Page 1 39757 Updated Project Information Document (PID) This is an update of the original PID dated June 2002 following a request by Government to restructure the project, including changes in the Project Development Objectives (PDOs). The project has been in implementation since March 28, 2003, had a thorough mid-term review in June 2006, and is currently being restructured based on recommendations of the mid-term review. 1. Country and Sector Background Past Failures and Challenges from an Unsettled Environment . Guinea is recovering from the utter failure of a centrally planned economy, which prevailed until the mid- 1980s. The introduction of multi-party democracy in 1994 improved political accountability , even if elections have been plagued with widespread irregularities . Guinea’s stability has also been threatened by regional crises. Conflicts in Sierra Leone, Liberia and Cote d’Ivoire have resulted in an influx of refugees, the destabilization of border regions as a result of incursions of fighters, and the return of economic migrants from Cote d’Ivoire. There is close consultation among the presidents of Guinea, Cote d’Ivoire, Liberia and Sierra Leone to review security and cooperation matters in the framework of the Mano River Convention. Progress in implementing the Marcoussis and Ouagadougou Peace Agreements in Côte d’Ivoire will be important for restoring stability in the region. Discontent amongst Guinea’s population is on the rise. Soaring food prices, rising electricity bills and unpaid state salaries provoked numerous strikes and street Project name GUINEA-MULTI-SECTORAL AIDS PROJECT (MAP) Region Africa Regional Office Sector HA - HIV/AIDS Project ID P073378 Borrower(s) GOVERNMENT OF GUINEA Implementing Agencies National Committee for the Fight against AIDS (CNLS) Address: Conakry, Guinea Contact Person: Dr Hadja Mariama Djelo Barry Tel: 224-41-52-83/41-52-52 Environment Category [ ] A [x] B Partial Assessment [ ] C [ ] FI [ ] TBD Date PID Prepared June 20, 2002 Date PID Updated May 4, 2007 Date of Appraisal/Negotiations Date June 20, 2002 Board Approval Date August 7, 2002 Page 2 2 demonstrations, this situation ended up by the nomination of a new Prime Minister designated by the Workers Unions in February 2007. Poor Social Indicators. In the 1990s, Guinea made significant strides in human development, particularly in education, and managed to reduce the gap related to averages for sub-Saharan Africa (SSA). School enrollments increased from under 30 percent in the 1980s to 56 percent by the end of the 1990s. Girls' enrollment rates doubled from 20 to 40 percent. Important achievements were made in the health sector during the past decade to develop a basic health care system. Vaccination rates for Polio3 increased from 15% in 1982 to 17% in 1990, and reached 54% in 1995. However, Guinea continues to compare poorly with other SSA countries. In 1999, for instance, one child out of four suffered from chronic malnutrition and one woman out of ten suffered from acute malnutrition. Success to Build Upon. Guinea was a pioneer in implementing a decentralized cost- recovery system for primary health care. The success of this system might be in great part responsible for the higher decrease in infant mortality among the poor than among the non-poor in the 90's, a result in equity that no other country of Africa has achieved. In the last few years however, it seems that local health committees started mismanaging the committee's funds due to lack of proper supervision. In addition, the bankruptcy of the bank where all the committees' revolving funds were held contributed to the problem. Another success in Guinea is its tuberculosis control program which covers the whole country with the DOTS system that was established in 1990. Since its inception, the program has never experienced a drug stock-out. All donors, under the leadership of the national tuberculosis (TB) program, plan drug supply needs, and drug procurement and distribution collaboratively. It is estimated that approximately 17% of new TB patients are infected with HIV. Epidemiological Situation of HIV/AIDS. The low official HIV prevalence rate reported in the past few years was more attributable to poor reporting and monitoring than to reality. The sentinel sites which had been established to monitor Sexually Transmitted Infections (STIs) and HIV/AIDS prevalence haven't functioned since 1996. With no data, it was assumed that Guinea's HIV prevalence rate mirrored that of Senegal, its neighbor, it was said for example that the population of reproductive age had a rate around three percent in 2000. However, the national prevalence survey which was undertaken in July 2001 showed that the HIV prevalence rate is much higher than anticipated. Pregnant women tested showed that HIV prevalence has reached a critical point in the urban areas throughout the country, at 4.4%, with particularly alarming rates in Conakry (5%) and Guinée Forestière region (7%). The higher rates in Guinée Forestière region probably stem from conflict situations, including a large military presence, increased migration, as well as the well traveled road going to neighboring countries such as Cote d'Ivoire. In the late 1980s, the gender ratio of HIV infected people, who reported to health facilities, was eight men for one woman. According to the 2005 Demographic and Health Survey (DHS), the ratio of people infected with HIV is 210 women for 100 men. The national HIV/AIDS prevalence rate is 1.5. A number of factors contribute