Page  1
1
INTEGRATED SAFEGUARDS DATA SHEET 
CONCEPT STAGE 
Report No.:  AC1333 
 
Date ISDS Prepared/Updated: March 3, 2005 
 
I.  BASIC INFORMATION 
 
A.  Basic Project Data 
 
Country: Madagascar 
Project ID: P090615 
Project Name: Second Multisectoral 
HIV/AIDS project 
Task Team Leader: Nadine T. Poupart 
Estimated Appraisal Date: April 1, 2005 
Estimated Board Date: September 30, 2005 
Managing Unit: AFTH3 
Lending Instrument: Specific Investment 
Loan 
Sector: Other social services (65%); Health 
(35%) 
Theme: HIV/AIDS (P); Other 
communicable diseases (P); Participation 
and civic engagement (S); Gender (S); 
Other social protection and risk 
management (S) 
Safeguard Policies Specialists in the task team:  Hope Neighbor 
Loan/Credit amount ($m.):  
IDAH: 30 
Other financing amounts by source:  
Borrower 
($m) 
1.5 
B.  Project Objectives  
 
The project development objectives would be to support the Government of 
Madagascar’s efforts to promote a multi-sectoral response to the HIV/AIDS crisis, and to contain 
the spread of HIV/AIDS on its territory.   
 
To achieve its objectives, the project will build capacity and scale-up the national 
response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and 
contributor to the spread of HIV/AIDS.   In addition, the MSPP II will also seek to improve the 
quality of life of persons living with HIV/AIDS through increased accessibility to quality 
medical care and non-medical support services.  The current HIV prevalence rate is estimated at 
0.93%.  Because the rate is low, the project will continue to focus at-risk groups in high 
prevalence areas, while offering limited services to other affected populations. 
 
The project will maintain its support the three “ones” principles of one national 
HIV/AIDS policy framework, one national coordinating authority, and one national M&E 
system.  The project will: (i) revise the national strategic framework to incorporate the results of 
the recent studies, include the proposed interventions of the various partners, and serve as a 
Page  2
2
consensus-based management tool for the period 2007-2010; (ii) maintain the institutional 
arrangements which were carefully established during MSPP I, but will revise the different 
operational manuals to reflect improved capabilities and to streamline existing procedures; and 
(iii) ensure that the management information system (MIS) funded by MSPP I serves the needs 
of the national monitoring and evaluation strategy as well as those of all partners.  As needed, the 
MSPP II will support revisions to the MIS system. 
 
C.  Project Description  
 
The proposed project will include five components: 
 
Component 1:  Harmonization, Donor Coordination and Strategies.
 
Under MSPP I, eight 
different sectoral strategies were developed, but the process has been difficult and the results 
tentative at best.  This component will be revised to include donor coordination, the updating of 
the national strategy, and a more selected support to sectors.  This component will emphasize 
five activities:  
(i) 
Harmonization and Donor Coordination
:
This activity will support practical 
mechanisms of coordination among donors to ensure better impact and cost-
efficiency of HIV/AIDS interventions.  Although Madagascar has achieved two 
of “Three One principles” (one national authority for HIV/AIDS, and one 
strategic framework) donor coordination needs to be intensified, particularly on 
the M&E system.
 
(ii) 
Updating of the National Strategic Plan 
.
The current Plan covers the period 
through the end of 2006, and will need to be updated and re-validated thereafter. 
(iii) 
Updating and piloting of the MSPP II communications strategy
.
Though 
knowledge of HIV and information on prevention is now relatively widespread,
1
actual sexual practices remain risky,
2
and stigma strong.  The MSPP II will update 
the communications strategy that will maintain mass media campaigns,  but will 
place more emphasis on grassroots communication (small groups, peer to peer 
education, etc.) for behavioral change, particularly in the most at risk places, and 
reduction of stigma.  
(iv) 
Support for Implementation for a limited number of sector strategies 
and action 
plans (two to three)
.
The health sector and sectors which focus on high risk 
groups (e.g. Education for the youth, Defense for the militaries etc.) will receive 
priority.  If  implementation progresses satisfactorily, the number or sectors may 
be expanded during the course of the project.  
1
The DHS 2003-04 showed that knowledge of HIV/AIDS satisfactorily progressed since 1997 from 69% to 79% for 
women and it is at 88% for men in 2003. 
2
The 2004 pilot PLACE survey among risk groups in certain hot spot areas showed  that condom use by women 
with non regular partners varies between highs of 71% (Mahajanga) and lows of 24% (Ilakaka).
 
