400,000 300,000 4,000,000 1,500,000 1,800,000 1,000,000 730,000 470,000 12,000,000 Table C: Allocation of Grant Proceeds Expenditure Category (1) Works (2) Goods (a) Goods, other than those in (b), including vehicles (3) Consultant Services, including training and audits (4) Multisectoral Sub-projects (5) Incremental Operating Costs (6) Community Subgrants (7) Refunding of Project Preparation Advance (8) Unallocated Total Proiect Costs (b) Pharmaceuticals Financing Percentage 100% 100% 100% 100% 100% 100% 100% 100% Amount due pursuant to Section 2.02 (c) of this Agreement A project Mid-Term review is planned for November 30,2006, and the Recipient's contribution to the Mid-Term Review is expected to be received by IDA by September 30,2006. - 74 - Page 81 Use of statements of expenditures (SOEs): 22. Civil works contracts below US$lOO,OOO, goods contracts below US$lOO,OOO, and services contracts below US$lOO,OOO for firms and US$50,000 for individuals, and training contracts costing less than US$50,000 each, and Multi-sectoral Sub-grants, Community Sub-grants, and Incremental Operating Costs, will be made on the basis of Statements of Expenditures (SOEs). All multisectoral sub-projects and community sub-grants will be disbursed on the basis of SOEs. Documentation will be maintained by the CAU/ES and made available for review by members of IDA supervision missions and verified by the external auditors annually. Documentation relating to SOEs will be retained for up to one year after the final withdrawal from the Grant. All civil works contracts will be subject to prior-review. 23. Documentation for Withdrawals. Withdrawal from the grant proceeds will be based on IDA'S traditional disbursement methods, SOEs, direct payment, and Special Account (SA) replenishment. The latter will be based on receipt of appropriate documentation. Applications for contracts for works of more than US$lOO,OOO, goods of more than US$lOO,OOO, and for consulting services of more than US$lOO,OOO for firms and US$50,000 for individuals, for training of more than US$50,000 will be presented with full documentation for disbursement. Special Account: 24. To facilitate disbursements against eligible expenditures, the government will establish two Special Accounts (SA), each in a commercial bank, to be operated by the CAU during the transition phase, and then by the ES under terms and conditions satisfactory to IDA. The SA-A will be established to run all parts of the project (Components 1-3) except the Community Intervention Sub-grants (Component 4). 25. The authorized allocation of the SA-A will be established at US$1.0 million, which represents about 4 months of estimated disbursements from the IDA grant. Initially, the allocated amount will be limited to US$0.7 million, until disbursement reaches US$3.0 million equivalent, at which time the full Authorized Allocation could be claimed. Application for the replenishment of the SA would be submitted monthly or when one-third of the initial deposit has been utilized, whichever comes first. The replenishment application would be supported by the necessary documentation, bank statements of the SA, and a reconciliation of these bank statements against the Association records. The SA would be audited annually by independent auditors acceptable to the Association. 26. The second Special Account (SA-B) will be established for the purposes of the Community Intervention Sub-grants. The authorized allocation of US$500,000 represents about 3 months of estimated disbursements from the IDA Grant. Initially, the allocated amount will be limited to US$250,000, until disbursement reaches US$1.5 million equivalent, at which time the full Authorized Allocation could be claimed. The same procedures apply as in the above paragraph. Project Preparation Fund (PPF): 27. To advance the preparation of the project, a PPF (Q322-0-DJI) in the amount of US$350,000 was approved on March 14,2002, and countersigned by the Recipient on March 26, 2002. A second PPF was established (4322-1-DJI) in the amount of US$380,000 to cover the cost of additional activities, which was approved on December 24, 2002, and countersigned on January 3, 2003. Disbursements under the PPF are made using traditional Bank disbursement methods. The PPF funds are managed by the Credit Administration Unit of the Ministry of Health. - 75 - Page 82 Annexe 6. b. Evaluation of the Project’s Financial Management System and Measures to Implement a Satisfactory System Administrative and Financial Capacities of the Implementing Agency During the appraisal mission focused on assessing the existing management capacities of the administrative and financial functions of the implementation agency. The appraisal mission determined that the action plan left at the end of the pre-appraisal mission of October 2002 had not been carried out according to the planned timeframe. This led the mission to reassess and clarify the project set-up and functionalities with the newly appointed Executive Secretary of the Executive Secretariat, responsible for the management of the project, and the necessary actions to be taken to implement the outstanding activities. Decisions were taken to implement the minimum required. A follow-up assessment will be undertaken during a post-appraisal mission (May 2003). Institutional organization The implementation of the interministerial institutional framework is consistent with the project, and is justified considering the different stakeholders involved in this project, particularly in view of the participation of eleven ministries and a substantial community intervention element (roughly ten supervisory NGOs and about thirty community-based organizations). The President of Djibouti recently signed the decree establishing the authority and attributes of the different governing bodies of the project. This decree establishes: 1. An Interministerial Committee to Control HIV/AIDS, Malaria, and Tuberculosis, responsible for: 0 0 Defining the overarching goals and axes for the control of HIV/AIDS, malaria, and tuberculosis; Provide impetus to and organizing a framework for consultation and dialogue to implement the strategic measures that apply to all the stakeholders as part of the effort to control these transmissible diseases; Amend, validate andor reorient the National Multi-sectoral Plans to control these diseases, based on the annual report submitted by the Technical Interministerial Committee; and Advocate with the national and international partners for resource mobilization and assistance to support the control of HIV/AIDS, malaria, and tuberculosis. 0 0 2. A Technical Interministerial Committee to Control HIV/AIDS, Malaria, and Tuberculosis. This is the technical arm that has the following mission: 0 On the basis of technical and financial reports submitted by the Executive Secretariat, validate or amend the participating ministries’ sectoral strategies in the control of these transmissible diseases; Coordinate HIV/AIDS, malaria, and tuberculosis control activities at the national level; 0 3. An Executive Secretariat (ES), responsible for the control of HIV/AIDS, malaria, and tuberculosis. Since the principle of autonomy in technical and financial implementation is a requirement, the ES is appointed as the implementing agency for the project. For the implementation of the National Strategic Plan, the ES is responsible for: 0 Coordinating the activities of the different multi-sectoral action plans; Monitoring and evaluating interventions performed as part of the multi-sectoral Action Plans; - 76 - Page 83 0 0 0 0 0 0 Monitoring and managing projects funded by other development partners intervening in the control of HIV/AIDS, malaria, and tuberculosis; Serving as secretariat for the Technical Interministerial Committee; Providing technical support to civil society partners, including NGOs, in the implementation of community interventions as part of the Strategic Plan; Participating in the design of studies or sectoral research projects in relevant areas and organizing thematic consultations; Monitoring and evaluating community interventions, mobilization, and social marketing activities; Providing sound project management (including financial and procurement management), strengthening, preparing and submitting quarterly reports that summarize progress in the implementation of the National Strategic Plans to the Technical Interministerial Committee. Memorandum of understanding Contractual organization Grant agreement Organizational relations for the execution of activities and financing will be governed by formalized contractual agreements, on the one hand, between the Executive Secretariat and the ministries in the form of a memorandum of understanding and, on the other hand, between the Executive Secretariat and the community support structures in the form of financing or grant agreements. The following chart shows the different relationships. The memoranda of understanding are to provide a clear description of the relations between the Technical Committee, represented by the ES, and the ministries, particularly with regard to the levels of authority, appointment of the focal point, and operating procedures. The grant agreements must contain the following: (i) a description of the purpose, with a brief description of activities, conditionalities, approval, evaluation, financing, and supervision processes; and (ii) suspension or termination clauses. The mission was informed that an agreement model has previously been used as a basis for finalizing agreement content. The mission brought to the attention of the ES the conditions for receiving grants, so that a procedure can be developed that responds both to the concerns of associations that seek simplicity in relations, and the constraints of the ES, whose procedures for receiving grants are subject to verification that the subsidized activities have been implemented. Multi-year agreements are necessary because they seem to be more suitable for strengthening overall funding efficiency than yearly agreements. The memoranda of understanding are to be governed by the same principles. In all cases, the use of funds have to be justified. A grant that is not used, or a grant used in a manner inconsistent with its purpose, must be retumed to the ES. Regarding the eligibility criteria for the selection of an association, the mission provided recommendations for processing procedures for grant applications. They must allow an association that - 77 - Page 84 is applying for a grant to demonstrate that it meets the general and special conditions for being awarded a grant. These pertain primarily to: (i) information about the association's identity (proof of its existence, articles of agreement, length of time in existence, activities and human resources, and financial information in terms of turnover); and (ii) information about the activity under consideration as part of its work in the project (description of the work and budget estimates). Organization and implementation procedures Here, the mission identified the procedure to be followed for project monitoring, from the standpoint of organization and planned information monitoring systems, and more specifically, the type of information sources, collection method, processing method, and presentation of results. I - Structures: Although no official organizational chart has been prepared, the human resources will be assigned as follows: For the Executive Secretariat The Executive Secretariat's staff will consist of 15 people: 13 are covered by the project (including two technical assistants), while two are on temporary assignment, theoretically from the Ministry of Health (in red). The Chief Administrative and Financial Officer and the accountant have been recruited. The accountant (CISU/ES) will be hired prior to project effectiveness. The profiles match those identified during the pre- appraisal mission of October 2002. The responsibility for planning, monitoring and evaluation, devolved to the Planning, Monitoring and Evaluation Unit, will be subcontracted out through a competitive process. For the ministries The mission met with several focal point representatives: Ministry of National Education and Higher Education; Ministry of the Interior and Decentralization; Ministry of Communication; Ministry of Youth, Sports, Recreation and Tourism; - 78 - Page 85 Ministry of Justice, Penitentiary and Religious Affairs, and Ministry of Wakfs and of Muslim Affairs; Ministry of Health. Generally, the organizational measures that the ministries have adopted are based on assigning ministry employees to what is called a specialized unit to carry out project activities. These units are or will be placed under the authority of a technical directorate. Some activities may be decentralized (Police, National Education, etc.). Thus, (i) for the Ministry of the Interior, the specialized unit is under the authority of the Police Department; (ii) for the Ministry of National Education and Higher Education, under the authority of the General Directorate of Pedagogy; (iii) for the Ministry of Youth and Sports, under the authority of the Directorate of Youth and Sports; and (iv) for the Ministry of Health, three specialized units (tuberculosis, malaria, and STIs/AIDS), under the authority of the Directorate of Public Hygiene. The focal points have been appointed in each ministry. The mission found that most of the persons met already have project management experience. As managers of delegated funds, they will assume responsibility for the budgetary appropriations that will be assigned to them. Moreover, the mission highlighted to the ES the responsibilities of each: (i) to accredit themselves with their respective accountants, to whom their spending orders will be submitted, in other words, to inform them of their appointment and provide a specimen of their signature, with a copy to the ES; and (ii) of opening an account with a commercial bank. Nonetheless, some practical issues were addressed, especially the accountant’s capacity. The mission pointed out that it was essential to separate this function from that of funds manager. Generally, the rule is that two signatures are required to issue checks: (i) that of the funds manager; and (ii) that of a de jure or defacto public accountant (the directorate to which the