to the spread of HIV/AIDS, including: inadequate knowledge and inappropriate attitudes, precocity of sexual relations, high prevalence of risky behaviors, women's subordinate status, importance of mining and trucking activities, large number of Page 3 3 refugees and displaced people, and, more generally, high incidence of poverty. About 40 percent of households are below the poverty line. The high rate of STIs is a major factor in the spread of HIV/AIDS. According to the 2005 DHS results among adult women and men who declared having had an STI during the last twelve months, the HIV prevalence rate is 2.2 and 1.4, respectively, compared to the national prevalence rate of 1.5. Government and Donors Response to the HIV/AIDS Challenge. Since the notification of the first AIDS case in 1987, the Government response has been slow and uncoordinated but since then many efforts have been made. The National Plan for the Fight against HIV/AIDS (PNLS) was coordinated by a National Committee created in November 2000 and chaired by the Minister of Health (MOH). In early 2002 the PNLS was abolished to be replaced by a multi-sectoral National AIDS Committee (CNLS) under the leadership of the Prime Minister. The CNLS Executive Secretary was selected in May 2002. Focal points for HIV/AIDS exist in most ministries, and Regional committees (CRLS) as well as Prefectoral committees (CPLS) have been established under the chairmanship of the Health Director in each Region and of the Medical Officer in each Prefecture. The prefectoral committee includes a representative of youth organizations, a teacher and a prominent person at the local level. The Government's national budget has included a line item for AIDS since 1998. Although this budget line continues to exist in the National Budget but no expenses can be charged to it due to treasury constraints . The following AIDS prevention activities have been financed from multiple sources: the Ministry of Agriculture trained 128 trainers, 1,500 agricultural extension agents , and 1,000 auxiliary agents in HIV/AIDS prevention who have reached more than 700,000 farmers and 110,000 cattle breeders. The Bank-financed village community support project (PACV) trained 50 persons in 33 prefectures. The Bank-funded reproductive health project (PPSG) financed several micro-projects related to HIV/AIDS prevention. USAID and KfW finance a social marketing of condoms program which is managed by a national NGO and covers the whole country, but the condoms are not widely used in spite of their low price of GNF 25 per unit (US$0.02). USAID also provides technical assistance for drugs stock management. GTZ has been active in peer education. Canada is financing its second HIV/AIDS and STI prevention project in two regions and could increase its coverage if further financing was available. WHO is involved in providing training activities. UNICEF has been active in helping to set up 22 anti-AIDS clubs in secondary and technical schools. UNFPA is involved in condoms provision among other activities. The major mining company has started an HIV/AIDS prevention campaign for its personnel. An HIV/AIDS network of NGOs called ROSEGUI has been established, within which such NGOs as SIDALERTE and MST UNIVERSITE work with truck drivers and commercial sex workers. For refugees, the UNHCR and MSF, along with the NGO IRC, work on HIV/AIDS in refugee camps. At present, Guinea has a National Blood Transfusion Policy which includes the prevention of HIV/AIDS and 100% of blood units in hospitals are regularly and adequately screened. UNAIDS set up an extended national committee including bilateral donors. This Committee meets on a regular basis for coordination purposes. Since the creation of the CNLS, the UNAIDS Committee is working in even closer collaboration with Government. Page 4 4 Assessment of Results and Shortcomings. In January 2002, the MOH undertook a critical analysis of the Government's response to the AIDS epidemics. It noted the following weaknesses: non functionality of the different committees, poor coordination, poor intersectoral collaboration, lack of political commitment by sectoral ministries, lack of information and training. Indeed, while initiatives taken so far are steps in the right direction, their efficiency has been sorely limited by lack of resources and the narrow focus on the health sector. The Government therefore decided to adopt a multi-sectoral approach in the fight against HIV/AIDS. The CNLS was created and placed in the Prime Minister's office, and its membership has been broadened to all line ministries and partners involved in the fight against HIV/AIDS. Religious groups are increasingly involved in the fight against HIV/AIDS and are expected to participate actively in the preparation of the new National Strategy (2008 –2013) and its action plan. Associations of People Living With AIDS (PLWA) are established and are represented in the institutional framework. Government Strategy. The initial Government's multi-sectoral strategy for the fight against HIV/AIDS covered the period 2002-2006, and it emphasized seven areas for action: (i) activities covering the whole population, namely community mobilization for HIV/AIDS prevention; (ii) improving communication for behavior change through local radios, religious leaders, and advocacy at various levels; (iii) targeted interventions especially for youth, commercial sex workers, refugees, miners, prisoners, military and police; (iv) health sector response emphasizing epidemiological