ISDS THE WORLD BANK GROUP AWorld Vrto ol Povtrty - u - - - _ _ Inohop Report No AC19 Integrated Safeguards Data Sheet (Updated) Date ISDS Prepared/Updated: 04/07/2003 Section I - Basic Information A. Basic Project Data Country: DJIBOUTI Project ID. P073603 Project. HIV/AIDS, Malaria and TuberculosIs Control Task Team Leader Michele L. Lioy Project Authorized to Appraise Date: Marclh 25, 2003 IBRD Amount ($m) Bank Approval: May 29, 2003 IDA Amount ($m). IDA GRANT FOR HIV/AIDS 12 Managing Unit: MNSH-D Sector Other social services (60%), Health (30%); Lending Instrument: Specific Investment Loan (SIL) Central government administration (10%) Status: Lending Th eme: Civic engagement, participation and community driven development (P); Gender (P); Fighting communicable diseases (P); Social analysis and monitoring (S) I.A.2 Project Objectives: In accordance with the main goal of MAP2, the overall objectives of the project are to assist the Government of Djibouti in settmig up and implemiienitinig the response against HIV/AIDS, sexually transmitted infections (STIs), malaria and tuberculosis (TB), which are important risk cofactors. Djiboutl meets the criteria for MAP2 eligibility and only key features are highliglhted below wlviclh are relevant to the HIlV/ADS epidemic in Djibouti and the DjiboutLi HIV/AIDS, Malaria and Tuberculosis Control Project The proposed project will be to support the National Strategic Plans to respectively fight against IHV/AIDS, malaria and tuberculosis (plan s1rat6gique national de prevention du VII-I/SIDA, plan stral6gique de lutte contre Ic Paludisine et plan strategique national de litle contre la Tuberculose)for the period 2003-2008. The objective of the Project is to contribute to the chanige in behavior of the Djiboutian population in order to containi or reduce the spread of the HIV/AIDS epidemic and to mitigate its impact on ilfected and affected persons aiid to contribute to the contr-ol of malaria and tuberculosis. It will do so throughi a multi-sector approach by: (i) prevenltinig the spread of HIV/AIDS by reducing transmission, in particular among higlh risk groups; (ii) expanding access to treatment of opportunistic illnesses and malaria, and to provide care, support and treatmenit to People Living wvith HIV/AIDS (PLWHA) in Djibouti; and (mi) supportilg multi-sectoral, civil society and commllunity initiatives for HIV/AIDS preventioni and care and malaria prevention. In the context of the above mentionied strategic plans, the project will support and promote civil society and community initiatives, for prevention and care of HIV/AIDS, malaria and tuberculosis put forward by beneficiary groups selected on1 the basis of the techllical quality, cost-effectiveness and likely impact of their proposals. 2 ISDS L.A 3. Project Description The project will support the implementation of Djibouti's HIV/AIDS National Strategic Plan, the Malaria Strategic Plan, and the National Tuberculosis Strategic Plan throughi a wide variety of public sector agencies, private and noni-governmeintal organizations, and communiity-based organizationls. The project will ilclude four major components as follows. I) capacity building and policy development; 2) public health-sector responses to HIV/AIDS, the managemenit of TB and STIs, including preventioni, treatment and care and malaria prevention; 3) multi-sector responses to HIV/AIDS prevention and care, and 4) support to communiity-based initiatives for the three diseases. These activities will take into account the existing conditions and Djibouti's capacity level both at the central and the district levels, recognizing that at present capacity is weak at both levels. Presented below are the main sub-comilponlenits of each component. For more details, see Annex 2. Component 1. Capacity Building and Policy Development (US$ 4.5 million) This component would aim at strengthening Djibouti's capacity to cope with the spread of HIV/AIDS, of malaria and tuberculosis by supporting. (i) the work of the Interrinisterial Committee, the Technical Interministerial Committee and the Executive Secretariat (ES), including project coordination and facilitation; (ii) the up-dating of the National Strategic Plans (for each of the three diseases) and aniual Action Plans; and (m) strengthiening of public, private and nongovermilenital institutions in preparing and implementing preventioni, care and treatment intervenitiols. Human resources are very limited both in number and in quality The acute shortage of humani resources remains the most important constraint to the success of the project For instance in the MOH the number of qualified persons is limited and most of these persons are already engaged in the launching of the HSDP and/or in implementing the ministry's programs. In order to address this problem, it has been agreed with the Government that. (a) some tasks would be contracted out (monitorinig and evaluation); (b) some Djiboutian experts will be recruited on the basis of a competitive process and hired with one-year contracts renewable on the basis of performance; (c) training will be organized, in particular for specialized tasks and for NGOs and ABC before they are awarded financing to implemenit a project; and (d) two long term