focal point or the ministry’s Financial Manager is assigned). With regard to the special circumstance of the Ministry of Communication and the Ministry of Justice, wherein the focal points do not fall under the actual ministry, the mission asked the ES to clarify this situation as quickly as possible, so that the accountant’s scope of authority could be defined. Actually, (i) for the Ministry of Communication, the appointed focal point is a person assigned to a public entity. The mission believes that this situation must be viewed as management for third party account, with this person carrying out the financial transactions that the requester, in other words, the ES, asks it to carry out. With this in mind, the accountant should be appointed from within the public entity, in this case, SociCtC de TClCvision de Djibouti; and (ii) for the Ministry of Justice, the focal point appointed is an individual, serving as legal counsel. The most prudent solution would be for this person to be under the financial control of the ministry who assigned him this task. In any case, these provisions are to be clarified before the planned memoranda of understanding are prepared, before July 3 1,2003. I1 - Spending procedures: For project monitoring, the ES is in charge of the following: 1. Managing the launch of the bidding processes 2. Managing the technical monitoring of contracts 3. The management and administrativelfinancial monitoring of expenditure transactions, including proper accounting for the project 4. Disbursement monitoring 5. Preparation of financial statements and quarterly financial monitoring reports. The mission identified some but not all of the main transactions that may be transferred to the administrative and financial monitoring officers: Opening of accounts. The proper management of project expenditures assumes that two conditions will be met: (i) a condition of substance: the existence of debts as a basis for spending by submitting an annual activity plan translated into budget terms (document subject to IDA’S approval); and (ii) a - 79 - Page 86 condition of form, of budgetary law, with annual authorization given by the budget. Entry in the General State Budget for a budget year allows the chief authorizing officer (the Prime Minister) to cover the different expenses. The funds are then delegated to the ES officer on behalf of the President of the Technical Interministerial Committee for the Control of HIV/AIDS, Malaria, and Tuberculosis. Budget entries in the ES’s accounts are broken down, at a minimum, by component. A portion of the expenses (linked to the activity) will be allocated to the ministries or deconcentrated government bodies that are stakeholders in the project. Expense commitment documentation. Budget transactions result in expenditures of funds for a given heading. For any expenditure, supporting documents, such as a contract or order form, must only be established once the availability of committed funds, eligibility and validity of the expenditure have been verified and validated. For accounting, the expenditure of funds is recorded on a commitment sheet, prepared by the funds manager. The commitment sheet should specify the purpose of the expense, the performance period, the name of the supplier, the amount of the goods or services, the budget allocation, and its cost allocation (activity). The advantage of this presentation is that it identifies the reasons for the expense and facilitates consistent data consolidation. A consistent model must be prepared and distributed to the focal points. This model must be part of the project procedures manual to be prepared. The following agreements have been reached: 0 Capital expenditures, such as vehicles, computer equipment, etc., would be incurred by the ES in compliance with IDA’S procurement procedures. The items would then be assigned to the recipients. Certain expenditures, such as drugs, printed materials, television announcements, etc., which, when combined, may generate a substantial economic advantage, will be procured by the ES on behalf of other stakeholders. Expenditures incurred for contractual employees hired for the ministries or other governmental bodies will be governed by the following rules: (i) the beneficiary will interview and select the employees; and (ii) the ES will prepare the employment contract and the salary and payment vouchers. 0 0 Thus, for the funds delegated to the ministries, the expenditures that these ministries incur should be related mainly to their activities, such as the preparation of seminars, room rentals, training services, small supplies, etc. Authorization transactions: for expenses incurred and paid, the accounting entries are made after ascertaining: (i) the validity of the expenditure, as evidenced by valid supporting documents, in particular: the order form, the validity of the contract and compliance with procurement procedures, invoices, itemization documents, startup advance, etc.; and (ii) the accuracy of the calculations of the itemizations relative to the contract and liquidation clauses. Financial flows: The financial flows are described in the following chart: - 80 - Page 87 Source NGO and CBO advances ES special accounts Special account: program Special account: community Ministry and other government body advances Dircit pdy”ts Bank accounts (special accounts and advance accounts) are opened with commercial banks. Withdrawal requests are made by the ES for funding the two special accounts. It has been agreed that the advance accounts would operate as State-managed accounts and would be funded (once per quarter) based on the amounts indicated in the annual action plan presented by the focal points or community organizations; they must first obtain the “no objection” each year from IDA. Their operating procedures must be described in the memoranda of understanding or grant agreements (method of information transfer, frequency, etc.). Ex-post controls will be performed. The working procedures for the two special accounts are described in the Development Grant Agreement. Expenses will be paid above a certain threshold, either by direct payment to the bank or by local payment. Moreover, in the contract with the auditing firm in charge of certifying the accounts, a provision should be included that this item is subject to a specific appropriate control. I11 - Collection and processing media: Currently, the ADETIP has an integrated management and financial system, which fully captures the different key stages of an expenditure file and the transactions for paying the expense, as well as the steps involved in updating the databases. In its design, the system processes eight main modules (i) parameters, (ii) general accounting, (iii) cost accounting, (iv) budget monitoring, (v) financial monitoring, (vi) fixed assets, (vii) financial statements, and (viii) contract management, the main features of which are shown in the following table: Module General accounting Cost accounting Financial monitoring Functionalities 0 0 Bank reconciliation 0 0 0 0 Components 0 Subcomponents 0 Budgetary reporting 0 Geographic location 0 Method of financing 0 0 Transaction entry (charging to the general account; auxiliary; debit credit amounts; local and foreign currency; costing) Manual or automatic writing of third-party accounts Publication of statements in local or foreign currency Cjournals; general ledgers; balances) Closing of accounts (monthly; annual) Publication of statements (general ledger; balance) with the possibility of extracting data from several fiscal years. Monitoring currency for agreements (local and two foreign currencies) - 81 - Page 88 3udget monitoring Module Parameter management Utility management zontract management Functionalities 0 0 0 Foreign currencies 0 Decentralized input sites 0 0 Journals 0 Donors 0 Agreements 0 0 0 Project identity and currency used Fiscal periods in which transactions are recorded Structures of plans used (accounting, budget, costing and geographic plans) Categories and breakdown of coverage of disbursements Data saving; retrieval; adjustment; purge Import/export of data to/from other TemPro applications Management of financial statements Monitoring of fixed assets - Request for withdrawal of funds Features of requests for withdrawing funds Adjustment of requests for payments based on actual disbursements Budget input in quantity and financial volume (monthly or annual; local and foreign currencies) Financial agreement reporting, geographic location; cost ledger Publication of statements (budget, budget-actual) single- or bi- criteria analysis) B Type of procurement I Contract registration (advances, retention money, penalties, etc.) B Disbursement estimate chart B Contract number B Purpose of contract B Successful bidder B Launchdate B D Final acceptance date 0 Nationality of supplier 0 Contract assignment (general account; cost account; budget item; financial category; geographic code) 0 Publication of list of contracts 0 Management of standard statements (balance sheet; income statements) 0 Financial statements on the duration of the project 0 Identification of fixed assets (nature, quantity, value; startup date) 0 Supplier 0 Accounting allocation; cost account; budget account 0 Location 0 Depreciation management 0 Management of outflows ’ 1 1 Management of direct payments I 1 Provisional acceptance date “No objection” date - 82 - Page 89 For this application, the plan is to differentiate between transactions related to the projects and their funding source; this should make it possible to translate the objectives and activity of a project into financial and accounting terms. The concept that has been developed should permit monitoring of transactions for the duration of the grant and, in particular: (i) by budget classification; (ii) by component and subcomponent; (iii) by use (type of establishment, site and district); (iv) by category of expenditure; and (v) in local and foreign currencies. The extraction of multicriteria data is planned; this facilitates a dynamic approach as required for the management of project monitoring. It should also permit the analysis of the results of project monitoring and their interpretation, as well as retrieval of information on actual transactions of the project stakeholders (State, bA and Auditor). All the procedures are programmed in the transactional mode. All system users have access to certain authorized transactions that allow them to enhance the information in the system. The mission recommends that the ES: (i) launch at this time the competitive bidding process for the project financial monitoring information system, based on the description of the special conditions of the functionalities for this application; (ii) ascertain that all of these functionalities are present in the information system to be chosen and that they meet the requirements, mainly those of producing the data required in the FMR; and (iii) ascertain that the monitoring of procurement operations are functional, including the processing of specific operations, namely the launch of the competitive bidding process for the contract. Failing that, the mission suggests the development and implementation at this time of an application that meets this requirement. It should be designed to monitor the contracts and identify any issues. The data managed could include but not be limited to the following: (i) the competitive bidding number; (ii) procurement method; (iii) date of publication; (iv) date for submitting bids; (v) date for receipt of bids; (vi) number of bidders; (vii) date for convening the selection committee; (viii) date of bid opening; (ix) date of award; and (x) date for IDA “no objection,” etc. By way of information, and without incurring any additional major costs, it may be possible to use Excel or Access-type software from Microsoft. IV - Administrative management: Above and beyond information systems, the mission recommends that the organizational guidelines and management procedures be outlined in the procedure manual for the following purposes: (i) ensure full comprehension of the data processing system; (ii) procedure consistency; and (iii) access to reliable information. The mission requests that the ES organize working meetings with the different stakeholders so that actions are taken to prepare: (i) a general organization manual that would identify the relationships between the ES and the ministries; and (ii) an intemal procedures manual for the ES, which would provide a description of its own operations. These manuals would include: (i) supporting documents for inflows and outflows; (ii) information channels; (iii) tasks assigned to each employee; (iv) processing carried out; and (v) control points. Furthermore, the mission: - provided the ES with a copy of the “Financial Monitoring Reports for World Bank-Financed Projects: Guidelines for Borrowers.” In collaboration with the ES, it has been agreed: (i) that the tabular models used will be those described in “Annex A Example 1;” and (ii) to add in the special conditions of the bidding document for the information software the parameters for the output statements needed. - made the ES aware of the fact that activities funded under the PPF currently managed by the Credit Administration Unit (CAU) need to be officially transferred to the ES and that the procedures for transferring data are integrated in the overall project data. Evaluation of the Executive Secretariat’s (ES) management capacities to perform the administrative and financial monitoring of the future project: The contacts made with the representatives of the ES, focal points, and the financial directors of certain ministries have made it possible to refine the organizational and management procedures to be implemented to effectively perform the administrative and financial monitoring of the project. The mission regrets that the activities planned during the pre-appraisal mission of October 2002 had not been fulfilled. Clearly, with the many - 83 - Page 90 stakeholders involved in this project (1 1 ministries and considerable community interventions by about ten supporting organizations and around 30 community-based NGOs), special procedures need to be put in place, in addition to the procedures that must be adopted for project monitoring, both in terms of organization and monitoring information systems, and more specifically, for the type of sources of information, collection and processing methods, and presentation of results. This complex set of activities, with the ensuing coordination issues, should not be underestimated. To harness both intemal and external management constraints, the mission recommends: (i) standardization of data processing and consolidation, proceeding with the acquisition of management software appropriate for project monitoring, such as the software used currently by ADETP, or at the very least, software with similar functionalities, (ii) that the ES make every effort to recruit the employees necessary for preparing the project and organize working meetings with all the relevant stakeholders, so that it can do identify the organizational aspects of data collection and management procedures. Furthermore, it may be necessary to prepare procedures manuals that outline the functionalities which characterize project management. It was agreed that these activities would be financed under the PPF and undertaken according to the following schedule. Lction to be taken Iire the AFUJES Financial Director lire the AFU/ES Accountant Eire the CISUIES Accountant .aunch the competitive bidding process for hiring a inn to implement: 1. The project monitoring system, to be finalized before July 15,2003. 