Madagascar - Multi-sectoral STI/HIV/AIDS Prevention Project

Report No. PID10213 Project Name Madagascar-Multisectoral STI/HIV/AIDS ... @ Prevention Project Region Africa Regional Office Sector HA - HIV/AIDS Project ID MGPE72987 Borrower(s) Government Of Madagascar Implementing Agency Address MSPP UNITe DE GESTION (UGP) Address: B.P. 248, Antananarivo, Madagascar Contact Person: Mr. Alain Randriamaherisoa Tel: 261 20 22 65449 Email: ugp@dts.mg Environment Category B Date PID Prepared November 14, 2001 Projected Appraisal Date November 14, 2001 Projected Board Date December 20, 2001 1. Country and Sector Background 2.1 Main sector issues:Although the prevalence rate of HIV/AIDS infection in Madagascar is currently estimated to be less than one percent, a low prevalence situation can easily explode if no proactive steps are taken. The risk of a rapid increase in Madagascar is very real given the alarmingly high rates of STIs, one of the most important risk factors.2.1.1. Current dimensions of the HIV/AIDS epidemic in MadagascarHIV was first diagnosed in Madagascar in 1984. In 1998, out of 13.9 million people, 37 AIDS cases and 233 HIV positive cases were reported to the World Health Organization (WHO) in that year. Epidemiological studies confirm that 96 percent of HIV infections were acquired through sexual transmission. The Ministry of Health has reported that HIV has more than doubled in three years, from 0.07 percent in 1996 to 0.15 percent in 1999. UNAIDS information, using sentinel surveillance data, show that HIV infection among antenatal clinic patients is increasing very rapidly. For example, in Tamatave, 0.2 percent tested positive in 1995, and 1 percent in 1996, a fivefold increase in one year. In the tourist areas of Antsiranana and Maroansetra, almost 1 percent of pregnant women attending antenatal clinics tested positive. HIV prevalence among CSWs in Antananarivo increased from 0.3 percent in 1995 to 1 percent in 1998, and two percent of the STI clinic patients in the capital tested HIV positive in 1998. Despite these periodic studies, however, the sentinel surveillance system has not been fully operational since 1996, creating doubts about the real prevalence of HIV/AIDS infection, particularly since different sources report conflicting results. Although a rapid increase in HIV/AIDS prevalence is associated with an increase in tuberculosis (TB), the National Tuberculosis Program in Madagascar has not noticed an abnormal increase in the number of new TB cases, but is monitoring the situation. Thus, with the exception of a few surveys in  urban areas, available data on HIV prevalence is unreliable, preventing any real conclusions about the status of the HIV epidemic. A comprehensive MOH-led epidemiological study is being launched and partly financed under the MSPP's PHRD grant. 2.1.2. Risk and Vulnerability FactorsExtremely High STI ratesThe country's STI rates - the most important risk factor along with unprotected sex - are extremely high. Studies indicate that in some areas, over 45 percent of the population have an active STI at any given time. Syphilis and gonorrhea rates, in particular, are among the highest in the world. In 1998, active syphilis in pregnant women was as high as 14.8 percent and over 35 percent among sex workers in some regions. In a May 2000 study of around 1000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. Prevention of STIs through condom use is critical in the fight against HIV/AIDS because ulcerative STIs, such as herpes genitalis and syphilis, increase the risk of HIV transmission by 50 to 300 times (male to female). High risk sexual behavior and misconceptions Women begin child bearing at a very early age. By the age of 18, half of all women have one child or are pregnant with their first. Lack of knowledge of effective prevention methods constitutes a major determinant. Almost two in every five young girls who knew about HIV/AIDS and were sexually active, did not know what a condom was and only 7 percent among them had ever used a condom (DHS 1997). Population Services International (PSI) ranked Madagascar last in the overall percentage of women who know about HIV/AIDS. Misconceptions regarding STI/HIV/AIDS are consistently reported among youth (15-19 years of age) including the belief that HIV/AIDS can be transmitted by insect bites, kissing, sharing dishes and touching someone with AIDS. Cultural barriers and misconceptions about transmission, may help to explain why condom use remains very low. Poverty (a vulnerability factor)Poverty is more likely to be associated with: (i) commercial sex; (ii) failure to use condoms; (iii) poor treatment of STIs; and (iv) lack of awareness of effective preventive measures. Poverty is rampant in Madagascar, where almost 70 percent of the population lives on less than US$1 a day. HIV/AIDS exacerbates poverty because of its negative impact on all aspects of development. Several studies by the Food and Agriculture Organization (FAO) have shown that HIV/AIDS can drive households into poverty by forcing sale of assets (e.g. livestock) to cover medical costs or by reducing household labor available for agricultural activities. This is particularly relevant for Madagascar where 78 percent of the national population lives in rural areas and 83 percent depend on agriculture. The high prevalence of STIs, combined with the high percentage of the poor