international techinical assistants (a procuremenlt/implemenitationi specialist and a social communication expert) and some short term experts for specialized tasks (for example, training in counseling or development of a condom distribution strategy) will be recruited. All the termis of reference of the technilcal assistants specify that one of their task is to transfer competences. Each TA will have an official counterpart named or recruited by the DjiboIitianl authorities This coi-nponent will also include training activities, under contract with local institutions, for the NGOs and governmental institutiolns wilicil will have the responsibility to supervise and train other entities and for the ministries' units and local NGOs and associations which will be implemiientinig activities. Some study tours may be included as part of this training as well as for selected members of the IC, the TIC and ES Finally, the building of a laboratory and the rehabilitation of the building next to the offices of the Aids Control Program of the MOH and the Center YouLIis Toussaint, will be included In this component. The laboratory equipment is being finaniced Linder the I-SDP, but the laboratory building itself is presently located in unsafe or temporary buildings whichi need to be replaced as soon as possible. The rehabilitation work being envisaged will provide space for expanding the role of Younlis Toussaint Center to counselilg, voluntary testing and care and treatment of sero-positive persons. It will also provide space where information will be available and where NGO and associations can meet. This will be one of the centers included in the AIDS treatmenit pilot project included in the Public health 3 ISDS component (see next section and Annex 2 for more details) Component 2. Public Health Sector Response to HIV/AIDS, TB and STI Management (US$2.3 million) The Ministry of Healthi (MOH) and more broadly the healtil community, have special responsibilities for malaria, STIs, HIV/AIDS, and opportunistic infections (includinig tuberculosis) prevention and managemiient. This sector therefore warrants a separate component, makinlg provision for prevention, care and treatmenit from a health sector perspective This component will aim at expanding access to preventive measures such as condomils, to treatment of STIs, opportunistic illnesses (including tuberculosis and malaria, and to care, support and treat People Living with HIV/AIDS (PLWHA) in DjiboLitI. In addition, a subcomponient would have as an objective to increase cinical safety and ameliorate the treatment of solid medical waste Under this component, the project will include a) development of Voluntary Counselling and Testing (VCT) protocols as well as a significant role in traininig counselors and in carrying out VCT activities and follow-up; b) implemiienitation of syndromic algorithms for diagnostic and case maniagement of sexually transmitted infections, c) the strengthening of the health system for the treatment of malaria, HIV/AIDS, STIs, and opportunistic infections in particular TB; d) the setting up of measures to prevent the transmission of the HIV in clinical settings; e) the procurement of condoms, and a significant role in the distribution of condoms; f) the scaling up of activities geared to vulnerable/potentially high transmitter groups in collaboration with other sector partners (in particular, the project could finalice technical assistance for the IEC Unit of the MOH), g) the support to the decentralization program for TB screeninig and treatment, h) the strengthening of the detection, preventioni and response to malaria, and 1) the financinig of drugs, test kits, and medical consumliables, which will be bougIlt from the Central Drug Procurement Agency once it is set up. The possibility of a partnership with WHO for the supervision of some of the above activities is being explored, but needs to be discussed in detail with the MOH, the ES and the Government. The Bank has also been working closely withi its IUNAIDS partners, drug companies, and developing-country govermilenits on access to ARV therapy This is an evolving situation which progressively allows for low cost choices and alternative options The project intends to support the development of guidelines and the strengtheninig of health infrastructure to allow ARV therapy drugs to be used in a safe, effective, and sustainable maniner It will assist the MOH, in collaboration with other partners (e g., the French Cooperation, WHO and UNICEF) in puttilng in place a one-year pilot project including the treatment with ARV of sero-positive persons in the three public health systems of the country (Ministry of Health, Ministry of Defense and Ministry of Employmenit Organisation de la Protection Sociale [OPS]). This pilot project will be used to assess the feasibility and cost of extending the treatment program to the whole couLitry The drugs for the pilot project are being included In the first purchase being procured linder the HISDP The Govermenlt of Djibouti is now eligible to apply to the Global Fund and is preparing a proposal for the next rouid. It is hoped that in future, at least part of the drugs for the program can be bought with Global Fund financinig The prevention of mother to child transmission of the HIV (PMTCT) is not included in the project because UNICEF is presently setting up a PMTCT program in two centers in Djibouti (one in a public maternity center and the other in the MCH Center of SPO). The project, however, may contribute to the training of counselors, as the pilot program may be scaled up, and to providing artificial milk for mothers who decide not to breastfeed. 