2. Prepare and send to IDA a draft financial monitoring report (FMR) adjusted to the project, to be discussed during the negotiations. The model may be prepared using an Excel spreadsheet for this purpose, pending formalization in the information system to be acquired. 3. Organize a workshop on management procedures between the ES and the ministries 4. Prepare topics for analyses for retrieving the financial statements and classifications used (budget, accounting, components and subcomponents) for the draft Formalization of Legal Instruments (memorandum of understanding between the ES and ministries) 5. Formalize and prepare the financial and accounting management procedures manual and the internal control manual 6. Train the employees in the system that has been developed Stake- holder PMUJES PMU/ES PMUJES PMUJES PMUJcons PMUJcons PMUJcons PMUJcons Source of funding PPF PPF PPF PPF PPF PPF Deadline Done Done Project effectiveness 0413 012003 04/07/2003 (done) 05/15/2003 0513 112003 06/15/2003 06/30/2003 In addition, the objective of setting-up specific structures is to improve the coordination of activities which will be undertaken by the ministries. As such, the relationships need to be formalized in memoranda of understanding that include a concise description of each party’s scope of authority, the nominatioddesignation of the focal point and the operating rules which must be consistent with established budgetary practices. - 84 - Page 91 In terms of general organization, the relevant implementation structures (ES, focal points and regional committees) seem satisfactory with regard to the qualification and number of employees assigned to or to being considered for the project. Beyond intentions, the creation of programming and implementing units, the nomination of the Executive Secretary and focal points, as well as clarifications on management procedures are all elements which presuppose ownership by the different project stakeholders. - 85 - Page 92 Annex 7: Project Processing Schedule DJIBOUTI: HIVIAIDS, Malaria, and Tuberculosis Control Project Project Schedule Planned Actual Time taken to prepare the project (months) First IDA mission (identification) 0 111 5/02 02/08/02 Appraisal mission departure 02/13/03 03 12 510 3 Negotiations 04/07/03 04/07/03 Planned Date of Effectiveness 09/30/03 14 Prepared by: The project was prepared in collaboration with the Ministry of Health and the Program to Fight Against AIDS (Programme de Lutte contre le SIDA) (PLS). In addition, once the Executive Secretariat (ES) for the control of HIV/AIDS/STI, malaria, and tuberculosis was established and the Secretary nominated, the project benefited from their input. The project team also worked closely with the UNAIDS Thematic Group in Djibouti, the multilateral donor agencies, bilateral agencies, and participating stakeholders, as well as those living with HIVIAIDS. The Credit Administration Unit (CAU) of the Ministry of Health is currently managing the PHRD grant, as well as the PPF for the project (financial and procurement aspects). The CAU will continue to do so until such time as the Administrative and Financial Unit of the ES is in place. Preparation assistance: The project benefited from a Country-Executed PHRD grant (TF026825), under which the consultant fim CREDES prepared, with the government, the National Strategy on HN/AIDS/STI, Malaria and Tuberculosis, as well as certain components of the project. In addition, a PPF was requested and granted to the government to undertake preparatory activities, focusing on carrying out the populatiodtarget group surveys, qualitative study on infectedlaffected population groups, and an environmental assessment on medical waste management, and the preparation for the Project Operations Manual for the Community-based Initiative. - 86 - Page 93 IDA staff who worked on the project included: Name Michele Lioy Meskerem Brhane Hocine Chalal Rafika Chaouali Mikael Mengesha Abdulgabbar Al-Qattab Omar Faye Kishor Uprety Yasser El-Gamma1 Sameh El-Saharty A. Mohsen Farza Hovsep Melkonian Alaa Hamed David Robalino Hassine Hedda Claudine Kader Qaiser Khan HClkne Talon Eileen Sullivan Speciality TTL, Sr. Population Specialist, AFTH3 Social Scientist, MNSHD Environmental Specialist Consultant, MNSRE Sr. Financial Management Specialist, MNACS Sr. Procurement Specialist. MNACS Operations Officer, MNACS Consultant, Environmental Specialist Sr. Counsel, LEGMS Sr. Operations Officer, MNSHD (Procurement Accredited) Sr. Health Specialist, MNSHD Consultant - Community Based Interventions Specialist Sr. Finance Officer, LOAGl Sr. Health Specialist, MNSHD Economist, MNSHD Finance Analyst, LOAGl Language Program Assistant, MNSHD Sr. HR Economist, MNSHD MNA Translator (MNCO 1) Operations Analyst, MNSHD Reviewers included: Aloysius Ordu, Quality Advisor, MNACS; George Schieber, Sector Manager, MNSHD; Maryse Pierre-Louis, Lead Health Specialist, AFTH2; Christopher Walker, Lead Specialist, HDNHE; John Collier, Operations Analyst, MNSRE, Ayo Akala, Health YP, MNSHD; - 87 - Page 94 Annex 8: Documents in the Project File* DJIBOUTI: HlVlAlDS, Malaria, and Tuberculosis Control Project A. Project Implementation Plan CEDES Report : Tome 1 : Analyse de la situation et de la reponse nationale Tome 2 : Cadre strattgique 2003-2007 Tome 3 : Plan opkrationnel2003-2005 Tome 4 : Manuel de suivi et tvaluation B. IDA Staff Assessments Procurement Assessment Financial Assessment Environmental Management Plan on Waste Management Social Assessment C. Other Qualitative Study on the impact of HIV/AIDS on those infected and affected (3 volumes): RapportJinal de 1 '&de qualitative sociale sur l'impact du VIHKDA 2 Djibouti-Ville Deuxieme programme de cooptration, Djibouti-FNUAP, 2003-2007, Projet de santt de la reproduction (DJ(I03IPOl). Ministere de la santk. Janvier 2003. Proposition pour une demarche de planification annuelle. Ministere de la santt, Djibouti. Septembre 2002. Dtcret No. 2003-0049/PR/MEF/MS, mise en place d'un cadre institutionnel de lutte contre le SIDA, le Paludisme, et la Tuberculose. Rkpublique de Djibouti. 25 mars 2003. Note de service no. 080/2003/MS, portant nomination du Coordinateur du Programme de lutte contre le SIDA (PLS) du Ministere de la santt. Ministere de la santt, Djibouti. le" mars 2003. Note de service no. 002/2003/MS, portant nomination du Secrttaire extcutif de Lutte contre le SIDA, le Paludisme et la Tuberculose. Ministire de la santt, Djibouti. 9 ftvrier 2003. Mise en ceuvre de la Strattgie nationale d'inttgration de la femme dans le dtveloppement. Ministire dtltgut aupres du Premier ministre chargk de la promotion de la femme, du bien- &re familial et des affaires sociales, Djibouti. Septembre 2002 et Dtcembre 2002. Plan cadre des Nations unies pour 1'Assistance au dtveloppement, UNDAF, Djibouti 2003- 2007. Bilan commun de pays (CCA), Systeme des Nations unies, Djibouti. mai 2002. - 88 - Page 95 Project ID Purpose FY Annex 9: Statement of Loans and Credits DJIBOUTI: HIVIAIDS, Malaria and Tuberculosis Control Project 16-Apr-2003 PO71062 2002 DJ-Health Sector Development Project P 0 6 5 7 9 0 PO44585 2001 School Access and Improvement Program PO69930 2000 DJ-INTL. ROAD CORRIDOR REHAB. PROJECT PO44584 1999 DJ-PUBLIC WORKS/SOC.DEV PO44174 1997 DJ-TECH.ASSIST (PATARE) 2002 DJ - FISCAL CONSOLIDATION CREDIT Original Amount in US$ Millions IBRD IDA 0.00 15.00 0.00 10.00 0.00 10.00 0.00 15.00 0.00 14.80 0.00 6.50 Total: 0.00 71.30 Difference between expected and actual disbursementsa Cancel. Undisb. Orig Frm Rev'd 0.00 15.51 0.39 0.00 0.00 5.22 5.11 0.00 0.00 4.47 -3.16 0.00 0.00 4.43 3.98 0.51 0.00 4.93 4.21 0.00 0.00 1 .80 2.06 2.06 0.00 36.36 12.59 2.58 - 89 - Page 96 FY Approval FY Approval Company Total Portfolio: DJIBOUTI STATEMENT OF EC's Held and Disbursed Portfolio In Millions US Dollars Ju~ 30 - 2002 Committed Disbursed IFC IFC Company Loan Equity Quasi Partic Loan Equity Quasi Partic 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Approvals Pending Commitment Loan Equity Quasi Partic Total Pending Commitment: 0.00 0.00 0.00 0.00 - 90 - Page 97 Annex 10: Country at a GlanceDJIBOUTI: HIVIAIDS, Malaria and Tuberculosis Control 1981-91 1991-01 2ooo 2o01 (average annual growfh) Agriculture 16 20 20 Industry -5 1 10 1 1 Manufacturinq -9 0 10 10 Services -0 2 16 11 Private consumption 28 1 2 General government consumption -3 5 -2 0 Gross domestic investment 44 lmoorts of aoods and services 32 19 POVERTY and SOCIAL Djibouti Growth of exports and imports (%) l5 '0 5 0 -5 40 2001 Population, mid-year (millions) GNI per capita (Atlas method, US$) GNI (Atlas method, US$ billions) Average annual growth, 1995-01 Population I%) Labor force (%) Most recent estimate (latest year available, 1995-01) Poverty (% of population below national poverty line) Urban population (% of total population) Life expectancy at birth (years) Infant mortality (per 7,000 live births) Child malnutrition (% of children under 5) Access to an improved water source (% ofpopulation) illiteracy (% ofpopulation age 75+) Gross primary enrollment (% of school-age population) Male Female KEY ECONOMIC RATIOS and LONG-TERM TRENDS GDP (US$ billions) Gross domestic investmenVGDP Exports of goods and serviceslGDP Gross domestic savings/GDP Gross national savings/GDP Current account baiance/GDP Interest payments/GDP Total debtlGDP Total debt service/exports Present value of debtlGDP Present value of debt/exDorts (average annual growth) GDP GDP per capita 1981 1981-91 1991-01 -1.1 .. -3.2 0.64 890 0.57 1.8 45 84 46 115 18 100 35 37 43 31 1991 0.46 0.5 49.6 2000 0.7 -1.3 M. East 8 North Africa 30 1 2,000 601 2.0 2.9 58 68 43 15 89 34 97 103 90 2000 0.55 12.9 44.6 -5.3 5.2 -7.7 0.6 54.7 31.3 64.9 2001 1.6 -0.7 Lower- middle- income 2,164 1,240 2,677 1 .o 1.2 46 69 33 11 80 15 107 107 107 2001 0.57 13.4 45.5 -4.4 6.7 -6.7 0.6 56.2 2001-05 2.6 0.8 1 Development diamond' Life expectancy T I GNI Gross capita enrollment Access to improved water source Djibouti Lower-middle-income group Economic ratios' Trade Investment Domestic savings I 1 Indebtedness Djibouti Lower-middle-income oroup ~N,s;IL Note: 2001 data are preliminary estimates * The diamonds show four key indicators in the country (in bold) compared with its Income-group average. If data are missing, the diamond will be incomplete. - 91 - Page 98 Djibouti 100 0 PRICES and GOVERNMENT FINANCE Domestic prices (% change) Consumer prices Implicit GDP deflator Government finance (% of GDP, includes current grants) Current revenue Current budget balance Overall surplus/deficit TRADE (US$ millions) Total exports (fob) Food and live animals Coffee and derivatives Manufactures Total imports (cifl Food Fuel and energy Capital goods Export price index (1995=100) Import price index (1995=100) Terms of trade (1995=100) BALANCE of PAYMENTS (US$ millions) Exports of goods and services Imports of goods and services Resource balance Net income Net current transfers Current account balance Financing items (net) Changes in net reserves Memo: Reserves including gold (US$ millions) Conversion rate (DEC, local/US$) EXTERNAL DEBT and RESOURCE FLOWS /US$ millions) Total debt outstanding and disbursed IBRD IDA Total debt service IBRD IDA Composition of net resource flows Official grants Official creditors Private creditors Foreign direct investment Portfolio equity World Bank program Commitments Disbursements Principal repayments Net flows Interest payments Net transfers 1981 5.7 1981 1981 177.7 I981 30 0 0 5 0 0 35 -1 0 0 0 0 0 0 0 0 0 1991 6.0 8.6 I991 1991 100 177.7 I991 226 0 34 14 0 0 52 46 0 0 0 11 3 0 3 0 3 2000 2.4 2.4 30.9 1.5 -1.8 2000 72 6 5 46 272 70 12 96 124 121 102 2000 247 347 -101 15 43 -43 47 -5 70 177.7 2000 302 0 60 0 1 25 9 1 8 0 0 2001 2.5 2.5 31.0 2.4 -1.2 2001 78 7 6 50 284 12 101 130 126 103 ai 2001 26 1 363 -102 17 47 -38 42 -4 72 177.7 2001 322 0 69 0 1 10 9 1 8 0 8 Inflation (x) 1 1: 98 97 98 99 00 01 i~ I * -GDPdeflator +CPI I Export and import levels (US$ mill.) I 1300 - I I 95 98 97 98 99 00 0 Exports Imports I Current account balance to GDP (%) 1 Composition of 2001 debt (US$ mill.) I G: 15 A ~ IBRD B . IDA D - Other multilateral F - Private C ~ IMF E - Bilateral G - Short-term - 92 - Page 99 Annex 11: SUPERVISION ARRANGEMENTS DJIBOUTI: HIVIAIDS, Malaria, and Tuberculosis Control Project The project will require intensive supervision, given its multisectoral and multi-agency nature, fast-track preparation, and large span of activities. Moreover, some of the actors to be involved (Le. associations of PLWHA, local NGOs, and CBOs) have relatively limited experience with Bank operations. Some of the slulls required for supervision will be needed on a regular basis while others will be required on an ad-hoc basis. Therefore, a core supervision team will be established, to be complemented by other technical specialists, as agreed upon with the Recipient. The core team would carry out annually, on average, 2 three-week supervision missions comprised of approximately 5 staff. Other