who cannot afford to pay for STI treatment, is a strong argument for subsidizing STI treatments or making them available at no cost. Illiteracy associated with poverty, prevents the poor from access to relevant Information, Education, and Communication (IEC) messages. A high HIV/AIDS prevalence rate is also increasingly a factor considered by private sector investors when making strategic investment decisions, particularly in labor-intensive industries, such as mining, tourism and agribusiness. Stigma, fear and denialSince the Malagasy population has not yet seen the devastating impact that HIV/AIDS can have, the level of awareness and concern over the disease is low. Persons living with AIDS are feared and shunned by society. The government has begun to become more vocal but it will need to take a different approach to generate awareness and behavior change than in countries where the prevalence is high. 2.1.3 Low implementation capacity of actorsThe capacity to respond to the threat of STI/HIV/AIDS infection is insufficient in Madagascar. Financial, material - 2 -  and human resources are lacking. The institutions, other than the MOH, responsible for the response to curb the spread of HIV/AIDS have only been recently established and need capacity building. The sentinel surveillance system has not functioned properly for the last five years and needs to be strengthened. The large number of small initiatives have not been implemented in a coordinated effort. Organizational and management capacity also needs strengthening. Financial resources and materials are required to enhance and expand ongoing successful, critical programs. Implementation capacity is uneven across line ministries, and the majority of these ministries have not worked on HIV/AIDS issues in the past. With the exception of some religious groups, many civil society entities and NGOs are relatively young and inexperienced. The results of the institutional and organizational capacity assessment, carried out under the PHRD grant, indicate that sharing of information and lack of communication are major bottlenecks to implementation. 2.2. Government strategyThe CNLS, initially established as an inter-ministerial body, was created in 1990 under the MOH to manage the PNLS. Although the CNLS was later opened up to include religious groups, NGOs and other partners, it never managed to lead a multisectoral approach to HIV/AIDS. In 2001, the Cellule, under the Office of the Prime Minister, and its executive office -- the Bureau de Coordination national (BCN) -- headed by the national Focal Point were created to develop a multisectoral response to the fight against STI/HIV/AIDS. Despite the lack of a clear strategy over the past few years, the Government has been engaged in numerous activities mostly from a health perspective. These include:All health workers at district level were trained to systematically screen blood for HIV/AIDS and all were sensitized on blood safety issues. In addition, health workers in all health facilities were trained to diagnose and treat STIs according to the syndromic approach. The syndromic approach to STI management is available but not always consistently. STI treatment kits contain the necessary antibiotics to treat the STI; educational brochures (with pictures) to explain the STI and how to take the medicine; condoms for the duration of the treatment period; and a referral card for the usual sex partner. Prepackaged STI treatment in different kits is expected to facilitate the approach in both the public and private sectors in the near future. A USAID funded project (the Commercial Marketing Strategies project - CMS) was put into place in 1998 and is managed by a consortium of NGOs and private sector. The project began a national social marketing program for condoms with more than 25,000 selling points and 700 wholesalers, selling over 5 million condoms last year. CMS has reached hundreds of thousands of Malagasy using both innovative mass media (radio, television, special events) and interpersonal communication techniques, including its mobile video unit (cinemobile) and peer educators. It has worked with specific target groups (such as sex workers and truckers) and conducts workplace initiatives to guarantee condom distribution and basic STI/HIV/AIDS knowledge. This program needs to be scaled up to a level required to modify behavior and prevent further spreading of the infection.Staff of the BCN conducted field visits to seek active participation from civil society and the decentralized levels of government for the development and finalization of the NSP and the preparation of this project. The NSP is multisectoral and identifies a broader set of priorities for the future (see table below). Summary of the priorities identified in the NSPAreasStrategyPolicies and strategies- advocacy among religious and traditional leaders- development of a national HIV policy- application and monitoring of existing laws- participatory strategic planning- -3 -  strengthening of the monitoring systemMultisectoral mobilization- establishment of a multisectoral structure at all levels- appointment of focal points for each sector- inclusion of HIV/AIDS activities in all development projectsMonitoring of the epidemic- adoption of an appropriate methodology in a low prevalence country- operational research- expansion of the surveillance system- establishment