Documentof The World Bank FOR OFFICIAL USE ONLY ReportNo: 33917-GH PROJECTAPPRAISAL DOCUMENT ONA PROPOSEDCREDIT INTHEAMOUNT OF SDR 13.9MILLION (US$20 MILLION EQUIVALENT) TO THE REPUBLIC OF GHANA FORA MULTI-SECTORALHIV/AIDS PROJECT (M-SHAP) October 18,2005 HumanDevelopmentI1 AfricaRegionalOffice This document has a restricted distribution and may be used by recipients only in the performance o f their official duties, Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective October 11,2005) CurrencyUnit = Cedis 9199Cedis = US$1 0.651220 SDR = US$1 US$1.53558 = SDR 1 FISCAL YEAR January 1 - December31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal clinics ART Anti-Retroviral Therapy ARV Anti-Retrovirals BCC Behavior Change and Communication CAS Country Assistance Strategy CBO Community-Based Organization CRIS UNAIDScountry response information system csw Commercial Sex Worker D A C District AIDS Committees DANIDA Danish InternationalDevelopment Assistance DFID Department for InternationalDevelopment (UK) FBO Faith-Based Organization FP FundingPartners GAC Ghana AIDS Commission GARFUND Ghana AIDS Response Fund GDHS Ghana Demographic and Household Survey GFATM Global Fundfor AIDS, Tuberculosis and Malaria GOG Government o f Ghana GPRS Ghana Poverty Reduction Strategy HIV Human Immuno-virus IEC Information, Education and Communication HSSP Health Sector Support Program M A P Multi-Country HIV/AIDSProgram MDA Ministries, Departments and Agencies MDG Millennium Development Goals M O H MinistryofHealth M O U Memorandum o f Understanding M O M Y MinistryofManpower andYouth M-SHAP Multi-Sectoral HIV/AIDSProject 11 .. FOROFFICIAL USEONLY M S M MenHaving Sex withMen MTR Mid-tennReview NACP National AIDS Control Program NGO Non-governmental organization NSFI1 National Strategic Framework 2006-2010 O M Operational Manual ovc Orphans and Vulnerable Children PAD Project Appraisal Document PLWHA People Livingwith HIV/AIDS PMTCT Preventiono fMother to Child Transmission POW Program of Work PRSC Poverty Reduction Strategy Credit PSR Project Status Report S I L Specific Investment Loan STI Sexually Transmitted Infection SWAP Sector Wide Approach TAP Treatment Acceleration Program UNAIDS Joint UnitedNations HIV/AIDS Agency USAID UnitedStates Agency for International Development VCT Voluntary Counselling and Testing WHO World Health Organisation ~~ Vice President: Gobind T. Nankani Country Managerhlirector: Mats Karlsson Sector Managermirector: Alexandre Abrantes Task Team Leader/Task Manager: EileenMurray/Laura Rose This document has a restricted distribution and may be usedby recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization. TABLE OF CONTENTS A. STRATEGIC CONTEXT AND RATIONALE ......................................................................................... 4 1. COUNTRYAND SECTORISSUES ........................................................................................................................ 4 2. THENATIONAL STRATEGY............................................................................................................................... 3. STRATEGICALIGNMENTWITH THECAS. PRSP. MDGSAND THE HEALTH SECTORPROGRAMOF WORK ......56 4. RATIONALEFORBANKINVOLVEMENT ............................................................................................................ 6 5. COMPLIANCEWITH REPEATERREQUIREMENTS ............................................................................................... 6 B. PROJECTDESCRIPTION .............................................................................................................................. 7 1. LENDING INSTRUMENT 7 2 PROJECT DEVELOPMENT OBJECTIVES AND KEYINDICATORS .......................................................................... 7 3.. .................................................................................................................................... KEYPERFORMANCE INDICATORS; ................................................................................................................... 7 4. PROJECT INTERVENTION 5. AREAS...................................................................................................................... 8 LESSONS LEARNED REFLECTEDTHEPROJECT AND IN DESIGN ........................................................................ 9 10 C.6. ALTERNATIVES CONSIDERED AND REASONS FORREJECTION .......................................................................... IMPLEMENTATION ..................................................................................................................................... 11 1. PARTNERSHIPARRANGEMENTS: PROGRESSTOWARDS 11 2. ACHIEVEMENT "THETHREEONES"..................... OF INSTITUTIONAL ARRANGEMENTS 3. ................................................................................................................... 11 IMPLEMENTATION ARRANGEMENTS .............................................................................................................. 12 4. MONITORING EVALUATIONOFOUTCOMES~RESULTS AND 13 5. ............................................................................. SUSTAINABILITY ............................................................................................................................................ 13 6. CRITICAL RISKSAND POSSIBLECONTROVERSIAL ASPECTS ........................................................................... 14 D. APPRAISAL SUMMARY .............................................................................................................................. 15 1. 2 3. . FINANCIALAND ECONOMICANALYSIS .......................................................................................................... TECHNICAL.................................................................................................................................................... 16 15 16 4. SOCIAL ........................................................................................................................................................... ENVIRONMENT ............................................................................................................................................... 17 18 6. 5 . SAFEGUARD POLICIES .................................................................................................................................... READINESSIMPLEMENTATION FOR 7 . ................................................................................................................ 18 CREDIT CONDITIONS AND COVENANTS ......................................................................................................... 18 ANNEX1: RESULTS ANNEX2: KEYPERFORMANCEINDICATORS: BASELINE TARGETS...................................................... FRAMEWORK. MONITORMG EVALUATION...................................................................... AND 20 AND 24 ANNEX3A: SECTORBACKGRO~D ........................................................................................................................ 25 ANNEX3B: MAJORRELATED PROJECTSFINANCEDBY THE BANKAND/OR OTHERAGENCIES ................................ 34 ANNEX4: DETAILEDPROJECTDESCRIPTION .......................................................................................................... 37 ANNEX 5 : ESTIMATED PROJECTCOSTS .................................................................................................................. 44 ANNEX6: IMPLEMENTATION ARRANGEMENTS ....................................................................................................... 46 ANNEX7A: FINANCIALMANAGEMENTDISBURSEMENT AND ARRANGEMENTS ...................................................... 54 ANNEX 7 B: PR0CUREMENTARRANGEMENTS ......................................................................................................... 61 ANNEX8: SAFEGUARD POLICY ISSUES ................................................................................................................... 68 ANNEX 9: ECONOMIC AND FINANCIAL ANALYSIS.................................................................................................. 71 ANNEX10: PROJECTPROCESSINGSCHEDULE AND SUPERVISION STRATEGY ......................................................... 74 ANNEX 11: DFIDSTATEMENT ............................................................................................................................... 76 ANNEX12: DOCUMENTS INTHE PROJECT FILE ....................................................................................................... 78 ANNEX 13: STATEMENT OF LOANS CREDITS ................................................................................................... 79 ANNEX14: COUNTRYAT A GLANCE....................................................................................................................... 81 AND ANNEX15: MAPOF GHANA(IBRD33411)........................................................................................................ 83 iv GHANA MULTI-SECTORALHIV/AIDSPROJECT (M-SHAP) ProjectAppraisal Document AFRICA AFTH2 Date: October 11,2005 Team Leader: Laura Rose Country Director: Mats Karlsson Sector(s): HIV/AIDS(100%) Sector Manager: Alexandre Abrantes Theme(s): Health/Nutrition/Population Project ID: PO88797 Lending Instrument: Specific Investment Loan Project FinancingData [ ] Loan [XI Credit [ ] Grant [ ]Guarantee [ ]Other BORROWEWRECIPIENT 7.0 0.0 7.0 IDA 19.0 1.o 20.0 DfID(UK-Dept.for InternationalDev't.)' 7.0 1.3 8.3 Total: 33.0 2.3 35.3 FY 2006 2007 2008 2009 2010 Annual 2.5 4.0 5.5 5.5 2.5 Cumulative 2.5 6.5 12.0 17.5 20.0 'DfID'sfundingis only for 2006. Future flows to be confixmedbyNovember 1,2005 1 Does the project depart from the CAS incontent or other significant [ ]YES [x]nO respects? Ref.PAD A.3 Does the project require any exceptions from Bank policies? [ ]YES [x]nO Ref. PAD Have these been approved by Bank management? [ ]YES [ In0 I s approval for any policy exception sought from the Board? [ ]YES [ In0 Does the project include any critical risks rated "substantial" or "high"? [XI YES [ ] nO Ref. PAD C.6 Does the project meet the regional criteria for readiness for [ X I Y E S [ In0 implementation? Ref. PAD D.6 Project development objective Ref.PAD B.2 Reduce the new infection among vulnerable groups and the general population; mitigate the impact o fthe epidemic on the health and socio-economic systems as well as infected and affectedpersons; and promote healthy life-styles, especially inthe area o f sexual and reproductive health. Project description RefPAD B.4, Technical Annex 4 Policy, Advocacy andEnabling Environment. Reviewing, formulating and enforcingpolicies to protect the rights o fpersons livingwith HIVIAIDSand/or people affectedbyHIV/AIDS, including creating an enabling environment and carrying out activities to empower and assist persons living with HIV/AIDS,orphans and vulnerable children; coordinating and implementing the national response to HIV/AIDS; and decreasing vulnerability o f target groups to infection through support and advocacy. Coordination and Management o f the Decentralized Multi-Sectoral Response. Coordinating and managing the Ministries, Departments and Agencies (MDAs), Regional AIDS Committees (RACs), Metropolitan, MunicipalAssemblies (MMAs), and District AIDS Committees (DACs) inimplementing theirprograms. Thisincludes defining roles andresponsibilities at central, regional, district and community levels; supporting key agencies to develop, implement and monitor activities; helpingto develop HIV/AIDS sectoral plans, workplace interventions and staff training. The components also includes advocacy to increase political commitment through sensitization programs, development o f annual plans o fwork and improved information flows at central, regional, district and community levels. Mitigating Economic, Socio-Cultural and Legal Impacts. Carrying out o f activities aimed at mitigating the impact o fthe HIV/AIDS epidemic on vulnerable social groups, including provision o f educational support andtraining for orphans and vulnerable children, development o f income generation activities for vulnerable households, provision o f community-based and institutional care for orphans, andprovision o fpsycho-social support for affected families, including legal support. Prevention andBehavior Change Communication. Developing and implementingactivities aimed at bringingabout behavioral change among at-risk groups, including in-school youth and mobile populations. Programwould include: promoting utilization o f quality sexually transmitted infection services, voluntary counselling and testing; and prevention o fmother to 2 child transmission, encouraging private enterprise partnership, minimizing the risk o fHIV transmission through blood and blood products, delaying the medianage o f sexual debut, promoting utilization o f condoms duringhigher risk sexual encounters, and reducing occupational exposure to HIV and other infections. Treatment, Care and Support. Scaling up anti retroviral therapy, voluntary counselling and testing, management o f sexually transmitted infections, opportunistic infections, home-based and community care and support to maintain health andwell-being o fpersons livingwith HIV/AIDS, affected families, and orphans andvulnerable children. Research, Surveillance, Monitoring and Evaluation. Carrying out o f activities to enable the effective assessmento fthe HIV/AIDS epidemic andnational response, including carrying out o f biological andbehavioral surveys, poverty analyses, program activity and financial monitoring, andpriority specialized studies. Resource Mobilizationand FundingArrangements. Establishinga flexible funding arrangement for mobilizing and channelling HIV/AIDS resources for the national response; streamlining the budgetingprocess for HIV/AIDSresources; establishing an effective targeting andresource allocation process; strengthening financial management and monitoring; and carrying out o f procurement and financial audits. Which safeguard policies are triggered, ifany?RefPAD D.5 Technical Annex 8 The project contains risks associatedwith the handling anddisposal o fmedical waste and general health waste. Significant, non-standard conditions ifany, for: Ref. PAD D.7 Board Presentation: None LoanKredit effectiveness: None Disbursement: None Covenants applicable to project implementation: Ref. PAD D.7 (i) The Annual Programo fWork for the respective fiscal year has been approvedby IDA and other pooled fundingpartners. (ii) The Borrower shall: (a) not later than January 1,2006, ensure that the national budget includes provisions for full fundingo f all non-salary operating costs o fthe GAC Secretariat; (b) not later than December 1,2006, adopt a sustainability plan for the GAC, acceptable to the Association, and thereafter implementthe measures identified insaid plan and (c) not later than January 1,2008, ensure that the national budget includes provision for full funding o f all salary costs o fthe GAC Secretariat 3 A. STRATEGIC CONTEXT AND RATIONALE 1. COUNTRYAND SECTORISSUES The first case o f AIDS in Ghana was diagnosed in 1986, and by the year 2004 an estimated 380,000 adults and 14,000 children were HIV-positive (UNAIDS, 2004). By 2004, the cumulative number o fpeople diagnosed with AIDS was 36,000. Prevalence rates increased from an estimated 2.6 percent in 2000, to 3.6 percent in 2003, and 3.1 percent in 2004 (National AIDS/STD Control Program, GHS, 2005).* The nature o f the epidemic in the country has exhibited a different pattern from that found in Eastem and Southem Africa where prevalence rates have exceeded 25 percent within a short period. Considerable variations also exist by geographic region, gender, age, occupation, and, to some degree, urban-rural residence. According to the 2003 sentinel surveillance report based on clients o f antenatal clinics, prevalence rates inthe country's ten regions varied from below 2 percent in the Upper West Region to around 4 percent in Greater Accra, to almost 7 percent inthe Eastern Region. These regional data remain very similar in the 2004 Sentinel Survey. Eight o f the 30 sentinel surveillance locations reportedprevalence o f more than 5 percent in 2003, and six o f 35 sites in 2004. These pockets o f high rates indicate that "severe epidemics, by Ghana standards, are raging invarious non-contiguousparts o fthe Country" (Ghana AIDS Commission, 2002). Females are estimated to be 1.3 times more likely to become infected than males. This sex ratio has declined sharply since the early stages o f the epidemic when it was around 3:1, still indicating that the risk o f infection for females i s higher than males (National AIDS/STD Control Program, GHS, and MOH, 2003). The 2003 DHS found that females who are widowed, divorced or separated have significantly higher rates than those who were in marital unions, Similarly, the DHS found that females with two or more sexual partners inthe last year had HIV infection rates three times higher than females with only one partner. Cote et al. (2004) have estimated that transactional sex accounts for about 84 per cent o f HIV infections among males aged 15-59 years in Accra. In addition to sex workers and their clients, other groups believed to have above-average prevalence rates include uniformed service personnel, teachers, and miners, prisoners, long-distance truck drivers, national service volunteers, cross-border traders, and female long-distance traders (Anarfi et al., 1997 cited in Ghana AIDS Commission, 2003). Female STI clinic attendees at Adabraka (in Accra), a clinic that also serves sex workers in Greater Accra Region, had a prevalence rate o f 39 percent in 1999, reinforcing the well documented close association between HIV and other sexually transmitted infections. The 2003 GDHS results show high rates o f infection among employed middle income groups. This differs from the prevailing view o f the epidemic being associated with poverty. There is, therefore, an emerging trend which needs to be understood and which will require new thinking and strategies about target groups. Incontrast, prevalence rates inSouthernandEastemAfrica expandedmuchmore rapidly over the same period, exceeding 25 percent insome countries. Neighboring Cote d'Ivoire has shown still another pattern, generally maintaining a rate between 10 and 15% for most o f the period. 4 2. THENATIONALSTRATEGY Ghana i s preparing its second poverty reduction strategy paper -known as the Ghana Poverty Reduction Strategy. The goal o f the GPRS I1i s "to achieve accelerated and sustainable shared growth, poverty reduction, promotion o f gender equality, protection and empowerment o f the vulnerable and excluded within a decentralized, democratic en~ironment."~Attention to the HIV/AIDSepidemic is akeypart ofthat strategy bothfor growth and for addressing issues o f vulnerability. The attention to the growth inthe GPRS I1i s along the lines with the new policy developed in the World Bank's Africa Action Plan. HIV/AIDS has a negative impact on productivity, loss o f productive assets, hightreatment costs and the break inthe transfer o f valuable livelihood knowledge from one generation to the next. Ghana's strategy for addressing HIV/AIDS i s presented in its National Strategic Framework. This project will support the national strategy as outlined in the NSF 11. Implementation o f the NSF I1i s referred to as the "national response" to distinguish the entire strategy from smaller, more targeted projects. The second National Strategic Framework for combating HIV/AIDS has beenprepared (NSF I1 2006-2010) and sets the stage for an expansion o f efforts, including creating a supportive environment, preventing new infections, targeting behavior change programs to specific vulnerable groups, and expanding treatment, care and support. The NSF I1was developed using a participatory and consultative process which enabled partners and other stakeholders to "buy into" the program from the outset, therefore, ensuring a strong degree o f commitment and support during its implementation. The strategy is based on maximizing efforts to reduce the rate o f new HIV infections among the general population, with appropriate attention to those at highest risk, while reducing HIVIAIDS morbidity and mortality by expanding access to care, support and antiretroviral treatment. The primary goal is to integrate HIV prevention and treatment activities in a comprehensive, combined response to maximize synergies. Proven prevention interventions in Ghana that will continue to receive emphasis include mass media campaigns, VCT services, peer counseling for sex workers, school-, youth- and workplace-based programs, condom promotion and distribution, treatment for STIs, PMTCT, blood safety, and universal precautions to prevent infection. Since increased uptake o f V C T services where HAART i s available has been shown to enhance broader prevention effectiveness, special emphasis will be given to scaling up V C T services. By involving communities in the scale-up o f treatment access, strengthening local NGOs and linkages to existing and planned community mobilization efforts, crucial opportunities will be created for increasing community involvement in prevention activities. These interventions will substantially reduce the resource needs for treatment inthe long term. Ghana Poverty ReductionStrategy 11,FinalDraft, September 2005 5 3. STRATEGIC ALIGNMENTWITH THECAS, PRSP,MDGSAND THE HEALTH SECTOR PROGRAM OFWORK CurrentCAS: 27838-Gh BoardDiscussiondate: March 16,2004 As mentioned above, the proposed project 'is entirely consistent with the GPRS 11. Ghana recognizes that HIV/AIDS, a public health priority, i s also a development issue and that poverty reduction strategies must be linked if national development goals are to be reached. This i s in line with the most recent CAS o f providing services for human development and strengthening growth. The country's priorities match those o f the UN MDG strategy, specifically Goal 6, which i s to halt and begin to reverse the spread o f HIV/AIDS by 2015. Under the WHO 3x5 initiative, Ghana has committed to treating 29,000 PLWHA, or 50% o f people in need o f treatment. 