Page  3
3
(v) 
Support to local authorities
.
MSPP II will increase the number of commune-level 
AIDS councils (CLLS), particularly in the most affected areas, and will provide 
technical support for planning the communal response (
Plans Stratégiques 
Locaux
). 
Component 2:  Support for Health Sector Response
.
Under the MSPP I, the Ministry of 
Health was involved only in the implementation of a major STI program, and the implementation 
of the medical waste management plan.  The involvement of the health sector will be 
strengthened under the MSPPII.   This component will provide funding to the Ministry of Health 
to fight HIV/AIDS, complementing general funding to the sector provided through the Second 
Health Support Project ($40 million for the original credit and $22 million for a supplemental 
credit that will be submitted to the Board in early FY06).
3
It will target high risk places, persons 
living with AIDS (PLWHA), and their families and care-takers.  Examples of activities to be 
financed under this component are provided below.      
(i) 
Support for STI control
.
MSPP I made a significant effort to control STIs by 
financing a) training based on the Syndromic Approach and b) the sale of two STI 
treatment kits at subsidized prices in both the public and in private sectors
4
.
MSPP II 
will expand these activities. 
(ii) 
Support for care and treatment of PLWHA
.
Based on the preliminary experience of 
the IDA-financed Regional Treatment Acceleration Program (TAP),  and on the 
Interim Review of the MAP Program in Africa, MSPP II will help the Ministry of 
Health establish a range of complementary services such as:  (a) expansion of the 
VCT centers in all district hospitals and in health centers in high-risk areas
5
;
(b) 
psycho-social, nutritional, and other support for persons infected and affected by 
HIV/AIDS, including home-base care; and (c) treatment of PLWHA, including 
PMTCT, and treatment of opportunistic infections. 
(iii) 
Other health sector response activities.  
MSPPII  will provide complementary 
funding as needed to activities supported by other donors such as laboratories and 
ARVs (mainly supported by the Global Fund), and blood transfusion (mainly 
supported by the African Development Bank).  It may also finance some human 
resource development. 
Component 3: Fund for STI/HIV/AIDS Prevention and Care-taking Activities
.
Under 
MSPP I, some 850 NGO, CBO, and association-sponsored sub-projects have contributed to a 
range of preventive interventions in higher prevalence areas.  These activities will be pursued but 
with a stronger effort to identify the places where the population is at greatest risk of being 
3
The objective of this project is to contribute to the improvement of the health status of the population through more 
accessible and better quality health services. 
4
More than 400,000 STI kits for genital discharge were sold in 2004 at approximately $0.5 through social marketing 
in the private sector and at $0.35 in the public sector.  STI kits for genital ulcer are being commercialized through 
social marketing and will soon be available in the public sector at the same price.   However, this activity has not 
been evaluated.  
5
Along with the reconstruction/rehabilitation of 300 health centers, a comprehensive needs assessment was recently 
performed at district (first-referral) level providing the needed information to prioritize the creation of VCT centers 
and the strengthening of lab facilities.   
Page  4
4
infected or of transmitting the infection.  Under MSPP II, sub-projects will continue to include 
condom distribution. 
 
Communication activities will shift from general knowledge (the 
traditional Information Education and Communication (IEC) to Behavioral Communication for 
Change  (BCC).  NGOs and CBOs will be encouraged to engage more heavily in care-related 
activities such as VCT, home-base care, community support for PLWHA and associations of 
PLWHAs, and programs for orphans and vulnerable children.   NGOs and CBOs will be 
encouraged to work with at risk groups to increase their demand for HIV/AIDS services, to 
implement outreach programs, training of peer educators, training of counselors, reducing stigma 
and discrimination against PLWA.  The MSPP I developed standardized activities to increase the 
Fund’s effectiveness and methods of avoiding over-programming for geographic areas and target 
populations. These tools will be updated, and used under the proposed project.  The update may 
be based on an assessment of the Fund impact
6
,
and on an ex ante cost-effectiveness analysis of 
the Fund’s interventions, using the “Allocation By Cost-effectiveness” model
7
.
Component 4: Monitoring and Evaluation System
.
A
Monitoring Plan will be built upon the 
management information system (MIS) which is already operational at the MSPPI.  This existing 
MIS is composed of 4 sub-systems (sectors, Fund sub-projects, structures and PIU operations).  
Although the system is in place, it will need to be strengthened to allow for a more detailed 
analysis of data (below the province level), and to include the new project activities.   In addition 
to supporting ongoing collection of comprehensive data on financial and physical inputs, the 
project will monitor key project outputs by carefully and rigorously sampling selected 
performance indicators over time.  In order to achieve the necessary rigor at minimum cost, the 
project will apply the techniques of Lot Quality Assurance Sampling (LQAS) and other sampling 
techniques as deemed appropriate during project implementation.   
Key project indicators subject to sampling by LQAS methods (Annex 1) will continue to include: 
(i) increases in the proportion of the population knowledgeable about STIs/HIV/AIDS; (ii) 
increases in condom use; (iii) reduction of the population with more than one regular sex partner 
over a year’s time; and (iv) decreases in the rate of STIs.  Since some key indicators from MSPP 
I
were too ambitious (particularly attitudinal and behavior change regarding prevention within a 
four-year timeframe) or inappropriate (e.g., the measurement of gonorrhea rather than syphilis to 
measure STI Levels) or unavailable (because they were not part of the national M&E plan), these 
will be dropped and a small number of other indicators will be agreed on at appraisal with the 
GOM and its partners (within the framework of the "Three Ones"). Among the criteria for 
choosing these additional indicators will be whether they can be feasibly collected, whether they 
are likely to vary in the population over the project horizon, and whether they are more than just 
measures of inputs.   
To monitor changes in knowledge, risk behavior and in the epidemiology of the virus, the project 
will continue to support a systematic "second-generation" surveillance system by contributing to 
the conduct of large-scale surveys and studies. This will include biannual behavioral surveillance 
6
Requested during the MSPP I Mid-Term Review (December 2004) 
7
The « Allocation By Cost-effectiveness »  or ABC model will determine the resource allocation that will prevent 
the maximum number of new HIV infections at any given budget level.  
Page  5
5
surveys among high risk groups (sex workers, truck drivers, military, and youth)
8
,
and annual 
biological surveillance surveys (sex workers, pregnant women, and IST patients)
9
.
The Evaluation Plan will contain an evaluation framework which identifies the strategic linkages 
between AIDS-related government inputs (whether or not they are supported by Bank
 