technical experts would provide support periodically, as required. During the first year, a heavier supervision program would be expected, with 3 missions, tapering down over subsequent years. On the other hand, as the project grows, more people will be involved, and the need for continuous, intensive assistance will increase. IDA’S supervision task would be facilitated by the continuous monitoring of the Procurement and Project Implementation International Specialist in the Administrative and Financial Unit, the presence of the Social Communication International Specialist in the Social Communication Unit of the ES and the work done by the firm that will be subcontracted for Monitoring and Evaluation. The core team would be comprised of the following experts from headquarters and from the Egypt and the Yemen country offices: (i) task team leader with experience in health projects, with particular focus on HN/AIDS operations; (ii) operation officer who would oversee day-to-day implementation of project; (iii) financial management specialist who would review adherence to Bank procedures with regard to fiduciary responsibilities; and (iv) procurement/implementation specialist who would be responsible for the procurement, implementation, and institutional issues. In addition, a consultant specialist in community-based and multi-sectoral intervention should be part of the team. The core team could also include representatives from Djibouti’s development partners active in the control of HN/AIDS/STI, malaria, and tuberculosis and present in Djibouti, e.g., UNICEF, WHO, UNDP, and WFP. As mentioned in section C4 on “Implementation Arrangements,” these partnership are not as yet finalized. As begun during project preparation, partners from the extended UNAIDS Thematic Group in Djibouti would be invited to participate in supervision missions to ensure complementarity of interventions, build strong partnerships, and facilitate a cross-fertilization of experiences. During preparation, WHO, UNICEF, UNDP, and the French Cooperation were involved in project preparation, while all other at-large UNAIDS partners were involved in specific discussions as well as during regular mission briefings and debriefings. UNAIDS has appointed a regional AIDS program officer (for the Middle East and North Africa) based at the UNDP office in Djibouti, and is in the process of recruiting a country program advisor who should contribute to the supervision and facilitation of the HN/AIDS program implementation. - 93 - Page 100 The core team will be primarily responsible for the review of: (i) quality of project management and implementation, and adherence to the project Project Operations Manual (POM) and the Procedure Manual for Community Interventions; (ii) monitoring and evaluation results; (iii) financial management, including FMR performance, procurement procedures, environmental safeguard, and technical and financial audits; (iv) spot-check quality and relevance of sub- projects financed under the Fund component; and (v) progress on the development and implementation of sectoral plans. StaffiConsultants Task Team Leader Egypt CO Operations Specialist HQ Financial Management Specialist The core team would visit the country at least once a year, either by themselves or accompanied by other specialists. For the first year, a total of 36 staff weeks are planned, of which 15 headquarter staff weeks, 5 for a consultant, and 16 country office staff weeks (respectively 11 from Egypt CO and 5 from Yemen CO) to emphasize that the country offices assume greater responsibility for the supervision of the project than headquarters. Six weeks will be for consultants. Consultant Staff Number of Estimated Total Travel for Year Staffmeeks for the Labor Budget First Year for Year (US$) 3 trips x 3 wks 11 44,000 3 trips x 3 wks 11 27,500 2 trips x 2 wks 4 12,800 The core team would be complemented with other technical experts in the following areas: (a) sector specialists (e.g., environmental specialist, rural development, education, transport), when necessary to review progress in the respective sector; (b) Monitoring and Evaluation; (c) communications specialist to review BCC/social communication interventions; (d) social scientists to explore the social aspects of the diseases, and in particular of HN/AIDS; and/or (e) economists to assist in priority setting and in monitoring the impact of the epidemic on households. The team has proposed the following breakdown of staff weeks: Procurement Specialist or Operations AnalystJprocurement Yemen CO Social ScientistEommunity-based and multi-sectoral intervention Total 2 trips x 2 wks 5 10,000 3 trips x 2 wks 5 15,700 About $80,000 36 $110,000 The total supervision budget for the first year would be about US$190,000. Expected yearly supervision missions for the other years: Yearly end-of-year progress review mission to take stock of what has been accomplished and to decide on next year's action plan (annual review). These missions should be led by the government and held jointly with other donors. About six months after the end-of-year progress review mission, a regular supervision mission. A mid-term review will be carried out about 30 months after effectiveness. - 94 - Page 101 Project progress reviews will be held annually at the end of the calendar year to assess the performance of the project and its contribution to the national effort to reduce the spread and impact of HIV/AIDS and to control malaria and tuberculosis. They will be held jointly with the UNAIDS Thematic Group. Monitoring and Evaluation information and conclusions of site visits conducted by the supervision team will form the basis of the discussions. Progress reviews would include a presentation by the ES on progress attained, problems encountered, and future steps. A progress report will be prepared for annual review attendees to be distributed at least one week prior to the meetings. The presentation will employ data derived from the project M&E system and observations made during site visits. Other information available at the time, including studies conducted by the project or other donors, will be employed to complement M&E data. Progress reviews will culminate in stakeholder meetings that will form a basis for re-planning for the next year. These meetings will be used to share information on trends and best practices and to provide general technical information. Regular supervision mission will be concluded by a debriefing to which all the stakeholders will be invited. The mid-term review will be preceded by a beneficiary assessment and an evaluation of the project performance done by an outside consultant. - 95 - Page 102 Annex 12: ENVIRONMENTAL MANAGEMENT PLAN DJIBOUTI: HIVIAIDS, Malaria, and Tuberculosis Control Project Health Care Waste Management Plan Executive Summary 1. Objective The inappropriate handling of infectious materials constitutes a serious danger to public health, particularly for health facility staff. The objective of the study is to improve public health by developing a system of health care waste management (HCWM) and an implementation plan. Both the study and the HCWM plan will take into account environmental, technical, and sociocultural concerns. The HCWM will reinforce better coordination by determining the requisite changes in management and will identify needs in terms of specific investments, capacity-building programs, and training programs. 2. There are 52 health facilities in Djibouti with a 980-bed global capacity: 7 Hospital Medical Centers (CMH); 11 Health Centers (CS); 22 Health Posts (PS); 3 private clinics; 6 private medical centers; 2 dental and pharmaceutical centers. The health staff in the public sector is comprised of 930 agents, among them: 98 doctors; 130 midwifes; and, 60 nurses. The solid waste production in health facilities is estimated at 2,144 kg/day, and Health Care Waste (HCW) represents nearly 634 kgJday. Main acknowledgements of the study The main problems identified are structured on the following: 2.1. The institutional and legal framework is deficient with regard to HCW management The national health policy does not set HCW management as a priority. There is no HCW legal framework, and there is a clear absence of regulations pertaining to HCW and to HCW procedures within health facilities. Neither can sound HCW management be construed, nor can individual responsibilities be defined. 2.2. The organization and equipment of HCW management are not performing Health facility HCW management is deficient, despite the efforts noted in some health centers. The major constraints are: lack of a plan or internal management procedures; absence of viable data regarding HCW production and characterization; no responsible person designated to follow up on HCW management; insufficient amount of appropriate collection supplies and protection equipment; no systematic separation of HCW and mixing of HCW with household waste; and, constraints in designing, building, and operating local (craft) incinerators. 2.3. The behaviors and practices of HCW management are generally poor In general, the medical staff have no knowledge of HCW management; in practice, attitudes are poor. Among hospital support staff (cleaners, caretakers, etc.) training and sensitizing is needed. - 96 - Page 103 2.4. Civil society is not involved in HCW management The civil society does not take part in HCW management. This causes a major constraint in the professionalization of the sector. For external transportation, the inexistence of companies specializing in HCW collection constitutes a major constraint for health centers in need of extemal treatment. 2.5. The financial resources allocated to HCW management are insufficient Without regular and significant HCW budget allocations, sustainable improvement of HCW management is impossible to consider. Compared to the financial resources allocated to medical care, the financial resources generally allocated to HCW management are purely symbolic. 3. Main recommendations Plan of Action. The objective of the HCW Management Plan is to trigger a process and to support the respective local response. The plan will stress preventive measures, especially actions to be taken in order to reduce health and environmental risks related to the current practices. Pertinent actions must eventually foster behavioral change, sectonvide protection from the associated risks of infection, and ecological sustainability of HCWM. In this prospect, pertinent measures will support the intervention strategy. The most relevant are: Improve the institutional and legal framework in the field of HCW management - Set up a structure to coordinate and follow up on the HCWM plan - Develop a national policy on environmental health, public hygiene, and HCWM - Develop rules and regulations linked to HCWM - Develop technical guidelines for HCWM. Improve HCW management within health facilities - Regulate HCWM within health facilities - Appoint a responsible in charge of HCWM issues and follow-up - Provide health facilities with materials and equipments for HCWM - Conduct systematic sorting of items and rationally manage the disposal of sharp objects - Promote the use of recyclable materials - Determine HCW treatment and final disposal for any type of health facility - Estimate financial resources in order to fund HCWM activities. Train the hospital staff and waste operators - Elaborate training programs and train-the-trainers - Train all the operators acting in the HCWM system - Evaluate training programs. Inform and make populations aware of HCWM-related risks - Inform populations of dangers related to HCW and to the use of recycled objects - Ensure a sound HCWM plan for households providing at-home medical care. Promote inclusion of private companies in HCWM - Implement a partnership framework between public, private, and civil society sector - Reinforce managing capacities of civil society in HCWM. - 97 - Page 104 Support the implementation of HCWM plan - Validate the HCWM plan - Prepare operational activities - Follow up on implementation and evaluate the HCWM plan. 4. The launching workshops aimed at national and local authorities and the preparation of operational activities for the HCWM plan will occur in the first three months of the first year under the responsibility of the Department of Planning of the Ministry of Health (DEPCI). Activities to reinforce the institutional and legal framework (conducting thorough studies for a national policy on public hygiene, HCWM regulations and technical guidelines, and health facility HCWM regulations) will occur in the first six months of the first year under the direction of Public Hygiene (DPHP) and Basic Health Care (DSSB). During this period training programs (e.g., train-the-trainers and staff training) and public awareness campaigns will be conducted under the supervision of the National Health Training Center (CFPS) and Health Education Services (SEPS), respectively. Action plan for the implementation The activities to provide heath facilities with protection, treatment, and collection equipment and to encourage the involvement of private companies in HCWM will occur in the second year of the program under the direction of DSSB. Throughout the program there will be regular (monthly and yearly) follow-up on implementation. International consultants will evaluate the HCWM plan at the project’s mid-point and end. At the national level, the plan will be conducted mainly by the following institutions within the Ministry of Health: DSSB; DPHP; DEPCI; SEPS; and CFPS, and under supervision of PLS. Health Districts will follow up on the activities at the regional and local levels. 