4. RATIONALE FOR BANKINVOLVEMENT InGhana, the Bankhas several comparative advantages inthe fight against HIV/AIDS. First,the Bank i s a multi-sectoral institution which facilitates addressing the epidemic in the multi-sector approach as i s required. The Bank's expertise in macro-economics and close relationship with the Ministry o f Finance and Economic Planning are added advantages. The Bank is a leader in the movement towards donor harmonization and therefore best positioned to begin to develop a programmatic approach for addressing HIV/AIDS. This will be, however, the last project the Bank will finance that i s especially targeted to HIV/AIDS. 5. COMPLIANCE WITH REPEATER REQUIREMENTS Compliance with basic repeater requirements4. The on-going GHANA AIDS Response Fund (GARFUND) has been rated satisfactory for implementation progress and achievement o f development objectives (DOs) in all Project Status Reports (PSRs) and Implementation Status and Results reports (ISRs) (see Annex 4B for more detail on this Project). Data show that the impact o f the project has been consistent with those in the PAD. There are no unresolved fiduciary issues, or any identified environmental, social or safeguard problems. M&E has been ratedhighly satisfactory over the past two years. A joint Government and Development Partner mid-term review o f the 2000-2005 National Response was completed in June 2004. At the same time, the Bank was carrying out an Interim Review o f the Multi-Sectoral HIV/AIDS Program (MAP) by visiting selected countries, one o f which was Ghana. Both reviews found that the Ghana AIDS Commission (GAC), the implementing agency for the GARFUND, had effective capacity to expand its role beyond the goals and objectives o f the GARFUND. The reports also suggested that further harmonization between development partners and stakeholders would improve the national response. OPCS Guidelines 6 Compliance with MAP repeater requirements5. Ghana satisfies the requirements to be a MAP repeater. The Ghana AIDS Commission (GAC), the main partner inthis project, i s coordinating the national response, leaving program implementation to stakeholders. The on-going GARFUND project has been identified as a good practice example o f ensuring timely grant processing to implementing partners. A national strategic framework for 2006-2010 (NSF 11) has been prepared along with a corresponding monitoring and evaluation (M&E) framework, a five-year program of work (POW) and an annual POW. The M&E system i s fully operational and has been decentralized to each o f Ghana's 138 districts. Decentralization o f fiduciary management to the district assembly level i s also envisaged under M-SHAP. This will be done inparallelto switchingto output-based contracts for upcomingprograms. B. PROJECTDESCRIPTION 1. LENDING INSTRUMENT 0 The M-SHAP i s a Specific Investment Loan (SIL) under IDA'SMAP for the Africa Region. 2. PROJECT DEVELOPMENT OBJECTIVESAND KEY INDICATORS M-SHAP'sdevelopment goals are those oftheNSFI1which areto: 0 Reduce the new infection among vulnerable groups and the general population; 0 Mitigate the impact o f the epidemic on the health and socio-economic systems as well as infected and affected persons; and 0 Promote healthy life-styles, especially inthe area o f sexual and reproductive health. 3. KEY PERFORMANCE INDICATORS: Ghana and its development partners are committed to using a single, unified set o f indicators to monitor the HIV/AIDS activities. The objective i s to harmonize the indicators and the monitoring and evaluation (M&E) systems used for the Global Fund, UNGASS, the GPRS, the Health SWAp, and the GAC-led national response. The following key performance indicators (KPIs) have been agreed upon. Key Performance Indicators6 No. Indicators 1. HIVprevalence amongpeople aged 15- 19years. 2. HIVprevalence amongyoungpeople aged 15-24 years. 3. % o finfants bornto HIV -infectedmothers who are infected. 4. Median age at first sex. 5. % o fwomen andmenwho have hadhigherrisk sex inthe past 12months. 6. % o f men and women aged 15 - 49 reDorting the use o f a condom during.higher risk Africa RegionMAP 2 repeater requirements, 2004. Data on sources, baselines, and targets for the K P I s are inANNEX 2 7 sex. 7. Ratio o f current school attendance among orphans to that among non-orphans, aged 10- 14. 8. % o fpeoplewith advanced HIV infection receiving antiretroviral combination therapy. 9. % o f total national HIV/AIDS funds spent on prevention activities for selected vulnerable groups (CSW, MSM, prisoners). 10. Execution rate o f total HIV/AIDS allocation o f the key ministries, departments and agencies. (MOE, MOH, MOMP, MOLG, Dept o f Social Welfare, MOWAC) 4. PROJECTINTERVENTION AREAS The project will support the seven areas which comprise the national response as described in NSFI1and 5-year POW. Namely: Policy, Advocacy and Enabling Environment. Reviewing, formulating and enforcing policies to protect the rights of persons living with HIV/AIDs and/or people affected by HIV/AIDS, including creating an enabling environment and carrying out activities to empower and assist persons living with HIV/AIDS, orphans and vulnerable children; coordinating and implementing the national response to HIVIAIDS; and decreasing vulnerability o f target groups to infection through support and advocacy. Coordination and Management of the Decentralized Multi-Sectoral Response. Coordinating and managing the Ministries, Departments and Agencies (MDAs), Regional AIDS Committees (RACs), Metropolitan, Municipal Assemblies (MMAs), and District AIDS Committees (DACs) in implementing their programs. This includes defining roles and responsibilities at central, regional, district and community levels; supporting key agencies to develop, implement and monitor activities; helping to develop HIV/AIDS sectoral plans, workplace interventions and staff training. The components also includes advocacy to increase political commitment through sensitization programs, development o f annual plans o f work and improved information flows at central, regional, district and community levels. Mitigating Economic, Socio-Cultural and Legal Impacts. Carrying out o f activities aimed at mitigating the impact o f the HIV/AIDS epidemic on vulnerable social groups, including provision o f educational support and training for orphans and vulnerable children, development of income generation activities for vulnerable households, provision o f community-based and institutional care for orphans, and provision o f psycho-social support for affected families, including legal support. Prevention and Behavior Change Communication. Developing and implementing activities aimed at bringing about behavioral change among at-risk groups, including in-school youth and mobile populations. Program would include: promoting utilization of quality sexually transmitted infection services, voluntary counselling and testing; and prevention o f mother to child transmission, encouraging private enterprise partnership, minimizing the risk o f HIV transmission through blood and blood products, delaying the median age o f sexual debut, 8 promoting utilization of condoms during higher risk sexual encounters, and reducing occupational exposure to HIV and other infections. Treatment, Care and Support. Scaling up anti retroviral therapy, voluntary counselling and testing, management of sexually transmittedinfections, opportunistic infections, home-based and community care and support to maintain health andwell-beingo fpersons living with HIV/AIDS, affected families, and orphans and vulnerable children. Research, Surveillance, Monitoring and Evaluation. Carrying out o f activities to enable the effective assessment o f the HIV/AIDSepidemic and national response, including carrying out o f biological and behavioral surveys, poverty analyses, program activity and financial monitoring, andpriority specialized studies. Resource Mobilization and Funding Arrangements., Establishing a flexible funding arrangement for mobilizing and channelling HIV/AIDS resources for the national response; streamlining the budgeting process for HIV/AIDS resources; establishing an effective targeting and resource allocation process; strengthening financial management and monitoring; and carrying out o fprocurement and financial audits. 5. LESSONS LEARNED REFLECTEDINTHEPROJECTDESIGN AND The following recommendations from the 2004 Ghana MAP Interim Review and the Joint Review o f Ghana's National HN/AIDS Response (June 2004), have been taken into account in the design o f M-SHAF'. Priority should be on targeted interventionsfor high risk groups. Currently, HIVprevalence in Ghana i s highly concentrated among certain high-riskgroups such as commercial sex workers, and those living in"hot spots." (e.g. border towns with bars and restaurants with a large transient population.) Evidence from other countries at the same stage o f the epidemic shows that reducingthe spread o f the infection among these highrisk groups significantly attenuates wider scale heterosexual transmission. Evidence from the GARFUND shows that targeting o f highrisk groups and high prevalence areas i s feasible. For this reason, it i s envisaged that activities proposedinthe 2006 POWwill focus on such groups. MAP program implementation is more successful in countries where the national AIDS council has defined its role as `ffacilitation and %oordination rather than "control" and " " `%nplementation." Adequate management systems are critical to coordinate the national response. A major objective o f this project i s to assist the GAC to assume its appropriate role. Rather than beingperceived as the implementing agency o f a Bank financed project, it should be perceived as a Government Commission with the capacity to manage the national response. This would includemonitoring and evaluation andbudgetingfor the epidemic. Ex-posts audits are necessary. Due to the decentralized nature o f sub-projects, it i s important that at least 25% of projects are visited at random in order to determine if funds were spent for the intended purposes. This practice will be continued during M-SHAP not only to deter any possible misuse of funds, but also to collect data for decentralized program monitoring purposes. 9 Linkages with the Ministry of Health must be strengthened: Linkages with the Ministry o f Health need to be strengthened in order to ensure a better coordinated national response. This includes improving the planning, financing and monitoring and evaluation o f HIV/AIDs activities in order to improve complimentarity and reduce overlap. During preparation o f this project, an MOUhas been signed by the GAC and MOH. Monitoring and evaluation systems need to be significantly strengthened if the project is to show results. The M&E system inGhana, while relatively good compared with other countries, could be strengthened. Intensive work has recently gone in to improving the system. Details are below. 6. ALTERNATIVES CONSIDEREDAND REASONSFORREJECTION Stop Supporting HIVIAIDS activities. The option o f stopping World Bank support for HIV/AIDS was never seriously considered. However, this i s the last "project" the Bank intends to finance. In the future the Bank will continue its support for HIV/AIDS via budget support. This will be addressed in more detail at the M T R in order to ensure a smooth transition from project funding. Supplementalfunding for GARFUND. One alternative considered was to request supplemental funding for the on-going GARFUND. However, the MTR o f GARFUND and the MAP Interim Review in 2004 concluded that it was urgent to move towards a more harmonized approach in Ghana to ensure more efficient use o f current and future resources, reduce transaction costs, and fully empower the GAC to coordinate the National Response. The reviews also advised that the GAC move into treatment. Supplemental funding for the health SWAP. The health SWAP i s well established in Ghana and the Ministry o f Health has a demonstrated capacity to manage pooled funding as i s proposed under the M-SHAP. However, the MOH does not have the capacity to administer the non- clinical activities managed by the GAC. In the future, one would expect that the M O H will strengthen its health promotion and disease prevention capacity and use o f local community organizations through the CHPS program in order to assume more responsibility for managing the epidemic. Funding of HIV/AIDS programs through general budget support (PRSC). The PRSC dialogue has addressed issues such as trends in prevalence rates, targeting, decentralization o f interventions and fiscal issues. However, the PRSC i s most effective in those areas where there i s a mature dialogue between the GOG and the partners. While this dialogue i s rapidly improvingin Ghana, there are still advantages to working more at the program level rather than elevating the entire HIV/AIDS program to general budget support. None the less, it i s very likely that inthe future financing for HIV/AIDS activities will be channelled through the general budget. 10 C. IMPLEMENTATION 1. PARTNERSHIPARRANGEMENTS:PROGRESSTOWARDS ACHIEVEMENTOF"THETHREE ONES" The "three ones" are meant to harmonize and align donor and multi-lateral activities in support o f HIV/AIDS. The first of these principles - adoption o f a single HIV/AIDS action framework that provides the basis for coordinating the work o f all partners -has largely been achieved. The preparation o f the NSF I1was done i s such a way that all key stakeholders participated. There is, however, no signed agreement aligning all development partners behind the NSF 11. Efforts to develop one national AIDS coordinating authority, with a mandate for HIV/AIDS overall policy and coordination, has also largely been achieved with the formation o f the GAC. However, a separate Country Coordinating Mechanism (CCM) which supports the implementation o f the Global Fund activities continues, and responsibilities between the GAC and MOH have not always been clear. The third o f the "three ones", agreement on a country level monitoring and evaluation system, was achieved for NSF Iand continues for NSF 11. There i s a high level o f commitment o f the donors in all sectors in Ghana to rally around one set o f government procedures. This includes not only the harmonization o f donor M&E requirements, but also amongst reporting requirementsinGhana such as the GPRS and MDBS. On-goingefforts inharmonization are inline with the recent Report of the Global Task Teamfor Improving AIDS Coordination Among Multilateral Institutions and International Donors which was completed in June 2005 outlining the way forward to address many o f these harmonization and alignment problems. 2. INSTITUTIONAL ARRANGEMENTS The following institutions, all o f which had similar responsibilities inimplementing MAP I, will beinvolved inthe implementationofthe M-SHAP. The GhanaAIDS Commission (GAC). The GAC was created by Parliamentary Act No. 613 in January 2002 as a supra-ministerial and multi-sectoral advisory body to direct and coordinate the involvement o f all ministries, the private sector and NGOs, and other civil society groups, in the fight against HIV/AIDS. The GAC, as the highest policy making body in HIV/AIDS, is responsible for formulating national policies and strategies, and establishing program priorities. The GAC i s also responsible for mobilizing, controlling and managing resources and monitoring their allocation and utilization. The President o f the Republic o f Ghana and the Vice President are Chairman and Vice Chairman respectively o f the GAC which consists o f 47 members from line ministries, trade unions, NGOs, and other civil society organizations. The GAC Secretariat. M-SHAP will be implemented by the GAC Secretariat which was established to implement the policy decisions o f the GAC and to coordinate HIV/AIDS programs. It i s the executive arm o f GAC and as such i s the focal point in HIV/AIDS policy research, program planning, oversight and monitoring for national, regional and district level organizations. The GAC Secretariat i s divided into the following four divisions: (1) technical services, (2) policy planning, research, M&E, (3) finance, and (4) administration. It i s likely that 11 during the implementation of the NSF 11, the GAC will change as more of its functions are mainstreamed into the work o f the MDAs. The project will assist with this transition, while at the same time ensuring that the GAC continue to exist, perfonning the fundamental activities as outlined inthe Act. TheMinistry of Health. The M O Hhas the mandate to oversee all clinical aspects o f the NSF 11. The GAC and the M O H have signed an MOU in order to better define their respective roles to ensure better linkages between treatment andpreventionprograms. Regional AIDS Committees (RACs). The RACs maintain oversight responsibility for the region's local level responses to HIV/AIDS in line with the National Strategic Framework as well as ensures that the district needs (such as capacity gaps) are addressed. District AIDS Committees (DACs). The DACs are responsible for preparing and implementing their plans to address HIV/AIDS. This responsibility includes having oversight o f NGOs, faith- based organizations (FBO), andCBO. District Response Management Team (DRMT). The D R M T which i s part of the D A C i s an important link for the successful implementation o f local level interventions to HIV/AIDS. It includes five (5) members namely district M&E focal person, District Directors o f Education, Health, Social Welfare and one other, district assembly staff. DRMTs will be responsible for providing technical assistance to the D A C in the development o f district HIV/AIDS plans and district program implementation, evaluation and selection o f projects submitted by NGOs, FBOs andCBOs andmakerecommendations for fundingto the DAC. 3. IMPLEMENTATION ARRANGEMENTS Common implementation arrangements described in an MOU will allow the IDA and DFID to further streamline support and reduce transaction costs by pooling funds in a common Pooled Account managed by the GAC. A second Earmarked Account will be set up to accommodate those FundingPartners who preferto earmark some o f their funds. Both the Pooled Account and the Earmarked Account will be managed by the GAC. Only partners who contribute to the Pooled Account will be allowed to sign the MOU. The Annual Program of Work, based on the 5-year program of work, will describe which activities are to be financed for that year. At that time, it will also be decided who will be the implementingagency. The main implementation agencies will be one o fthe following: MDAs, Districts, Regions, CBOs, FBOs, NGOs, or the private sector. Details o f these arrangements are in Annex 6. A GAC Operational Manual, agreed to by the Funding Partners, describes specifically how these agencies will be selected, what they can finance, procurement rules, and how results will be measured. A Partnership Forum will take place twice a year. This Partnership Forum will include development partners, stakeholders, line Ministry staff from the central, regional and district levels, NGOs and GAC. It will help to establish the priorities for the coming year, review and 12 endorse the annual POWs and budgets, and oversee the implementation o f the annual POWs usingagreed uponperformance indicators as a basis for oversight. 4. MONITORINGEVALUATION OUTCOMES/RESULTS AND OF As part of the NSF Iand in line with the "three ones" principles, Ghana has developed an excellent national M&E system with a corresponding National M&E Plan7. Monitoring and evaluation under the MAP Iwas consistently rated as highly satisfactory. Institutional arrangements for M&E are in place at the regional and district levels. At the regional level, Regional Coordinating Councils (RCCs) have responsibility for M&E. At the district level there are M&E focal point (138 in all) who are responsible for visiting all funded programs in their districts and reporting back to the regional and central levels. At the community level, stakeholders are involved and participate in M&E activities through the community networks and operational research. The GAC also relies on information from other sectors (primarilyhealth) and NSF I1presents an opportunity for the GAC to strengthen sector- wide M&E by ensuring technical assistance for capacity in developing M&E plans, guidelines and tools; and collection, aggregation and use o f M&E data for program refinement. The institutional arrangements for M&E are described inmore detail inAnnex 6. NSF I1intends to build on these achievements to further harmonize and strengthen the national M&E system. Although the data collections system is well developed, not all partners at national or sub-national levels routinely and systematically share the data they collect. Under NSF 11, guidelines for reporting to GAC will be established. A central repository for M&E data will be established at GAC. Country Response Information System (CRIS) may serve as a tool. The piloted system will be expanded, and modified where necessary, to suit the country needs. CRIS will also serve as a tool for effective information sharing between the different levels, and by making information available to all stakeholders and the public. The GAC intends to explore linkages and opportunities created through other Health Information strengthening initiatives such as usingplanned activities of the Health Metric Network to further strengthennational HIS for HIV/AIDS care and treatment. Indicators in the national M&E plan will be reviewed annually as part o f preparation o f the annual POW. The MTR o f M-SHAP will take an in-depth look at a large number o f completed projects to obtain some preliminary information on the impact of various programs vis a vis the National Response. Baseline data are available for all o f the indicators selected for monitoring NSF11.(see Annex 1) 5. SUSTAIN ABILITY Financial sustainabiZity. GOG funding available for the health sector, which comprises most o f the expenses for HIV/AIDS, i s likely to increase significantly over the next five years. Ghana Ghana AIDS Commission. The National Monitoring and Evaluation Plan for HIV/AIDSin Ghana, 2001-2005 (2002) 15 has already increased health sector spending from 9% in 2000 to 13% in 2004'. The National Health Insurance Levy is expected to contribute an additional $147 million to the national health budget in 2005, its first year o f operation. Another reason frequently given to demonstrate financial sustainability o f these programs i s that the costs o f drugs is likely to continue to dramatically decrease. Finally, while the Bank and other MDBSpartners may pool their existing HIV/AIDS programs into the general budget, there will other donors who will not and for whom HIV/AIDS will remain a priority. None the less, the HIV/AIDS epidemic i s unlikely to end in five year's time and earmarked donor financing i s unlikely to be available at its current levels. The GPRS I1and other policy documents o f the GOG indicate that the level o f commitment i s very high. The GOGhas agreed to assume the full cost o f non-salary operating expenditures of the GAC starting January 1,2006; adopt a sustainability action plan for the GAC by December 1, 2006, and finance GAC salaries starting January 1,2008. Institutional sustainability. The intent o fthe GOG i s to gradually mainstreamthe implementation o f activities o f the GAC into the line ministries anddistrict assemblies. The GAC would not be abolished, rather, it would become a lean secretariat responsible for monitoring and reporting on the national response. The GAC and DFIDhave supported programs for District Assemblies to improve technical and fiduciary skills inorder to enable themto implement a substantial part ofthis programbythe end ofthe project. 