Uganda - Sexually Transmitted Infections Project

CAj Qboc UO- Doeiut of The World Bank FOX OMCLAL USE ONLY Raqwt No. P-6227-UG NEOlANID1 AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMNT ASSOCIAON TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT IN THE AMONT OF SDR 36.3 MILLION TO THE GOVERNMENT OF UGANDA FOR A SEXUALLY TRANSMITTED INFECTIONS PROJECT MARCH 9, 1994 M1 Cj,.O(ARAPi' 1 UW$ Report No,: P' (;'.)227 US Type: MOP This docmaent has a restricted ditbtisoa aA may be used by recpien only in the perfomanc of heir offcial dities. Its co_et may not otberwise be disclosed without Wodd Bank uthotion  REPUBLIC OF UGANDA Sexually Transmitted Infections Project Currency Equivalents Currency Unit =Tganda Shilling (USh) US$ 1.00 =1282.9USh lUSh =0.077US$ US$ 1.00 =SDR 1.37817 Weights and Measures Metric System Government Fiscal Year July 1 - June 30  FOR OFFICIAL USE ONLY REPUBLIC OF UGANDA SEXUALLY TRANSMITTED INFECTIONS PROJECT Abbreviations and Acronyms ACP AIDS Control Program AIDS Acqured Immune Deficiency Syndome CBO Com BasedOrgizations CHAP Commnity Health and AIDS Project CI Care Indicators DANIDA Danish Intational Development Agency DES District Execive Secrtary DHT District Health Team PHP First Health Project GOU GovenmUent Ugnda GPA Global Program on AIDS HV Human Immuno Defficieny Virus ICB international Compedtive Bidding IDA Inteational Devedopment Associon IEC Information, Education and Comnications KfW Kreditanstlt fur Wiederauf_a KABP Knowledge, Attitudes. Beliefs and Practices MCH Matemal and Child Health MOFP Ministry of Finance and Economic Planning MOH Minit of Health moi Ministr of nformation MOLO Ministy of Loc Goenment MlP Medium Term Plan NGO Non Governmental Organization NMS National Medical Stores NTLP National Tuberculosis and Leprosy Program NOP National Operational Plan ODA Overseas DeWeopment Adminon (UK) OPD Oulpatent Department PI Prevention Indicators PHC Primary Health Care PIU Project Implementation Unit PS Permanent Secetary SIDA Swedish Intenational Development Agency STID Semually Transmitted Diseses SlI Sexually Transmitted Infections TFR Total Fertility Rate UAC Uganda AIDS Commission UDHS Uganda Demographic and Health Survey UNDP United Nations Development Program UNICEF United Nations ChildreWs Fund USAID United States Agency for International Development WHO World Health Organization This document has a restricted distnudon and may be used by recipi:nts only in the pemom of thei official duties Its contents may not otherwise be disclosed without Wordd Bank autoizaton.  UGANDA SEXUALLY TRANSMITrED INFECTIONS PROJECT Credit and Project Summary Borrower: Republic of Uganda Implementing Agencies: Ministry of Health (MOH); Non Government Organizations (NGOs); and Community Based Organizations (CBOs) Beneficiaries: Men and women at risk in their reproductive age groups, and their dependents (approximately 10 million people). CrditAmount: SDR 36.3 million (US$50 million equivalent) Terms: Standard, with 40 year maturity Financing Plan: Local Foreign Total US$ million Government 7.4 0.0 7.4 KfW 0.0 6.8 6.8 ODA 4.2 4.2 SIDA 1.0 4.0 5.0 IDA 9.5 40.5 50.0 TOTAL 17.9 55.5 73.4 Rate of Rehtrn: Not Applicable Povert Categmoy:Program of Targetted Interventions StaffAppraisal Report: 12630 Map: IBRD 25052  MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF UGANDA FOR A SEXUALLY TRANSMIlTED INFECTIONS PROJECT 1. I submit for your approval the following report and recommendation on a proposed development credit to the Republic of Uganda for SDR 36.3 million, the equivalent of US$50 million, on standard IDA terms with a maturity of 40 years to help finance a Sexually Transmitted Infections Project. The Government, approximately 10 percent of total project costs or about US$ 7.4 million. KfW (Germany), ODA (UK) and SIDA (Sweden) have agreed to suprort this project through cofinancing totalling US$16 million. Their respective contributions are KfW (US$6.8 million) ODA (US$4.2 million), and SIDA (US$5.0 million). Other donor agencies providing support include WHO and USAID. Sector Background: 2. The health status of Uganda's 16.5 million people is poor. Life expectancy at birth is only 47 years; the crude death rate is 19 per 1000 population; the under-5 mortality rate is 185 per 1000 live births (versus 100 per thousand in low-income countries); and about 23% of children in a survey were found to display low weight-for-age, reflecting nutritional deficiencies. The leading causes of death are AIDS, tuberculosis, and malaria, for adults; and malaria, pneumonia, and diarrhea for children. Uganda's health problems are compounded by a high total fertility rate (TFR) of 7.3, reflecting a contraceptive prevalence rate of only 5%, and yielding a high population growth rate of 3.1%. Uganda's maternal mortality rate of about 500 per 100,000 live births is more than twelve times higher than in developed countries. 