4 ISDS Finally, with regard to condoms, a consultant may be recruited either under the PPF or early durinlg project launcih, to develop a condomil distribution strategy. Condomiis will be provided on a no-cost basis to STI patients, but condoms must also be made available outside of the health system as needed (based on the strategy developed) Component 3. Multi-sector Responses for HIV/AIDS Prevention and Care (US$ 3.1 million) As has been demonstrated in other couLntries, and in order for the fight against HIV/AIDS to be efficient, it is necessary to have a multi-sectoral approach in order to better target Priority Vulnerable Groups. Although the multi-sectoral response is presently very weak, the ministries of Social Affairs and Women Promotion, and Defense, already carry out some IEC and condom distributioni activities The project will reinforce on-going activities and provide support to the following key miniistries outside of the MOH the ministries of (a) Economiiy, Finances and Planninig, (b) Youthi and Sport, (c) National Educationi, Women Promotion, (d) Social Affairs and Family Welfare, (e) Defense (army), (f) Employment and National Solidarity, (g) Communicationi, TelecommIinicationi and Culture, (h) Justice, Penitentiary and Religious Affairs, (i) Ministry of Wakfs and Islamic Affairs, (j) Interior and Decentralizationi (police), and (k) Equipment and Transport. This componienit will provide these ministries with resources and traiilig to improve their capacity to respond to the HIV/AIDS epidemic, emphasizing prevention and care. Most of the above mentioned ministries are finalizinig their action plans which include performance indicators and define monitoring systems and budgets Thle action plans are targeted to staff of line ministries and focus on training peer educators on issues of HIV/AIDS and STIs, the importance of condoms in the fight against these diseases, includinig other support mechanisms to encourage a change in behavior These plans will be integrated into the ministries' ongoing operations. At this point it is not planied that the project assists the Ministry of Transportbecause Save the Childre?7financed by USAID/Ethiopia, is providing support to that Ministry, which could in addition, receive additional support through the Regional Project for the Horn of Africa being developed by ActAfrica in the context of the NMAP2. The Ministry of Communication will have a special role to play: at the beginninig of the project, it will assist the international specialist in communication and its Djiboutian counterpart, in developing a nationial commuliication strategy for the fight against HIV/AIDS, Malaria and Tuberculosis. During this process, its role in the strategy will be defined. At a later stage, it is expected that it will disseminate audio-visual and written materials prepared in the context of the communication strategy The preparation of these materials will be contracted out Activities in the Ministries will be financed on the basis of an annual workplan and budget The Ministry will receive a first tranche whicih it will have to Justify il order to receive the second tranche. The Administrative and Fiianicial Manager of each Ministry who will imianage these funds will receive training if necessary Component 4. Support to community-based initiatives (US$ 2.1 million) In order to enlist communities in the fight against HIV/AIDS and to provide them withi the means to mitigate the impact of the epidemic, it is necessary to provide them the resources at the local level. The objectives of this component are to. (a) strengthen communities and Djiboutian associations and NGOs, so that can implement some essential activities for the reductioll of the vulierability to HITV/AlDS, malaria and tuberculosis; and (b) strengthieni institutional capacities of Djiboutiani NGOs and associations so that they can deliver essential services needed to the most vulnierable groups. Project suppor-t will be provided in such a way as to ensure that community interventions are complementary and in synergy with interventions carried out by governmenital services and other potential partners. In order to ensure that this componienit takes into accoulit Djiboutian realities, a pilot project will be developed, wvith the assistance of an NGO, to provide uItritionial support to PLWHA in Djibouti-Ville and the Hospital Paul 5 ISDS Faure (TB Hospital). This will done during the preparation phase of the project so as to fine tune the mechiaiiisnis of intervention and define an acceptable and reasonably priced social package (which could also include assistance for disabled HIV/AIDS persons) Essential activities identified for communlity interventions can be classified in three categories. (i) prevention of HIV, TB and malaria transmissioni; (ii) reduction of the impact of