of a multisectoral system of information sharing and dissemination.IEC- integration of IEC messages in traditional ceremonies- research on behavior change and the Malagasy context and culture- strengthening and scaling up of existing activities- development of a national communication strategySTI treatment- development of a national STI treatment program- development of MCTC prevention program- strengthening of health personnel in VCT- program for home treatment of prostitutes- promotion of professional ethics and confidentiality 2. Objectives The development objective of the Multisectoral STI/HIV/AIDS Prevention Project (MSPP) is to support the Government of Madagascar (GOM) in maintaining the prevalence rate of HIV/AIDS at less than the currently estimated 1%-. To do so, the project will scale up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor and contributor to the spread of HIV/AIDS. 3. Rationale for Bank's Involvement IDA's leveraged funding. Under the umbrella of UNAIDS, many donors are supporting the government's efforts to step up efforts to combat HIV/AIDS. However, no donor alone is able to mobilize the amount of resources necessary to finance the government's National HIV/AIDS Strategic Plan. IDA's support to the NSP is leveraged by the ongoing portfolio, including the Second Health Sector Support project, the Education Sector Development project, the Transport project and the Mining project, the approved PHRD Grant for this project (in the amount of US$452,400), the Poverty Reduction Strategy process, and the allocation of HIPC resources. Cross country experience: The Bank is the largest financier of HIV/AIDS and STI control projects and contributes its experience in the design, implementation and evaluation of these programs. Through its regional AIDS Campaign Team for Africa (ACTafrica), the Bank is well-positioned to provide Madagascar with regional and international experiences and lessons learned. Moreover, through its involvement in various sectors in Madagascar and its experience with supporting decentralized, community-based projects, such as the social fund projects and the two community nutrition projects, IDA is well placed to assist the Government in undertaking the national effort to fight HIV/AIDS in a truly multisectoral and community-oriented manner. 4. Description This project contributes to financing the NSP to curtail the spread of STI/HIV/AIDS. It consists of four components:1) a Fund to finance existing and new HIV/AIDS preventive sub-projects;2) Development of key sector strategies and sector action plans, and financing of pilot projects;3) a Monitoring and Evaluation system; and4) Project Management and Capacity Building. The project builds on activities already underway, creates synergies with ongoing interventions and projects, and utilizes existing structures to implement its interventions. This credit is but one of many sources of technical and financial assistance with other donors - 4 -  contributing to the fight against HIV/AIDS with both new and on-going projects. The details of the project components are described in Annex 2. 1. Fund for HIV/AIDS Prevention Activities 2. Development of Sector Strategies, sector Action Plans and Financing of Pilot Sub-Projects 3. Monitoring and Evaluation 4. Project Management and Capacity Building Contingencies 5. Financing Total ( US$m) BORROWER 0.7 IDA 13.37 LOCAL COMMUNITIES 0.58 Total Project Cost 14.65 6. Implementation Institutional Set-UpThe Cellule, chaired by the Directeur du Cabinet of the Office of the Prime Minister, is responsible for: (i) guiding the development of the NSP and defining priorities; (ii) ensuring the coherence of national and regional HIV/AIDS activities and issuing guidelines to the BCN; (iii) providing comments on the UGP's annual work program and budget; (iv) approving annual technical and financial audits and providing recommendations for follow-up to all reports; and (v) approving requested - by UGP - modifications to the Manuel de Procedures of the Fund. The Cellule was established by decree and is made up of representatives of key ministries, civil society organizations and NGOs.The BCN is the executive secretariat of the Cellule and is responsible for ensuring coordination of all multisectoral HIV/AIDS activities in Madagascar. In this capacity, the BCN performs the following functions: (i) organizes meetings of the Cellule and prepares minutes; (ii) collects, analyzes and disseminates data and information on HIV/AIDS ongoing activities; (iii) distills, collects and disseminates good practices; and (iv) applies the Cellule's guidelines for national coherence. To ensure the BCN's ability to undertake these responsibilities, its capacity and infrastructure will be assessed and capacity gaps identified during appraisal. Strengthening of capacity through providing opportunities for study tours and other training are being financed under the PPF. The UGP ensures the day-to-day execution of MSPP activities and reports directly to the Office of the Prime Minister, which reviews and approves the annual work program, implementation results and outcomes, and the budget. It is directly responsible for: (i) development of the annual work program and budget; (ii) financial management oversight of project components and the Financial Management Agency (FMA) in charge of the financial management of component 1; iii) the