Page 1 PROJECT INFORMATION DOCUMENT (PID) CONCEPT STAGE Report No.: AB3496 Project Name Burundi – Second HIV/AIDS Project Region AFRICA Sector HIV/AIDS Prevention (%), Poverty Reduction (%), Capacity (%) Project ID P109964 Borrower(s) Republic of Burundi Implementing Agency Permanent Secretariat of the National Council for HIV/AIDS control (SEP/CNLDS) Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared October 4, 2007 Estimated Date of Appraisal Authorization February 25, 2008 Estimated Date of Board Approval July 15, 2008 1. Key development issues and rationale for Bank involvement In 2000 the Bank and the Government of Burundi, with UNAIDS support, began a policy dialogue on how to control the spread of the HIV/AIDS epidemic in the country and reduce its social and economic impact. The resulting National HIV/AIDS Control Strategy (2002-2006) was the basis for an IDA Multisectoral Grant of about US$32 million, approved in June 2002. At the time IDA was the first and only donor supporting the country in its fight against the epidemic. Despite the unstable political and security situation, and the fact that Burundi is one of the poorest nations in the world, the Government put in place a set of institutions and staffed them with adequate personnel. As a result, activities financed under the first Grant are being carried out with minimal delays and the Project is likely to achieve its development objectives when its activities are completed in December 2007. The Borrower has repeatedly shown its commitment to HIV/AIDS control by, among other things: (i) including HIV/AIDS as one of the six central themes of the PRSP; (ii) regularly allocating government budget and HIPC resources; (iii) creating an HIV/AIDS Ministry; (iv) creating and maintaining a competent team to manage HIV/AIDS activities; and (v) preparing the new 2007-2011 strategy, through a participatory process, approving it, and presenting it to the donor community at the June 2007 roundtable. Currently, the estimated amount needed to implement the National Plan is US$145 1 million, of which only about 35% is currently covered the current MAP, the Government (HIPC), and the Global Fund (US$ 3.5, US$20 and US$29 million, respectively). Burundi has not been selected as recipient of resources from the round seven from the Global Fund. Therefore, since no other donors have expressed an intention to contribute in a substantial way to finance the National Strategy and Plan, it is safe to say, that the country is facing substantial shortage of resources to continue its efforts to curb the epidemic. The IDA Grant (US$20 1 It is entirely possible that the financial needs are underestimated since very important strategies like male circumcision services are not included. The government has requested technical assistance to ASAP to help calculating the real costs and prioritizing the activities before the end of the year. Page 2 million) will help cover part of the gap and will given the country the breathing space until the eight round of the Global Fund in mid 2008. In any case it is probably safe to say that even in the best-case scenario, total available financing will probably be insufficient to achieve Burundi’s MDG HIV/AIDS targets. IDA’s resources are thus fundamental to even a moderately successful curbing of the epidemic, and will initiate the process of streamlining HIV/AIDS activities in key ministries thus leveraging additional resources from other sectors. Besides much-needed financial resources, IDA brings added value to the Program through: (i) convening power, which has all along helped the Government implement the “three ones”; (ii) intense technical guidance and M&E support through careful supervision; (iii) its ability to work with multiple sectors receiving Bank support in order to foster a sustainable, multi-sectoral response; (iv) the possibility of helping the government in its efforts to increase convergence with other health Programs and strategies through our upcoming health operations; (v) its unique capacity to finance system development, capacity building; and, (vi) flexibility to cover unforeseen financial gaps in key activities. Government, communities and partner agencies have indicated that they consider IDA’s continuing involvement in the national program as critical, particularly in the areas of prevention and support to civil society. Consequently, the Government has presented a draft Project document and submitted a PPF request. 2. Proposed objective(s) Although the proposed operation will contribute to achieve the NHAS objectives, its limited size forces to adopt realistic specific development objectives (DO). Thus the DO of the IDA- financed operation are to: (i) increase the access to efficacious prevention services and practices among high risk groups ; (ii) increase the proportion of persons living with HIV/AIDS receiving care, support and treatment; (iii) integrate program activities, in the adequate country institutions to increasing its institutional sustainability; (iv) improve the quality of general program management and monitoring and evaluation. The National strategy includes specific indicators for each of these objectives, and a few have been selected for the PPF request. A final agreement on key indicators that includes the scorecard indicators approved by ACTafrica will be agreed upon before appraisal. 