l-V/AIDS (including psycho-medico-social support and care to PLWHA and their families; social/economic support, includinig food, to PLWHA and their families; and income generatilng activities for the families of PLWHA), and (iii) legal support (see Annex 2 for more details on activities). In order to implement the above activities, it will be necessary for the project to finance support activities to'strengtheni the institutionial capacities of the Djiboutian NGOs. In order to do so, NGO personiel will be trained in the following areas (a) management and development of social projects; (b) basic information on HIV/AIDS, tuberculosis and malaria, (c) analysis of vulnerability and identification of appropriate solutionis; (d) quality control for activities being financed at community level; (e) mobilization and promotion of community participation; and (f) supervision and evaluation of services. This training could either be contracted out to local institutions, or if the Government agreed, by the UNDP in the context of their 2003-2006 program, (through cost-sharinig or other arrangements). The need for training and supervisioni of local NGOs and associations was assessed during the development of the HIV/AIDS National Strategic Plan. Support to local NGOs and associations will be provided by governmental and non-goverinimienital institutions whiich will be responsible for training and supervision (called "Techniical Assistance (TA) Institutions" or "TA NGOs"). The preparation team is conlscious of the fact that even the capacities of these TA institutionis will need to be strengthenied. At the end of the training, an exam will identify the best 5 to 9 institutions to serve as TA institutionis, takiig into account the criteria defined during a consenisus workshop on training and supervision. The ES is responsible for preparing the Procedure Manual for Community Interventions (underway) This Manual should be finalized prior to effectiveness, througih a consensus workshop organized in collaboration with the UN Agencies and which would be attended by all the miniistries concernied with the fight against HIV/AIDS, civil society and other partners The consultanit being recruited under the HSDP to prepare the project Procedure Manual will be requested to prepare the Procedure Manual for Commullity Intervenitions as well as the Project Operations Manual (POM) on the basis of the model elaborated by the ActAfrica team. With regard to the identificationi of local projects for communLity intervenitionis for the first year of the project, it will be done in a realistic manner which will prioritize learning and the development of capacities of the personnel involved as well as quality contiol Coverage will be gradually increased. On the basis of the response analysis carried out in 2002, it has been agreed upon that about 30 communilty projects will be developed for 2004. These projects will be implemented by 25 to 30 local NGOs and associations assisted by 5-9 T A institutions, and the ministry dealing withi the same vulnerable group and the Comm11ullity Intervention Support Unit (CISU) of the ES. The preparation and selection process of community projects to be fiiaiced by the project will be an annual process which will be carried out in each district (or neigilborhiood) tinder the responsibility of the regional HIV/AIDS Counlcils. The project will be identified and selected taking into accouint the essential activities necessary to reduce the vulnerability of priority grouips in each district of the country and neighborhood of Djibouti-Ville and governmental interventionis identified in the sectoral plans. The implementation of these projects will be monitored and supervised, at the central level, by the 6 ISDS CommUnity Interventioni Support Unit (CISU) in close collaboration with the person responsible for sectoral response in the ES and at the regional level, with the TA institutiolIs, the HIV/AIDS regional committees and the consultanit to which monitoring and evaluation will be contracted out. The modalities of these arrangements will be defined in the Monitoring and Evaluation Plan. The financing of community projects and of contracts withi TA institution1s will be carried out by the CISU in agreemenit withi the Communi'ty Intervention Procedure Mauial wvhicih will need to be finalized before the project becomes effective The mechaniisms to chanilel funds from the CISU to communities was agreed uponi during the February 2003 mission. The selection process of the projects will be carried out by an independenit Committee Govermiient, civil society and donor representatives. The selection modalities will be stipulated in the Procedure Manial for CommuLi1ty Interventions Components. Capacity Building and Policy Development Public Health Sector Response to HIV/AIDS, TB and STI Management Multi-sector Responses for HIV/AIDS Prevention and Care Support to community-based initiatives I.A.4. Project Location: (Geographic location, information about the key environimental and social characteristics of the area and population likely to be affected, and proximity to any protected areas, or sites or critical natural habitats, or any other culturally or socially sensitive areas.) Republic of Djibouti. The