6. CRITICAL RISKS AND POSSIBLE CONTROVERSIAL ASPECTS Risk Risk Risk-MitigatingMeasures Rating GAC has difficulty in assuming additional As part o f the GPRS 11, Government has responsibilities M indicated a strong commitment to continuing to build the capacity o fthe GAC. GOG is unable to finance the operating A sustainability plan, outlining precisely the costs and staff salaries o f GAC actions that will be taken to ensure the Secretariat, causing implementation to continued fbnctioning o f the GAC following slow and achievement o f PDO's more S the end o fthe project, will beprepared. This difficult. plan will address risks such as moral hazard inGAC employees for the first two years of project implementation * Plans to integrate the activities o f the A MOU between the GAC and MOU has GAC and MOH prove to be more difficult M been signed. And the M O H will participate thanexpected. inannual POWpreparation Districts lack the capacity to assume the Several Development Partners provide direct role o f administering and monitoring the financing for building the capacity o f small grants that have been such a districts. The M&E system will be It is projectedthat govemment spendingon healthwill achieve 15.1% oftotal govemment spendingin2005. Ministry of Health.The GhanaHealthSector2005 Programof Work, January2005 (inpress). 14 successful part o f the GARFUND. In substantially strengthened during the first 1 ~~ particular, they may not have the technical M year to help districts monitor progress. capacity to ensure that programs Pressure from the population and press to adequately respond to needs or control improve transparency o f grant mechanisms misuse o f funds. are likely to assist Districts in monitoring o f programs. The GAC adopts a broad, population KPIs will be closely monitored and program based approach rather than focusing on changes made as necessary in the high risk groupdareas which diminishes S preparation o f the annual programs o fwork. the probability that the number o f new infections is reduced. The financial commitment o f some o f the N FundingPartners does not extend beyond two years. Overall Risk of M-SHAP M RiskRating-H(HighRisk), S (SubstantialRisk),M(Modest Risk),N(Negligibleor LowRisk) D. APPRAISAL SUMMARY 1. FINANCIALAND ECONOMIC ANALYSIS The five year cost for implementing the NSF I1i s US$ 575 million. The current commitment o f the two FundingPartners is US$28.3million. This is expected to rise as DFID approves additional funding for 2007-2010 and other development partners, such as UNAIDS, sign the MOUandjoin the pool. The "Economic Analysis o fHIV/AIDS" contained inthe Second Multi-Country HIV/AIDS Program (MAP2) (APL) for the Africa Region (Report No P7497) provides the economic justification for the Ghana M-SHAP. As the report indicates, HIV/AIDSundermines the three major determinants o f economic growth, namelyphysical, human, and social capital. Most economic analyses show that the benefit o f prevention andtreatment o f HIV/AIDS exceeds the cost, thereby meetingone objective o f an economic analysis. InGhana, there has been no analysis that compares the use o f funds for HIV/AIDS as opposed to some other intervention such as malaria. However, modeling does suggest that by 2015, nearly halfo f the total deaths amongst 15-49 year olds will be due to AIDS. Furthermore, data indicatethat HIV/AIDS in Ghana the infection has taken on a new pattern and those who are employed, middle income, and with primary or secondary education were disproportionately infected. These people are intheir economicallyproductiveperiod and HIV infection among this population has implications for the national economy. HIV/AIDSinGhana also has apoverty dimension. While prevalence is highest inthe second, third, and forth income quintiles, HIV/AIDSdoes pushmany either into poverty or deeper into poverty. One study showed that ifpoverty reductionwere to continue at the same rate until2015 as it didbetween 1991/92 and 1998/99,20% o f that reduction would be lost due to HIV/AIDS. 15 2. TECHNICAL M-SHAP i s built on the principles o f internationally-accepted best practices for HIV/AIDS, taking into account Ghana's specific socioeconomic circumstances and epidemiological situation. The proposed approach i s one o f addressing a concentrated epidemic which will focus on targeting groups most at risk such as commercial sex workers, truck drivers, etc. Inthis case, experience from other countries demonstrates the effectiveness o f HIV/AIDS programs that focus intensively on the core transmitters and hot spots which are driving the epidemic with an emphasis on prevention programs. Standard protocols, as recommended by UNAIDS and the World Health Organization (WHO), are beingused for the provision o f voluntary counseling and testing and other related counselingprograms. 3. SOCIAL Data from the National AIDS/STI Control Program show that almost two-thirds o f the AIDS- reported cases are females. This imbalance may occur for a number o f reasons, including the fact that women are more biologically prone to infection than men during unprotected sexual intercourse. Similarly, women are more vulnerable to other reproductive tract infections/sexually transmitted infections (RTIs)/STIs, the presence o f which greatly enhances the risk o f HIV infection. The project will address gender issues by ensuring that behavior change and communication programs are sensitive to gender and ensuring that messages are cross cutting and provide overlap between groups (e.g. messages on transaction sex for women's groups). Procedures have been reviewed to ensure that when districts are reviewing project proposals, a higher degree o f priority will be given to those projects that will ensure participation from women and other marginalized groups. The selection o f patients to access services will be based on the principles o f serving the most needy first, and ensuring that cost and other obstacles, for example, lack o f transport, are not barriers. Inthe case o f VCT services, a special effort will be made to reach out to young men, a target group that has traditionally been reluctant to access VCT services. Strategies being tested to encourage men to participate include men's nights and incentives for couples to attend. Concerted efforts will be made to facilitate access to PMTCT sites for pregnant women in rural and other deprived areas by providing transport or other incentives to make it easier for them to access services. Services for PMTCT and antenatal care and delivery for all pregnant women seen in public health facilities are free. Strategies for ensuring equity in access to services are contained in the PMTCT Manual (December 2003). The proposed targets o f at least one VCT and PMTCT site per district, with additional VCT and PMTCT centers planned for purposively selected sites within highprevalence communities, described inthis proposal as "hot spots," will ensure that the vast majority o f Ghanaians have access to VCT and PMTCT services. Criteria for the selection o f patients in need o f HAART are outlined in the national guidelinesg. Criteria for the enrolment of patients ifARVs have been developed and feature inthe guidelines and national scale-up plan. Patients with the lowest CD4 counts or in the greatest need for HAART, i.e., with one or more AIDS-defining opportunistic infection(s), will be treated first if ARVs or other resources are limited. Clinical and social criteria developed for screening patients ~ Ministry of Health.Guidelinesfor Antiretroviral Therapy inGhana(UpdatedMarch2005). 16 accessing HAART will be applied equally to all clients. These strategies will guarantee equal access and ensure that cost does not constitute a barrier. The National Health Insurance Scheme will provide support for the treatment o fopportunistic infections (01s). Participatory approach in project design and implementation. The NSF I1was prepared with considerable up fi-ont stakeholder consultation. The draft was circulated throughout the country to most districts which have had an opportunity to provide feedback. In addition, GAC secretariat staff have been holding meetings in many areas o f the country to engage local governments, NGOs, CBOs, and FBOs into discussions on HIV/AIDS and their potential participation. 4. ENVIRONMENT The proposed project has been classified as category "By'for environmental screening purposes given the risks associated with the handling and disposal o f medical waste and general health waste. As a repeater project, M-SHAP will make use o f the existing arrangements for safeguard issues which have been designed and successfully implemented under the Health Sector Support Program (HSSP). A Health Care Waste Management Plan was developed by the MOH and approved by the Bank prior to appraisal o f the HSSP. This document has been re-disclosed in the country and at the Bank Info Shop inMay 2005. Implementation o f the Health Care Waste Management Policy began in 2005. Its recommendations are being piloted in two districts. In addition, standard waste management procedures have been developed for district hospitals. These procedures describe the necessary stages o f managing waste (e.g. point o f generation o f waste, point o f disposal o f waste). Training modules are also being developed for health facility staff and staff o f other relevant public, private and philanthropic organizations on waste segregation and disposal procedures. The Ministry o f Health (MOH) has drawn up comprehensive capacity development programs on health care waste management and this covers HIV/AIDS-related generated wastes. A key element will be on public education. M-SHAPwill take lessons from the implementation o f the National Environmental and Sanitation Policy developed under the auspices o f the Ministry of Local Government and Rural Development. The project will draw on existing capacities (e.g., within the Occupational Health and Environmental Unit of the Ghana Health Services, Environmental Protection Agency, Health and Sanitation Sub-committees of municipal and district assemblies, etc) for managing waste and ensuring compliance and enforcement o f safeguard systems. The project can help minimize the danger of poor segregation and disposal of health care waste by financing the procurement, installation and monitoring o f equipment and facilities. 17 5. SAFEGUARD POLICIES Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [XI [I NaturalHabitats (OP/BP 4.04) 11 [XI Pest Management (OP 4.09) [I [XI CulturalProperty (OPN 11.03, beingrevised as OP 4.11) [ ] [XI Involuntary Resettlement (OP/BP 4.12) [I [XI Indigenous Peoples (OD 4.20, beingrevised as OP 4.10) [ ] [XI Forests (OP/BP 4.36) [I [XI Safety o f Dams (OP/BP 4.37) [I [XI Projects inDisputedAreas (OP/BP/GP 7.60)* [I [XI Projects on International Waterways (OP/BP/GP 7.50) [I [X I 6. READINESSFOR IMPLEMENTATION The Project meets the following readiness for implementation criteria. The following documents have beenpreparedand clearedby Bank staff e The NSF I1 e 5-year POW e 2006 POW e M&EFramework; 0 Accounting andAdministrative Manual e Procurement Manual e Procurement planfor the first 18 months of the M-SHAP e GAC Operational Manual e M O Ubetween the MOH and GAC e NationalHealth Care Waste ManagementPolicy andAction Plan Key management staff are also inplace and an MOU agreeingto pooling arrangementshas been agreedwith IDA, DFID, and GOG. 7. CREDIT CONDITIONSAND COVENANTS Conditions of Effectiveness: e There are no effectiveness conditions as it is a repeater project other than the Standard General Conditions requirement for a legal opinion after signing of the DCA. Covenants: e The Annual Program of Workfor the respective fiscal year has been approved by IDA and other pooledfunding partners. By supporting theproposedproject, the Bank does not intend toprejudice thefinal determination of theparties' claims on the disputed areas 18 e The Borrower shall: (a) not later than January 1, 2006, ensure that the national budget includes provisions for full funding of all non-salary operating costs of the GAC Secretariat; (b) not later than December 1, 2006, adopt a sustainability plan for the GAC, acceptable to the Association, and thereafter implement the measures identfied in saidplan and (e) not later than January 1,2008, ensure that the national budget includes provisionfor full funding of all salary costs of the GAC Secretariat. 19 3 sU oua 5 3 a"0D 3 0 w N N - I- n - 223 3A'm0 E: Y -I- + + I 7- + ANNEX3A: SECTORBACKGROUND" GHANA: MULTI-SECTORAL HIV/AIDS PROJECT 1. Backgroundof the HIV/AIDS Epidemicin Ghana The first case o f AIDS inthe country was diagnosed in 1986, and by the year 2004 an estimated 380,000 adults and 14,000 children were HIV-positive (UNAIDS, 2004). By 2004, the cumulative number of people diagnosed with AIDS was 36,000 (Figure 2). Prevalence rates increased from an estimated 2.6 percent in2000, to 3.6 percent in2003, and 3.1 percent in2004 (National AIDS/STD Control Program, GHS, 2005).16 The nature o f the epidemic inthe country has exhibited a different pattem from that found in Eastem and Southem Africa where prevalence rates have exceeded 25 percent within a short period. Considerable variations also exist by geographic region, gender, age, occupation, and, to some degree, urban-rural residence. According to the 2003 sentinel surveillance report based on clients o f antenatal clinics, prevalence rates in the country's ten regions varied from below 2 percent in the Upper West Region to around 4 percent in Greater Accra, to almost 7 percent in the Eastem Region (Figure 1).These regional data remain very similar inthe 2004 Sentinel Survey. Eight o f the 30 sentinel surveillance locations reportedprevalence o fmore than 5 percent in2003, and six o f 35 sites in 2004. These pockets o f high rates indicate that "severe epidemics, by Ghana standards, are raging in various non-contiguous parts o f the Country" (Ghana AIDS Commission, 2002). Females are estimated to be 1.3 times more likely to become infected than males. This sex ratio has declined sharply since the early stages o f the epidemic when it was around 3:1, still indicating that the risk o f infection for females i s higher than males (National AIDS/STD Control Program, GHS, and MOH, 2003). The 2003 DHS found that females who are widowed, divorced or separated have significantly higher rates than those who were in marital unions, Similarly, the DHS found that females with two or more sexual partners inthe last year had HIV infection rates three times higher than females with only one partner. The 2004 Sentinel Survey showed that there was a decline in mean HIV prevalence among the 15 to 24,20 to 24, and 15 to 49 age groups. The 15 to 19 and 25 to 29 years age group recorded a slight increase of 0.1% from the prevalence o f 2003 from 1.9% to 2% and 4.4% to 4.5% respectively. The 25 to 29 year group i s the age group with the highest prevalence and inthe 45 to 49 age year group, out o f 53 samples collected, no one was HIV positive hence the dramatic drop to 0% prevalence recorded. Among age groups 30 to 34, 35 to 39 and 40 to 44, decrease in mean HIVprevalence was observed. IsThis section is from the NSF I1 l6Incontrast, prevalence rates inSouthernandEasternAfrica expandedmuchmorerapidly over the same period, exceeding 25 percent insome countries. Neighboring Cote d'Ivoire has shown still another pattern, generally maintaining a rate between 10 and 15% for most o f the period. 25 Cote et al. (2004) have estimated that transactional sex accounts for about 84 per cent o f HIV infections among males aged 15-59 years inAccra. Inaddition to sex workers and their clients, other groups believed to have above-average prevalence rates include uniformed service personnel, teachers, and miners,prisoners, long-distance truck drivers, national service volunteers, cross-border traders, and female long-distance traders (Anarfi et al., 1997 cited in Ghana AIDS Commission, 2003, p. 9). Female STI clinic attendees at Adabraka (inAccra), a clinic that also serves sex workers inGreater Accra Region, had aprevalence rate o f 39 percent in 1999, reinforcing the well documented close association betweenHIVandother sexually transmittedinfections. The 2003 GDHSresults show highrates of infection among employed middle income groups. This differs from the prevailing view o fthe epidemic being associated with poverty. There is, therefore, an emergingtrendwhich needs to be understood andwhich will require new thinkingand strategies about target groups Figure 1. HIV Prevalenceby Region 7 6 5 6 5 I 4 5 I 4 - 3 8 i 35 E 3 0 m ~ i v ~ n v a ~ e n c c 3 4 1 7 - . -r -7- Reglon HIV Sentinel Report,March2004 The observed patterns of high rates of five per cent or more in some areas, the male-female variations, the extremely high rates among some sections o f the population and the emerging increasing rates among people inthe middle income group have formidable implications for the socio-economic development of the country. As an epidemic affecting people intheir productive 26 and reproductive ages, it will affect the number o f people available for work, health, and the economy, and create an orphan population with which the existing social system may be unable to cope. Thus,,ifnot checked, the effects o fthe epidemic can negate developmental efforts. BehavioralFactorsinthe HIV/AIDS Epidemic One o f the clearest findings from research inthe country i s that there is near-universal awareness o f the HIV/AIDS epidemic and this has been the case for more than a decade now. Furthermore, results from the Ghana Demographic and Health Surveys (GDHS) o f 1998 and 2003 have shown that 88 percent o f men and 81 percent o f women knew that condoms could be used to avoid HIV/AIDS infection (Ghana Statistical Service and MacroIntemational, 1999; 2004). Inthe 2003 GDHS survey, more than 80 per cent o f men knew that a healthy-looking person could be HIV/AIDS positive. Despite widespread and generally correct information on HIV/AIDS, the majority o f Ghanaians do not feel personally vulnerable to HIV infection (Ghana Statistical Service and MacroInternational, 2004) in part because many do not think o f themselves as promiscuous, and do not realize that their vulnerability i s related to infidelities o f their spouse or partner (Appiah, Afrane, and Price, 1999). As Hochbaum (1958) demonstrated almost 50 years ago, a belief in personal vulnerability i s essential to ensure appropriate preventative health behavior. Although Ghanaians are aware o f HIVIAIDS issues, knowledge o f how to prevent HIV was frequently inadequate, includingamong some high-riskpopulations such as sex workers inAccra and Obuasi, male police officers in Accra, and male miners in Obuasi (Research International and Family Health International, 2001). Results from the 2003 GDHS indicate that although some women reported being aware o f the protective effect of condoms, they were not able to influence their partners to use a condom during sex due to poor bargaining power. Some women have beenfound to be overconfident in relying on fidelity as a strategy to avoid HIV/AIDS infection. Two-thirds o f women indicated that AIDS can be avoided by "sticking to one partner." However, monogamous women may underestimate the threat from husbands who may not be monogamous. The cultural pattern o f postpartum sexual abstinence for women, but not for men, promotes multiple partnerships and sexual networking which are contributing factors to the spread o f HIV.Other cultural practices, such as early marriage, genital cutting, subordination o f women to men, relative powerlessness in sexual decision-making, and inadequate sex negotiation skills, all contribute to women's vulnerability to HIV infection. The proportion o f men aged between 15 and 49 years who reported not having had sex in the entire year prior to the DHS survey increased from 21 percent in 1993 to 34 percent in 1998. Of those cohabitating, 79 percent o f women and 62 percent o f men reported they were faithful during the past 12 months. Among those who were married, 96% of women and 84% o f men had no extra-marital sex over the same 12 month period. These results point to some possible behavioral changes taking place and the next generation o f HIV/AIDS information and communicationwill include messages that aim at reinforcing these positive changes. 