consolidation of project accounts and the production of annual financial statements and quarterly Financial Monitoring Reports (FMRs) in compliance with international accounting standards and IDA requirements; (iv) procurement and disbursement activities; and (v) oversight of the monitoring and evaluation (contracted out locally) of the project.Civil society organizations (including NGOs, religious organizations, women's and farmers associations, unions, and private enterprises) as well as private sector bodies will be contracted to implement project activities. The financial management of the project will be contracted out by the UGP to a FMA in line with MAP best practice experience of contracting out - 5 -  project administration and coordination activities to established experts (see Annex 2). To drive the development of the various sector strategies, a tripartite comite sectoriel (CS) have been established for each sector, made up equally of representatives of public, private and civil society organizations. Members are selected by their peers. One or more representatives of each CS will also sit on the national Comite Inter-sectoriel (CIS). The CIS will coordinate the development of sectoral policy, ensure coherence between sectors, prevent duplication of efforts, and lead the development of national sectoral operational activities. Moreover, the CIS will be responsible for approving requests to the MSPP/Fund over $25,000. Since certain HIV/AIDS prevention activities are the health sector's responsibility directly and fall within the mandate of the MOH; specific attention must be given the role of the MOH within this framework. b) Flow of fundsA chart showing the flow of funds is given below:To ensure timely and reliable flow of funds, two special accounts will be opened as follows: The Special Account Funds (S/A: A) will be managed by the FMA and will cover transactions related to component l;The Special Account B will be managed by the UGP and will cover transactions related to components 2,3 and 4.To facilitate the operation of FMA's provincial/regional offices and to ensure prompt payment of service providers, the "special account 90-day advance procedure" will be used. Under this procedure, the FMA will advance funds sums covering no more than 90 days estimated expenditures to provincial/regional FMA offices based upon approved budgeted work plans. Subsequent replenishments should be based on periodic (monthly or quarterly) consolidated reports accompanied by reconciled bank statements while supporting documents are kept at the level where expenses are incurred and paid for examination by external/internal auditors and bank staff.The initial advance to contractors (NGOs, CBOs, civil society, other organizations) will be made in conformity with the terms of contract signed between the FMA and the contractors. Subsequent payments will be based on review of periodical progress reports (financial and physical) submitted to the provincial/regional FMA by the contractors. The project implementation and accounting manuals will describe in details all procedural aspects regarding financial management (payments, replenishment, reporting, internal control) and reference to the procedures outlined in these manuals will be indicated in the DCA.c) Audit arrangements The project financial statements (for all components) will be audited in accordance with international audit standards by independent and experienced auditors acceptable to IDA. The auditors will review and provide opinion on the financial statements, the special account (one for each executing agency) and statements of expenditures. The auditors will be also required to carry out a comprehensive review of the internal control procedures and provide a management report outlining any recommendations for their improvement. The auditors report will be submitted to IDA not later than 6 months after the end of each fiscal year. The terms of reference of the audit will be reviewed with the financial analyst of the Bank/IDA. A financial and technical audit of sub-projects should be also carried out by auditors on a selective basis to ensure the efficient use of funds for intended purpose. 7. Sustainability The project is expected to become institutionally sustainable during implementation. It is built on strong government ownership and emphasizes the strengthening of the capacity of all players, including civil society - 6 -  and the private sector. The Cellule de Coordination, who will oversee the implementation of the NSP, will be strengthened. The coordination and advocacy role of the executive secretariat of the Cellule, the BCN, will be also be developed and strengthened while the UGP will build capacity in management, financial management, procurement and monitoring and evaluation through transfer of knowledge from the various contractors. At present, 3 percent of the HIPC funds have been allocated to the fight against HIV/AIDS and it is the role of the Cellule to ensure and sustain the flow of government funds to this cause. 