5. The estimated cost of the HCWM plan is FD64,500,000 (USD360,OOO). FD53,100,000 (USD296,OOO) would be allocated to strengthening institutional and legal frameworks, and conducting training and public awareness campaigns. FD 1 1,400,000 (USD64,OOO) would be allocated to complementary measures aimed at improving HCW collection and treatment in health facilities (modem incinerators, homemade incinerators, health burial pits, protection devices, and collection materials). Cost of the HCWM plan Mbaye Mbengue FAYE February 2003 - 98 - Page 105 Objectifs et StratCgies du Plan de Gestion des DCchets sanitaires @S) StratCgie d’intervention du plan de gestion Axes d’intervention. Le Plan de Gestion des DS propost ici a pour objectif d’initier un processus et d’appuyer la rkponse nationale en matikre de gestion des dkchets de soins de santk. I1 mettra l’accent sur les mesures prkventives, notamment les initiatives a adopter en vue de rCduire les risques sanitaires et environnementaux liks aux pratiques actuelles, a partir d’actions concrktes devant permettre, a terme, un changement de comportement, une gestion Ccologiquement durable des DS et une protection des acteurs contre les risques d’infection. Dans cette perspective, la strattgie d’intervention du projet devra Stre sous-tendue par un certain nombre de mesures dont les plus importantes concement les points suivants : renforcer les capacitks institutionnelles et techniques dans le cadre d’une consultation avec les autoritks gouvemementales, pour initier la formulation de la politique et de la rkglementation relatives a la GDS, avec pour finalitt la mise en place de cadres organisationnels et l’klaboration d’outils de gestion adtquats; rtaliser des activites de formation des diffkrents acteurs (personnel de santk, agent d’entretien, collecteurs municipaux et collecteurs privks de dkchets, etc.) ; entreprendre des campagnes d’information, d’kducation et de sensibilisation en direction des populations a la base sur les enjeux de la gestion kcologiquement durable des DS ; soutenir les initiatives de partenariat entre les services publics, les opkrateurs privCs et la sociktt civile dans la collecte et la gestion des DS. Ces activitts feront l’objet d’une estimation financikre et constitueront une partie inttgrante des activitks du projet de lutte contre le SIDA. StratCgie de formation et de sensibilisation Formation des agents de santC et collecteurs. La formation des agents de santk s’inscrira dans le cadre de la strattgie nationale de formation continue du MS, et reposera fondamentalement sur ses principes majeures, notamment la dtcentralisation de la formation au niveau District ; l’harmonisation de la formation continue avec la formation de base ; la collaboration avec les institutions nationales de formation (notamment le CFPS); la validation des programmes de formation continue ; la coordination du programme de formation par le CFPS. Le programme de formation et de sensibilisation vise a : Rendre optrationnelle la stratkgie de gestion des DS ; Favoriser l’tmergence d’une expertise et des professionnels en gestion des DS ; Elever le niveau de conscience professionnelle et de responsabilitt des employis dans la gestion des DS ; Prottger la santk et la stcuritt des personnels de santt et de collecte. - 99 - Page 106 Sensibilisation des populations. Les programmes d’information et de sensibilisation au niveau des centres de santC, mais surtout en direction du public en gCnCral et des dCcideurs en particulier, sont essentiels pour rCduire les risques d’infection et d’affection par les DS. Dans la mesure du possible, les programmes d’information et de sensibilisation sur la gestion des DS devraient Ctre reliCs aux campagnes plus larges de lutte contre les ISTNIHISIDA, menCes a l’kchelle communautaire, sectorielle, rtgionale ou nationale. Dans le cadre de leur rtalisation, il conviendra de s’appuyer sur des informations fiables et actuelles relatives aux DS, aux modalitts de leur gestion, aux prtcautions A prendre en cas de manipulation, aux impacts sur les personnes et le milieu, etc. Autant que possible, les campagnes devront &tre intCgrCes dans les politiques et programmes existants, notamment au niveau du Ministkre de la SantC. L’information, 1’Cducation et la communication pour le changement de comportement (CCC) doivent Ctre axCes principalement sur les problemes de santC liCs au DS qui se posent a la population ainsi que sur les mCthodes de prtvention et de gestion pour y remkdier. Ces interventions doivent viser a modifier qualitativement et de fagon durable le comportement de la population. Leur mise en ceuvre rkussie suppose une implication dynamique des services de santt et de tous les membres de la communautk (parents, diverses associations, animateurs de santt.. .). Dans cette optique, les animateurs de santC et les Clus locaux chargCs de la santC doivent &re davantage encadrCs pour mieux prendre en charge les activitCs de CCC. La production de mattriel pkdagogique doit Ctre dCveloppCe et il importe d’utiliser rationnellement tous les canaux et supports d’information existants pour la transmission de messages de santC appropries. Les media publics jouent un rBle important dans la sensibilisation de la population sur le SIDA. 11s se font 1’Ccho des messages qui sont dClivrCs en permanence par les autoritCs nationales et locales. Les structures fCdCratives des ONG et des OCB devront aussi Stre mises a contribution dans la sensibilisation des populations. Cadre de Dartenariat dans la GDS Cadre de Partenariat. La stratCgie du projet de lutte contre le SIDA repose sur I’intCgration de toutes les entitks publiques, privCes, ONG, associations et la sociCtC civile afin de garantir la cohtrence des actions entreprises et l’atteinte des objectifs. Dans cette logique, la strat6gie d’implication des populations et des partenaires dans un cadre de partenariat formel, devra pennettre de dCterminer pour chaque catkgorie d’acteurs, les rBles et responsabilitts potentiels ainsi que les contributions attendues. Implication de la SociCtC Civile. Les populations s’organisent de plus en plus en structures formelles ou informelles, dont celles des jeunes et des femmes se rCvklent les plus dynamiques. Ces organisations cherchent a amCliorer leurs conditions de vie, a participer au dkveloppement de leur localit6 et sont ainsi des partenaires incontournables. Sous ce rapport, le projet devra privilkgier les formes locales qui bCnCficient de l’effet de proximitC et de connaissance du milieu. C’est pourquoi, dans le cadre de sa strattgie de partenariat, le projet devra baser son choix en priorit6 sur les structures d’autogestion locales, ayant une prCsence effective sur le terrain , disposant d’une exptrience avCrCe dans le domaine de l’EC, notamment sur le VWSIDA, ayant aussi une bonne connaissance de la zone d’intervention et rkellement motivCes. La mise en place d’un systeme des gestion rationnelle et durable des DCchets sanitaires (DS) devra s’articuler autour des objectifs stratkgiques suivant : (i) amCliorer le cadre juridique de la Gestion des dCchets sanitaires (GDS); (ii) amtliorer la gestion des DS dans les formations sanitaires ; (iii) former le personnel de santC sur la GDS ; (iv) Sensibiliser les populations et les collecteurs de dtchets sur les risques liCs aux DS ; (v) Impliquer les optrateurs privCs dans la gestion des DS ; et (vi) appuyer la mise en ceuvre du Plan de gestion des dCchets sanitaires (PGDS) . - 100- Page 107 Objectif 1 : AmCliorer le cadre juridique de la GDS. Pour cette composante, il s’agira d’abord de mettre une structure de pilotage et de suivi du plan, ensuite d’elaborer un document d’orientation politique complktk par un texte juridique (qui indiquent les principes et objectifs nationaux en matiire de gestion des DS et determinent les responsabilites et obligations des difftrentes institutions), mais aussi de mettre au point des guides techniques de gestion des DS. Sur un autre plan, il conviendra de dCfinir au niveau central des politiques, des lois et des riglements en vue de completer et de renforcer les arret& et autres procedures adoptks aux Cchelles locales, notamment par les collectivites. I1 faut ajouter qu’un appui technique du niveau central et un renforcement des capacitts de management seront nkcessaires pour une meilleure maitrise du processus de gestion des DS. Tant que les procedures ne seront pas dtfinies et les responsabilites clairement dklimitkes, il ne sera pas possible d’amkliorer de fagon notable le processus de gestion des DS. Si l’on veut promouvoir un systkme de gestion rationnelle des DS, il s’avire necessaire d’elaborer des directives techniques nationales et de standardiser les procedures de gestion des DS. Ces directives devraient mettre un accent particulier sur le tri source. Objectif 2 : AmCliorer la GDS dans les formations sanitaires. Les activites suivantes devront Ctre entreprises: a) RCglementer la gestion des GDS au niveau des formations sanitaires. I1 s’agira notamment de dtfinir les rBles et les responsabilites des diffkrentes institutions publiques dans la gestion des DS; b) DCsigner un responsable chargC du suivi de la GDS. Ce responsable sera charge du suivi du tri a la source, du suivi de l’application des bonnes pratiques par le personnel de santC, du suivi de la collecte, du transport et de l’klimination interne des DS ; c) Doter les formations sanitaires d’kquipements et matCriels de gestion des DS. I1 s’agira de doter les formations sanitaires de poubelles approprites de prC- collecte, de conditionnement et de stockage des DS, ainsi que de systkmes performants de traitement et d’tlimination ecologique des DS solides et liquides ; d) Instaurer le tri systkmatique des DS et gCrer rationnellement les dbchets pointus et tranchants. Compte tenu des difficult& auxquelles les ttablissements de soins sont confrontks (insuffisance de poubelles, systkmes de traitement deficients, etc.), la priorite devrait &e donnee a la gestion des dtchets les plus dangereux (dtchets pointus et tranchants ; e) Promouvoir l’utilisation de matCriels recyclables. L’utilisation de materiels recyclables (boites de mtdicaments ou autres contenants en plastique, flacons, bouteilles vides, etc.), constitue une option inthressante dans le processus de minimisation des volumes de dtchets, d’autant plus que cela pennet de rkduire les dkchets A incinkrer ou a traiter autrement ; f) Choisir un systkme de traitement des DS pour les formations sanitaires. I1 s’agira de determiner les systkmes de traitement les plus appropriks pour chaque de type de formation sanitaire (HBpitaux de refkrence, CMH, Centres de SantC, Postes de santt) pour l’tlimination des dtchets solides et liquides ; et g) PrCvoir des ressources budgCtaires suffisantes pour financer la GDS. Instaurer des lignes d’tcriture spkcifiques pour la gestion des DS au niveau des centres de santt. - 101 - Page 108 Objectif 3 : Former le personnel hospitalier dans la GDS. I1 s’agit d’informer et de former le personnel de santk, les agents d’entretien sur les dangers liks a une mauvaise gestion des DS. En outre, au niveau des modules de formations du CFPS, il conviendra d’intkgrer la problkmatique de la GDS notamment pour les agents qui s’occupent de la manutention des dkchets (personnel hospitalier, manipulateurs de dkchets, collecteurs municipaux), d’klaborer et de diffuser un programme national de formation des formateurs sur les risques sanitaires et les bonnes pratiques de gestion des DS. Les activitks de formations du MS sont gkntralement axkes vers la qualitk des soins de santt concemant les agents mkdicaux et paramtdicaux, et a un degrt moindre vers la prkvention des infections. C’est pourquoi il est ntcessaire de renforcer les connaissances, mais surtout d’amkliorer les pratiques de ces agents dans la manipulation et la gestion des DS. La formation devra concemer aussi les operateurs prives et les techniciens municipaux actifs dans les travaux d’entretien, de nettoiement et de gestion des dkchets solides. En effet, les services publics municipaux aident a collecter les dkchets solides dans certaines formations sanitaires. La plupart des agents collecteurs n’ont rep aucune formation sur les DS qui sont mklangks avec les autres ordures dans les containers qu’ils collectent. Les impacts qui rtsultent de cette situation concement l’exposition de la santk des agents face aux risques d’infection, le rejet anarchique des dtchets solides dans les dkp6ts sauvages d’ordures mtnageres et surtout les risques de contamination du milieu environnant par ces dkversements non contrdles. Objectif 4 : Sensibiliser les populations et les collecteurs de dCchets. Prksentement, au niveau du Service d’Education Pour la Santk du MS, il n’existe pas de programmes opkrationnels d’information et de sensibilisation des populations axes de fagon explicite sur les prkoccupations likes a la gestion des DS. Pour l’essentiel, les programmes dtja rkalisks ou en cours couvrent les domaines liks la santk en gknkral (soins de sante, prkvention des maladies, etc.), comme cela a ttk le cas concernant la formation pour les agents de santk communautaires, les associations de quartiers, etc. C’est pourquoi, il s’avere nkcessaire de rkaliser des programmes de sensibilisation en direction surtout des populations foumissant ou recevant des soins de santt a domicile, des personnes utilisant des objets recycles ou vivant A proximitk des dkcharges d’ordures ainsi que des rtcupkrateurs de dkchets. Ces programmes devraient Ctre menks avec l’appui des ONG et OCB ayant une large expkrience des questions d’environnement et de santk. Objectif 5 : Impliquer les opCrateurs privCs dans GDS. A ce niveau, le plan de gestion qui sera proposk devra dkvelopper une approche de professionnalisation de la filibre afin qu’elle puisse genkrer des revenus et des profits. Une telle option suppose que le plan prenne en compte l’exigence du soutien aux initiatives privkes et du dkveloppement du partenariat publiclprivelsociktk civile pour assurer le financement de la filikre. Dans ce cadre, il serait souhaitable de dkterminer des mkcanismes de financement autonomes pour l’klimination des DS, de dkvelopper des ressources financieres spkcifiques et d’inciter les partenaires publics et privks a s’engager dans le financement de la filiere en renforgant leurs capacitks techniques et manageriales en vue de favoriser l’kmergence d’une expertise et d’un leadership dans ce domaine. En effet, le choix de technologies approprikes nkcessite une expertise eprouvke et des ressources financieres conskquentes. C’est pourquoi les gestionnaires de dkchets solides devront Ctre encourages a participer a des rencontres techniques (skminaires, conftrences, etc.) qui leur offrent des opportunitks d’echanges d’expkriences avec d’autres. Ainsi, ils pourront bknkficier de paquets de formation orientke principalement vers les domaines suivants : (i) choix d’kquipements appropriks de collecte, (ii) moddes de planification efficiente des circuitsiitinkraires