27 The DemographicContextandHIV/AIDS Since the start o f the HIV/AIDSepidemic in the 1980s, the number o f people infected with HlV inGhana hasrisen steadily. In1994, an estimated 118,000 Ghanaians were livingwith HNand the number more than tripled to about 400,000 by 2004. Population growth i s expected to increase the incidence o f HIV/AIDS over the next six years. In addition, improvement in the care and treatment o f PLWHA, especially with the use o f ART and HAART, will lead to improved survival. Thus, the number o f PLWHA i s expected to increase to about 500,000 by 2015 even ifnew strategies are developed to reduce the spread o fthe virus. The number o f new AIDS cases has increased dramatically over the last 10 years - from an estimated 5,500 in 1994 to 36,000 in 2004 (Figure 2). Both the annual number o f new AIDS cases and the annual number o f AIDS deaths are projected to increase to over 45,000 by 2015. Inaddition, the estimated number ofAIDS orphans (children under the age of 15 who have lost one or both parents to AIDS related causes) i s likely to double over the next 10 years - increasing from 132,000 in2004 to 291,000 by 2015. The results from the 2000 Population and Housing Census indicated that the country had a population o f 18.9 million. Between 1984 and 2000, the population grew at an annual rate o f 2.7 percent. Population density doubled from 36 persons per square kilometer in 1970 to 70 in 2000 (Ghana Statistical Services, 2002). Since 1960, the proportion o f the population in urban areas has increased substantially. The proportion increased from 23 per cent in 1960, to 29 percent in 1970, to 44 percent in 2000. The increase in urban population i s worth noting because, with a few exceptions, HIV prevalent rates are higher in urban areas, such as regional capitals, than rural areas. Young people aged 10-24 years account for 30 per cent o f the population while the proportion o f the population aged 65 years and above is about five per cent. Life expectancy has increased from 50 years for males in 1984 to 55 years in 2000, and from 54 years for females to 60 years improvement in health conditions -- apart fi-om H N / A I D S - and progress in socio-economic during the same period. These overall changes reflect persistently highbut declining fertility, development. These positive achievements in socio-demographic conditions can be eroded by highrates ofHIV/AIDSinfection. The demographic context has implications for HIV/AIDS programming. Prevention efforts are required almost everywhere, but urban areas and other "hot spots" require additional targeted efforts. The provision o f treatment, which requires substantial expansion, can reasonably start in large urban centers, and regions with higher prevalence, and spread to District Capitals and beyond as experience and resources become available. The population aged 5-14 years i s frequently referred to as a "window o f hope," and will require concerted effort to ensure that they remainuninfected. The Socio-Economic Context 28 Ghana has made some progress in reducing poverty levels in the 1990s. Between 1991/92 and 1998/99,the proportion o f the population inextreme poverty declined from 37 per cent to 27 per cent (Ghana Statistical Service, 2000). Within this national pattem, considerable poverty still exists in some areas and inpockets around the country. For instance, eight out o f ten persons in the three northern regions were classified as poor in 1998/99. Within regions and urban areas, pockets o f extreme poverty exist. The general observation i s that poverty and other economic pressures on individuals constitute pre-disposing factors for HIV infection. For example, unemployment, limitedjob opportunities and the rising cost o f living are aspects o f the poverty cycle that promote rural-urban migration o f young people, transactional sex and early sexual relations (Tanle, 2003). The available evidence indicates that over 70 per cent o f HIV/AIDS infected persons are aged 20-39 years due mostly to high sexual risk-taking behavior by individuals or their partners/spouses. Results from the 2003 GDHS also points to a new pattern o f infection. According to the results, employed, middle income persons and those with primary or junior secondary education were disproportionately infected (Ghana, 2004). These are people in their economically productive period and HIV infection among this population has implications for the national economy. It will affect the proportion o f the population available for work, training, and the pace o f work. The economic costs o f HIV/AIDS to employers in terms of care, absenteeism and retraining, i s highand will continue to increase ifthe trend i s not reduced. Thus, the current pattern o f HIV/AIDS infectionposes a threat to the economy o f the country. HIV/AIDS also impacts on boththe supply and demand aspects o f education. The gains made in the education sector, such as an increase in the proportion o f children in school will be difficult to sustain if an increase inHIV/AIDS cases among teachers reduces their availability. HIV/AIDS among teachers can put adolescent females at risk due to sexual relationships between male teachers and female students (Social Surveys Africa and Health Development Africa, 2004). As more adults become infected, their children are likely to drop out o f school because these children will be requiredto care for sick family members and/or may not be able to pay for their up-keep inschool. Ghana has a highly mobile population. Rural-urban migration, particularly by young people in search o f non-existent jobs, leaves them stranded in cities and thus further exposes them to the risk o f transactional sex. Street children are vulnerable as transactional sex is common among them (Anarfi, 1997). There i s also rural-rural migration which exposes migrants to new lifestyles, including transactional sex, if they are young adults who travel alone. Long distance drivers, uniformed service personnel and itinerant traders are believed to be particularly exposed to the risk o f casual sex (and sex as a component o f business deals), and hence HIV/AIDS infection. The country has a diverse ethnic and cultural composition, leading to differing cultural practices and perspectives on social issues. Inspite o f these differences, there are common features such as strong communal and family support based on the extended family system. Inrecent times, particularly with urbanization and the consequent rural-urban migration and Westernization, 29 these systems are breaking down, resultinginthe development o f nuclear families. A side-effect o f this process emerging insome parts o f the country i s the inadequate social and family support for PLWHA and people affected by HIVIAIDS. Gender issues are basic to confronting the HIV/AIDS epidemic. Women frequently suffer from relative powerlessness compared with men. As a result, women and girls are often subjected to humiliating practices, while some experience subjugation from relations, boyfriends, partners, and husbands. This powerlessness makes it difficult for girls to decline sexual advances from older males, such as teachers, without facing coercion, violence or retaliation (Health Development Africa, Social Surveys Africa, 2004). The conditions also limit women's ability to access a wide range o f services or make decisions about their lives. Therefore, gender equity i s critical to assuringwomen's empowerment insexual and economic matters, as well as full access to information and services that can help reduce vulnerability to infection or mitigate the effects o fAIDS. Other socio-cultural factors such as stigma, discrimination, and denial make the care and support for PLWHA and those affected by H N / A I D S a daunting challenge. Polygamy, and sexual attitudes and beliefs which underlie gender inequalities, make it difficult for women to negotiate on issues about sex, reproduction and condom use, or to influence the sexual networking o f their partners . Prevailing belief systems about the causes o f the epidemic also have implications for the reporting and management of infection. For example, people immediately associate HIV/AIDS infection with a promiscuous lifestyle even incases o f faithful wives infected by their husbands(Appiah, Afrane, andPrice, 1999). The costs o f providing health care for opportunistic infections for AIDS patients, and increasingly for antiretroviral therapy, will make substantial demands on the health care system which will affect health care for the general public. Inrural areas especially, the rising number o f AIDS orphans will put enormous pressure on households and communities. Thus, HIV/AIDS infection will put severe stress on families, the social system, the health sector and the economy. 5. The Political and Policy Environment The country has the benefit o f continuing political commitment to HIV/AIDS issues. The President serves as Chairman o f the Ghana AIDS Commission (GAC), providing it the highest mandate, The Commission consists o f the President as Chairman andup o f 15 Ministers o f State and other stakeholders, and i s serviced by a Secretariat. A Steering Committee provides the technical backstopping for the activities o f the Secretariat. The GAC regularly conducts its work through technical committees which are composed o f experts and representatives from stakeholders, including MDA, development partners, NGO, and Civil Society organizations (CSO). The establishment o f the GAC followed the development o f the first National HIV/AIDS Strategic Framework o f 2001-2005. GAC was set up in 2001 by Act 613 o f Parliament as a supra-ministerialbody under the Office o f the President to coordinate the multi-sectoral national 30 response to HIV/AIDS. Since its creation, the GAC has made considerable progress in its functions o f advocacy, policy formulation, resource mobilization, monitoring and evaluation, research, and has provided strategic vision for the coordination o f the national response. Much o f these have been achieved through strong political support to the national response, the establishment and use o f decentralized institutional structures, enactment of supportive policies and legislation andwidespread participation o f civil society. The 1992 Fourth Republican Constitution guarantees the protection o f the right to life (Act 13); the right to the protection o fpersonal liberty (Act 14); the right to respect for human dignity (Act 15); and the right to equality and freedoms. Article 37(4) also mandates the Government to enact laws on population whenever necessary. The Ghana Poverty Reduction Strategy o f 2003 (Government o f Ghana, 2003), which i s the blueprint for the country's human and socio- economic development, also highlights the need for improved quality o f life and expansion o f opportunities for all memberso f society under its human development component. The National Population Policy (Revised Edition, 1994) emphasizes the harmful effects o f STD/HIV/AIDS and calls for the institution o f appropriate measures to prevent and control the epidemic. Numerous other policies make an explicit or implicit reference to HIV/AIDS in Ghana. These include: the National Youth Policy which identifies the provision o f services to young people living with HIV/AIDS as a priority; Adolescent Reproductive Health Policy that has as one o f its objectives the implementation o f programs aimed at reducing STD/HIV/AIDS; the Reproductive Health Standards and Protocols; the Labor Bill; the National HIV/AIDS/STI Policy, Policy Guidelines on Orphans and Vulnerable Children, Gender and Children Policy, the National Work Place HIV/AIDS Policy; draft Policies on Ageing and Gender; and Affirmative Action Policy Guidelines to facilitate a process o f ensuring gender equality and empowerment o f women in all aspects o f life. Finally, experiences from NSF Iand a Joint Review Report on the National Response have inspired the development o f this new NSF I1 (Ghana AIDS Commission, 2004b). 6. Ghana andIts InternationalCommitmentsinthe Context of HIV/AIDS The Government has either signed or subscribed to a number o f continental and international treaties, conventions and declarations on HIV/AIDS. It has endorsed The Abuja Declaration o f 1998 and The Declaration o f Commitment on HIV/AIDS adopted by the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in June 2001. As a signatory to the two Declarations, Ghana re-affirmed its commitment to HIV/AIDS, including protection o f PLWHA from discrimination under the section on HIV/AIDS and Human Rights. In fulfillment o f its commitment to UNGASS, indicators on HIV/AIDS activities have been submitted to UNAIDS. At the 2003 African Union Meeting inMaputo, all Heads o f State, including Ghana's, renewed their commitment to reduce the impact o f the epidemic. Commitments to these obligations have informed some of the strategies that have been adopted so far. Among the international conventions which have implications for the management o f HIV/AIDS and which Ghana has endorsedare the Universal Declaration o f HumanRights, the International 31 Convention on Economic, Social and Cultural Right, the African Charter on Human and People's Rights, Convention on the Elimination o f all forms o f Discrimination against Women (CEDAW), NEPAD Declaration, and the Convention on the Rights o f the Child (CRC). Ghana was the first country to sign the latter, indicating strong commitment to the rightsof children. 7. The Challengeof HIV/AIDS UNAIDS reports that, in2004, there were 4.9 million new HIV infections, which was more than in any year before. Some 39.4 million people are living with HIV/AIDS, which killed 3.1 million in 2004, and over 20 million since the first cases o f AIDS were identified in 1981 (UNAIDS, 2004a). Available evidence indicates that about 60 percent o f infected persons and nearly 80 percent o f all new infections are insub-Saharan Africa. The infection i s at its peak ina continent which is the least developed, making it an epidemic associated with poverty and under- development. It i s partly within this context that the Millennium Goal 6 seeks to address the problem o fHIV/AIDS, malaria and other diseases. Since 2002, both multilateral and bilateral agencies have renewed their commitment to fighting the epidemic. Donors have considerably increased their funding and are also exploring innovative ways to channel resources to where they are most needed to combat HIV/AIDSmore quickly and efficiently. The cost of antiretroviral medicines has decreased considerably, and concerted efforts are being made to extend treatment to millions o f people in low- and middle- income countries. Together, many o f these approaches are making a difference in curbing the spread of HIV and restoringquality o f life to infectedpeople and their families. Figure2. 32 Experience has shown that the natural course o f the epidemic can be changed with the right combination o f leadership and comprehensive action. Forthright national leadership, widespread public awareness and intensive prevention efforts have contributed to decline in new HIV infections in some countries. At the same time, we now have antiretroviral medicines that can prolong life and reduce the physical effects o f HIV infection. Coordinated national and international action has greatly reduced the prices of these medicines inlow- and middle-income countries. Associations of people living with HIV have become global force and are providing leadership inrespondingto the epidemic ina number o f countries (UNAIDS, 2004a). Recognizing the possible impact of HIV/AIDS on health and socio-economic development generally, Government seeks to respond to the epidemic through this Second National Strategic Framework for the period 2006-2010. 33 ANNEX3B: MAJOR RELATEDPROJECTSFINANCED THE BANKAND/OR OTHERAGENCIES BY GHANA: MULTI-SECTORALHIV/AIDS PROJECT WorldBank The World Bankhas helpedfinance or co-finance three HIV/AIDS programs to date inGhana. 1. World Bank MAP 1(Ghana AIDS Response Fund 1,GARFUND 1) 2. World Bank Abidjan-Lagos Corridor Project 3. World Bank Treatment Acceleration Project (TAP) WorldBankMAP 1(GhanaAIDS ResponseFund1, GARFUND 1) $27.8 million - (2001-2005) Credit This 4-year program aims to reduce the spread o f HIV infection and reduce the impact o f AIDS on those infected and their families through a balanced, diversified, multi-sector response, engaging all government sectors, non-government organizations, and grassroots initiatives, civil society organizations, including NGOs, CBOs, trade and professional associations, PLWHA associations, districts, and key line ministries other than M O H to complement MOH's ongoing program and ensure a rapid, multi-sector scaling up o f activities in all regions o f the country and at all administrative levels. Main activities are prevention, care and support activities for those affected, and prioritizing community-level responses. The MAP 1program i s being implemented by the Ghana AIDS Commission. The bulk o f activities are being conductedby NGOs and civil society organizations. World BankAbidjan-LagosTransport Corridor Project $12.9 million(2003-2007) - Grant This 5-year, multinational, 5-country program targets high-risk groups and mobile populations that travel or live beside the heavily traveled coastal corridor that runs between Abidjan-Accra- Lome-Cotonou-Lagos. The program reaches people in border towns, drivers, traders, and commercial sex workers, especially people who frequent bars and restaurants in "hotspots" and other stopover sites, providing STI services, V C T services, using health sector facilities with management by fourth or fifth year leading to ART. World BankTreatmentAccelerationProject(TAP) $14.9 million(2004-2007) - Grant TAP is a 3-year, 3-countryYWorld Bank regional program involving Burkina Faso, Ghana and Mozambique designed to test approaches for 1) scaling up HIV/AIDS care and treatment service delivery at the country level, 2) strengthening institutional capacity for expanding HIV/AIDS 34 care and treatment, and 3) facilitating regional learning from TAP country experiences via WHO and UNECA. The program i s being implemented in four highHIV prevalence regions in Ghana (Eastem, Ashanti, Westem, Greater Accra). The bulk o f financial support i s for scaling up service delivery ($9.9 million) via sub grants to NGOs and IPS(63%), with $5.7 million (37%) allocated to strengthening institutional capacity and piloting approaches for scaling up, knowledge sharing and information dissemination. Global FundRound 1 $14,170,222 (January 2003-December 2007) - Ghana's Round 1 proposal for accelerating access to prevention, care, support and treatment o f all persons affected by HIVIAIDS was approved by the Global Fund at $14.2 million over 5 years, with a 2-year grant agreement o f $5.0 million. Year 1-2 disbursements received to date from the Global Fund, $3.6 million of $5.0 million, have enabled Ghana to scale up HIV/AIDS services, especially HAART, at the first 4 sites, especially Korle-Bu and Komfo Anokye teaching hospitals. Receipt o f the balance o f Year 1-2 disbursements for Round 1, $1.4 million, combined with $9.2 million for the 3-year Phase I1extension, 2005-2007, will enable Ghana to procure additional ARVs and commodities and extend the scale-up to 10 regional hospitals. ARVs will account for 37%, 47% and 76% o f plannedexpenditures in2005, 2006, and 2007, as treatment i s scaled up, while training costs will decrease from 16%, 14% to 5% during the same period. DFID and JICA are also supporting the expansion o f HIV/AIDS services to regional hospitals, DFID with $6.4 million for systems support, 2004-2005, and JICA with $870,000 for CD4 machines and consumables. However, this expansion o f HAART to regional hospitals would not be possible without Global Fundsupport for the purchase o f ARVs. Other multilateral programs The majority o f other multilateral programs for HIV/AIDS currently underway or planned in Ghana are conducted by U.N. agencies, especially UNICEF, UNDP, UNFPA, UNAIDS and WHO. In2005, it is estimated that these agencies will invest $5 million o f their own resources in the national response to HIV/AIDS, an increase o f 10% over 2004. Many U.N.programs in Ghana are co-financed by bilateral donors. Contributions by bilateral donors towards activities sponsored or undertaken inwhole or inpart by U.N.agencies are counted separately. Bilateraldonors Financial support for HIV/AIDS activities in Ghana from bilateral donors totaled $25 million in 2005, with major support from DFID ($12.5 million), USAID ($7 million per year), Dutch ($2 million), JICA ($1 million), CIDA ($400,000), European Union ($300,000), GTZ ($300,000), and DANIDA ($200,000). Many o f these countries, especially DFID, Dutch, DANIDA, and European Union, are important contributors to the Ghana Health Fund, another resource for HIV/AIDS17.JICA and USAID also provide additional support for the national health budget "DonorinflowstotheHealthFundfor2005areprojectedat$66.7million.MinistryofHealth.TheGhanaHealthSector2005 Program of Work, January 2005 (inpress). 35 with earmarked funds. Despite many programs targeted to scaling up HIV/AIDS services, including VCT, PMTCT, STI services, and HIV/AIDS treatment, care and support, no bilaterally-fundedHIV/AIDS program to date in Ghana has provided for the procurement of ARVs or other HIV/AIDS drugs, a key funding gap which needsto be filled. On the other hand, current andplannedactivitiesfundedbybilateral donors will be essentialto supportingthe "pull through" of scaling up HAART and other HN/AIDS services, such as the USAID-financed SHARPprogram(StrengtheningHIVIAIDSResponsePartnerships). 36 ANNEX4: DETAILEDPROJECT DESCRIPTION GHANA: MULTI-SECTORAL HIV/AIDS PROJECT The M-SHAP will support the areas o f intervention outlined in the 2006-2010 NSF, as defined and budgeted for in the Annual POWs. The main goals o f the 2006-2010 NSF I1are to reduce new infections among vulnerable groups and the general population; mitigate the impact o f the epidemic on the health and socio-economic systems as well as infected and affectedpersons; and promote healthy life-styles, especially inthe area o f sexual and reproductive health. These goals will be met by focusing on seven key intervention areas (see below), for which the GAC Secretariat acts either as a coordinator/implementer or as a financier through the HIV/AIDS grants making windows where the majority o f M-SHAP fbnding will go. Funds from DFID, and IDAwill be disbursedinto the Pooled account, to finance those elements o fthe annual POWthat are not being fbnded by earmarked funding, or through the parallel financing of interventions outside o f GAC. Distribution of fbnding among the key intervention areas is indicative, since final allocations will depend on the priorities as identifiedinthe annual POW. ProjectComponent1: Policy,AdvocacyandEnablingEnvironment-US$4 million The favorable socio-political environment within the country inspired the development o fNSF I and NSF 11. The 1992 Constitution recognizes and affirms the basic rights o f citizens. The President also serves as the Chairman of the Ghana AIDS Commission, and the involvement o f key Ministries, the private sector, traditional and religious leaders and civil society have helped to create a favorable response to the epidemic. One of the challenges is the utilization of this social and political commitment in the development and implementation o f effective programs and activities. Some o f the intended programs are likely to be controversial and require social and attitudinal change in diverse areas such as enforcement o f laws against stigma and discrimination, norms regarding transactional sex, and multiple sexual partnerships. NSF I1 recognizes the need to develop and operationalize laws and policies to protect the rights o f PLWHA, meet the challenges posed by stigma and discrimination, as well as new demands involved in expanding prevention, treatment, care and support. Advocacy and social mobilization will constitute important tools in addressing socio-cultural issues such as eliminating stigma and discrimination against PLWHA and improving the rights and status o f women, orphans and other vulnerable persons. PLWHAs will play an important role in the development and execution o f many o f the activities under this component partly because they are the mainbeneficiaries andpartlybecause they can provide the information necessary to identify areas requiringattention. The component will also empower PLWHAs and people affected by HIV/AIDS through activities to improve their skills and self-development, and to support the formation o f associations or groups that can provide community support in tackling the various issues. This would also support policymakers' direct and personal involvement inthe fight against HIV/AIDS, urgingthem towards public statements and debate on the issue. Therefore, this component will support all activities that can improve 37 and enforce the overall national policy environment, as well as advocacy activities, that can contribute to bringinga change inGhanaian society for these vulnerable groups. This intervention area will focus on the review, formulation and enforcement o f policies that protect and affect the rights o f PLWHAs andor people affected by HIV/AIDS. It will also promote activities to empower PLWHAs, OVCs and other vulnerable groups by ensuring a continuous supportive socio-political environment to address the challenges faced by the vulnerable groups. Project Component2: CoordinationandManagementof the DecentralizedMulti-Sectoral Response-US$6.8 million Coordination and management of the national response through the decentralized system constitute key components o f HIV/AIDS program implementation. The Ghana AIDS Commission (GAC) as the national coordinating body blends both political focus and technical dimensions to ensure a harmonized nationalresponse. Among the strategies neededto achieve an effective decentralized response will be the strengthening o f the Ghana AIDS Commission, establishing clearly defined roles and responsibilities for all implementers and stakeholders, and capacity buildingo f all participants -National, Regional and District levels, NGO, CBO and the private sector - to implement and monitor all the steps necessary to combat the HIV/AIDS epidemic. In NSF I1the private sector, civil society, organized labor, religious and traditional leaders will be mobilized for programs and to ensure that HIVIAIDS i s kept at the centre stage o f the political aspects o f coordination, policy direction and guidance, and the