8. Lessons learned from past operations in the country/sector 1. Stakeholder and donor collaboration. The project was prepared in close consultation with the UNAIDS theme group and bilateral donor agencies as well as civil society. In addition, the UNAIDS theme group is spearheading the production of an Inter-Agency Program to support the government in its fight against HIV/AIDS, of which this project forms part. The development of this document was undertaken by a diverse working group that meets regularly and includes representatives from NGOs and civil society. This document also forms the basis for the gap-analysis that was undertaken during appraisal to better define the activities to support under the MSPP. A successful collaboration has begun between public, private and NGO sector in the promotion and distribution of condoms, within the larger framework of behavioral change. SOMARKT and CMS in Madagascar are private/commercial actors and the main distributors of condoms. Nonetheless, several issues remain, such as cost recovery and pricing, that need to be resolved in order to create conditions for self-sustaining service providers. The project will address these issues and in principle, follow the existing scheme of promotion and distribution.2. Need for multisectoral approach. Experience around the world and in Madagascar shows that there is a need for a multisectoral approach to the prevention of the spread of HIV/AIDS, since this epidemic is not just a health problem but also a development challenge. Key ministries as well as representatives in the private sector and civil society of all sectors have been involved in the development of the NSP and continue to be involved through the MSPP. The second component of this project targets specifically these partners in developing sector strategies and operational plans that will lead to the financing of activities as part of a larger country strategy. At the same time, the role of the Ministry of Health is recognized as key particularly in the reduction of risk factors. For example, early appropriate STI treatment can reduce HIV transmission by over 40 percent; therefore consideration will need to be given to providing universal free or highly subsidized access to the syndromic approach based STI treatment. 3. Importance of Socio-Cultural Context. Madagascar is unique in its socio-cultural environment blending traditional beliefs from Africa and Asia (specifically Indonesia). Evaluation of various IEC efforts in Madagascar indicates that efforts have generally been made in developing 'information' rather than 'action-based' messages. The clear link between information and specific behavioral change has not been evident nor pursued. The project will therefore emphasize the adaptation of the IEC messages to the Malagasy socio-cultural context. An analysis of the behaviors, attitudes and practices of individuals, high-risk groups and communities toward sex, use of condoms, and incidence of STIs, by specific characteristics of each province (KAP studies), is being undertaken under the PHRD grant. This analysis facilitates the more defined identification of high-risk groups -7 -  (CSWs, truckers and taxi-brousse drivers) and high risk communities (urban slums, people living next to tourist resorts, mining communities, etc.) for which special targeted sectoral interventions will be developed. 4. Importance of Data for Monitoring and Evaluation. M&E is critical for evaluating progress and impact of project activities and in turn, formulating lessons learned, good practices and any corrective measures to be periodically incorporated into the project. An adequate STI/HIV/AIDS surveillance system is essential for effective monitoring and evaluation of the impact of the activities. The PHRD grant, in collaboration with the Center for Disease Control (CDC), will contribute to the financing of a MOH-led comprehensive cross-sectional epidemiological study of HIV/AIDS and STIs by specific characteristics and profile of each province. This will ensure a precise diagnosis of the epidemic at the country level. 5. Contracting out of Financial Management. Lessons from the MAP highlights the importance of contracting out financial management of project activities to ensure: (i) rapid disbursement and handling of a large volume of transactions by an experienced agency; (ii) enhanced transparency; (iii) minimal establishment of new structures to avoid duplication; (iv) clear contractual obligations and performance monitoring; (v) knowledge transfer from FMA to the implementing agency during the contract period; and (vi) cost efficiency in the FMA undertaking mandated functions, such as audits. Criteria have been developed (and are included in the Manuel of Procedures of the Fund) for the selection and evaluation of a financial management agency. The UGP will use performance-based contracting to ensure maximum efficiency. 9. Program of Targeted Intervention (PTI) Y 10. Environment Aspects (including any public consultation) Issues : Environmental category B rating. A medical waste plan will be prepared before effectiveness. The plan will include specifications regarding the institutional arrangements for implementation of the plan and accountability, and will include a cost budget. 11. Contact Point: Task Manager Claudia Rokx The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: 202 473 3619 Fax: 202 522 3234 12. For information on other project related documents contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-5454 Fax: (202) 522-1500 Web: http:// www.worldbank.org/infoshop Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. - 8 -  This PID was processed by the InfoShop during the week ending November 30,2001 -9-