surveillance, STI control, blood safety, mother to child transmission, and more generally testing and counseling; (v) care and psycho-social support to HIV infected people and affected families; (vi) research on HIV/AIDS; and (vii) strengthening the institutional framework, where the national, regional and local HIV/AIDS committees will be reinforced. Their membership will be broadened to include representatives of institutions and groups active in the fight against HIV/AIDS. Their operations will be strengthened through training and allocation of additional resources. At the local level their role will be to support initiatives by NGOs, local groups and more broadly, the civil society. The National AIDS Committee will review action plans prepared by line ministries and large enterprises and provide support as needed. Certain areas of this plan will be covered by other donors than the World Bank, in particular for refugees and basic research. Some donors are already financing other areas on a small scale, which will be expanded with Bank financing, such as targeted interventions for youth and STI control. The Bank has been financing parts of this national strategy since September 2003. As indicated above, a new national strategy for the period 2008- 2013 is under preparation in consultation with all stakeholders. 2. Objectives The project is part of the World Bank's Multi-country HIV/AIDS Program for the Africa Region (MAP2, Report P7497-AFR) approved on February 7, 2002. In accordance with the main goal of the MAP2, the overall objective of the project is to assist the Government of Guinea in limiting and reversing the trend of the epidemic, by preventing new infections. This objective, however, was found to be unrealistic and it is currently being proposed that it be revised, as explained in section 3 below. The project supports the implementation of the National Plan against HIV/AIDS and promotes civil society and community initiatives for prevention and care. Page 5 5 3. Rationale for Bank's Involvement The Multi-country HIV/AIDS Program for the Africa Region places the epidemic at the center of the development agenda. Curtailing the spread of HIV is pivotal if human development and overall development goals in the region and in countries such as Guinea are to be achieved. The Bank has provided leadership to the donor community in assisting Guinea move from a state-controlled economy to a market-based economy. It has helped Guinea focus on poverty issues and strategies for improving the delivery of basic services to the population. Considerable progress has been made in past years. This progress is not sustainable, however, if strong efforts backed by the international community are not made to help Guinea implement its HIV/AIDS program. Donors have expressed interest in supporting the program and indicated that Bank involvement was essential for its success. IDA has played a pivotal role in supporting the National HIV/AIDS Strategy. The IDA- funded Multi-Sectoral HIV/AIDS Project (US$20 million Grant) has been the main source of funding for the implementation of this strategy, followed by the Global Fund with US$12 million for three years. The Bank ’s strategy in the field of HIV/AIDS aims at supporting the country’s efforts to stem and reverse current rising HIV/AIDS cases and provide effective care and treatment to infected and affected persons and communities as spelled out in the National HIV/AIDS Strategic Plan. To this end, the objective of the Project was to support the Recipient’s multi-sectoral efforts to limit and contain the spread of the HIV/AIDS epidemic through: (i) implementation of the Government's National HIV/AIDS Plan to increase access to prevention services as well as care and support for those infected and affected by HIV/AIDS; and (ii) promotion of civil society and community initiatives for HIV/AIDS prevention. Based on the experience and lessons learned from the implementation of project activities in the last 3 years, acknowledging that measuring HIV incidence is currently beyond the country’s capacity, and because it is not possible to determine if the Project interventions would be solely responsible for having an impact on the incidence, the Government has requested the Bank to change the PDO to make it more realistic and achievable. However, the project description will remain the same. The revised PDOs are: · PDO1: "Increase in HIV/AIDS knowledge and in low-risk behaviors"; · PDO2: "Improvement in the coverage and in the use of HIV/AIDS prevention, care, treatment and support services ". 4. Description The project supports the implementation of Guinea's strategic plan through a wide variety of public sector agencies, private and non-governmental organizations, and community-based organizations. It is being implemented over a five-year period, since March 28, 2003, and is expected to close on July 31, 2008. The project includes four major components as follows: Component 1: Support to Community-based Initiatives in the area of prevention, social support, and mitigation. This component builds upon the experience of the two Bank financed projects, PACV and PPSG. Under this component, the project supports action plans Page 6 6 and proposals prepared by local communities, youth clubs, women organizations, PLWA associations, as well as local NGOs and religious groups. Activities are identified by the communities through a participatory diagnosis process supported by local NGOs specialized in this process. Activities include prevention, social