development o f partnerships. This component will promote the coordination and management by GAC to harmonise efforts and guide the various Ministries, Departments and Assemblies (MDAs), Regional AIDS Committees (RACs), Metropolitan, Municipal Assemblies (MMAs), and District AIDS Committees (DACs) in implementing their sectoral mandates and responsibilities that will compose part o f the national HIV/AIDS response. This component will cover activities to strengthen the arrangements and decentralized institutional frameworks for multi-sectoral coordination o f the response to the epidemic by ensuring there are clearly defined roles and responsibilities identified for all implementers and stakeholders at each level: central, regional, district, and community level. This will also include support for capacity building o f key agencies to develop and implement their policies and programs in line with the 2006-2010 NSF I1priorities. Activities will include, but not be limited to: (a) the development and revision o f HIV/AIDS sectoral plans for effective mainstreaming and monitoring o f progress under the M&E framework; (b) workplace interventions and training o f staff; (c) strategic communication for behavior change and advocacy to increase political commitment through sensitizationprograms; (d) and training inHIV competence for highlevel MDA staff; (d) the development of the annual POWs by GAC inpartnership with the MDAs, MMAs, RACs, DACs, and donors; (e) provision of technical support to MDAs inmainstreaming and implementing HIV/AIDS programs for their 38 internal and external clientele; (0 provision o f support to the M C s , MMAs, and DACs to build their capacity to coordinate and monitor activities being implemented by both government, private, and NGOs, within their region or district; and (g) improved information flow between the GAC and the different stakeholders at each level to ensure that there are no gaps in the national response. Support will also be provided to the GAC to improve their coordination role in tracking and monitoring the HIV/AIDS activities o f partners outside the decentralized government mechanism, such as intemational NGOs and donors, and to build GAC's capacity to mobilize resources to meet the needs o f the national response. ProjectComponent3: Mitigatingthe Social, Cultural,Legal andEconomicImpacts-US$ 2.6 million The HIV/AIDS epidemic poses a developmental and social challenge to Ghana. The spread o f HIVis strongly influencedbythe social, cultural and economic environment. The sexual, social and spatial milieus in which people operate, and the political structures which provide the framework for governance, have implications for the pattern o f spread and the nature o f responses to the epidemic. Affecting the most active, productive and the reproductive members o f the society, HIV/AIDS impacts on a country in diverse ways. At the economic level it lowers productivity and increases the cost o f business. The challenges involve identifying and enhancing the positive social aspects that may help to reduce transmission and mitigate the effects o f the epidemic, such as reinforcing and supporting strong families and communities. At the same time, the program will identify and eliminate negative social aspects, such as the subjugation o f women and other gender issues that have implications for the spread, prevention and mitigation o f the impact o f the epidemic. The economic impact o f the epidemic i s large and growing, and it will affect the national economy in many ways. Mitigating the impact o f the epidemic at the societal level will involve mainstreaming HIV/AIDS into a number o f national programs -- the Poverty Reduction Strategy, addressing gender-based vulnerability, domestic violence, coercion and marginalization o f women -- and harmonizing some national laws with the international laws that various Governments o f Ghana have signed and which have implications for the management o f HIV/AIDS and rights o f persons. Programs will also be pursued that will provide PLWHA with resources (e.g. micro credit) to improve their wellbeing and survival. This component will support activities geared towards reducing the economic impacts o f HIV/AIDS on infected and affected households, as well as OVCs and other vulnerable groups. It will also enhance the mechanisms for social mobilization to support activities meant to reduce the socio-cultural burden o f HIV/AIDS on vulnerable and high-risk groups. The identification and adoption o f socio-cultural practices, which promote relevant HIV prevention, care and support and reinforce positive behavioral change, will be critical to this component. Activities under this component will include: (a) raising nationwide awareness o f the socio- economic impact of HIV/AIDS households, families, communities, and companies; (b) 39 empowerment through micro-financing, education and skill development for women, PLWHAs and their families, other affected and vulnerable groups; (c) the promotion of increased private sector involvement in AIDS programming, as well as enforcement o f workplace AIDS policies; (d) identification and development o f strategies to mitigate or raise awareness o f socio-cultural practices that have positive and negative implications for the prevention, transmission o f HIV; and(e) improved attention andprotection for the rights of vulnerable groups such as women and children, including legal support. ProjectComponent4: PreventionandBehaviorChange Communication-US$3.2 million One o f the challenges of the national response i s developing the next generation o f interventions, including Behavior Change Communication (BCC), which focus on changing individual risky sexual behavior as well as community perceptions and attitudes about HIV/AIDS and PLWHA. Such programs will target the general population, specific vulnerable groups, such as sex workers and their clients, STI clinic attendees, migratory populations, youth (particularly those on the street), itinerant traders, women (especially subgroups that suffer disproportionately from the disease such as those not currently in marital unions) and middle class employed persons. Also geographic areas where there i s high prevalence, and places such as bars, markets, border towns and truck stops where unprotected, casual sex takes place will be targeted in a non- stigmatizing manner. Under this component, the GAC will advance its prevention efforts to maintain the low prevalence rate in Ghana and reduce the number o f new infections in highrisk groups to a large extent. Activities for the general population will be focused on reducing the stigma associated with group-specific targeting, which limits the effectiveness o f interventions. This component will further address new prevention issues that have arisen over time, as well as promoting more efficient measures to bring about behavior change in the populations. In particular, the introduction o f ART services encourages the emergence o f new attitudes to HIV transmission because people on ARV may either abandon or become lax in taking preventive measures, so it will be critical to support and emphasize the prevention message as part o fthe provisiono fART. Activities under this component will also deal more specifically with identification o f interventions and implementation for behavior change among at-risk groups that can be captured in well-packaged programs, such as in-school youth and mobile populations. In particular, communication and other prevention activities would focus on: (a) the development, implementation and management o f targeted behavior change and communication (BCC) and other prevention programs; (b) promoting the utilization of quality STI, VCT, PMTCT, and PEP services to vulnerable groups and the general population; (d) minimizing the risk o f HIV transmission through blood and blood products; (e) promotion o f programs to increase the median age o f sexual debut and utilization o f condoms duringhigher risk sexual encounters; and (f) reducing the incidence o f occupational exposure to HIV and other infections. 40 ProjectComponent5: Treatment, Care and Support-US$2.2 million Opportunities for comprehensive treatment, care and support have expanded rapidly within the last five years. For example, antiretroviral drugs have become increasingly accessible and affordable and are currently beingsuppliedto an increasing number o f people. ARV therapy has been simplified and funding has become increasingly available in developing countries as a result o f stronger bilateral and multi-lateral partnerships and strengthened international commitments to the fight against HIV/AIDS. These developments set the stage for a rapid scaling-up o f treatment programs. Adopting this plan implies working towards the goal o f providing treatment to all people who require it. This may lead to substantial shortages in the availability o f drugs at some period during the scaling-up. Therefore it will require the development o f access policies which include gender and age equity. At the same time, care and support programs for PLWHA will require substantial expansion o f institutional, community, and family efforts, and an appropriate manpower mix which i s feasible, affordable, and meets the needs o f all who require care and support. The solution will be a combination o f professional personnel and volunteers, all o fwhom will require substantial training and continuing support. Under this component, the GAC aims to build upon the success experienced to date inprovision of ARV therapy to people inthe Manya and Yilo G o b o districts o f the Easternregion by scaling up treatment efforts nationwide. Inaddition, the component also covers the broad continuum o f treatment, which includes VCT, management o f STIs and OIs, provision o f ART when it becomes necessary, and the home-based and community care and support that i s necessary as well to maintain the overall health and well-being o f PLWHAs and their affected families. Communities have been providing care and support, including home-based care, but the GAC intendsto take this a step further by ensuring that this care and support is monitoredto ensure the highest quality and linked to health facilities so that medical treatment can also be provided to PLWHAs. Under this component, the GAC will work more closely with the M O H to ensure that the areas o f expertise o f each institution are clearly recognized and that activities are complementary to each other and carried out intandem, where applicable. Proposed activities will include: (a) strengthening o f infrastructure and human resources capacities necessary to rapidly scale up the provision o f treatment, care and support for PLWHAs, OVCs, and other vulnerable groups inpublic and private institutions at all levels; (b) promotion of early diagnosis o f HIV through use o f VCT; (c) improved access to quality management o f OIs, including the availability o f adequate laboratory support for clinical care services at all levels; (d) universal access to ARVs; (e) ensuring high standards for community and home-based care for PLWHAs and OVCs; (0promoting psychosocial support as an integral part o f a comprehensive care and support package for vulnerable groups; (g) strengthening linkages and referrals between the community and clinical and preventive services, and promoting public-private partnerships for accelerated treatment, care and support for PLWHAs and other affected groups; and (h) promoting adequate nutrition for PLWHAs and mothers as part o f the treatment and care programs. 41 Project Component 6: Research, Surveillance, Monitoring and Evaluation - US$ 1.2 million Under this component, the GAC will ensure that it has all the available epidemiological, biological, behavioural information on the trends in the epidemic in Ghana which can be used to guide and amend the direction o f the nationalresponse. The data on indicators collected from monitoring and evaluation o f the activities carried out by various implementing partners and agencies at all levels, will provide information to the GAC on the geographic coverage o f and scale o f activities beingimplemented, inorder to allow the GAC to transfer attention to areas or issues being missed inthe national response. In addition, this component will continue to support the existing national M&E system in Ghana to capture the overall national AIDS response, in keeping with the Three Ones. GAC's M&E system i s decentralized. Each o f Ghana's 138 districts has an M&E focal point trained to collect data at the district level. This district data i s then captured and aggregated at the regional and national levels to provide information for evaluating the outcome and impact o f the 2006-2010 NSF. GAC's M&E systems will continue to be strengthened at all levels to ensure that these systems can continue to provide timely disaggregated information on the types o f sub-projects, service providers, etc. to inform the Partnership Forum. The revision o f performance indicators for 2006-2010 as part o f the NSF I1i s critical to the continued development o f the M&E system through the 2006-2010 M&E Framework. Every development partner and all stakeholders have bought into the concept o f one M&E system that they will all contribute to and provide data. Activities will include: (a) the development o f a monitoring database on HIV/AIDS indicators, programs and research, based on the UNAIDS country response information system (CRIS); and (b) the continued strengthening o f the M&E system for the decentralized response. Project Component 7: Resource Mobilization and Funding Arrangements - US$ 0.0 million". While not a specific component in the true project sense, the NSF I1 includes research mobilization and funding arrangements as one o f its seven priority activities. Resource mobilization and utilization are critical elements in meeting the huge human, financial and material resources required for the expanded and diversified programs envisaged. Under NSF 11, resource mobilization and funding will be enhanced and effectively coordinated through a partnership forum under the leadership o f GAC. The objective is to ensure that resources committed to HIV/AIDS activities from all sources are pooled into an integrated system to support the national response. Inaddition, the Framework will ensure sustainable availability o f resources to implement national HIV/AIDS priority activities. Strategies for accomplishing this will include re-engineering the GARFUND into a coordinated multi-donor funding arrangement, strengthening the transparent and consultative mechanism for the disbursement o f funds developed under NSF I,as well as mechanisms for monitoring disbursed funds, and improving the capacity o f staff at all levels. '*Totalcost of this component i s only $50,000, inwhich case IDA'Sportion i s miniscule. 42 This PAD follows the structure of the NSF 11. This component includes establishing common hnding arrangements for mobilizing and channelling HIV/AIDS resources to the national response. The GAC aims to mobilize additional resources for the Ghana national AIDS response, and to encourage all donors providing financial support through the GAC to pool their finds in the common arrangements accepted by the Funding Partners. However, the GAC may also mobilize support for HIV/AIDS resources related to the national response, even if they are channelled through one of the larger MDAs for mainstreaming o f HIV/AIDS activities in that sector. Activities under this component will include: (a) the establishment o f a flexible finding arrangement for mobilising and channelling HIVIAIDS resources for the national response; (b) streamlining the budgetingprocess for HIV/AIDS resources; (c) the establishment o f an effective targeting and resource allocation process; and (d) strengthening the financial management and monitoring system. 43 ANNEX5: ESTIMATEDPROJECTCOSTS GHANA: MULTI-SECTORAL HIV/AIDS PROJECT Table 1: FundingAvailablethrough M-SHAP, 2006-2010, US$ million NSFI1 80.4 96.7 114.5 131.1 153.2 575.9 M-SHAPas YOofNSFII 14.7% 5.7% 6.1% 5.3% 2.6% 6.1% 44 Table2: Cost by ProjectComponentand % ofBankFinancing IndicativeFiguresOnly 1No. I Component IN S F I II % I Pooled 1Earmarked I Total I % 1 I cost NSF M-SHAP M-SHAP M-SHAP M-SHAP WB (US$M) (US$M) (US$M) (US$M) (US$M) Policy, Advocacy and 1 Enabling Environment 17 2.96% 5.9 0.0 5.9 20.0% 4.0 Coordination and Management o f 2 Decentralized Response 23 4.00% 10.1 0.0 10.1 34.0% 6.8 Mitigating the Social, Cultural, Legal, and 3 Economic Impacts 121 21.04% 3.9 0.0 3.9 13.O% 2.6 Prevention and Behavior Change 4 Communication 259 45.04% 4.8 3.8 8.6 16.0% 3.2 Treatment, Care, and 5 support 109 18.96% 3.3 1.5 4.8 11.O% 2.2 Research, Surveillance, 6 M&E 46 8.00% 1.8 0.3 2.1 6.0% 1.2 Resource Mobilization andFunding 7 Arrangements 0 0.00% 0.0 0.0 0.0 0.0% 0.0 TOTAL 575 100.00% 29.7 5.6 35.3 100.0% 20.0 45 ANNEX6: IMPLEMENTATION ARRANGEMENTS GHANA: MULTI-SECTORALHIV/AIDS PROJECT 1. Implementation M-SHAP implementation will be guided by the time frame o f the 2006-2010 National Strategic Framework. M-SHAP implementation i s expected to begin on January 2, 2006 and continue through December 31,2010. The M-SHAP will be implemented by public, private, and civil society organizations, coordinated by the Ghana Aids Commission (GAC) based on national procedures and guidelines. Itwill support institutions at national and at decentralized levels. Implementing Partners. These will include: 1) Ministries, Departments and Agencies (MDAs) and Regional Coordinating Councils (RCCs); 2) District Assemblies, Municipal and Metropolitan Assemblies (MMAs); 3) NGO's, CBO's, umbrella organizations and FBO's; 4) Private sector; 5) International NGO's, Research and Academic Institutions. Program Oversight and Policy Guidance. The Ghana AIDS Commission (GAC) i s a supra- ministerial and multi-sectoral advisory board attached to the Office o f the President and formed by Act 613, 2002 o f the Ghanaian Parliament. The members of the GAC include: key line Ministries, representatives from labor and PLWHA organizations, NGOs, FBO's, and civil society. The GAC i s the highest policy making body on HIV/AIDS and provides effective and efficient leadership in the coordination of the National Response to HIV/ADS. The GAC Secretariat has been established to provide technical and administrative support to the Commission. The GAC Secretariat will hereafter be called the GAC, as this i s how it i s referred to in Ghana. It i s the responsible body for the management o f the coordination o f National Response. One o f the technical committees established under the GAC i s the Steering Committee which approves and guides the work o f GAC. GAC Organizational Structure. Inaddition to the coordination o f the National Response, GAC will be responsible for overseeing the implementation o f the national response and other programs where donors will have earmarked funds for GAC to oversee the implementation o f specific projects (e.g. teacher training on HIV/AIDS awareness). GAC's organizational structure i s being re-visited to ensure that it will be able to carry out concurrently these two highly visible and important functions. 5 year Program of Work (POW). A 5 year POW and budget has been derived from the 2006- 2010 NSF. This 5-year POW i s the "operational" aspect o f the 2006-2010 NSF and will translate intervention areas into proposed programs, activities, targets and corresponding budgets. 46 Annual Program of Work (POW). The annual POW will be the key operational document guidingthe implementationo fthe 2006-2010 NSF. GAC will be responsible for the preparation o f the Annual POW which will include key intervention areas, indicators, partnership arrangements, financing provisions for key stakeholder programs supporting the national response. This would enable GAC as the coordinating entity for the National Response to have an overview o f upcoming key interventions and would provide some insight as to areas and activities which are either over funded, under funded. This would also be the basis for GAC to go back to the stakeholders and recommend certain modifications to their programs to ensure optimum use o f resources in support o fthe 2006-2010 NSF. Partnership Forum. The Partnership Forum will be responsible for the exchange o f information and promote a strong policy dialogue between GAC, MOH, development partners and other stakeholders on matters related to the implementation o f the 2006-2010 NSF. This Partnership Forum would also review and endorse the Annual POW and budget and provide an opportunity for partners and stakeholders to further buy-into the sector wide approach. Business Meetings. The Business Meetings will be held quarterly and include the development partners supporting the 2006-2010 National Response, either financially or through technical assistance, as well as the MOH. At these meetings, issues related to the progress o f the implementation o f the Annual POW, orientations o f interventions for upcoming POWs based on newly available data and epidemiological trends will be discussed and development partners will confirm their financial contributions to the Annual POW. Operational Manual. The GAC has revised its Operational Manual to take into account the sector wide approach concept which M-SHAP will support, particularly for pooled and earmarked funding arrangements. The Manual details the key steps, with an emphasis on the consultative process which GAC will need to follow to come up with an Annual POW encompassing partner and stakeholder activities. This Manual also describes the types o f activities and organizations which can be funded through pooled or earmarked funds in support o f the annual POW and other projects which GAC will be administering. Allocation o f funds i s made annually for each o f the seven components o f the NSF 11, depending upon priorities. Once activities have been agreed upon, a "window" for funding i s selected for most activities. The four windows change slightly depending upon who i s the implementing agency. In addition, funding may be earmarked to specific activities as agreed in the Annual Program o f Work. The windows are defined as follows: Window A will fund proposals from Ministries, Departments and Agencies (MDAs) and Regional Coordinating Councils (RCCs), and will finance activities for their staff and clients. Window B will fund proposals o f Metropolitan, Municipal and District Assemblies (MMDAs) to finance activities for their staff and clients as well as proposals o fNGOs, FBOs CBOs, and associations o f PLWHAs or groups of these 47 entities (including affiliation networks) within the district for activities as described inthe approved District HIV/AIDS Strategic Plan. Window C will fund proposals from the private sector, including trade and professional associations. Window D will cater for funding o f proposals such as national programs that can only be directed and controlled at the national level (e.g. national condom distribution, curriculum development and network programs) as well as innovative projects to address the changing and evolving trends o f the epidemic. Other sub-projects under Window D would include those to be