3. Preliminary Project Description. The Grant would be a SIL supporting the National HIV/AIDS Plan (2007-2011). However, to reflect the lessons learned, the proposed IDA grant will finance a limited set of interventions with greater intensity , as oppose to the more general financing of the first MAP. The interventions to be financed are selected on the bases of appropriateness for Burundi’s epidemic as per ongoing survey results, proven cost-effectiveness, and complementarity to activities financed by other donors, mainly the GF. By focusing on building capacity to achieve results, development and improvement of processes and systems, in key ministries, and prevention intervention for high risk groups, IDA funds would enable the Borrower to use the existing resources (GF, general budget, donors support to education and health sectors, HIPC resources etc) more efficiency. The Grant will have a unified category only so that reallocation can be easily done in case potential financing for some critical activity fails to materialize. The team considered a programmatic loan and budget support but the weakness of Burundi’s financial Page 3 management capacity, as experienced in the management of HIPC funds, suggest that a SIL would be more appropriate in current conditions. IDA funds will finance the following limited set of interventions, under components which follow the four axes of the National Program. Specifically: Component 1: Reduction of HIV transmission through reinforcement and extension of effective preventive activities . This component will focus on a few activities in two of the three programs included in the first axe of the NHAS. Specifically it will finance interventions to reduce sexual transmission in high risk groups, and will promote male circumcision in the general population. It will also finance the extension of MTCT services to the whole territory. Component 2: Improvement of life conditions of persons living with HIV/AIDS . Again this component will support only two of the three subprograms in the second axe of the NHAS. This component will support the expansion of ARV treatment and opportunistic infection prophylaxis and treatment to HIV+ people to the whole country. The extension of services will be done through a new system of performance-based services with public and private health facilities at peripheral level. that provide ARVs and care for opportunistic infections. It will also help develop and launch community-based home care services. Component 3: Reduction of poverty and other determinant factors of HIV/AIDS vulnerability . While this goal, which corresponds to the third axe of the NHAS, is certainly worthwhile, the SEP/CNLS is not the best placed institution to deal with the widespread issue of poverty in Burundi. Therefore financing for interventions under this component will be limited to income generating activities among those affected with HIV/AIDS and commercial sex workers, and support to double orphans and widowed women with their land tenure issues. Activities can be channeled through civil-society groups or via the developmental commune councils once those will be constituted, in application of the decentralization law Component 4: Improvement of the national response management and coordination . This component will finance of activities under two of the three strategic programs included in the NHAS fourth strategic axe. Namely, the grant resources will be used to finance: (i) part of the SEP/CNLS coordination and fiduciary activities; (ii) maintain and improve the current monitoring and evaluation system; (iii) investment and part of recurrent costs to decentralize/devolve the execution of activities to the provincial authorities and Ministries. Financing of activities under this last point will increase the financial and institutional sustainability of HIV/AIDS control interventions while, also helping to progressively limit the SEP/CNLS function to its original coordination mandate, away from it current execution role. The proposed Grant would permit consolidation of recent gains on the ground and allow for the scaling-up of the local integrated response to HIV/AIDS while and other well-performing HIV prevention activities. It would also allow the strengthening of the quality of current interventions and the strengthening of key public agencies, in particular the MOH. The support to the MOH would follow the National health strategy, ensuring a coordinated and harmonized approach to health services. Page 4 The implementation arrangements under the additional financing would be virtually the same as for the ongoing project, as they are working well. The only difference will be the creation of a dedicated MOH sub-account. This sub-account would be managed by the general directorate of resources of the MOH. This directorate direction will hire an accountant, an assistant accountant and a procurement specialist to manage those resources in accordance with IDA procedures. Annual disbursements to that account will be agreed upon at the latest in the month of October of the previous year, after approval by the SEP/CNLS and IDA of an annual work plan and performance indicators. In terms of decentralization of local personnel to provincial level, the Project would follow the current practice of provincial accounts to be justified regularly. 4. Safeguard policies that might apply. Progress on environmental issues realized under the first Project was limited by civil conflict and low country capacity. The team suggests that the operation be considered a category B on environment to further expand activities for adequate disposal of biologically hazardous materials to areas not covered under the last Project. The assessment and action plan carried out under the previous operation has been updated to reflect the changing country situation, and is being reviewed by ASPEN. The results of the updated assessment and the plan to mitigate potential negative effects will be made public prior to appraisal. The Project is likely to include minor rehabilitation of a limited number of health facilities. In that case, civil works contracts will include clauses for the adequate provision of waste materials, use of non-toxic construction materials and respect for cultural property. 5. Tentative financing Source: ($m.) BORROWER/RECIPIENT 15 International Development Association (IDA) 20 Financing Gap 105 Total 35 6. Contact point Contact: Montserrat Meiro-Lorenzo Title: Sr. Public Health Specialist Tel: (202) 473-0161 Fax: 202-473-8107 Email: Mmeirolorenzo@worldbank.org