support, and care of AIDS cases Local mining companies which qualify as "communities" and submit AIDS prevention and care activities for their employees and their families are being co-financed by the Project. The size of any single activity is not large (many are around US$1,000), with the larger activities for organizations needing multi-year commitment. Quality is being controlled by the Ministry of Rural Development which is helped in this task by specialized institutions such as qualified NGOs. The selection of these specialized institutions is made according to predefined criteria and their mode of intervention is described in the Manual of Procedures. Component 2: Support to Public Sectors. Under this component, the project supports annual action plans prepared by ministries, at the central and regional levels, and by other public agencies. These proposals are formalized in Annual Agreements which are signed by the CNLS Secretariat and the central ministry concerned. Some agreements are also signed directly with regional representatives of the ministries. The proposals made by the Ministry of Health cover the full spectrum of prevention and care activities, in particular blood safety, voluntary testing, prevention of mother-to-child transmission, and sentinel sites. 60% of the funds for this component are earmarked for the Ministry of Health. This is justified by the fact that the Ministry of Health plays a large role in terms of testing, counseling, caring as well as in prevention through STI prevention programs. The proposals made by the Ministry of Education also include school-based HIV/AIDS education. The proposals by the Ministry of Communication include mainly reinforcing HIV/AIDS programs of rural radios as well as advocacy campaigns. Proposals made by other ministries focus mainly on staff training and sensitization of the segment of population they serve. Four national reference training guides which were designed by different ministries are now being used everywhere in Guinea. The four guides are: (a) Guide for Peer Sexual Education, prepared by the Ministry of Education, but in collaboration with other ministries; (b) Guide for counseling for testing, designed by the Ministry of Health; (c) Guide for social mobilization, done by the Ministry of Youth; and (d) Guide for advocacy and social communication designed by the Ministry of Communication. Component 3: Capacity Building. This component aims to strengthen the capacity of government agencies, civil society, rural organizations and private sector in preparing and implementing HIV/AIDS prevention and care projects. It reinforces the resource management, monitoring and evaluation capacity of the HIV/AIDS committees. It finances pooled cross- sectoral activities such as training, advocacy, as well as technical assistance to sectors. It provides support and training to the HIV/AIDS units of line ministries, to the CNLS Secretariat, and to other sectors. It includes a comprehensive on-the-job training for health personnel in all activities related to prevention and care. It helps NGOs provide support to local groups in the formulation and execution of proposals. Most of the activities are being contracted out to local or international institutions specialized in communication or training. Some entities which have shown success in executing HIV/AIDS and SIT programs are also being contracted to rapidly expand their services and to also serve as technical support to the CNLS and ministries in terms of building capacity in the different sectors they work with mainly through training and supervision. In this regard contracts have been established with GTZ, SIDA3/University of Page 7 7 Montreal, and AGBEF. Other specialized NGOs have been identified through a selection process after the first year of implementation. Component 4: Project Coordination and Facilitation. This component provides support to facilitate the programming, coordination and monitoring of project operations, including support to the HIV/AIDS committees. The project management component supports the incremental cost of the Executive Secretariat. The Secretariat includes a Monitoring and Evaluation unit where a contract monitoring system has been installed and funds have been made available for financing services provided by consultants. 5. Implementation The project is implemented by a large number of public agencies and civil society organizations. The CNLS Secretariat coordinates implementation of the project at the national level and is operating on the principle of "faire faire ". The Secretariat includes a maximum of six professional staff: a program officer, a procurement specialist, a financial and administrative specialist, a community initiatives/private sector coordinator, a public sectoral response coordinator, and a monitoring and evaluation specialist. Staff were hired through a competitive process. A number of tasks are being contracted out such as financial management and contracts monitoring. The CNLS is supervising the project implementation. Review groups are established to approve proposals made by public sector agencies and civil sector organizations. Each review group includes about seven representatives of the public sector and of the civil society. Regional, prefectoral and sub-prefectoral committees supervise implementation of action plans and proposals at local levels. The project puts in place decentral ized units such as “CRLS” and “CPLS” to help with certain administrative, financial and procurement