undertaken by national umbrella organizations and international NGOs with the capacity and track record to carry out specific programs and activities identified by GAC. They would also include specific projects and activities to be funded by a Funding Partner through earmarked finds and outside the pooled funding mechanism. Sub-projects to be financedunder this Window may extendbeyond one (1) year. MSHAP will also find consultancies, workshops, conferences, advocacy materials, etc in accordance with the Procurement Plan and Procurement Manual. The implementation o f the M-SHAP will be carried out through decentralized structures down to the district level that will support the GAC in management o f finds and the monitoring o f activities. FundingPartners. All changes will bereflected inthe Operational Manual. MSHAP will make funding allocation by the various windows in line with the priorities o f the National Strategic Framework, 20006-2010, and as approved in the Annual Program o f Work. GAC will also identify specific activities for entities in line with the Annual Program o f Work for them to submit proposals for funding. MSHAP will give priority to proposals that: Focus on vulnerable groups like youth in and out o f school, commercial sex workers, women, long distance drivers, orphans, street children, mobile and migrant populations and the physically challenged and impaired. Focus on high incidence and highrisk areas like miningtowns, border towns, entertainment centers and market centers. Focus on voluntary counseling and testing Focus on PLWHAs Focus on provision o f nutritional supplements to PLWHAs. Focus on giving assistance to institutions to assist in testing herbal preparations that can be used by PLWHAs, e.g. Centre for Medicinal Research, Mampong, Noguchi MemorialInstitute for MedicalResearch. Promote BCC 48 The priority areas shall be reviewed annually by the Partnership Forum. Project Review and Approval Committee (PRAC): A PRAC will be established to review and evaluate the proposals for funding under windows A, B, D and E. The PRAC will consist o f experts within different fields. The PRAC will work and report directly to the Director-General to whom they will refer their final decision for confirmation. Its scope o f work will be to assess the technical and operational feasibility o f the proposals submitted and review financing requirements. Regional AIDS Committee (RAC): The (RAC) is a multisectoral group constituted o f 10-20 members comprising the heads o f key decentralized MDAs, representatives o f religious and traditional leaders, NGOs and CBOs including the regional monitoring and evaluation focal person. Its main role i s to coordinate HIV/AIDS interventions at the regions local levels, aggregate M&E data and prepare semi-annual reports to the GAC, and facilitate capacity buildinginitiatives within the region. District AIDS Committee (DAC): The D A C is a crucial link in the implementation o f all decentralized programs described in the 2006-2010 NSF. The D A C i s a multi-sectoral group constituted o f 8 - 12 members comprising the heads o f key decentralized MDAs in the district, district assembly staff including the district M&E focal person, private sector and civil society representatives and representatives o f PLWHAs groups working in the district. Its main responsibility i s to formulate and operationalize the district strategic HIV/AIDS plans in a participatory manner, approve the recommendations on proposals for fimding o f NGOs, FBOs and CBOs made by the DRMT (see below), and be responsible to the GAC for the management of funds and reporting. District Response Management Team (DRMT). The D R M T which i s part o f the D A C i s an important link for the successful implementation o f local level interventions to HIV/AIDS. It includes five (5) members namely district M&E focal person, District Directors o f Education, Health, Social Welfare and one other, district assembly staff. DRMTs will be responsible for providing technical assistance to the D A C in the development o f district HIV/AIDS plans and district program implementation, evaluation and selection o f projects submitted by NGOs, FBOs andCBOs andmake recommendations for fundingto the DAC. Regional and District M&E Focal Persons: A Regional M&EFocal Person as well as a District M&E Focal Person report to their superior: the Regional Minister and the District Chief Executive respectively on the progress o f implementation o f HIV/AIDS interventions in their areas. They will support the RAC, the DRMT and the D A C as membedsecretary. They are also responsible for visiting the NGOs, FBOs and CBOs working intheir district to monitor progress o f implementation, gather M&E data. The Regional M&E focal person will aggregate the M&E data at the regional level and transmit it to GAC. Grants Facility. The GAC will have the overall management responsibility for the grants facility, which will make grants to the above implementing partners. Calls for proposals will 49 take place twice a year. Additional technical support i s expected to be provided to implementing partners who need help in preparing project proposals. The Operational Manual provides standard formats for sub-grant agreements which specify the eligible activities and expenditures, outputs, and implementation andreporting arrangements. The PRAC will review the proposals submitted under window A, By and C and make recommendations for funding to be approved by the Director-General o f the GAC, while the DRMT will review the proposals submitted under window C and make recommendations for approval by the District Chief Executive. The GAC will fund the implementing agencies directly under the windows mentioned. Transfers of Funds. The GAC will inform the D A C o f their level o f fbnding before the submission date o f proposals. When the D A C has decided on the proposals to finance, the GAC will transfer the funds to the DAC bank account. The DAC will then release the h d s to the NGOs, FBOs and CBOs and be responsible for reporting on the progress and the monitoring o f the financial management to the GAC. MSHAP Quarterly Monitoring. GAC will be responsible for preparing quarterly M-SHAP Monitoring Reports (financial, technical, M&E and procurement) will be prepared according to the format described in the Operational Manual, based on the World Bank Financial Monitoring Report format. The M-SHAP Monitoring Reports will be used as a basis for quarterly disbursements by Funding Partners. Annual M-SHAP Implementation reports will be prepared on the implementation o fthe M-SHAPduringthe previous year. 2. CommunityMobilization The capacity o f PLWHA groups, NGOs, CBOs and community treatment supporters to promote treatment adherence, support food and nutrition education, and provide home-based care will be strengthened to support the scaling up o fHIV/AIDS services at the regional and district level. Starting in2006, trained PLWHA will expand their public advocacy efforts, support for ARV treatment education, and community information efforts. The training will focus on key components o f the ARV treatment program, such as treatment adherence, HIV/TBpatient management, counseling and HIV testing. Special emphasis will be placed on referral andpatient monitoring to district HAART services by home-based care givers. Throughout the training the linkage with district and community groups will be emphasized to support the highperformance of healthworkers inhealth facilities. Specific initiatives will address stigma and gender imbalance indemand for services. 50 3. Monitoringand Evaluationof Outcomes/Results 3.1 NationalM&E system In line with the "three ones" principles, Ghana has developed a national M&E system. The systemis described inthe National M&EPlan'g, which was developed underNSFI. Institutional arrangements for M&E are in place at the regional and district levels. At the regional level, the Regional AIDS Committees (RACs) exist in each o f the 10 regions under the auspices o f the Regional Coordinating Councils (RCCs). The committees are charged with monitoring community HIV/AIDS activities within their region, lobbying for resources and funding, advocating for HIV/AIDS policies that address local challenges, establishing communication and knowledge transfer amongst districts and between national, regional, district and local level, and facilitating the development o f district level capacity. The RACs include M&E officers who collate regional data for activities implemented. District AIDS Committees (DAC) are established in all 138 districts. MDAs, NGOs, FBOs, traditional leaders, youth and women associations, PLWHA, and other relevant community groups are represented on the DACs. At the district level the focus i s on three functions: (i) formulation and operationalization o f district strategic HIV/AIDS plans, (ii)monitoring o f HIV/AIDSprograms focusing on program inputs, outputs and tracking activities implementation as per the plan, and (iii) provision o f data relevant for district-level monitoring and evaluation, e.g. monitoring the trends in behavior change and use o f services, such as VCT, PMTCT, and STI services, allowing for fine-tuning o f interventions. There is a trained M&E focal point in all 138 districts. This person i s responsible for visiting all funded programs in their districts and reporting back to the regional and central levels on achievements, beneficiary concerns, pace and efficiency of implementation, number of beneficiaries reached, value added o f the activities, etc. This process will be continued with greater emphasis on the quality and effectiveness o f activities implemented and steps will be taken to aggregate this information in a timely fashion to inform stakeholders on the quality and effectiveness o fprograms. At the community level, the beneficiaries o f this program are the sexually active population in the target districts, family care-givers and volunteers, health workers, community-based groups and voluntary/private agencies that will be supported to undertake specific care and support activities, and PLWHA and HIVITB clients in the project area. These stakeholders will be involved and participate in M&E activities through the community networks and operational research. By agreeing to access and use care and support services provided through this program, the target population and PLWHA and HIV/TB clients will actively contribute to the M&E process by reporting on the quality o f services, including reported instances o f stigma in the community. A feedback mechanism will be established linking all partners to share experiences through community network groups and a website to be created by MOH. Ghana AIDS Commission. The National Monitoring and Evaluation Plan for HIV/AIDSin Ghana, 2001-2005 (2002) 51 Program Monitoring. Over the past four years, systems have beeninplace to track key outputs such as the number o f projects underway and completed (by district), the NGOs which are involved, the types o f interventions funded, the approximate number o f beneficiaries reached, and the cost o f each activity. This process has proven useful as it enables comparisons o f unit costs o f specific programs. For example, OVC programs have been compared inorder to obtain information on the yearly cost o f funding an orphan. The data collection system i s well developed. However, not all partners at national or sub-national levels routinely and systematically share the data they collect. It has beennoted that guidelines for reporting to GAC, with timefiames, should be established and commitment to adhere to them should be received from all key data sources. 3.2 Assessment of nationalM&E system Ghana has achieved considerable success with monitoring and evaluationbeing rated as highly satisfactory within the last two years. The progress report o f the national M&E Plan in2004 recognizedthe considerable advances inthe M&E system. Recognizingthe successes already achieved, there are several challenges which need to be addressed and opportunities that could be utilized to further harmonize and strengthenthe national M&E system.National and sub-national systems M&E for GAC implemented activities needto be strengthened without underminingthe monitoring and evaluation o f the national response. NSF I1provides an opportunity to further harmonize M&E systems between the GAC and other sectors, especially the Ministry o f Health. GAC is revising and updating the national H N / A I D S M&E plan and this is expected to be ready by end December 2005. The plan will clearly articulate the M&E strategy for the national response in Ghana; describing (i) partner, sector, national and sub-national roles and responsibilities; (ii) agreed indicators and guidelines for reporting to GAC; (iii)utilization o f existing capacity developed during NSF I;and (iv) harmonization o f M&E capacity building including standardization o f training manuals, alignment with M&E systems o f other national development strategies, reporting requirementso f all partners, funding sources and timelines. Regional and district level guidelines for M&E would derive from the national M&Emanual. As the national response evolves and new interventions are introduced, the indicators in the national M&E plan will be reviewed. Annual review o f indicators will take place concurrently during the preparation o f yearly POW, however, ensuring consistency and continuum in indicator selection over the period o f implementation o f the NSF 11. Quality assurance and service utilization for care and treatment remains a critical issue, In addition to relying on the M O H for epidemiologic and behavioral data, the GAC will continue joint planning for ongoing collection o f additional data on service quality and utilization for example Service Provision Assessment (SPA). The GAC will explore linkages and opportunities 52 created through other health information strengthening initiatives such as usingplanned activities o f the HealthMetric Network. NSF I1 presents an opportunity for the GAC to strengthen sector-wide M&E by ensuring technical assistance for capacity development o f sectors specifically in developing M&E plans, guidelines and tools; and collection, aggregation and use o f M&E data for program refinement. The GAC will institutionalize periodic meetings with all data providers to keep track o f implementation and to provide backstopping services where required. This may require capacity buildingon data use and institutions may needto modify their data collection forms or reporting forms so that the data are available ina format that i s more user-friendly. A central repository for M&E data will be established at GAC. Country Response Information System (CRIS) may serve as a tool. The piloted system will be expanded, and modified where necessary, to suit the country needs. CRIS will also serve as a tool for effective information sharing between the different levels, and by makinginformation available to all stakeholders and the public. Baseline data are available for monitoringNSF 11. The MTR o f M-SHAP will take an in-depth look at a large number o f completed projects to obtain some preliminary information on the impact o f various programs vis a vis the National Response. At the national level, the Monitoring and Evaluation unitis headedbythe Director o fPolicy Planning, Research, Monitoring and Evaluation. She has over 10years experience inthis field. She was responsible for the Monitoring and Evaluation Systems o fNSF Iand o f the first Bank fundedHIV/AIDS MAPproject inGhana, the GARFUND. She is assisted by a Monitoringand Evaluation Coordinator, a qualified Information Management Systems expert. They both worked on the first MAPproject providing guidance to regional and district levels insettingup their RACs and DACs and are therefore conversant with the Bank's Monitoring and Evaluation procedures 53 ANNEX7A: FINANCIALMANAGEMENT AND DISBURSEMENT ARRANGEMENTS FinancialManagementandDisbursementArrangements 1. ExecutiveSummary The objective o f the Financial Management Assessment i s to determine whether the entity identifiedto implement the MAP-I1HIV/AIDS project, the Ghana AIDs Commission (GAC) has acceptable financial management systems inplace that can be usedfor the financial management o f the project. These include the entity's system o f accounting, reporting, intemal controls and auditing. The entities' arrangement are acceptable ifthey are considered capable o frecording correctly all transactions andbalances, supporting the preparationo fregular andreliable financial statements, safeguarding the entities' assets, and are subject to auditing arrangements acceptable to the Bank. Financial management assessment o fthe FinanceDirectorate o f Ghana AIDs Commission was carried out in2005. The assessment was undertakenjointly by a World Bank Financial Management team and the GAC's finance team. FMAssessment Intemal Control Questionnaires were not used. The Finance Directorate is currently responsible for the on going World Bank fundedGARFUNDproject, the MAP-IHIV/AIDS project, and our assessment therefore involved the review o f the current systems and discussions on the improvements required. The assessment also took into account the fact that under the current project, one other partner expects to pool their financial resources with that o fthe World Bank to fund the implementation o f the project. The pooled arrangements have been detailed out ina Memorandum o f Understandingbetweenthe partnersand the GOG/GAC. The Director o fFinance is a professionally qualified accountant who was responsible for the GARFUNDproject. H e is assisted by an accounts manager and3 other accounting staff, who have all receivedtraining on World Bank financial management and disbursement procedures. GAC has revised its financial procedures manual to take account o f the use o f its system as basis for managing the pooled funds as well as other funds GAC may receive, and have put inplace mechanism for the audit o f all GAC resources including the Bank's funds. Inconclusionour assessmentshavefoundthe financial management arrangements put inplace, as documented inGAC's financial procedures manual, for the purpose o f managingthe pooled financial resources from partners, including the World Bank's funds and all resources that may bereceivedby GAC, are adequate andmeet the Bank's minimumfinancial management requirements for Bank funded projects. 54 CountryIssue The Government o f Ghana has implementedseveral reforms inresponse to the findings o fthe Country Financial Accountability Assessment (CFAA) for Ghana, carried out in2001 and updated inJune 2004. Some o fthe key actions taken include the enactment of; i) Financial Administration Act 2003, inresponse to the identifiedweakness o fthe fragmented legal structures that govemedpublic financial management; ii) the InternalAudit Agency Act 2003, inresponseto the setting up ofthe nonexistence o f modem internal audit for government departments; iii) thePublicProcurementAct,toimprovetheefficiencyofpublicprocurementsystems andpractices. The summary risk analysis i s based on the country work and knowledge o f the systems o f Ghana AIDS Commission, the institution responsible for the management o f the second phase o f the AIDS project. 2. Summary of FinancialAccountabilityRiskAnalysis Risk Risk Rating Risk Mitigation Measure InherentRisks: Country a) Non-effective S Government has introduced a new implementation o fNew comprehensive legal framework for public Financial Administration Act financial Management- the Financial Administration Act (FAA), with related regulations for implementation. There i s need for close monitoring to ensure effective implementation o f this Act. b) Non-compliance of statutory H Government needs to institutemeasures that regulations andnon- ensure the systematic review, update and enforcement o f Denalties. enforcement o fpenalties for non-compliance. c) MDA may not fully comply S Government has passed legislation, Intemal with new IntemalAudit Audit Agency Act (CIAA), for all MDAsto Agency Act, inthe establish internal audit function within their establishment o f internal audit offices. Assistance will be provided to unitswithintheir offices. strengthen the Intemal audit o f GAC to meet the Act's requirements. Overall Inherent Risk S IControl Risks 55 staffing at the GAC and lmjleienting Partners (IPS) a) Accounting staff at the M 3AC will be assistedto recruit qualified staff as GAC may leave or resign from :eplacement o f any staff who resigns or leave. emdovment. b) That IPSmaynot employ M 3AC will institutea rigorous review process to requiredcaliber o faccounting :nsure that only IPSwith adequate staff and staff, thereby affecting the systems are selected to implement quality o f financial reporting. mterventions. IPSwill also be subject o f monitoring and financial reviews to enhance werall controls to ensure the efficient use o f funds. Funds Flow a) Delays inreleasing o f funds M SAC will be assisted to effectively plan for from the GAC to the IPS. their resource needs. The partners poolingtheir funds will ensure that funds will be released on the basis o f GAC realistic cash flow projects. b) Difficulties inthe timely M Funds will only be released to IPSthat meet an submission o f accounting agreedminimumfinancial criteria, including retums from the Assemblies to the existence o f financial procedures and the center to facilitate adequate accounting staff, to enable them preparation o f withdrawal manage their project funds. This will make each applications. IPresponsible and accountable for funds received. I nternalAudit a) No professional intemal S Government i s inprocess o f setting up a audit (IA) function exists at modem IAunitwithin Government, with MinistryandAssembly levels. assistance from donors. Ministry o f Local b) Government IAis limited to Government will be assisted to strengthen its IA pre-auditing, with no added unitto perform checks andreviews as part of value. implementing arrangements. Project will also hireindependent audit or financial consultancy firms to carry out routine andperiodic financial reviews as a mechanism to strengthen financial systems within the DA. Findingso fweaknesses will provide input into the design o f further FMtraining for DA finance staff. The project will also provide assistance to the D A s inthe establishment o f their intemal audit 56 units as requiredby the new Internal Audit Act andhelp fundthe related training cost. External Audit Project audit reports likely to M GAC will institute mechanismwhere the audit be submitted late. program for the relevant year are agreed with the auditors prior to year end and monitored to ensure compliance. Auditors' contract will be limited to one year and renewal will be contingent on timely completion and submission o ftheir audited reports. Reportingand Monitoring a) Delays inthe submission o f M Since disbursement i s based on the submission agreed Financial monitoring o f FMR, there i s incentive for the preparation reports (FMRs), and other andsubmission o fthe requiredreports. There relevant reports. will be support providedbythe partners to improve overall FMo f GAC. I nformation Systems Overall ControlRisk M Ratings: H-High; S - Substantial; M-Modest; N-Negligible 3. ImplementingArrangements (The detailed implementation arrangements are described inAnnex 6). 