financing) 
and outcomes and then proposes additional specific data collection efforts which will permit the 
Malagasies and the Bank to evaluate the impact of the inputs on these outcomes and ultimately to 
maximize the cost-effectiveness of their intervention strategy .  The additional data collection 
will extend in two key ways what would be collected for monitoring alone.  First, data would be 
collected in areas where project implementation has either not started or is less advanced as well 
as in areas where project implementation is proceeding rapidly.  For example, LQAS techniques 
will be applied to assess the difference in indicator values in areas that have undertaken 
community initiatives in comparison with those that have not yet done so.  This comparison 
should lead to inferences about the conditions under which the value-added of the community 
initiatives can be maximized.  Second, LQAS and other appropriate sampling techniques will be 
used to focus measurement of changes in knowledge, behavior and STI incidence tightly at the 
site(s) of the intervention.  Building on the results of the PLACE surveys, the evaluation 
component will sample the people who can be found at the social meeting spots to track 
reductions in risk behavior that occur after interventions are introduced at those sites.  Similarly, 
focused sampling will be used to evaluate the efficacy of the current practice of distributing STI 
treatment kits over the counter rather than by  prescription.  The appraisal document will contain 
a
small prototype cost-effectiveness analysis of the government's HIV prevention and treatment 
interventions as an example of the kind of analysis that will be possible with much more 
precision based on the project's implementation of the monitoring and evaluation framework. 
Component 5: Project Management and Strengthening of Institutional Capacity Building.  
MSPP II will support the institutional arrangements and operational modalities established under 
MSPP I, at the central level (CNLS, the PMPS Council, and UGP), at the provincial level (BCP), 
and at the regional level (UCL).  This component will finance 
part of  each level’s staff, 
equipment and operating costs; periodic technical assistance;  and some training based on annual 
capacity building plans. 
D.  Project location (if known) 
 
Project activities will be implemented nationwide.
 
E.  Borrower’s Institutional Capacity for Safeguard Policies [from PCN] 
 
1.1 
The borrower has demonstrated the capacity to properly develop and implement a 
Medical Waste Management Plan (MWMP).  The MWMP is the only safeguard-related study 
required for this project.   
 
