Tanzania - Multi-Sectoral AIDS Project

Updated Project Information Document (PID) Report No: AB132 Project Name TANZANIA-Multi-Sectoral AIDS Project Region Africa Regional Office Sector Other social services (75%); Health (25%) Theme Fighting communicable diseases (P); Civic engagement, participation and community driven development (P); Health system performance (S); Population and reproductive health (S); Vulnerability assessment and monitoring (S) Project P071014 Borrower(s) GOVERNMENT OF TANZANIA Implementing Agency(ies) GOT Address: Prime Minister's Office Magogoni Street, P.O. Box 3021, Dar es Salaam, Tanzania Contact Person: Ms. Rose Lugembe, Permanent Secretary Tel: 2135076, 2117249 Fax: +255-22-2121981 Email: PS@PMO.GO.TZ Environment Category B (Partial Assessment) Date PID Prepared June 18, 2003 Auth Appr/Negs Date April 28, 2003 Bank Approval Date July 3, 2003 1. Country and Sector Background The first AIDS cases in Tanzania were recorded in 1983. Since then the epidemic has increased to a level where UNAIDS estimates that at the end of 1999 about 8.1 % of the adults in the country were infected with HIV and about 1.3 million people were estimated to be living with HIV/AIDS. About 140,000 people are estimated to have died due to AIDS in 1999 alone. The number of orphans created by the AIDS epidemic was estimated to be 1.1 million (cumulative), 700, 000 of whom were estimated to be alive in 1999. HIV/AIDS has also had an impact on the occurrence of tuberculosis which is having a significant resurgence with unusual presentation and a tendency to emergence of multidrug resistance strains. The HIV epidemic in Tanzania has affected both urban and rural areas. The peak age group of infected females is the 25-29 year old group, while amongst males it is the 30-34 year old group. Generally females acquire HIV infection at an earlier age compared to males. A survey in 1999 found that the under-five mortality rate, including child and infant mortality rate, has not decreased over the past three years, this is attributed to the HIV/AIDS epidemic. Widespread illness and deaths due to HIV/AIDS are projected to lead to a reduction in GDP. Presently, some of the most productive age-groups in society are thought to be infected by HIV and the productive sectors are experiencing a loss of skilled labor, increasing costs for recruitment and benefits, and reduced productivity. Government response In Tanzania, the presence of HIV/AIDS was recognized quite early on, primarily as a health issue. The response to HIV/AIDS underestimated the extent to which it would spread and the devastating impact it would have on social and economic development. Institutional efforts to control the spread of HIV in Tanzania date back to 1985 when a Short Term Plan was prepared by the Ministry of Health for 1985 and 1986. Since 1985, three national plans have been formulated  2 PID to guide the Tanzanian National AIDS Control Program. The First Medium Term Plan (MTP-I) covered 1987 - 1991, the Second Medium Term Plan (MTP-II) covered 1992 - 1996, and the Third Medium Term Plan (MTP-HII) covers 1998 - 2002. Significant progress has been made by government over the past year aimed at putting in place the institutional framework required to effectively scale-up the response against HIV/AIDS in Tanzania. Several important accomplishments are worth mentioning. First, there is growing commitment among national and local leaders - political, religious and commercial - to encourage all members of society to play a role in stopping the spread of HIV and care for those affected. Secondly, the President established the Tanzania Commission for AIDS ( TACAIDS ). This body is expected to provide the strategic leadership necessary to galvanize the national social movement to effectively reduce the spread of HIV/AIDS. Thirdly, the Poverty Reduction Strategy includes HIV/AIDS as a central development challenge requiring that all sector and district plans address this issue. And finally, there is a draft national policy on HIV/AIDS that cuts across disciplinary and institutional sectors to provide the framework for a national response. The Government of Tanzania has requested access to IDA resources within the framework of the umbrella Multi-Country HIV/AIDS Program (MAP) for the Africa Region approved by the Board of Directors of the World Bank Group on September 12, 2000. Tanzania would be eligible for MAP funding if it satisfies the following four MAP criteria: a) Satisfactory evidence of a strategic approach to HIVIAIDS. Tanzania should have a coherent national, multisectoral strategy and action plan for HIV/AIDS prevention, care and treatment that has been developed through a participatory approach. Tanzania has draft HIV Policy and Strategy documents for a multi sectoral response. b) A high level HI V/AIDS coordinating body. Tanzania should have a national AIDS Commission which will have broad representation of key stakeholders from all sectors, to oversee and coordinate the implementation of the National HIV/AIDS policy. The creation of TACAIDS has been announced by the President and is in the late stages of being formalized as a semi autonomous body under the Prime Minister's Office. c) Government agreement to use appropriate implementation arrangements. Government has to agree to accelerate project implementation by channeling funds directly to civil society organizations, communities and decentralized sub-national levels of project implementation. The Govemement is committed to channeling funds to civil society and to use whatever is the most effective means to do this, across the whole country. d) Government agreement to use andfund multiple implementation agencies. Government has to agree within the public sector to expand HIV/AIDS activities to a broad range of ministries, departments and parastatals, as well as to fund activities undertaken by the private sector, the civil society organizations including non-government and community-based organizations, and AIDS service providers. Government has to agree to further expand HIV/AIDS activities to community level and to support community initiated HIV/AIDS activities. The government is planning a wide multi sectoral approach. It is still evaluating what implementation modes are, or may be successful in Tanzania.  