4. AccountingSystems at GAC The mission reviewedthe present financial management system inplace at the GAC secretariat. These systems have beenadapted to cover multi-donor participation. The key financial arrangements and requirements under the SWAP are detailed inthe Memorandum o fUnderstanding (MOU) signed by the participating partners. The current financial management system of GAC has beenrevised and documented ina procedures manual, the Administrative and Accounting Manual, and will be usedfor the purpose o fmanaging the M-SHAPproject. 57 The Accounting and finance unito fGAC is headedby a Director o fFinance andAdministration. H e i s a professionally qualified accountant, with previous experience inmanaging Bank funded projects. Hewas responsible for the financial management o f the first Bank fundedHIV/AIDS MAPprojectinGhana, the GARFUND.Heis assistedbyan accounts manager also aqualified staff and2 other accounting officers. All the current accounting staff worked on the first MAP project and are therefore conversant with the Bank's financial and disbursement procedures. 5. Flow of funds Ithas been agreed that theFundingPartners will enter into a"disbursement pooling arrangement" for the purpose o f fundingthe implementation o f the project. GAC will operate a special account denominated inU S dollars, into which funds from the credit account (World Bank Funds)will bepaid. Fundsfrom the other participating partners will also be paid into this same account for the purpose o f fundingthe M-SHAP activities. On approval o f proposals from implementingpartners (IPS)for the various windows, GAC will release funds to them intranches as follows: i) approvedproposals will include the requiredbudget and the cash flow statements to indicate the timing o ftheir cash needs; ii) GAC will release the first tranche based on the cash flow requirements, but should not exceed 40% o f the required funds. This will ensure that moneys received are accounted for prior to receiving subsequent tranches; iii) IPSwillreceivetheirsubsequenttranchesonsubmissionoftheirfinancialreportsand other technical reports; iv) GAC will ensure that prior to paying the last tranche, the IP's statement o f accounts has been fully reconciled and the last payment will be the balance o f the IP's proposal. These proposals are to ensure that GAC i s able to submit the required financial monitoring reports underthe project on timely basis. Periodic requests for funds will be made by the GAC to the World Bank. The request shall be made on quarterly or six monthly or from time to time, by submitting a withdrawal application duly authorized bythe recognized signatories, The withdrawal application shall be supported by the GAC's quarterly Financial Monitoring Reports (FMRs) duly certified by the Director o f Finance and Administration. Although the funds provided by the World Bank for the M-SHAP project will not be earmarked for any specific activities, the other participating partners have indicatedthat they will earmark some o f their funds for specific activities. The overall arrangements for this type o f funding are be covered inthe MOUsigned bythe partners, the Operational Manual, andthe Administrative andAccounting Manual. Additional specific requirements will be coveredbythe particular partners. 58 6. AuditingArrangements Independent and qualified auditors acceptable to the Partners would carry out the annual financial audit o f the program. The financial auditors would be inplace by effectiveness o f the program. It i s recognized that it i s the responsibility o f the Auditor General o f Ghana to audit these government entities, as a result, the selection o fthese independent auditors will be done in collaboration with the Auditor General. The auditors' reports and opinions including the Managements letter of the annual financial audit would be fumished to the World Bank and all partners within six months o f the close o f each fiscal year. An additional mechanism for periodic financial reviews o f all participatingImplementing Partners, will be established for effective monitoring purposes. The GAC will institute a system o f financial proceduralreviews, including compliance with all agreedprocedures including sub- project eligibility criteria and efficient use o f resources. The selection of all financial consultants shall be on competitive basis inaccordance with the GOGguidelines. Inorder to reducetransaction costs, theprocurementauditwill becombinedwiththe financial management and take place at the same time. 7. ReportingandMonitoring The Bank requiresprojects to prepare quarterly financial monitoring reports (FMRs) inthe areas of finance, procurements including contract details and project progress. The quarterly FMRs include; The Quarterly Financial Reports; consisting o f Sources o f funds and their Uses, Statement o f Uses o f Fundsby Project Components and Activities, Special Account Reconciliation statement and a six months Project Cash Forecast where needbe; Quarterly Project ProgressReport; consisting o f Output MonitoringReport on contract Management and on Unit o f Output byproject activity; Quarterly ProcurementReport; consisting ofprocurement process monitoring and contract expenditure reports for goods, works and consultants' services. The report compares procurement performance against the planagreed at negotiations and appropriately updated at the end o f each quarter. The report should also provide any information on complaints by bidders, unsatisfactory performance by contractors and any contractual disputes. GAC will beresponsible for preparing and submittingthe FMRrequiredto be produced under the program. GAC will beresponsible for preparing one set o freports bothtechnical and financial and as such will coordinate, collate and consolidate these reports into a project wide 59 FMRandsubmit copies to the Bankandpartnerswithin 45 days ofthe endo feachquarter (or six months). 8. DisbursementArrangement GAC will maintain a separate control account inits books to recordthe financial resources contributedby each Partner to the Program. The financial resources allocatedto the Pooled, Special Account will be usedonly for agreed purposes under the Annual Program o f Work. The contributions o f the Partners will be drawn down into the PooledAccount inaccordance with the progress of the Program and according to the budgetary and disbursement mechanisms o f the Co-operating Partners. GAC will maintain two special deposit accounts in"commercial bank" (to be agreedwith MOFEP) for donors' contributions to and disbursement from the PooledAccount. The first special deposit account will be inU S dollars. Contributions from Partners, including IDA, to the MAP-I1 Account will be made into the U S dollar account. Draw-downs inCedis, fkom the pooled dollar account will be credited periodically to the cedi account to meet forecast expenditures as a result o f approvedproposals. IDAwould replenishthe USdollar account inaccordance withReportBaseddisbursement mechanisms, using quarterlyfinancial monitoring report preparedby the GAC. These reports would be supported by a bank reconciliation o f the PooledAccount, together with copies o f the bank statements. The content and format o f these reports would be agreed at negotiations. Use Statement o f Expenditures (SOEs) The project will not use the SOE method o f disbursement. All disbursements will be report based, andwill not be strictly quarterly but as and when the GAC request for such funds. 60 ANNEX7B: PROCUREMENTARRANGEMENTS GHANA: MULTI-SECTORAL HIV/AIDS PROJECT 1. General Procurement through International Competitive Bidding (ICB) and selection o f consultants estimated to cost more than US$ 200,000 for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement Under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" dated May 2004, and the provisions stipulated in the Development Credit Agreement. All other procurement and selection o f consultants will be carried out inaccordance with the Ghana Public Procurement Act 663 o f 2003. The various expenditure categories for items to be finance through M-SHAPare described below. For each contract to be financed by the credit, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank project team on behalf o f all Funding Partners in the Procurement Plan, The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements ininstitutional capacity. Procurement of Works: N o major works contracts are expected to be procured under this project. Minor works include: rehabilitation o f offices o f the Ghana Aids Commission. The procurement will be done usingthe Bank's Standard BiddingDocuments (SBD) for any ICB and National Standard Tender Documents as stipulatedinSchedule 3 o fthe Public Procurement Act. Procurement of Goods: Goods procured under this project would include: computers, a few vehicles, office equipment, stationery, IEC materials, software, spare parts and accessories using Bank's SBD for all ICB and National Standard Tender Documents. Procurement of non-consulting services: N o n -consulting services procured under this project include surveys, workshop facilitation services and IEC services. These contracts are expected to cost less than US$ 100,000 and National Standard Tender Documents satisfactory to IDA will be used for non-consulting services Selection of Consultants: Consulting services to be procured under the project will include various studies for prevention, treatment, care and support, research, monitoring and evaluation, o f H N / A I D S related activities. Short lists o f consultants for services estimated to cost less than US$ 200,000 equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines. operational Costs: which would be financed by the project would be procured using the procedures in the Public procurement Act 663 and the G A C Operational Manual which were reviewed and found acceptable to IDA 61 Subprojects:The detailed procurement procedures to be followed under the Grants are described inthe GAC OperationsManual. Public entities which obtain grants will berequiredto follow the provisions o f the Public Procurement Act intheir procurement. 2. Assessment of the agency's capacityto implementprocurement Procurement activities will be carried out by the GAC, MDAs and MMDAs. The GAC Procurement unit i s staffed by a procurement specialist who reports to the Director o f Finance. An assessment o f the capacity o f the Implementing Agency to implement procurement actions for the project was carried out by Kofi Awanyo in February 2005 and also by independent procurement auditors. The assessment reviewed the organizational structure for implementing the project and the interaction between the Procurement Specialist and the GAC's unit for administration and finance. Most o f the issuedrisks concerning the procurement component for implementation o f the project have been identified and include poor consultant selection practices as a result o f not fully utilizingthe skills ofthe GAC Procurement specialist. The corrective measures which have been agreed are formation o f the GAC tender committee and continuous procurement training for key staff o fthe GAC. The overall project risk for procurement is average. 3. ProcurementPlan The procurement plan for the first 18 months o f the project has been prepared by the Borrower, reviewed during appraisal, and signed by the Borrower during negotiations. The procurement plan will be available in the World Bank Ghana Country Office. It will also be available in the Project's database and in the Bank's external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements ininstitutional capacity. 4. Frequencyof ProcurementSupervision In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment o f the ImplementingAgency has recommended one supervision mission every year to visit the field to carry out post review o f procurement actions. The procurement post review will supplement the annual independent procurement audit to be carried out by procurement auditors hired directly by GAC in consultation with the Public Procurement Board and the Auditor General. The intent i s to conduct the procurement and financial audit concurrently, thereby reducing the transaction costs for the GAC. 62 Table 1:Thresholdsfor ProcurementMethodsandPriorReview Expenditure ContractValue Procurement Contracts Subject Category (Threshold) Method to US% 'rior Review Works >=2,000,000 ICB All Contracts >=50,000 - < 2,000,000 NCB Contracts>=US$ 500,000 <50,000 Shopping None All values Directcontracting illcontracts Goods and non- >=250,000 ICB/LIB All contracts Consulting Services >=30,000 - <250,000 NCB/LIB/UN None <30,000 Shopping/UN None All values DirectContractine 411contracts Consulting Services >= 100,000 firms QCBS All contracts Below 100,000 firms QCBS/LCS/FBS/CQS None >= 50,000 individuals Individual All contracts < 50,000 individuals Individual None All values Single Source Selection All contracts 63 . 0 ? 2 2 0 2 5 2 . 0 ? s 3 3 Y '- m >Q 2 2 7- Z0 I I I I e e e e e e W W b W W b m w m m w m 0 0 0 0 0 0 & & & a & & m m m m m m .3 2% .3 8 2% Y Y a fi 8 0 0 2 9 8 3 3 2 N 0- W m N u 0 E 8 2r EM I I 3 N m 9 9 - 1; 9 m % 9 CA VI a CA VI iY a . 2 >525 eW iD 0 U 0 hl Y d 3 & M 3 :g m ? 1 2 f e W B hl 4 ? e m I 0 -4 hl 3 3 .8 3 3 2+ 28 !28 1.52 Yv) Y a0 P. B 1 2 v1 0 80 3, t o\ W hl d d I N m d E P. (t 4 3 [c T 5I; . . d a c t.9: 0 0 0 0 0 0 0101 -t-t L > i c F i > j , t2 ANNEX8: SAFEGUARD POLICYISSUES GHANA:MULTI-SECTORAL HIV/AIDSPROGRAM 1. Background Like other Bank-financed projects, health projects must comply with the 10 Safeguard Polices and the policy on Disclosure o f Operational Information because implementation o f project activities could cause adverse environmental, health, and social impacts. 2. Findings A preliminary screening o f the project's potential environmental and social impacts was carried out at the early stage o f project identification and revealed that OP 4.01 (Environmental Assessment) may be triggered. This was based on the premise that project would provide comprehensive treatment, care and support through the expansion o f ARV therapy, VCT, 01and STI . This initial screening failed to show the likelihood that other Safeguard Policies could be triggered. Based on these outcomes, the preliminary screening report recommended that a study be undertaken to assess the nature, extent and severity o f any perceived potential environmental and social impacts and to illustrate time-bound and costed preventive and mitigative measures for addressing these effects if they do occur. A crucial element o f any such a management plan would include an elaborate institutional arrangement for effective implementation and a set o f indicators for measuringprogress inremediation. 3. PublicDisclosureand StakeholderConsultations Earlier during the preparation o f the closed Ghana Health Sector Project (a sector-wide approach) an environmental assessment was carried out that recommended the development of a National Health Care Waste Management Policy and Action Plan (NHCWMP). This was done and implementation o f action plans derived from the policy framework was adopted by Government o f Ghana for implementation throughout the country's health facilities, both public and private. Led by the Occupational Health and Environmental Unit o f the Ministry o f Health implementation of the health care waste management plans has been ongoing, resulting in full buy-inat all levels. The NHCWMP is a comprehensive policy document, covering indeed the management o f all nature o f health care and treatment waste generated including those associated with the treatment o f HN/AIDS, care o f and support to people living with the disease. Its comprehensiveness and successful implementation during the lifetime o f the Health Sector Project convinced the Bank to accept it as a practical response to the screening exercise carried out during M-SHARP preparation. Based on lessons learnt during previous implementation o f the NHCWMP, the policy has been further refined and re-disclosed in-country and re-submitted to the Bank's Infoshop. In collaboration with key stakeholders inhealth care delivery including the Ghana Aids Commission (GAC), the Ministry o f Health has conducted extensive countrywide stakeholder consultations and sensitization on the NHCWMP since its adoption. In 68 addition, personnel from few public health care facilities have beentrained in health care waste management. The Borrower's implementingagencies, particularly the Occupational Health and Environmental Unit o f the Ghana Health Service, Inspectorate Division o f the Ministry o f Employment and Manpower Development, Ministry o f Local Government and Rural Development and Environmental Protection Agency and the Health and Sanitation Sub- committees o f the various District Assemblies will continue the consultation and sensitization process with all groups throughout the country. 4. Institutionalarrangementfor safeguarddue diligence The Ministryo f Health i s currently mobilizing support to formulate legislation to strengthenthe implementation and monitoring o f the NHCWMP and has set a target date o f 2006 for commencement o f the exercise. It i s expected that a lot o f consultation and sensitization about the subject matter will be carried out even during the formulation stage. This indeed will strengthen the hands o f the supervising Ministryto enforce compliance with the management o f health care waste. It i s also expected that the re-introduction of environmental and sanitation monitors into community set-ups will raise consciousness among communities andhealth facility personnel about the proper disposal o f waste. Capacity development has been identified as a key factor in the improvement in health care delivery system within the country and deliberate efforts have been made inthe past to lift this up. Formal and informal training will be supported under the M-SHARPand it has been agreed that hnds will be made available to assess gaps and train health personnel and staff o f other relevant agencies (e.g., municipal and district assemblies) at the national, regional, district and community level (and within both public and private facilities) inhealth care waste management. The Occupational Health and Environmental Unit o f the Ghana Health Service is advocating strongly for mainstreaming health care waste management into in-service curricula for health personnel. Although the project i s a direct response to the National HIV/AIDSagenda, it has also been agreed that training and public education will not be limited to only how to manage HIV/AIDS-related generated waste but a comprehensive program will be drawn to cover the training and education in the management o f all waste types generated across the country's health care facilities. Under the leadership o f the Occupational Health and Environmental Unit o f the Ghana Health Service and expert advice o f the Environmental Protection Agency (EPA), the NHCWMP will be implemented in a collaborative and consultative manner. It i s also planned that knowledge in screening, assessment, auditing and monitoring o f environmental and social impacts, management and mitigation plans will be transferred to key actors through targeted training and experience gathering. The project will be implementedwithin the context o f existing prescribed national waste management and sanitation policy alongside the Bank's Safeguard Policies and WHO guidelines. GAC, inconsultation with the Occupational Health and Environmental Unit of the Ghana Health Service, the EPA, the Environmental and Sanitation Sub-committees at the district assembly level and other relevant organizations will monitor and report, within the broad fi-amework o f project M&E on (i) ensuringdue diligence with regardto the remediation measures on the basis 69 o f findings and results from assessments done on specific project interventions, (ii) o fstatus implementation of remediation measures, and (iii) attainment o f remediation indicators as check on achievement of mitigation objectives. The M&E system for tracking progress in implementing the health care waste management plan and assessing impacts on the project and beneficiaries will form an integral part o f the project's overall design, budget, implementation, monitoring and evaluation system. 5. Installationof basic equipment The project can help minimize the danger o f poor disposal o f health care waste by providing funds to finance the procurement and installation of simple but efficient disposal and packaging infrastructure as well as storage equipment at the sites of waste generation. In addition, project funds should be usedto provide neededcapacities to manage the packaging, storage and disposal facilities and ensure efficient monitoring o f the performance o f these systems. Heads o f health care institutions in both public and private health set-ups will be held responsible for the environmentally-sound performance o f such systems. 70 ANNEX9: ECONOMICAND FINANCIALANALYSIS GHANA: MULTI-SECTORAL HIV/AIDSPROJECT 1. EconomicAnalysis There are two studies now showing that HIV/AIDS currently has no appreciable impact on the macro-economy inGhana: a 2004 study on Economics and AIDS in Ghana by DFID and a 2005 study on health andthe cocoa industry study. The main economic impact o f HIV/AIDS in Ghana i s reflected at household level. Studies have been carried on HIV prevalence by wealth quintile (quintile 1denotes the poorest quintile, while quintile 5 is the richest). Figure1:HIV/AIDS prevalenceby wealth quintile i HIVprevalence 3.5% 3.0% female 2.5% 2.0% male 1.5% 0total 1.0% 0.5% 0.0% q l 92 q3 94 q5 Source: Study o f the Social and Economic Impacts of HIV/AIDS inGhana: Facilitative Studies. 