de collecte, (iii) manipulation spkcifique des DBM, (iv) efficacitk des coiits des technologies disponibles. - 102 - Page 109 Objectif 6 : Appuyer la mise en ceuvre du PGDS. Les strategies sont les suivantes : a) Valider le PGDS. I1 s’agira, dans chaque District, d’organiser des stminaires de lancement, d’information et de validation du PGDS, dans le souci de rtaliser un consensus national tlargi A l’ensemble des acteurs ; et d’installer la structure nationale de coordination de la mise en ceuvre du PGDS ; b) PrCparer les activitCs opCrationnelles. I1 s’agit ici de proctder a l’tvaluation de dtmarrage ; et c) Suivre la mise en ceuvre et Cvaluer le PGDS. I1 s’agira d’assurer le contrble et le suivi mensuel au niveau District et national ; d’effectuer l’tvaluation 21 mi- parcours (fin 2eme annte) ; d’effectuer l’tvaluation finale du PGDS (fin du projet). Articulation du PGDS a la politique sanitaire nationale Ancrage institutionnel. Composante essentielle du Projet de lutte de lutte contre le SIDA (PLS), le PGDS devra &e, au plan institutionnel, ttroitement articult A la strattgie sanitaire nationale. Aussi, le plan de gestion devra s’inscrire dans une logique de compltmentaritt par rapport A la politique globale de gestion des dtchets particulikrement A la politique nationale d’hygiene et d’assainissement, qu’il importe d’elaborer sous l’tgide du MS. Ainsi, la coordination des activitts du PGDS devra &tre assurte par le PLS. ResponsabilitCs et compCtences institutionnelles. L’amtlioration de la gestion des DS suppose au prealable de clarifier la part de responsabilitts et les domaines de compttence de chacun des acteurs institutionnels concemts. Dans cette perspective, la rtpartition suivante peut $tre proposte : Au niveau central, le MS devra Stre responsable de la definition et de l’application de la politique nationale de gestion des DS. la Direction de la Prtvention et de 1’Hygiene Publique, (DPHP), la Direction des Soins de Santt de Base (DSSB), y compris le Service d’Education Pour la Santt, la Direction des Etudes, de la Planification et de la Cooptration Internationale (DEPCI), le Centre de Formation du Personnel de Santt devront assumer un r61e central dans le suivi de l’extcution du plan de gestion, notamment de la conformitt des proctdks de collecte, d’entreposage, de transport et d’tlimination avec les nonnes et proctdures qui seront tlabortes. L’tlaboration des textes ltgislatifs et rtglementaires relatifs A la GDS devra &tre confite A la DPHP, les activitts de formation au CFPS, l’tducation et la sensibilisation au SEPS de la DSSB ; 0 0 Au niveau district, les Districts Sanitaires auront la responsabilitt administrative de la gestion des DS dans leur zone d’influence. 11s mettront en place des unitts techniques optrationnelles chargtes de veiller a l’application de la politique nationale au sein des structures sanitaires de leur zone ; 0 Le Directeur de chaque formation sanitaire sera administrativement responsable de la GDS dans son ttablissement. I1 devra veiller A l’application du reglement et des proctdures de bonnes pratiques. I1 devra dtsigner les tquipes en charge du tri, de la collecte, de l’entreposage, du transport et de l’elimination des DS ; 0 le MHUEAT devra veiller A la stricte application des normes et proctdures environnementales (normes de pollution, proctdures d’tlaboration et d’approbation d’EIE) dans toutes les activitts de gestion des DS, notamment lors de la mise en place des incintrateurs; - 103 - Page 110 0 les Communes auront la responsabilite de veiller a la salubritk de zones situtes dans leur territoire, notamment en s’assurant que leurs containers publics (surtout ceux placts dans les formations sanitaires) et les dkpotoirs d’ordures qu’elles gbrent ne regoivent pas des DS non traitks. Elles devront kgalement donner leur avis sur tout projet susceptible de porter atteinte A la santk des populations locales, notamment les projet de collecte, transport et elimination des DS dans leur territoire. des DS pour chaque type de formation sanitaire activitks de GDS Prkvoir des ressources budgktaires pour financer les Sensibiliser les populations (familles, gardes malades, rkcuperateurs, enfants, ) : messages tklk, messages radio, affiches, banderoles et skances d’animation de quartier Sensibiliser et effectuer un plaidoyer auprbs des dkcideurs gouvernementaux Plan de suivi de la mise en Deuvre du PGDS ____ ____ ____ _--- ____ ____ ---- ---- __-- ____ ____ ____ ___- ---- ____ _-__ ___- ---- ==== Principes. Pour mesurer l’efficacitk du Plan de Gestion des DS sur le niveau de rkduction des infections et affections sur les personnes principalement concernkes, notamment la skcurite en milieu de soins, les actions prkconiskes devront faire l’objet d’un suivilkvaluation, dans le cadre d’une structure de coordination qui devra impliquer tous les acteurs aussi bien le PLS, les services du MS et du MHUEAT, les formations sanitaires (notamment les hbpitaux de rkfkrence) ainsi que les communes et les ONG actives dans le domaine de la santk et de l’environnement. Le PLS (avec l’appui de la DEPCI) assurera la coordination du suivi et centralisera les informations et donnkes de suivilkvaluation dans le cadre d’une banque de donnkes et d’un systbme d’information pour la gestion des DS qui pourrait &re gkrke au niveau de la DEPCI du MS. - 104- Page 111 Former les formateurs Former le personnel hospitalier dans la gestion des DS Evaluer l’application des programmes de formation Mettre en place un cadre et des mkcanismes de partenariat entre le secteur public, les privks et la societe civile dans la gestion des DS Renforcer les capacites manageriales des prives dans la gestion des DS PrCparer les activites opkrationnelles (evaluation demarrage, etc.) Suivre la mise en ceuvre et evaluer le PGDS -_ __ ____ ____ ____ ____ -___ ---- ---- ---- ____ _--- ---- ---- ”- 500 CoQt du plan de eestion des DS. Le coilt du plan de gestion est estime A globalement 60 950 000 FD pour les cinq annees d’intervention du programme. Tableau : CoQts de la mise en ceuvre du PGDS 1500 750.000 Amelioration du cadre juridique 600 800 20 Formation du personnel de sante et des agents privts collecteurs de dkchets 15 000 9.000.000 10 000 8.000.000 15 000 300.000 18.650.000 Forfait 500.000 Sensibilisation des populations 12 60 ActivitCs 400 000 4.800.000 100 000 6.000.000 Mettre en place une structure de coordination du PGDS Validation du PGDS et mise en place d’un plan d’action 20 150 000 (d’operations) Elaborer politique nationale de GDS 3.000.000 16.300.000 et les textes juridiques (code, decrets application) Elaborer les guides techniques de GDS Sous-total cadre institutionnel Personnel encadrement (30 agents pendant 3 jours, soit environ 90 Wj) Personnel medical et paramCdical(5 sessions prks de 120 agents, pendant 3 jours de formation, soit environ 600Wj) Personnel appui : garqons et filles de salle, matrones, etc. (400 agents pendant 2 jours, soit 800 Wj) Renforcer les capacites des prives dans la gestion des DS (10 cadres pendant 2 jours, soit 10 Wj) Sous-total formation Production messages communication Diffusion messages televises (spots) Diffusion messages radio (spots) Affiches dans les centres de sante Animations publiques Sous-total SensibilisatiodIEC Unit6 H/j U H/j H/j H /j W U U U U U CoQt Total unitaire 15 000 400 I 2.000.000 5000 I - 105 - Page 112 Amtlioration Boites a seringues U 1000 3 000 de la collecte Poubelles de salle U 1000 1500 traitement des 3 .OOO.OOO 1.500.000 ceuvre du PGDS Suivi mensuel au niveau rkgional Suivi au niveau national Wj Plan de financement proposC I TOTAL Cotit des activitbs li inclure dans le Projet WWSIDA. Le coat des activitts A inclure dans le programme SIDA comprennent des activitts de renforcement du cadre institutionnel et juridique (9.750.000 FD), de formation et de sensibilisation des acteurs concemCs (18.650.000 et 16.300.000 FD respectivement), et A l’appui A la prtparation et la mise en ceuvre du PGDS (8.400.000 FD), pour un total de 52.100.000 FD rtpartis sur les 5 anntes du programme. Evaluation a mi-parcours exteme H/j 30 100 000 3 .OOO.OOO Evaluation exteme finale H/j 30 100 000 3 .OOO.OOO Sous-total appui 8.400.000 64.500.000 Cotits des mesures complkmentaires. En plus des activitks d’appui institutionnel et de renforcement des capacitis des acteurs concemis par la gestion des DS, il nous a semble ntcessaire d’identifier et de proposer, dans le cadre de l’ttude, d’autres actions compltmentaires pertinentes qui depassent le domaine strict du programme VM/SIDA. Ces actions, chiffi-6s a 11.400.000 FD, pourraient Stre rCalisCes par les institutions publiques chargCes des questions sanitaires et environnementales dans le cadre de leurs programmes respectifs, selon un tchtancier qu’elles dttermineront et en fonction de leurs disponibilitts budgttaires. Les actions les plus importantes concement l’amklioration du processus de gestion des DS dans les Ctablissements de soins par la fourniture de matkriel de collecte et de traitement ainsi que des tquipements de protection pour le personnel. - 106 - Page 113 Objectives and Strategies of the Sanitary Waste Management Plan (PGDS) Intervention strategy and management plan Intervention paths. The objective of the Sanitary Waste Management Plan (PGDS) proposed herein is to initiate a process and support the national response to the question of managing health care waste. It will emphasize preventive measures, in particular initiatives to be adopted with a view to reducing the health and environmental risks associated with current practices, starting from concrete steps which should ultimately make it possible to induce a change in behavior and bring about the ecologically sustainable management of sanitary waste and the protection of all parties concerned against risks of infection. In this perspective, the intervention strategy of the project should be supported by a number of measures, the most important of which relate to the following points: 0 strengthening institutional and technical capacities in the framework of a consultation with government authorities to initiate the formulation of policies and regulations on the management of sanitary waste, with a view to establishing appropriate organizational frameworks and developing adequate management tools; 0 conducting training activities for the various parties (health personnel, maintenance staff, municipal and private trash collectors, etc.); l engaging in information, education, and public awareness campaigns aimed at grassroots populations regarding the stakes involved in the ecologically sustainable management of sanitary waste; * supporting partnership initiatives with public agencies, private operators, and civil society as regards sanitary waste collection and management. These activities will be subject to the preparation of financial estimates and will constitute an integral part of the Program for AIDS Control (PLS). Training and public awareness strategy Training of health personnel and collectors. The training of health personnel will be carried out as part of the Ministry of Health’s national strategy for continuing training, and will be built primarily around district level; the national training validation of the CFPS. that strategy’s major principles, including the decentralization of training at the harmonization of continuing training with basic training; collaboration with the institutions (in particular the Health Personnel Training Center-CFPS); the continuing training programs; and coordination of the training program by the The training and public awareness campaign is designed to: l Make the sanitary waste management strategy operational; l Promote the emergence of sanitary waste management professionals and expertise; * Raise the level of professional conscientiousness and staff responsibility in sanitary waste management; and Protect the health and security of health and collection personnel. Enhanced public awareness. Information and public awareness programs aimed at the health centers, but especially at the public in general and decision-makers in particular, are essential for reducing the risks of infection and contamination from sanitary waste. To the greatest extent Page 114 possible, the information and public awareness programs on sanitary waste management should be tied to the broader campaigns to combat HIV/AIDS/ST1 that are carried out at the community, sector, regional, or national level. In conducting these programs, it will be advisable to make use of current and reliable information regarding sanitary waste, the approaches to its management, the precautions to be taken in handling same, impacts on individuals and the environment, etc. To the greatest extent possible, the campaigns should be integrated with existing policies and programs, in particular within the Ministry of Health. Information, education, and conrmunication (IEC) for behavioral change must be focused principally on the public health problems associated with sanitary waste and the prevention and management methods for addressing these problems. These activities must target achieving qualitative and sustained change in people’s behavior. Successful implementation assumes the dynamic interaction of the health services and of all members of the community (parents, various associations, leaders in the health sector, etc.). In this perspective, the health sector leaders and local elected officials responsible for health matters should receive additional training in order to better assume responsibility for behavioral change communications. The production of training materials must be advanced, and it is important to make rational use of all existing information channels and support mechanisms for the transmission of appropriate health messages. The public media play an important role in enhancing public awareness about AIDS by rebroadcasting the messages regularly delivered by the national and local authorities. The structures of NGOs and CBOs will also have to be called upon to contribute to enhancing public awareness. Partnership framework for sanitary waste management Partnership framework. The strategy of the Program for AIDS Control is based upon the integration of the efforts of all public entities, private entities, NGOs, associations, and civil society so as to guarantee the consistency of the efforts undertaken and achievement of the objectives pursued. In this context, the strategy for involving the people and the partners in a formal partnership framework should make it possible to determine the potential roles and responsibilities, as well as the anticipated contributions, of each category of stakeholders. Involvement of civil society. People are more and more frequently organized into formal or informal structures, among which youth groups and women’s groups are proving to be the most dynamic. These organizations endeavor to improve the living conditions of their constituencies and to participate in the development of their communities, which makes their partnership vital. Given this relationship, the project should devote special attention to local ways of leveraging the effect of proximity and familiarity with the surroundings. For this reason, as part of its partnership strategy the project should base its choice on a priority basis on local self- management structures that have an effective grassroots presence, acknowledged experience in IEC activities (in particular with respect to HIV/AIDS), as well as a solid familiarity with and genuine motivation to work in the intervention area. The introduction of rationalized and sustainable sanitary waste management should focus on the following strategic objectives: (i) improving the legal framework for sanitary waste management; (ii) improving sanitary waste management in medical facilities; (iii) training health personnel about sanitary waste management; (iv) enhancing the awareness of trash collectors and the general public of the risks associated with sanitary waste; (v) involving private operators in sanitary waste management; and (vi) supporting the implementation of the Sanitary Waste Management Plan (PGDS). 