3 PID 2. Objectives The project will support the goal of the Government of Tanzania which is to reduce the spread of HIV in the general population of Tanzania through multisectoral action involving Government, Non-Government, Civil Society and community organizations. While the project development objective is the reduction of the spread of HIV in the general population of Tanzania, the mitigation of the health and socio-economic impact of HIV/AIDS at individual, household and community levels and the strengthening of national capacity to respond to the epidemic will also be supported as activities of the project. 3. Rationale for Bank's Involvement The Bank has the unique position of being able to give support to a country in more than one sector, and having identified HIV/AIDS as a development issue, is well positioned to support Tanzania in a multisectoral war-like effort to control HIV/AIDS, as envisaged in the MAP approach. The IDA Africa regional HIV/AIDS line of credit, against which the present project will be drawn, gives the unique opportunity for Tanzania to give a speedy and enhanced response to HIV/AIDS, which is an urgent development challenge. 4. Description The project, under the Multi-Country AIDS Program (MAP) for Africa, will finance HIV/AIDS activities for a period of five years between 2002 and 2007. It will have the following three components: 1. Civil Society Fund 2. Public Multi-Sector Fund 3. Tanzania AIDS Commission Institutional Support Activities to be supported by the project will be co-ordinated by the Tanzania Commission for AIDS (TACAIDS). The purpose of the project would be to scale up and accelerate the national response to the HIV/AIDS epidemic taking into account the priorities identified in the draft HIV/AIDS policy and draft HIV/AIDS strategic plan being prepared for the prevention and control of HIV/AIDS. The project would support activities in the priority areas of prevention, care, support and mitigation of the socio-economic impact of HIV/AIDS, and institutional capacity building for TACAIDS. The project will be coordinated by TACAIDS and implemented by civil society groups and public and private service agencies. Component 1. Civil Society Fund. A fund will be set up to expand and strengthen HIV/AIDS activities being carried out by Non Governmental Organizations (NGOs) including Employers and Workers' organizations, Community Based Organizations (CBOs), private sector, religious sector, persons living with HIV/AIDS (PLWHAs) and communities. Activities to be funded will include the full spectrum of HIV/AIDS activities within the broad groups of prevention, care & support and mitigation of socio-economic impact. This component will focus on social mobilization and community level response to HIV/AIDS. The groups funded under this component will be encouraged to focus, but not necessary limit, their activities to the most vulnerable groups which include: people living with HIV/AIDS (PLWHA), hospital workers, orphans, youths, commercial sex workers and truck drivers. Component 2. Public Multi-Sector Fund. This component will comprise a fund to scale up and strengthen prevention, care, support and mitigation of the social economic impact of  4 PID HIV/AIDS through programs/activities of the public sector (ministries, local authorities and parastatals). Sub-contracting by ministries, local authorities and parastatals will be encouraged in order to make the best use of the implementation capacity that may be available outside the public sector. Each public sector agency will define a work program which, as a minimum, will address issues regarding HIV/AIDS among its employees. Public agencies will also be expected to extend HIV/AIDS services to their clients and neighboring communities. Component 3. Tanzania AIDS Commission Institutional Support. The project will support Tanzania Commission for AIDS (TACAIDS) to fulfill its national HIV/AIDS co-ordination mandate. Support, in particular, will be given to TACAIDS to create an effective secretariat and identify networks at the regional and district levels. Support will be provided for: (i) establishment of the Secretariat and networks to the regions and districts (ii) establishment of financial management and procurement systems; (iii) resource mobilization; and (iv) monitoring & evaluation systems. 