aspects. The procedures for preparation, appraisal, approval, implementation and supervision of action plans and proposals are detailed in an operational manual. The manual includes procedures for procurement, financial management and monitoring and evaluation. To provide assistance to local groups, several specialized NGOs were identified and selected to train local groups to design AIDS prevention and care activities which can be financed by the project. Such NGOs already exist and are working with local communities, doing participatory diagnosis and identifying relevant activities. An NGO assessment was carried out in order to set up an open roster of NGOs from which Government is selecting those to be contracted for different services. Technical support is being made available from a Financial Management Agency whose responsibilities includes: (a) the establishment of a financial accounting management system including installation of appropriate financial management software that will meet Government of Guinea and IDA reporting requirements and a Contract Management system and; (b) the overall responsibility of the project's financial management by placing a full-time Financial Management Specialist in the CNLS Secretariat. Page 8 8 The contracts management system should allow the early identification of problem contracts and should provide the necessary checkpoints to trigger subsequent actions. It is linked to the financial and administrative procedures. 6. Sustainability The sustainability of the program depends on the degree to which the strategy and activities become fully owned by the various partners at national, regional, prefectoral, and local levels. It hinges on improved capacity at all levels to develop and implement action plans and proposals that are effective in changing behaviors and providing care and support to affected groups. 7. Lessons Learned from Past Operations in the Country/Sector Project design took into account the lessons learned from international experience with HIV/AIDS programs, and from the implementation of Bank-financed projects in Guinea. Key lessons that were learned from the experience under the MAP-I included: · Importance of political leadership and commitment. Experience showed that strong commitment from the top political and religious leadership in the country is important for the success of HIV/AIDS efforts. The President of the Republic of Guinea, the Government and the leaders of the major religious groups have demonstrated strong support for the program. · Need for a multi-sectoral approach. Experience in Guinea and in other countries had shown that HIV/AIDS control activities start in the health sector, but needed to be expanded to other sectors rapidly. · Need for community participation. Local communities have a key role to play in the prevention of HIV/AIDS, the care of infected people and the support to affected groups. The spread of HIV/AIDS results in a heavy burden to local communities. They need support to cope with the HIV/AIDS epidemic. They are able to express their requirements. Appropriate mechanisms were put in place to facilitate the provision of support. · MAP projects tended to lose momentum after Board approval. Funds available under a PHRD grant and a PPF were used to sensitize representatives of public sector and civil society organizations, to establish program coordination and implementation mechanisms and to train community development agents. · Importance of partnerships: some MAPs had been prepared very fast and other development partners were not involved enough. In Guinea the MAP worked through the UNAIDS group which was extended to other non-UN partners. · The tendency for some National AIDS Committee to become bureaucracies: this was taken into account in Guinea by limiting the CNLS to six professionals, and by not creating decentralized units. Page 9 9 · Importance of Monitoring and Evaluation. The design of the monitoring and evaluation system should focus on who will use the indicators and how they will influence the decision-making process. The initial PDO that committed the country to reverse the HIV incidence with the Project’s support was determined to be unrealistic because it is not possible to determine if the Project interventions would be solely responsible for having an impact on the incidence. 9. Environment Aspects (including any Public Consultation) Issues: The program is not expected to have major environmental impacts. The handling and disposal of HIV/AIDS-infected materials is the most significant issue. An assessment of current practices was carried out. A clinical waste management plan was prepared. The plan includes training on how to safely dispose contaminated blood and other materials. This training was delivered to health staff in the majority of the facilities. Health organizations benefiting from proceeds to the credit are required to demonstrate that they have safe methods of waste disposal and that the training provided to their staff includes precautions in handling sensitive materials. The waste management plan has been implemented and is currently under review. 10. Financing BORROWER: US$2m IDA: US$20m Total Project Cost: US$22m 11. Contact Point: Task Manager: Ibrahim Magazi The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: 225-22 400 400 Fax: 202-473-8216 12. For information on other project related documents contact : The InfoShop The World Bank 1818 H Street, NW Washington, I.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500