2004 Figure 1 shows that quintile 2 and 3 have the highest prevalence rates, although HIV/AIDS prevalence i s registered in all quintiles. The figures also confirm the evidence that women have a much higher prevalence thanmen, except inthe poorest quintile. The same study has shown that when the impact o f HIV/AIDS is considered, households with a PLWHA in the poorest three quintiles will fall below the poverty line. HIV/AIDS in Ghana, as in most other developing countries, is closely linked to poverty, with poverty increasing the vulnerability to infection and 71 HIV infection increasing the level of poverty and vulnerability of households to fall below the poverty line. The economics of interventions are determinedby the dynamics o f the epidemic. Ghana has a somewhat stable epidemic over the past ten year, leveling o f f around the 3% infection rate. Neighboring countries show a similar pattern o f leveling off, be it at higher prevalence levels. Most importantly for prevention efforts, specific geographical areas and specific societal groups are far more affected than others. Therefore, and also because impact per sector cannot be shown, it i s inefficient to develop sector-wide interventions, e.g. the entire private sector or the entire cocoa or agricultural sector. Since youth less than 24 years old are hardly infected, even education-based interventions should be undertaken with some caution, as the link prevention o f new infections is unclear. Infections in Ghana occur at a much later age and it is unclear if prevention interventions at school age are cost-effective. There are no data available for Ghana on the costs o f averting a new infection per specific target group. However, there is clear evidence in Ghana that the far majority o f male infections are related to sex work. From a cost-effectiveness point o f view, targeting sex workers and their clients on a national scale and with sufficient intensity to achieve relatively quick results is the highest priority. Experience from Senegal and Southern Cote d'Ivoire has shown that these interventions can be effective at a cost o f perhaps $20-$30 per sex worker. Given that sex workers are a relatively small part of the population (estimates range from 30,000 to 100,000), these interventions have the highest efficiency inaverting new HIV cases, e.g. when compared to youth or formal sector workers, numberingseveral million andrequiring $5 - $ 10 per person for prevention interventions. Two other groups in Ghana might have high priority inmitigating new infections: prisoners, as initial studies have shown infection levels o f over 50% within some prison populations; and MSM,some ofwhom show extremelyhighriskbehaviors as have show to spreadHIVrapidly in Europe and the US. Efficiency o f preventive interventions among those groups might be high in Ghana. A new preventive interventionthat mighthave a highefficiency o f averting new infections is by not concentrating on specific groups but on specific places, where individual go to meet partners, do drugs, etc. The method i s promising as it can reach people who do not belong to a specific subgroup (MSM, CSW) but who do exhibit high-risk behaviors. This method (called PLACE) i s inanexperimental stage inGhana. The efficiency o f treatment activities for preventing new infections is extremely low and possibly non-existent, especially because ARVs are provided in the later stages o f the disease, when sexual activity would have been low. There is therefore little doubt that prevention activities should be the bulk on the response within the specific dynamic o f the epidemic in Ghana. 72 2. FinancialAnalysis The total gap in resources for HIV/AIDS between estimated costs and current and planned contributions from all sources i s expected to rise from $37 million in 2005 to $58 million in 2010. An analysis o f the gaps in the financing and programmatic coverage o f existing and planned programs shows that lack o f finds for the purchase o f antiretroviral drugs (ARVs), exacerbated by procurement and disbursement delays, remains the single most important rate- limiting factor affecting the speed o f scaling up HIV/AJDS services in Ghana, especially antiretroviral treatment (HAART). This finding gap stems from the high cost o f ARVs relative to other medicines, and the unwillingnesso f donors, other than the Global Fund, to finance the purchase o f ARVs. Ghana's National Health Insurance Scheme (NHIS) launched in 2004 will cover the cost o f some HIV/AIDS drugs to treat 01s but will not be able to cover the cost o f ARVs due to their high cost. This finding gap, not expected to change any time soon, directly affects the number o f people livingwith HIV/AIDSwho can be treated and the rate at which new HAART sites canbe opened. In5 years time, with continued economic growth, currently averaging 5% inthe past 10 years, and if the rate o f HIV prevalence can be maintained below 4%, the government believes that it can sustain the program after the initial investment has been made. One percent (1%) o f the government health budget ($5.6 million) currently goes to districts for services. The National Health Insurance Scheme (NHIS) launched in2004, which will cover the cost o f many 01drugs, i s expected to grow and may be able to offer partial coverage for ARVs after a 5-year period. Cost recovery programs already in place, including patient co-payments for ARVs and monitoring, backed by other internally generated funds (IGF) will also contribute towards the costs o f sustaining services. The National Health Insurance Levy is projected to provide $147.2 million (26%) o f the national health budget in 20Oj2O. Intemally Generated Funds (IGF) are projected to contribute $46 million (8%), and expected HIPC inflows another $23 million (4%). The Health Fund stands at $66.7 million in 2005, evidence o f the government's good relations with development partners. In addition, the cost o f ARVs, other HIV/AIDS drugs and commodities i s expected to decline in the next 5 years as buyers groups are formed and economies o f scale are realized. 2o Ministry of Health. The Ghana Health Sector 2005 Program o f Work January 2005 (in press). 73 ANNEX10: PROJECTPROCESSINGSCHEDULEAND SUPERVISIONSTRATEGY GHANA:MULTI-SECTORAL HIV/AIDSPROJECT ProjectSchedule Planned Actual Time taken to prepare the project (months) 7 First Bank mission (pre-appraisal o frepeater) 02/21/2005 Amraisal mission det>arture 05/08/05 09/26/2005 Negotiations 10/03/05 10/10/2005 PlannedDate o f Effectiveness December 31, 2005 Preparedby: Government of Ghana: Ghana AIDS Commission, Development Partners PreparationAssistance: BBFunds; Simplification Funds Bankstaffwho workedon the projectincluded: Name Speciality Eileen Murray Task Team Leader, AFTH2 (untilappraisal) Laura Rose Task Team Leader, AFTH2 (startingat appraisal) Senior Health Economist, AFTH2 EvelvnAwittor Health SDecialist. AFTH2 Albertus Voetberg Lead Health Specialist, AFTHV Michael Diliberti Sr. Country Officer, AFClO Beatrix Allah-Mensah Social Development Specialist, AFTS4 Frederick Yankey Sr. Financial Management Specialist, AFTFM EdwardDwumfour Sr. Environment hecialist. AFTS4 Tsri Apronti Procurement Specialist, AFTPC Nadeem Mohammad Sr. Operations Officer, AFTHV David Wilson Sr. M&E Specialist, GHAP Wolfgang Chadab DisbursementOfficer Christina Kimes Sr Operations Officer, AFTOS Kofi Tsikata Communications Officer, EXTPX Manush A. Hristov Counsel Marie-Christine Balaguer Paralegal Gregoria Dawson-Amoah ProgramAssistant, AFC10 Paul Geli Consultant 74 QualityAssurance team: Jonathan C. Brown (GHAP); Kristan Schultz (UNAIDS Kenya); Institution Staff Speciality DfID Emma Sticer. TTL Matilda Owusu-Amah HIV/AIDS Advisor William Guest DeputyProgramManager RubyBentsi Economic Advisor DANIDA Jakob Jakobson TTL Sanne Wennes Consultant GTZ Holger Till Medical Officer UNAIDS Warren Naamara TTL, Technical Co-Lead Lord Lartey Social Mobilizing Officer 1I Taavi Erkkola M&EAdvisor UNFPA EsiAwotwe Program Officer on HIV/AIDS UNICEF 1 Andrew Osei I Nat. HIV/AIDS Officer USAID Peter Wondergem M & E Lead WHO Melville George Country Representative I NaDoleonGraham Morkor Newman National Professional Officer on HIV/AIDS I HIV/AIDS Technical Advisor Rosalina Hernandez HlVTreatment (3x5 Officer) Selasie D'Almeida HealthEconomist 75 ANNEX11: DFIDSTATEMENT DFIDHIVIAIDS Strategy andthe Ghana MultiSectoral HIV/AIDS Project (MSHAP) Introduction DFID's country policy is to support countries with a sound andnationally drivenPoverty Reduction Strategy by transferring resources directly through the Government's budget. This i s accompanied by support for capacity buildingwithin Government, civil society organizations, private sector development, and for the strengthening o f institutions inside and outside Government which promote accountability. DFID pursues this approach inclose partnership with other Development Partners with the overarchingaim o fcontributing towards the achievement o f the MDGs inGhana. Frameworkfor DFIDAssistance At the core o f DFID's support is the implementation o f the GPRS, ensuring that the GPRS is well integrated into government planning and budgeting processes (the MTEF); that there is mainstreaming o f action to address the needs o fvulnerable and excluded groups; and that there i s effective, participatory monitoring and evaluation o f the GPRS to promote the accountability o f government to its citizens. Currently DFID supports Ghana by providing budgetary support through government systems and also byworking through multi-donor mechanisms. . Areas of DFID support in Human Development . Support for health and education through existing programs focusing on reducing inequalities and improving basic education andprimary health care; Facilitating greater donor coordinationharmonization inhealth, education and HN/AIDS. .. TA support to the Ministry o fHealth and Educationon planning, budgeting, management, monitoring and evaluation; Support to the Ghana Aids Commission for the national response program to the threat o f HIV/AIDS; Advocate mainstreaming HIV/AIDS through programs; particularly with the Ministryof Health and Education. The GhanaAids PartnershipProgram(GAPP) DFID's current E20millionfive-year HIV/AIDS program - the Ghana AIDS Partnership Program (GAPP) i s due to end during2006. GAPPwas designed as an "umbrella program" to support a range o f interventions broadly aligned with Ghana's 2000-2005 National Strategic Framework for HIVIAIDS. Funds were programmedbyDFID directly as the program 76 progressed. Specifically GAPP supported the M O H to StrengthenHIV/AIDS Surveillance systems and also to scale up antiretroviral therapy inthe country. The MinistryofEducationhas been supported to provide HIV/AIDS educational materials and training to teachers inall Public and Private Basic Secondary Schools. Prevention andbehavior change activities included capacity building for vulnerable and highrisk groups as well as the social marketingo f condoms. GAPP's main achievements have been to: help GoG to build a robust national HIV/AIDS surveillance system; ensure an adequate and reliable supply o f condoms inthe public sector and through social marketing; strengthen the analytical and co-ordination capacity o f the Ghana AIDS Commission (GAC) Secretariat; support HIV/AIDS teacher training and curriculum development in all public schools; and fund the first provision o f anti-retroviral treatment in the public and mission hospitals, including making available ARVs for infants. DFIDSupportto MSHAP The Multi Sectoral approach to HIV/AIDS promotes an effective multi-sectoral response in Ghana covering prevention, care and impact mitigation. The program has been designed in collaboration with all partners and i s recognized as consistent with the priorities and needs identified in the GPRS and the National Strategic Framework 2006-2010. DFID's support is aimed at strengthening the GAC's ability to implement a multisectoral approach within the broader policy environment and enabling Government sectors like health, education and local government as well as civil society and the private sector to become more effective. DFID will support the 2006-2010 National Strategic Framework through the MSHAP funding arrangements by makingboth earmarked and pooled contributions to the program. DFID intends to support the NSF I1for through out the period but will make commitment on an annual basis based on annual priorities as identified in the POW. In 2006 DFID will transfer to GAC management o f on-going HIV/AIDS programs with the Ministry o f Health, Ministry o f Education and a number o f civil society organizations, amounting to around $6million in total. The extent o fthese activities will be reflectedinthe MSHAPbudget. These programs are part o f DFID's E20 million HIV/AIDS Partnership Program, agreed with the Government o f Ghana for 2002-2006. By transferring management o f on-going activities DFID hopes to assist GAC in strengthening its co-ordination and engagement with key partners in the national response. Subject to the successful operation o f the mechanism inits first two years, DFIDwill un-earmark its finds progressively The mainrisks facing the DFIDprogram relate to the nature o fthe epidemic, Institutional capacity and performance o f GAC and value for money from DFID funds. 77 ANNEX12: DOCUMENTSTHE PROJECTFILE IN GHANA:MULTI-SECTORALHIV/AIDS PROJECT ProjectImplementationPlan Five Year Program ofWork: 2006-2010. GAC, September, 2005. Monitoring and Evaluation (M&E) Framework 2006-2010, October, 2005, Annual Program o f Work for CY 2006 GAC Administrative andAccounting Manual GAC Procurement Manual GAC Operational Manual MedicalWaste Management Plan. MOH, May 2005 2003 Sentinel Survey for HIV/AIDS 2003 GhanaDemographic and Household Survey results Bank StaffAssessments Policydocuments andProgramdescription The Joint Review of Ghana's NationalHIV/AIDS Response. GAC, June 2004. 2006-2010 HIV/AIDSNational Strategic Framework. 2004 NationalHIV/AIDS Policy 2004 National HIV/AIDS Workplace Policy Draft Orphans and Vulnerable Children's Policy Memorandum o fUnderstanding between the funding partners 78 ANNEX13: STATEMENT OFLOANS CREDITS AND GHANA: MULTI-SECTORAL HIV/AIDS PROJECT Difference between expected and actual Onginal Amount in US$ Millions disbursements Project ID F Y Purpose IBRD IDA SF GEF Cancel. Undisb. Ong. Frm. Rev'd PO56256 2005 GH-Urban Water (FY05) 0.00 103.00 0.00 0.00 0.00 104.13 0.00 0.00 PO81482 2005 H: Community Based Rural Development 0.00 60.00 0.00 0.00 0.00 60.23 2.17 0.00 PO84015 2005 Small Towns Water Supply & Sanitation 0.00 26.00 0.00 0.00 0.00 26.23 0.00 0.00 PO82373 2004 GH-Urban Env Sanitation 2 (BD FY04) 0.00 62.00 0.00 0.00 0.00 61.26 0.33 0.00 PO71157 2004 GHLandAdministration 0.00 20.51 0.00 0.00 0.00 20.80 3.04 0.00 PO50620 2004 GH-Edu Sector SIL (FY04) 0.00 78.00 0.00 0.00 0.00 74.17 -3.12 0.00 PO71399 2003 Partnerships w/ Traditional Authorities 0.00 0.00 0.00 0.00 0.00 3.60 1.70 0.00 PO73649 2003 2nd Health Sect. Prog. Support 0.00 57.30 0.00 0.00 0.00 53.90 -8.72 0.00 PO50623 2002 GHROAD SECTOR DEVELOPMENT 0.00 220.00 0.00 0.00 0.00 178.06 55.32 0.00 PROGRAM PO67685 2002 Ghana: GEF- Northem Savanna 0.00 0.00 0.00 7.90 0.00 5.91 2.84 0.00 PO71617 2001 AIDS Response Proj. (GARFUND) 0.00 25.00 0.00 0.00 0.00 8.12 -19.78 0.00 PO00968 2001 GH-Agricultural Services APL (FYOI) 0.00 67.00 0.00 0.00 0.00 46.46 60.16 0.00 PO50616 2000 COMMUNITY WATER I1 0.00 25.00 0.00 0.00 0.00 4.90 6.41 1.34 PO69465 2000 Ghana: RURALFINANCIAL SERVICES 0.00 5.13 0.00 0.00 0.00 3.60 20.61 0.00 PROJECT PO40659 1999 Community-basedPov. Red. 0.00 5.00 0.00 0.00 0.00 1.46 1.12 0.72 PO00974 1999 Nat. Func. Lit. Program 0.00 32.00 0.00 0.00 0.00 18.98 14.09 10.69 PO00970 1999 TRADE GATEWAY & INV. 0.00 50.50 0.00 0.00 0.00 23.26 21.49 0.00 PO00926 1995 G H Thermal (Power VII) 0.00 175.60 0.00 0.00 0.00 18.06 20.37 26.62 Total: 0.00 1,012.04 0.00 7.90 0.00 713.13 178.03 39.37 79 GHANA STATEMENT OF IFC's HeldandDisbursedPortfolio InMillions ofUS Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1990/91/96 AAIL 0.00 0.00 3.26 0.00 0.00 0.00 3.26 0.00 1993 AEF Afariwaa 0.16 0.00 0.00 0.00 0.16 0.00 0.00 0.00 1995 AEF Antelope Co. 0.40 0.00 0.00 0.00 0.40 0.00 0.00 0.00 2001 AEF GPPI 1.17 0.00 0.00 0.00 1.17 0.00 0.00 0.00 1998 AEF NCS 0.00 0.00 0.53 0.00 0.00 0.00 0.53 0.00 1997 AEF PTS 0.00 0.00 0.31 0.00 0.00 0.00 0.3 1 0.00 1999 AEF PharmaCare 0.05 0.00 0.00 0.00 0.05 0.00 0.00 0.00 1994 AEF Shangri-la 0.93 0.00 0.00 0.00 0.93 0.00 0.00 0.00 1996 AEF Tacks Farms 0.43 0.00 0.00 0.00 0.43 0.00 0.00 0.00 1989 ContAcceptances 0.00 0.88 0.00 0.00 0.00 0.88 0.00 0.00 2001 Diamond Cement 4.25 1.oo 0.00 0.00 4.25 1.oo 0.00 0.00 2000 ELAC 0.00 0.10 0.00 0.00 0.00 0.10 0.00 0.00 1991 GHANAL 0.00 0.44 0.00 0.00 0.00 0.44 0.00 0.00 2001 MFISSLC 0.00 0.49 0.00 0.00 0.00 0.49 0.00 0.00 Total portfolio: 7.39 2.91 4.10 0.00 7.39 2.91 4.10 0.00 ApprovalsPendingCommitment FY Approval Company Loan Equity Quasi Partic. 2004 BP Ghana 0.00 0.00 0.00 0.00 2004 Japan Motors 0.00 0.00 0.00 0.00 2004 Takoradi I1 0.06 0.00 0.00 0.00 Total pendingcommitment: 0.06 0.00 0.00 0.00 80 ANNEX14: COUNTRYAT A GLANCE GHANA: MULTI-SECTORAL HIV/AIDSPROJECT Sub- POVERTY and S O C I A L Saharan Low- Ghana Afrtca Income )evelopment diamond' 2003 Population, mid-year (miilions) 20.4 703 2,3Q Life expectancy GNI per capita (Atlas method, US$) 320 490 450 GNI(Atias method, US$ billions) 6.5 347 1,038 Average annual growth, 1997.03 Population (%) 2.6 2.3 1.9 Labor force (%) 2 2 2.4 2.3 >NI Gross rer primary M o s t recent estlmate (latest year available, 1997.03) :apita nrollment Poverty (%of population belownationalpo verty line) 40 Urban population (%of totalpopulatlon) 45 36 30 Life expectancyat birth (years) 55 46 58 L Infant mortality (per 1000live births) 60 103 82 Child malnutrition (%ofchildren underd) 25 44 Access to improved watersource Access to an improved watersource (%ofpopulation) 73 58 75 llliteracy(%ofpopulation age 15t) 26 35 39 Gross primaryenrollment (%of school-age population) 81 87 92 -Ghana Male 85 94 99 Low-income grow Female 78 80 85 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1983 1993 2002 2003 Economic ratios' GDP (US$ billions) 4.1 6.0 6.2 7.7 Gross domestic investmentlGDP 3.7 22.2 22.3 19.4 Trade Exports of goods and servicesiGDP 5.6 20.3 42.5 372 Gross domestic savingslGDP 3.3 6.0 10.3 5.6 Gross national savingslGDP 2.4 P.8 22.8 18.9 Current account balancelGDP -6.1 -9.4 0.5 -0.5 Interest paymentslGDP 1.1 1.4 1.2 1.4 Total debtlGDP 41.1 81.0 119.1 103.5 Total debt servicelexports 30.4 24.6 7.3 23.1 1 Present value of debt1GDP 63.4 Present value of debtiexports 147.5 Indebtedness 1983.93 1993-03 2002 2003 2003-07 (average annuaigro wfh) -Ghana GDP 5.0 4.3 4.5 5 2 4.9 GDP percapita 2.0 2.3 1.9 2.5 2.6 Lo w-inco me orouo STRUCTURE o f the ECONOMY 1983 1993 2002 2003 Growth o f investment and GDP (Oh) (%of GDP) I Agriculture 59.7 36.9 36.0 352 40 T Industry 6.6 24.8 24.3 24.8 Manufacturing 3.9 9.4 9.0 8.4 Services 33.6 38.3 39.7 40.1 Private consumption 90.8 79.5 78.3 82.9 General government consumption 5.9 14.4 11.4 11.5 Imports of goods and services 6.0 36.4 54.5 50.9 1983-93 1993.03 2002 2003 I Growth o f exports and Imports (%) (average annualgrovdh) I Agriculture 2.3 4.0 4.1 4.6 60 Industry 6.6 4.6 6.3 0.7 40 Manufacturing 3.9 4.0 0.o -1.4 20 Services 7.8 4.5 4.4 6.9 0 Private consumption 4.4 4.6 9.1 4.3 -20 General government consumption 5.9 3.9 -4.4 7 2 Gross domestic investment 62 2.0 -l7.6 24.1 ' I Imports of goods and Services 8.5 7.1 -4.4 7.7 -Exports -0-lmports 81 Ghana PRICES and GOVERNMENT FINANCE 1983 1993 2002 2003 1Inflation Domestic prices ( O h ) I (%change) Consumer prices P2.9 25.0 14.8 26.9 implicit GDP deflator P3.1 318 22.8 29.3 Government finance (%of GDP,includes current grants) Current revenue 5.5 23.5 20.2 24.3 I Current budget balance -19 5.5 0.2 4.1 O ' 98 99 00 01 02 0 4 Overallsurplus/deficit -5.6 -5.9 -4.5 -GDP deflator -CPI TRADE 1983 1993 2002 2003 (US$ miilionsj Export and import levels (US$ mill.) Total exports (fob) 1,064 2,681 3,015 5,000 T Cocoa 286 463 772 Timber 147 182 I76 4,000 Manufactures 3,000 Total imports @if) 1,888 4,099 4,469 2,000 Food Fuelandenergy 158 275 295 1,000 Capital goods 0 Export price index(s95=7.70) 94 76 81 88 97 88 99 00 01 02 03 import price index(895=7.70) 132 96 96 97 m Exports IIrQOrtS Terms of trade (S95=WO) 92 79 85 90 7 BALANCE of PAYMENTS 1983 1993 2002 2003 (US$ millions) Current account balance to GDP (%) Exports of goods and services 477 I208 2,6B 2,856 Imports of goods and services 634 2,n2 3,355 3,913 Resource balance -157 -964 -142 -1,054 Net income -90 -5n 12 -P9 -258 Net current transfers -2 901 1,"7 Current account balance -248 -559 30 -35 Financingitems (net) -7 600 127 4 B Changes in net reserves 256 -41 -151 -318 Memo: Reserves includinggold (US$ millions) 631 811 Conversion rate (DEC,locaVUS$j 45.4 649.1 7,932.7 8,677.4 EXTERNAL DEBT and RESOURCE FLOWS 1983 1993 2002 2003 (US$ millions) :omposition o f 2003 debt (US$ mill.) Total debt outstanding anddisbursed 1,666 4,834 7,339 7,926 iBRD P8 17 5 4 IDA 141 1,838 3,471 3,950 G:698 A ' 4 Total debt service 145 303 8 3 670 IBRD 20 20 2 2 IDA 2 17 30 29 Compositionof net resourcefiows Official grants 46 222 328 Official creditors 61 302 53 6 7 Privatecreditors 26 25 -23 -294 Foreigndirect investment 2 a 5 50 Portfolio equity 0 0 0 c:453 World Bank program Commitments 72 269 0 6 6 Disbursements 23 205 99 8 8 - \ E- Bilateral I IDA -- IBRD D Gther mltilateral . F Rivate Principal repayments 1) n P 13 :-IMF G- Short-ter 82 ANNEX15: MAPOFGHANA (IBRD33411) GHANA: MULTI-SECTORALHIV/AIDS PROJECT 83 IBRD 33411 2°W 0° 2°E To Tenkodogo BURKINA FASO To Hamale Navrongo U P P E R E A S T Bobo- Diolasso WalewaleTumu Bolgatanga GHANA Nakpanduri U P P E R W E S T Walewale To Dapaong 10°N Black Volta Kolpawn Wa Wa 10°N Gushiegu White Volta To Djougou N O R T H E R N Yendi To Tamale Ferkéssédougou BENIN Sawla Fufulsu Bole Daka To Djougou CÔTE Nakpayili Oti TOGO D'IVOIRE To BlackVolta Salaga Bouna Makongo Yeji Kintampo Dambai 8°N 8°N Jema V O L T A B R O N G - A H A F O Atebubu Kwadwokurom Tain Techiman Pru Berekum To Sokodé Sunyani Mount Afadjato (880 m) K w Bia a h Afram u Lake Kpandu nges AgbovilleoT P Volta To l Agogo Ra Abomey Goaso a t e a u Kumasi Bibiani E A S T E R N -Togo Ho Krokosue A S H A N T I Anum im To Porto- no Obuasi Diaso Birim p Novo a aT Kade Koforidua kw Volta Aflao 6°N Oda W E S T E R N A 6°N Dunkwa Enchi GREATER 2°E ACCRA AbidjanoT Tema Twifo Praso ACCRA Prestea C E N T R A L GHANA Ankobra Pra Tarkwa Winneba SELECTED CITIES AND TOWNS Cape Coast REGION CAPITALS Newtown NATIONAL CAPITAL This map was produced by Sekondi the Map Design Unit of The Axim Takoradi RIVERS World Bank. The boundaries, Gulf of G uinea colors, denominations and any other information shown MAIN ROADS on this map do not imply, on the part of The World Bank 0 20 40 60 80 Kilometers RAILROADS Group, any judgment on the legal status of any territory, REGION BOUNDARIES or any endorsement or 0 20 40 60 Miles a c c e p t a n c e o f s u c h boundaries. 2°W 0° INTERNATIONAL BOUNDARIES SEPTEMBER 2004 IBRD 33411 2°W 0° 2°E To Tenkodogo BURKINA FASO To Hamale Navrongo U P P E R E A S T Bobo- Diolasso WalewaleTumu Bolgatanga GHANA Nakpanduri U P P E R W E S T Walewale To Dapaong 10°N Black Volta Kolpawn Wa Wa 10°N Gushiegu White Volta To Djougou N O R T H E R N Yendi To Tamale Ferkéssédougou BENIN Sawla Fufulsu Bole Daka To Djougou CÔTE Nakpayili Oti TOGO D'IVOIRE To BlackVolta Salaga Bouna Makongo Yeji Kintampo Dambai 8°N 8°N Jema V O L T A B R O N G - A H A F O Atebubu Kwadwokurom Tain Techiman Pru Berekum To Sokodé Sunyani Mount Afadjato (880 m) K w Bia a h Afram u Lake Kpandu nges AgbovilleoT P Volta To l Agogo Ra Abomey Goaso a t e a u Kumasi Bibiani E A S T E R N -Togo Ho Krokosue A S H A N T I Anum im To Porto- no Obuasi Diaso Birim p Novo a aT Kade Koforidua kw Volta Aflao 6°N Oda W E S T E R N A 6°N Dunkwa Enchi GREATER 2°E ACCRA AbidjanoT Tema Twifo Praso ACCRA Prestea C E N T R A L GHANA Ankobra Pra Tarkwa Winneba SELECTED CITIES AND TOWNS Cape Coast REGION CAPITALS Newtown NATIONAL CAPITAL This map was produced by Sekondi the Map Design Unit of The Axim Takoradi RIVERS World Bank. The boundaries, Gulf of G uinea colors, denominations and any other information shown MAIN ROADS on this map do not imply, on the part of The World Bank 0 20 40 60 80 Kilometers RAILROADS Group, any judgment on the legal status of any territory, REGION BOUNDARIES or any endorsement or 0 20 40 60 Miles a c c e p t a n c e o f s u c h boundaries. 2°W 0° INTERNATIONAL BOUNDARIES SEPTEMBER 2004