5. Financing Source (Total (US$m) BORROWER/RECIPIENT ($7.00) IDA GRANT FOR HIV/AIDS ($70.00) NETHERLANDS: MIN. OF FOREIGN AFFAIRS / MIN. OF DEV. COOP. ($5.00) Total Project Cost: $82.00 6. Implementation The detailed project description, including implementation arrangements for each component will be included in Annex 4, and are summarized below. THE DETAILS OF THESE ARRANGEMENTS WILL BE A MAJOR FOCUS OF PRE APPRAISAL AND APPRAISAL. Overall Project Management. The Permanent Secretary in the Prime Minister's Office as the Accounting Officer will have overall responsibility for accounting for resources provided by the Project. Overall Coordination of activities and responsibilities for all parts of the Project will rest with the Tanzania Commission for AIDS (TACAIDS), that will be supported by a Secretariat. The TACAIDS Secretariat, will be responsible for day to day co-ordination, financial management, monitoring and evaluation. The TACAIDS Commnision will be responsible for identifying regional and district networks to be utilized as focal points. The establishment of financial management systems, the mobilization of resources and monitoring and evaluation systems of HIV/AIDS activities will also be the responsibility of the Commission. The Secretariat will prepare and present annual work plans and regular progress reports, including findings from monitoring and evaluation, to TACAIDS. In addition to reviewing annual work programs and progress reports, the Secretariat will convene meetings, as needed, to address major constraints in project implementation. TACAIDS will be responsible for annual planning, budgeting and supervision of the overall flow of funds for the components. Where necessary, TACAIDS may arrange for its activities to be sub-contracted out where others have a comparative advantage. Activities which could potentially be sub-contracted include financial management, resource mobilization, auditing, training, capacity building, large scale procurement, monitoring and evaluation. Civil Society Fund. TACAIDS will have responsibility for co-ordinating activities implemented by civil society under the Civil Society Fund. A specific account will be opened for disbursing funds from the Civil Society Fund to implementing agencies. Modalities for disbursements will be agreed upon and clearly spelled out in the Operations Manual. TACAIDS will be responsible for reviewing and approving plans, and monitoring implementation of the use of funds and approved activities. The process of review  5 PID will be an annex to the Operational Manual. Civil Society organizations in a District will prepare funding proposals for submission through their District. TACAIDS will review the proposals and approve the disbursement of funds to the District for allocation to implementing NGOs and CBOs. TACAIDS will enter into Memoranda of Understanding ( MOUs ) with the District Executive Directors to facilitate the transfer of funds to civil society. Larger organizations from the private sector or NGOs with programs extending to two or more districts will submit proposals directly to TACAIDS. Contracts will be drawn up between TACAIDS and the implementing agencies for implementation of the activities. TACAIDS will be responsible for building capacity of implementing agencies especially with respect to use of defined procedures for financial management, monitoring and evaluation. TACAIDS will not act as an implementing agency. The main functions of the TACAIDS will be national co-ordination, management, monitoring and evaluation of project activities. TACAIDS may establish presence at regional level if that will reduce the work-load and expedite the process of communications with implementers. Such a presence at Regional level would have to be absorbed by the existing administrative structures at regional level in order to avoid creation of a parallel structure. However, any regional presence of TACAIDS should in no way reduce the speed of communication and flow of funds to the implementers, nor should it duplicate the functions carried out by the District. TACAIDS will ensure that the process of reviewing proposals is transparent and efficient, in order to avoid unnecessary delays. Mobilization of communities, and in particular, enlightening of communities of the procedures for accessing project funds will also be the responsibility of TACAIDS. The operational manual will have a section clarifying the terms of reference for the TACAIDS, including, where needed at district and regional level. Public Multi-Sector Fund. The Permanent Secretaries of line ministries in their capacity as accounting officers and also Chief Executives of Parastatal Organizations will be responsible for preparation and implementation of annual work plans covering programs for their employees and for the populations they serve. The annual plans will contain activities to be implemented for the ministries' employees and activities for the population served by the ministry at the central and the decentralized levels (district and below). Each annual plan will include the monitoring and evaluation that will be undertaken. Once the plan has been approved by the Permanent Secretary or Chief Executive it will be submitted for review and approval by TACAIDS based on established criteria. Each Ministry will define the focal point of coordination of its HIV/AIDS programs. A separate account will be opened for disbursing funds to the line ministries. It is recognized that the capacities and state of preparedness for dealing with HIV/AIDS varies across ministries. The project will finance the activities of those ministries that already have identified and costed programs in the first year of the project based on guidance from TACAIDS, with emphasis on MOH and MOE. Concurrently, support will be provided through the TACAIDS to the rest of the ministries to prepare their strategies and programs/activities. Tanzania Commission for AIDS (TACAIDS) Institutional Support. In addition to providing support to TACAIDS in the fulfillment of its mandate to coordinate a multi-sectoral response to the AIDS epidemic in Tanzania, at national level, this component will provide support for establishing its four divisions, namely i) Policy Planning and National Response; ii) Monitoring Evaluation Research and Management Information; iii) Advocacy, Information Education and Communication