2 Page 115 Objective 1: Improving the legal framework for sanitary waste management. For this component, the first step will be to establish a PGDS steering and monitoring structure, and then to draft a policy orientation document complemented by legal provisions (indicating the principles and national objectives applicable to sanitary waste management and specifying the responsibilities and obligations of the various institutions), but also to draw up sanitary waste technical management guides. In addition, at the central level it is necessary to define policies, laws, and regulations with a view to complementing and strengthening the orders and other procedures adopted at the local level, in particular by the municipalities. Furthermore, technical support from the central level, as well as strengthened management capacities, will be necessary in order to enhance the control of the sanitary waste management process. Unless procedures are defined and responsibilities clearly delineated, it will not be possible to make any notable improvement in the sanitary waste management process. If the aim is to promote a rational system for the management of sanitary waste, it is necessary to draw up national technical directives and to standardize sanitary waste management procedures. These directives should place particular emphasis on sortin .g waste at the source. Objective 2: Improving sanitary waste management in medical facilities. This should include the following activities: (a) Regulate sanitary waste management at medical facilities. In particular, this will involve defining the roles and responsibilities of the various public institutions in sanitary waste management; (b) Designate an official in charge of monitoring sanitary waste management. This official will be responsible for monitoring waste sorting at the source, the application of best practices by health personnel, and the collection, transport, and domestic elimination of sanitary waste; (c) Provide medical facilities with sanitary waste management equipment and materials. This will involve providing medical facilities with appropriate disposal containers for pre-collection, processing, and storage of sanitary waste, as well as with high performance systems for the processing and ecological elimination of solid and liquid sanitary waste; (d) Introduce the systematic sorting of sanitary waste and rational management of dangerous waste (such as needles, cutting implements, etc.), Considering the difficulties facing health care facilities (shortage of waste disposal containers, deficient processing systems, etc.), priority should be accorded to management of the most dangerous waste (with sharp edges and points); (e) Promote the use of recyclable materials. The use of recyclable materials (medicine containers or other plastic containers, vials, empty bottles, etc.) constitutes an interesting option in the process of minimizing waste volume, especially as it makes it possible to reduce the waste requiring incineration or other processing; (f) Select a sanitary waste processing system for medical facilities. This will entail identifying the most appropriate processing systems for each type of medical facility (referral hospital, health centers with doctors (CMHs), health centers, health posts) for the , elimination of solid and liquid waste; and (g) Provide sufficient budgetary resources to finance sanitary waste management. Introduce specific budget lines for sanitary waste management at the health center level. Objective 3: Train hospital personnel in sanitary waste management. This objective addresses the issue of informing and training health services personnel and maintenance staff on the dangers associated with the improper management of sanitary waste. In addition, at the level of the training modules for the CFPS, the problems associated with sanitary waste management should be included, in particular for staff involved in handling waste (hospital personnel, waste handlers, municipal trash collectors), and a national program should be developed and disseminated to train trainers on health risks and on best practices associated with the management of sanitary waste. The Ministry of Health’s training activities are generally focused on quality of care and addressed to medical and paramedical personnel; they focus to a lesser degree on the prevention of infections. This is why it is necessary to enhance knowledge, but especially to improve the practices of these personnel in handling and managing sanitary waste. Training should also target private operators and municipal technicians active in maintenance 3 Page 116 and cleaning work and the management of solid waste. Indeed, at some medical facilities the municipal public services assist with collecting solid waste. Most trash collectors have received no training about the sanitary waste that is commingled with other trash in the containers they pick up. The impacts resulting from this situation relate to the health risk of the employees’ exposure to infection risks, the uncontrolled discharge of solid waste at unregulated dumps for household waste, and especially the risks of environmental contamination from the related uncontrolled runoff. Objective 4: Enhancing public awareness and the awareness of trash collectors. At present, the Ministry of Health’s Education for Health unit has no operational information and public awareness programs focused explicitly on the concerns associated with sanitary waste management. For the most part, the previous programs or those now underway cover topics associated with health in general (health care, disease prevention, etc.), as was the case for the training offered to community health personnel, neighborhood associations, etc. This is why it is necessary to conduct public awareness programs aimed primarily at the people providing or receiving health care at home, persons using recycled objects or living near waste disposal sites, as well as those who gather trash. These programs should be carried out with support from NGOs and CBOs with ample experience in environmental and health issues. Objective 5: Involving private operators in sanitary waste management. At this level, the proposed PGDS should develop an approach toward enhancing the professionalism of the sector to enable it to manage revenues and profits. Such an option assumes that the plan takes account of the need to support private initiatives and develop the public/private/civil society partnership to ensure the financing of the sector. Within this framework, it would be desirable to determine autonomous financing mechanisms for the elimination of sanitary waste, develop targeted financial resources, and create incentives for public and private partners to engage in the financing of the sector while strengthening their technical and managerial capacities with a view to promoting the emergence of expertise and leadership in this field. Indeed, the selection of appropriate technologies calls for tested expertise and substantial financial resources. For this reason, solid waste managers will have to be encouraged to participate in technical meetings (seminars, conferences, etc.) which give them opportunities to exchange experiences with others. Accordingly, they could benefit from training packages oriented principally toward the following fields: (i) the selection of appropriate waste collection equipment; (ii) models for the efficient planning of collection routes/itineraries; (iii) special handling of biomedical waste; and (iv) the cost effectiveness of available technologies. Objective 6: Supporting the implementation of the Sanitary Waste Management Plan (PGDS). The strategies are as follows: (a) Validate the PGDS. This will entail, in each District, organizing seminars to launch, provide information on, and validate the PGDS, with a view to achieving a national consensus encompassing all stakeholders; and establish the national structure for coordinating PGDS implementation; (b) Preparing operational activities. This will entail evaluating initial operations; and (c) Monitoring implementation and conducting evaluations of the PGDS. This will involve carrying out inspections and monthly monitoring at the District and national levels; conducting the mid-term evaluation (end of second year); and performing the final evaluation of the PGDS (end of project). Page 117 Interconnection of PGDS with national health policy Institutional anchoring. As an essential component of the Program for AIDS Control (PLS), on the institutional level the PGDS will have to be closely tied in with the national health strategy. Therefore, the management plan should have a complementary relationship with the overall policy on waste management, particularly as regards the national hygiene and sanitation plan which it is important to develop under Ministry of Health auspices. Accordingly, the coordination of PGDS activities should come under the PLS. Institutional responsibilities and jurisdictions. Improving the management of sanitary waste assumes that first there has been a clarification of the responsibilities and jurisdictions of each of the institutional stakeholders concerned. To this end, the following distribution could be proposed: At the central level, the Ministry of Health should be responsible for defining and applying the national plan for sanitary waste management. The Prevention and Public Hygiene Directorate (DPHP), the Basic Health Care Directorate (DSSB), including its Education for Medical facility (SEPS), the Research, Planning, and International Cooperation Directorate (DEPCI), and the Health Personnel Training Center will be called upon to assume a key role in monitoring execution of the PGDS, especially as regards adherence with collection, storage, transportation, and elimination procedures, in keeping with rules and procedures to be established. Drafting of the legislative and regulatory provisions relating to sanitary waste management should be entrusted to the DPHP, training activities to the CFPS, and education and awareness campaigns to the SEPS unit of the DSSB; * At the district level, the Sanitary Districts will bear the administrative responsibility for sanitary waste management in their area of influence. They will establish operational technical units charged with monitoring the application of national policy within the health structures in their area; * The Director of each medical facility will be administratively accountable for sanitary waste management in his or her institution. The Director will monitor application of the regulations and of best practice procedures, and will appoint the teams responsible for sanitary waste sorting, collection, storage, transport, and elimination; l The Ministry of Housing, Urbanism, Environment, and Territorial Development (MHUEAT) should monitor strict application of environmental regulations and procedures (pollution standards, procedures for the preparation and approval of environmental impact studies) in all sanitary waste management procedures, in particular when incinerators are installed; 0 the Municipalities will be responsible for ensuring the sanitation of the areas within their territory, in particular with ensuring that their public containers (especially those placed in medical facilities) and the trash receptacles they manage are not used for untreated sanitary waste. They should also express their views on any project which might affect the health of local populations, particularly those relating to sanitary waste collection, transportation, and elimination within their territory. Page 118 PGDS implementation monitoring plan ’ Principles. To measure the effectiveness of the PGDS in terms of reducing infections and contamination affecting the individuals primarily concerned, especially safety in health care environments, the recommended actions should be monitored and evaluated in the context of a coordination structure that involves all stakeholders as well as the PLS, Ministry of Health and MHUEAT staff, medical facilities (in particular referral hospitals), as well as the municipalities and NGOs active in the area of health and the environment. The PLS (with DEPCI support) will coordinate the monitoring activity and centralize the monitoring and evaluation information and data in a databank and information for sanitary waste management which could be administered by the Ministry of Health’s DEPCI. Implementation timetable. The table which follows sets forth the implementation timetable of the management plan. Table: Implementation Timetable Sanitary Waste Management Plan Activities 1 Yyr / Yyr 1 YTr ~ Y~~l-~~l I Establish a coordination structure Organize regional seminars to enhance awareness of leaders ==I= I I I I Develop a national policy on sanitary waste management =====I Prepare national legislation on sanitary waste management ==I=== Draft national directives on sanitary waste management ==== Regulate sanitary waste management at medical facilities Introduce procedures for monitoring sanitary waste management Designate an official in charge of sanitary waste management ==== ==== --- --- I I Equip medical facilities with sanitary waste management equipment I==== / ==== / ==5===: / ==== I / ==== I ==== / ===r== / ==I=== 1 Conduct systematic sorting and rationalized management of sharp and pointed waste i Promote use of recvclable materials I I ---- I --A- l ---- ---- ---- ---- ---- I ---- I Identify a treatment and final elimination system for each tvpe of health unit / /===== 1 / / 1 Provide budgetary resources for financing sanitary waste management activities ---- ---- Enhance public awareness (families, care givers, collectors, children): television and radio messages, posters, banners, and neighborhood awareness meetings Sensitize and make appeals to government decision-makers 1 ====I= 1 Train the trainers I -- -- I I I I I Train hospital personnel in sanitary waste management Evaluate implementation of training programs Establish a partnership framework and mechanisms involving the public sector, private parties, and civil society in sanitary waste management ====I= === ====I= I ---- ---- m--m ---- ---- ---- ---- ---- 6 Page 119 Strengthen private sector managerial capacities for sanitary waste management I Prepare operational activities (startup evaluation, etc.) 1 == I Monitor PGDS implementation and evaluate the Plan I ==== I=== I==== I==== I=== 1 Cost of Sanitary Waste Management Plan The estimated cost of the management plan is DF 64500,000 for the five years of program activity. Table: PGDS Implementation Costs Activity 1 Unit 1 Quantity 1 Unit;;st / Tota&lgst Improvement of legal framework Establish a PGDS coordination structure Validation of PGDS and introduction of an action plan (operations) Develop a national sanitary waste management policy and relevant legal provisions (code, implementing decrees) Develop technical guides for sanitary waste management Each Institutional framework subtotal 1 Training of health personnel and private waste collection staff sessions o matrons, etc. (400 personnei for 2 days each, or about 800 p/d) Strengthen private sector capacities Pers/ in sanitary waste management (10 day supervisors for 2 days each, or about 20 p/d) 20 15,000 300,000 Enhanced public awareness Training subtotal 18,650,OOO Production of campaign messages Each Lump sum 500,000 Broadcast of TV spots Each 12 400,000 4,800,OOO Broadcast of radio spots Each 60 100,000 6,000,OOO Posters in health centers I Each I 5,000 I 400 I 2,000,000 Public meetings IEC/Awareness subtotal Each 20 150,000 3,000,000 16,300,OOO Improved Needle disposal containers Each 1,000 3,000 3,000,000 collection and Ward trash receptacles Each 1,000 1,500 1,500,000 treatment of Boots for maintenance personnel I Each I 400 I 2,000 I 800,000 sanitary waste in health centers Individual incinerators I Each I 18 I 200,000 I 3,600,OOO Sanitary waste burial pits Eauix,ment/material subtotal Each 22 7 Page 120 support for PGDS preparation and imple- mentation Public awareness seminars Evaluation of activity preparation and startup Monthly monitoring at regional level Each 5 Persl 30 day Pers/ - dav Monitoring at national level External evaluation at mid-term Final external evaluation 1~~~1 1 30 1 loo,0bol3,000,000 1 Support subtotal 8,400,000 TOTAL 1 I I I 1 64,500,OOO Proposed financing plan Cost of activities to be included in HIV/AIDS Project. The cost of the activities to be included in the AIDS program includes the activities to strengthen the institutional and legal framework (DF 9,750,000), train and enhance the awareness of the stakeholders concerned (DF 18,650,OOO and DF 16,300,000, respectively), and support for the preparation and implementation of the PGDS (DF 8,400,000), for a total of DF 53,100,OOO over the 5 years of the program. Cost of complementary measures. In addition to the activities devoted to institutional support and the strengthening of stakeholders’ capacities for sanitary waste management, we deemed it necessary to identify and propose, as part of the study, other complementary activities which extend beyond the scope of the HIV/AIDS program strictly speaking. These activities, whose cost totals DF 11,400,000, could be carried out by the public institutions responsible for health and environmental matters as part of their respective programs, in accordance with a timetable they determine and in light of the funding available under their own budgets. The most important activities involve improving the sanitary waste management process in health care institutions by providing waste collection and treatment materials as well as equipment to protect personnel. Page 121 Annex 13: SOCIAL ASSESSMENT DJIBOUTI: HIV/AIDS, Malaria, and Tuberculosis Control Project Social Annex As part of project preparation, a social assessment of people infected or affected by HIV was prepared by the MOH through a research team led by a Djiboutian consultant and advised by the IDA social development expert. This study was the first of its kmd in Djibouti and used qualitative research methods to gain a deeper understanding of the difficulties, coping strategies, and cultural factors that intervene in managing the disease. The purpose of the study was to ensure that the project adequately considered the knowledge, attitudes, and practices of the wide community and of infected persons. The study: (i) (ii) (iii) (iv) Effectively demonstrated to the MOH that HIV is not only a public health but also a broad socio-economic issue; Contributed to initial steps of destigmatizing the effects of the disease; Provided a social and cultural understanding that has shaped the project’s design; Helped mobilize other donors (such as the World Food Program (WFP)) and medical centers in providing care and support to PLWHA and their families. The findings of the research were presented during several workshops consisting of: representatives of the MOH (including high officials), donor community, teachers, and local NGOs. This dissemination of the study helped inform a wider public of the social and economic issues faced by the PLWHA and their families, and it enriched the final document. It also helped launch a discussion on actions that communities and institutions can undertake to alleviate the burden of the disease on PLWHA and their families. The public discussion on the impact of the infection on sero-positive individuals and their families painted a human face and contributed to beginning the process of destigmatization. The draft report was reviewed and commented on by IDA. These recommendations are reflected in the final document. Research Method Qualitative research was conducted in July-August 2002 through a team of 9 investigators led by a social scientist, The team included staff from the MOH working with the PLS and a PLWHA as a key resource person who encouraged respondents to come forward. The PLWHA played a key role given the highly sensitive nature of the disease. The participation of medical staff in this activity (and the training sessions that were held for them by the consultant) helped improve their understanding of the non-public health dimensions of the disease, will strengthen their capacity to provide improved care and support to PLWHA. The study was carried out in Djibouti-Ville as it is where the majority of the population, including seropositives, reside. Since the discussion of the disease is taboo, the team used a variety of techniques to identify PLWHA ranging from recommendations by doctors to snowball sampling techniques in neighborhoods. Although they were able to identify a total of 513 potential interviewees and contacted 200, only 43 agreed to be interviewed and 12 died before interviews could be completed. During the course of the research, the team was able to: (i) enlist the support of the WFP in providing nutritional assistance to interviewees; (ii) provide counseling services to both interviewees and those who refused to take part in the study; and (iii) enlist the help of health professionals for medical assistance, including hospitalization. - 107- Page 122 In addition to interviews with PLWHA, interviews were also conducted with those affected by the disease (widows, orphans, other relatives), medical professionals working with PLWHA, pharmacists and focus group discussions with two groups at risk (sex workers and port workers). Highlights of Some of the Major Findings Some culturalfactors. Identity in Djibouti is group-based and revolves around the clan. Any individual misbehavior is perceived as tamishing the image of the whole clan. Because of the sexually transmitted nature of the vast majority of HIV/AIDS cases in Djibouti, there is a strong sense that HIV shames the entire clan. On an individual level, there is a sense of divine punishment for illicit actions. Prevention campaigns in the past have emphasized that “AIDS=Death” and, therefore, there is a sense of helplessness. All of these factors contribute to the taboo surrounding AIDS, prevent people from seeking help, promote its spread, and prevent the families from taking adequate measures for managing its impacts. Communal solidarity is still the most important form of coping for families of sufferers and becomes especially draining as prolonged illness forces them to depend for even the most basic needs on their clan or extended family. Funeral and related expenses place a particular strain on immediate and extended family due to their high cost (ranging between FDJ30,OOO and FDJ300,OOO). Support from the extended family is not always a viable long-term coping strategy and is often reserved for punctual needs (such as school books for children). Neighbors are seen as the source of the most durable support, especially for routine matters and also for psychosocial support. Gender and AIDS The study illustrates how differentially the disease affects men and women. Women are more vulnerable in contracting the disease due to their lack of control over their sexuality (forced marriage, unfaithful husbands, occupational hazards for CSW and domestic servants). In addition, women are economically more vulnerable when the male head of household or source of primary support contracts the disease. Costs associated with treating PLWHA, especially when the head of the household is male, drains the domestic budget; and taboos regarding the prevalence status prevent women from preparing themselves for the financial future of their families. Their weak social/legal status also puts them in a weaker position while negotiating their economic future (e.g., inheritance issues) with their in-laws. Institutional Responses and Key Needs of Affected Persons The most significant finding of the study is the poor institutional response to people who test positive: (i) tests are frequently done without the patient’s knowledge and results are not communicated; (ii) family members and others are sometimes informed before the patients themselves; (iii) there is very limited respect for confidentiality of the results; and (iv) medical personnel often do not know how to announce the results to the patient or what advice to offer since a positive result is perceived as a death sentence (true for both public and private health services). Consequently, people do not trust the medical establishment and are reluctant to seek treatment or advice. Those who can afford it prefer going abroad. ARVs are available, but costs are prohibitive (FDJ150,OOO-250,000 per month, equivalent to the monthly wage of a high-level government official), although one pharmacy has begun importing generic ARVs at a lower cost. The PLWHA’s primary need, whether they are sick, at home, or at hospital, is nutritional. Patients, when hospitalized, depend on their families to provide daily meals for them. The disease may cause the patient to be unoperative for long periods of time, unable to be economically active in a sustainable manner, and require high-cost drugs, all of which contribute to the financial burden placed on families and the inability to provide patients with the requisite nutritional needs. In addition, the inability to provide nutritional support is all the more felt by the members of the family when the PLWHA is the head of the household. The second most felt need - 108 - Page 123 is economic. Medical treatment leads to a shortage of cash, requiring families to sacrifice other expenses, such as rent, schooling, etc. And the third need is for proper medical treatment, which currently is inadequate and unsatisfactory. Some implications of the findings for the project The study contributed in several ways to the design of the project and to the activities that will be initiated under this project: 1. 2. 3. 4. 5. 6. Designing the training manual for health professionals and others who will be involved in counseling PLWHA; it also revealed the importance of providing counseling for immediate family and incorporating neighbors (through CBOs and other organizations), age groupings and other communal or social groups in providing a support network in a gender-sensitive manner. Providing prevention messages that also show that it is possible to live with HIV/AIDS, especially in the community intervention component. Importance of providing nutritional assistance for the sick and their families. A pilot intervention providing nutrition to sero-positive persons and their families will be launched in the coming weeks. Possibility of providing income-generating activities for families of PLWHA and helping families plan for the future, especially women-headed households. Need for providing affordable drugs in a medically sustainable way. Raise awareness and acceptance in the MOH that HIV/AIDS is a broad socioeconomic matter requiring attention on a wide front that goes beyond purely medical issues (key value of the study). - 109- Page 124 Page 125 MAP SECTION Page 126