consultanit has prepared the Environimlenital Management Plan on medical solid waste, and the report was submitted to the InfoShop on February 28, 2003. B. Clheck Environmental Classification: B (Partial Assessment) Comments A Solid Waste Management Plan was developed and received by IDA on February 27, 2003 C. Safeguard Policies Triggered Policy Applicability Environmental Assessment (OP/BP/GP 4.01) * Yes Cr No Natural Habitats (OP/BP/GP 4.04) Qt Yes * No Forestry (OP/GP 4.36) O Yes * No Pest Management (OP 4 09) 0 Yes * No Cultural Property (OPN I1 03) E Yes * No Indigenous Peoples (OD 4.20) C Yes * No Involuntary Resettlement (OP/BP 4.12) C} Yes 0 No Safety of Dams (OP/BP 4 37) C Yes * No Projects in Inteinational Waterways (OP/BP/GP 7 50) C Yes * No Projects in Disputed Areas (OP/BP/GP 7.60)* C Yes 0 No *By supporting the proposed project, the Bank does not intend to prejzudice thefinal determination of the parties' claims on the dispuited areas Section IT - Key Safeguard Issues and Their Management D. Summnary of Key Sofeguard Issues Pleasefill in all relevant questions. If informnation is not available, describe steps to be taken to obtain necessary data. 7 ISDS II D.la. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significanit and/or irreversible impacts The operation of incinerators proposed within the framework of the action plan can generate certain harmful effects in the environmental and medical plan. It should however be noted that taking into account the very reduced quantities that hospitals will incinerate on a daily basis, the environmental and medical impacts of this system will be relatively minor and the harmful effects won't be major. From the source, the sorting will have to be systematic to reduce waste to the minimum that has to be incinerated, and uncontaminated plastic objects should be carefully selected. II.D. I b. Describe any potential cumulative impacts due to application of more than one safeguard policy or due to multiple project component NA Il.D.lc Describe any potential long term impacts due to anticipated future activities in the project area. NA II.D.2. In light of 1, describe the proposed treatment of alternatives (if required) 1l.D 3 Describe arrangemiient for the borrower to address safeguard issues The main features of the EMP are to develop a nationial policy regarding waste managemenit, and the appropriate guides and legal texts; train key personnlel in all health facilities, disseminate to the wider population through different means of imnedia coverage, improve waste collection methods and purclhase of needed supplies towards that end, and monitor and evaluate activities undertaken 11 D.4. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Health facilities were consulted, as well as the larger reference hospitals In addition, iiterviews were held with local communities who suffer the effects of having waste disposal sites located in their viciniity, and NGOs involved in the health sector. E. SafeguardIs ClIssification. Category is determined by the highest impact in any policy. Or on basis of cumulative impacts from multiple safeguards Wheniever an individual safeguard policy is triggered the provisions of that policy apply. [ ] SI . - Signiificanit, cumiulative and/or irreversible impacts, or sign ificanit techniical and institutional risks in managemlienit of one or more safeguard areas [X] S2. - One or more safeguard policies are triggered, but effects are limited in their imipact and are technically and institutionially manageable S3. -No safeguard issues [ ] SF - Financial intermediary projects, social development fuLnds, community driven development or simiilar projects which require a safeguard fiamework or programmatic approach to address safeguard issues. F. Disclosure Requirements Envionnmental Assessmnen7t/A nalyssIMs/Iv7fcge,nient Plani Expected Actiual Date of receipt by the Bank 1/31/2003 2/27/2003 Date of "'in-counltry" disclosure 2/28/2003 2/27/2003 8 ISDS Date of submission to InfoShop 3/31/2003 2/28/2003 Date of distributing the Exec Summary of the EA to the ED (For category A projects) Resettlemenlt Action Plan/Framework Expected Actual Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Indigenoius Peoples Development Plan/Framevork Expected Actual Date of receipt by the Bank Date of "in-country" disclosure Date of submission to InfoShop Pest Mqanagenment Plan. Expected Acteal Date of receipt by the Bank Date of "in-coulitry" disclosure Date of submissioni to InfoShop Dam Safety Management Plan: Expected Actual Date of receipt by the Bank Date of "in-country" disclosure Date of submission to I nfoSliop If in-country disclosure of any of the above documelIts is not expected, please explain why Si2ned and submitted by Name Date Task Team Leader. Michele L. Lioy 3/25/03 Project Safeguards Specialists 1: John Bryant Collier/Person/World Bank 3/25/03 Project Safeguards Specialists 2: Mohamed Arbi Ben-Achour/Person/World Bank 3/25/03 Project Safeguards Specialists 3: Approved by: Name Date Regional Safeguards Coordinator: Sherif Kamel F. Arif 3/25/03 Sector Manager/Director: Jacques Baudouy 3/25/03 For a list of World Bank news releases on projects and reports, click here _____.H u FE.EDbACK SITE MAP 1 W(AOWCiE