and iv) Finance Administration and Resource Mobilisation. A separate account will be maintained for the activities of the TACAIDS' component. Project progress reports, audits, monitoring and evaluation of TACAIDS activities will be submitted in the same manner as for the other components of the Project. Support for  6 PID monitoring and evaluation will be the responsibility of TACAIDS, and it can make a decision to contract it out. Lessons learned by TACAIDS in the process of project implementation will be shared with stakeholders. IDA Implementation and supervision support. In view of the number of implementing agencies in the public sector and civil society community, from the national level, down to the district level, implementation and supervision activities will be intensive. Support and supervision activities will be provided by a team from the Bank and other stakeholders, including bilateral and multilateral organizations. Additional support would also come from the Bank teams that are supervising the Social Action Fund project, the Health Sector Development Program, the Human Resources Development Project, the Agricultural Sector Management Project, the Agricultural Research Project, the Roads II project, and the Railways Restructuring Project. The Country Director would have to allocate supervision resources from the Bank for this project that would be above the regional average in the first two years, supplemented by the contributions of other donors. The Operational Manual. The Tanzania Multi-Sectoral AIDS Project will be implemented in accordance with principles and procedures laid out in an Operational Manual (OM) which will be agreed with IDA and adopted by the Government prior to Project Effectiveness. The OM will delineate processes and responsibilities for overall management, institutional arrangements, procurement procedures, financial management including the flow of funds and disbursements. It will contain the terms of reference for relevant staff, terms of reference for internal and external audits acceptable to the Bank. Reporting requirements to civil society, the Government, and donors will also be elaborated in the OM. As a living document, the OM will be modified during the course of implementation to reflect lessons learned; modifications to the Manual will require IDA's agreement. A project launch workshop for those managing the implementation of the components, as well as representatives of beneficiary groups and organizations, will be held within one month of Credit effectiveness. 7. Sustainability The project is expected to be sustainable in the medium term because it is built upon strong government ownership and supports the expansion of HIV/AIDS activities that involve communities, civil society organizations and in particular, organizations of people living with HIV/AIDS. The project will scale up existing HIV/AlDS activities by mainstreaming activities into all government sectors and civil society, and by tapping into community organization resources. The project emphasizes institutional capacity building at national and local level which would further enhance the sustainability of the project and its local sub-projects. As far as financial sustainability is concerned, it is unlikely that the Government will be able to fully finance the program in the mid-term. It is realistic to expect that bilateral and multilateral development agencies will continue to finance HTV/AIDS activities in the country beyond the period of project implementation. The overall project risk is estimated to be moderate because there is good Government and civil society ownership, and because the AIDS Comrnission will benefit from the experience of several Commission members who have already been involved in HIV/AIDS activities in Tanzania. There is however a substantial risk that the project will not be able to significantly scale up operations because some line ministries and a number of local governments have little experience with multi-sectoral initiatives and no experience in HIV/AIDS control. Although the project will have to set up a new system to channel funds to community-led initiatives, given that Tanzania does not yet have an established social fund system, the approach used by the Tanzania Social Action Fund ( TASAF ) project will be considered. In addition, to reduce this risk, project supervision will be much more intensive than it would otherwise be, and when necessary, it will include substantial technical assistance.  7 PID To minimize risk and ensure the success in implementation of this project, IDA will have to: a) provide adequate resources for supervision which may be above the standard supervision coefficients b) conduct supervision with teams that have specialists from various sectors and in particular, have specialists in key areas such as financial management, procurement, monitoring and evaluation; and c) collaborate closely with internal/external partners and stakeholders. 