1.2 
A MWMP was developed for the MSPP I, approved and has been implemented since 
May 2004.  Under the MSPP I, three different agencies were responsible for, respectively: (i) 
8
The baseline survey was completed in 2004 
9
The baseline survey is under preparation and will be carried out in 2005.   
Page  6
6
ensuring development and implementation of the MWMP; (ii) implementing the plan; and (iii) 
supervising implementation of the plan at the provincial and district levels. 
1.3  
·
Ensuring development and implementation of the plan
:
The Project Implementation Unit 
(Unité de Gestion du Projet, UGP) has been responsible for ensuring development and 
implementation of the MWMP.  The UGP has satisfactorily fulfilled this role, supervising 
implementation of the MWMP according to the agreed-upon calendar and undertaking 
additional activities in support of implementation of the plan (national kick-off ceremony, 
annual evaluations of the plan).   
·
Implementing the plan
:
The Ministry of Health and Family Planning (MoH) has been 
responsible for implementation of the MWMP, and has demonstrated capacity to properly 
implement the plan.  Since May 2004, the MoH has installed 200 small-scale burners to 
burn medical wastes in all 200 health centers rehabilitated under the Second Health 
Sector Support Project.  Recent supervision found that burners are being used at the CHD 
of  Ankazobe, Antanifotsy and Faratsiho.  The construction of full incinerators at district 
level is underway, and some of them should be functional by June 2005.  The Plan also 
includes specific medical waste disposal and management actions, to be carried out in 
Madagascar’s different types of health facilities.  The MoH has demonstrated the ability 
to plan for and prepare these activities, as well.   
·
Supervising implementation of the plan:
The Office for the Environment of the Ministry 
of the Environment (MINENV) has been responsible for supervising its implementation 
at the provincial and district level.  It has performed this role satisfactorily. 
Page  7
7
II.  SAFEGUARD POLICIES THAT MIGHT APPLY 
 
Applicable?
Safeguard Policy 
If Applicable, How Might It Apply? 
[x] 
Environmental Assessment
(
OP
/
BP
4.01) 
Because the project involves risks associated with the handling and disposal of HIV-
infected materials.  These risks potentially affect personnel in hospitals, health centers 
and municipalities who handle waste, families whose income derives from the triage of 
waste and also the general public, to the extent that waste is not disposed of on-site nor 
safely contained in protected areas.   
[
]
Natural Habitats
(
OP
/
BP
4.04) 
[
]
Pest Management
(
OP 4.09
)
[
]
Involuntary Resettlement
(
OP
/
BP
4.12) 
[
]
Indigenous Peoples
(
OD 4.20
)
[
]
Forests
(
OP
/
BP
4.36) 
[
]
Safety of Dams
(
OP
/
BP
4.37) 
[
]
Cultural Property
(draft OP 4.11 - 
OPN 11.03
)
[
]
Projects in Disputed Areas
(
OP
/
BP
/
GP
7.60)
*
[
]
Projects on International Waterways
(
OP
/
BP
/
GP
7.50) 
Environmental Assessment Category:  
[
]
A
[X] B   [ ] C   [ ] FI   [ ] TBD (to be determined) 
 
If TBD, explain determinants of classification and give steps that will be taken to determine that 
EA category (mandatory): 
 
III.  SAFEGUARD PREPARATION PLAN 
 
A. 
Target date for the Quality Enhancement Review (QER), at which time the PAD-stage 
ISDS would be prepared.
 
*
By supporting the proposed project, the Bank does not intend to prejudice the final determination of the parties' claims on the 
disputed areas
 
Page  8
8
Not applicable.  The QER requirement was waived by the Sector Manager and the Country 
Director, as permitted under AFR guidelines on Repeater and Second Round HIV/AIDS 
Projects, each dated January 26, 2005. 
 
B.  For simple projects that will not require a QER, the target date for preparing the PAD-
stage ISDS 
 
The PAD stage ISDS will be prepared by March 10, 2005.   
 
C. 
Time frame for launching and completing the safeguard-related studies that may be 
needed.  The specific studies and their timing
10
 should be specified in the PAD-stage 
ISDS.
 
As noted above, the only safeguard-related study needed for this project is a Medical Waste 
Management Plan.  The MWMP was prepared for the first Multisectoral STI/HIV/AIDS 
Prevention Project, and was approved. The MWMP will be disclosed under the MSPP II prior to 
project appraisal, in-country and in the InfoShop. 
 
The existing MWMP includes proper disposal of hazardous bio-medical waste and a bio-safety 
training program for the staff of all hospital, health centers and community-based programs, 
including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and 
treatment. 
 
Though not required for HIV/AIDS projects, an Environmental Assessment of the Health Sector 
(which included HIV/AIDS) was also carried out as part of the preparation of the IDA financed 
Health Sector Support Project (CRESAN 2).   
 
The safeguards review and clearance responsibility has been accepted by the sector manager.   
 
IV.  APPROVALS 
 
Signed and submitted by: 
 
Task Team Leader: 
Nadine T. Poupart 
Date 
 
Approved by: 
 
Regional Safeguards Coordinator: 
Thomas E. Walton 
Date 
Comments 
 
Sector Manager: 
Laura Frigenti 
Date 
Comments 
10
 
Reminder: The Bank's Disclosure Policy requires that safeguard-related documents be disclosed before appraisal (i) at the 
InfoShop and (ii) in-country, at publicly accessible locations and in a form and language that are accessible to potentially affected 
persons.
 
Page  9
9