8. Lessons learned from past operations in the country/sector International experience on HIV/AIDS, and especially regional experience from countries like Uganda and Senegal, ongoing Bank supported HIV/AIDS projects in Africa within the MAP and country specific efforts in Tanzania, have been reflected in the project design. Key lessons learned from all this experience are outlined below. Political leadership and commitment: International experience has taught the world that political leadership and commitment is a key issue in mobilizing national and donor resources for the fight against the HIV/AIDS epidemic. The Government of Tanzania has indicated its firm commitment to the fight against HIV/AIDS. The people of Tanzania are among the hardest hit by the epidemic, and the political as well as the economic imperatives for faster growth will not be realized if the HIV/AIDS situation does not improve. Effective action requires national leadership and political commitment at the highest levels. The successful examples of control of the HIV epidemic in countries like Senegal and Uganda arose because of the political leadership driven by good epidemiological data, effective programs and a vibrant activist civil society participation. In the Tanzania situation, there is unanimity among the leadership, on the need to tackle the epidemic effectively. Vulnerability factors are key drivers of the epidemic: The HIV/AIDS epidemic is driven by underlying vulnerability factors among populations. The combination of poverty, gender disparities and information asymmetry provide very fertile soil on which the sown seed of HIV can rapidly grow and blossom. Therefore, any attempt at controlling the epidemic will have to address the vulnerability factors. This project will among others, focus on the vulnerable groups, including the youth, orphans, women and widowers in prevention and impact mitigation efforts. Community participation as a process of empowerment: The communities affected by the HIV/AIDS epidemic find themselves facing multifaceted challenges, and with very thin resources and capacity to respond. In addition, short term focused strategies may not meet the need for long term rehabilitation and healing in those communities. Community participation engages the people in a partnership to fight the epidemic. With external resources and the building of local capacity, the communities will be more empowered in their response to HIV/AIDS. Such a response is also more likely to be sustainable in the long term. This project will have a specific component on community-led HIV/AIDS initiatives. Multisectoral approach: It has been widely recognized that the HIV/AIDS epidemic extends far and beyond the narrowly defined health sector. The multi-dimensional nature of the epidemic and its impacts warrant a change in paradigm from a biomedical to a development one. In this context, the multi-sectoral approach in HIV prevention, care and mitigation offer best chances of success. This project will involve the active participation of all line ministries at all levels. The use of indigenous knowledge and practices: Indigenous knowledge and practices including drama  8 PID could also be complementary in the efforts to fight HIV/AIDS. In Mozambique, the involvement of traditional knowledge workers (healers) in awareness creation in a psychologically and socially sensitive area like sexuality had higher impact at lower cost. In Tanzania, the integration of local healers in AIDS prevention and mitigation strategies has already been attempted to increase access of services for poorer families. Along similar lines, the Bank is currently piloting the use of traditional channels of communication ("griot" network) to deliver culturally congruent messages in prevention of HIV/AIDS in West Africa. Local practices of looking after HIV/AIDS orphans in the community among foster parents, grandparents, or other relatives, have also been used successfully in Uganda, Zimbabwe, Kenya, Malawi and Zambia to cater for orphans without separating them from their communities. In this regard, this project will encourage access to and use of appropriate indigenous knowledge and practices that have been shown to work in the fight against HIV/AIDS. Complexity of supervision of MAP projects Given the innovative MAP approach and multitude of stakeholders and partners, leading to relative complexity of the projects, supervision of MAP projects deserves more attention and resources than the average projects. The experience so far gained suggests that supervision teams for MAP projects should draw on the resources of partners, particularly bilaterals and other stakeholders. The composition of the supervision teams should also be multisectoral. Robust Monitoring and Evaluation The key features of MAP are the scaling up of multi-sectoral programs and effective interventions, which require robust monitoring and evaluation systems. The monitoring and evaluation plan needs to be developed through a participatory process as a number of stakeholders will be involved in implementation, monitoring and evaluation activities according to their areas of expertise. Sufficient resources and skills should be made available for monitoring and evaluation of projects in the MAP, including this project. 9. Environment Aspects (including any public consultation) Issues : The project is not expected to generate any adverse environmental effects. However, inappropriate handling and disposal of medical waste and inadequate management of the respective disposal sites in urban or peri-urban areas is a threat. The project will finance training of health care professionals, traditional birth attendants/traditional healers, and community workers delivering care to HIV/AIDS patients. This training will include instruction on appropriate separation, transport and disposal of hazardous medical waste. The project will finance the revision of existing health sector guidelines on appropriate management of medical waste at medical facilities and at disposal sites to include the relevant sections regarding HIV/AIDS. 10. List of factual technical documents: 11. Contact Point: Task Manager Albertus Voetberg The World Bank 1818 H Street, NW Washington D.C. 20433  9 PID Telephone: 254-2-260-300, 260-400 Fax: 254-2-260-380, 260-381, 720-612 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.