3. Any discussion of the health sector in Uganda in the 1990s is dominated by STDs and AIDS in particular. Although other health issues remain critical, they are dwarfed by the magnitude and immediacy of an estimated 1.5 million Ugandans being infected with HIV. This translates to one in every six to seven persons being infected with HIV. The consequences of the AIDS epidemic are far reaching. First, the health and longevity of the population is threatened. Gains in quality of life indices such as life expectancy and infant mortality have been lost. Investments in educating Ugandans are being lost. And the painstaking accumulation of critical human capital is being lost. Second are the severe and long term economic implications for the country. AIDS affects mostly the productive segmnent of society--the 15-50 year olds. Industrial and private sector growth, along with development of institutional capacity, all need skilled workers and leaders. Loss of these individuals to AIDS has significant consequences for the rebuilding of the Ugandan economy. Third are the social consequences. It is difficult to measure the large scale disruption to families and communities, the personal losses and the stigmatization suffered by family members. Families and communities are faced with large numbers of children and elderly who have lost the people who support and care for them. In brief, Uganda is  2 experiencing an epidemic that rivals the worst ever experienced by any nation. Without a cure or vaccine for AIDS, neither of which is anticipated in the foreseeable future, even the most optimistic scenario shows a devastating and far-reaching impact on the social and economic fabric of the country. 4. Uganda was among the first countries in Africa to realize the possible impact of the epidemic. Up to June 1993 41,000 cases of AIDS have been reported to the Ministry of Health. It should however be realized that due to under diagnosis, under reporting, etc., this only represents a fraction of the cases that have actually occurred since the start of the epidemic. It is estimated that currently 1. 5 million people are infected in the country out of a total population of 16.5 million and that the actual number of cumulative AIDS cases is over 300,000. The WHO HIV/AIDS EPI-model projects that the number of HIV infected people could increase to more than 1.9 million in 1998. It also projects that between 1993 and 1998 565,000 adults and 250,000 children will die from AIDS. By 1998 almost 900,000 children below 15 year will have lost their mothers due to AIDS. The incidence of sexually transmitted diseases (STD) is high and the problem appears to be growing. STDs, particularly genital ulcers, are important risk factors for the transsmission of HIV. The Ministry of Health's planning unit report of 1992 stated that 4.5% of all Out-Patient Department (OPD) diagnoses were due to STDs. Since then various reports have quoted an upward trend in STDs. 5. The predominant mode of transmission in Uganda as elsewhere in Africa is heterosexual with roughly equal numbers of women and men affected. Of the new infections occurring in Uganda it is estimated that 84% are due to sexual transmission, 14% due to transmission from mother to infant, and less than 2% due to other routes of transmission. The only way to achieve control of AIDS in the foreseeable future is through prevention. There are two main strategies for prevention in Uganda: * promotion of safer sexual behaviors, which may include: abstinence before marriage and faithfulness to one's partner after marriage - if there is any variation at all from these requirements, a condom is essential and the only way to save lives. * prevention and treatment of other STDs. 6. Recognizing the severity of the AIDS epidemic, the Government established the Uganda AIDS Commission (UAC) with a Secretariat in 1991. Unfortunately, the UAC has had numerous start-up difficulties, including deinition of its role and responsibilities. The staffing of the Secretariat has not been suitable to undertake coordination activities. While there is a legitimate role for the UAC, the Secretariat needs restructuring and re- defining to enable it to coordinate national level activities and disseminate information. In 1993, a National Operational Plan (NOP) was developed, providing the backbone for the national efforts to prevent HIV infection and to mitigate the adverse health and socio- economic impact of the HIV/AIDS epidemic. The NOP calls for increased nationwide concerted efforts. The main features of the plan are:  3 * Decentralization, AIDS activities will be planned, managed and monitored at the district level. but activities will be decentralized further with responsibility for imnplementation at the sub-county and villa ga/coinmunity levels. * Community mobilization, communities will be assisted to mobilize their own resources to assess and deal with factors facilitating HIV transmission within the community and to handle the health and socio-econromic impact. * Non governmental organizations, will be encouraged to work with communities and to complement government activities. 7. Project Objectives: The objectives of the proposed project are: (i) To prevent sexual transmission of HIV by: Promotion of safer sexual behavior; provision of condoms; promotion of STD care seeking behavior; and provision of effective STD care. (ii) To mitigate the personal impact of AIDS by: Provision of support for community and home based health care and social support for people with AIDS; briefing of staff and provision of drugs for opportunistic infections and protective supplies for district health facilities (government and non government); and, provision of TB diagnosis and case management. (iii) To support institutional development to manage HIV prevention and AIDS care by: Strengthening the Districts capacity to plan, coordinate, inplement, monitor and evaluate integrated AIDS related activities; and, strengthening the national capacity to provide adequate te'mhnical support on health issues related to AIDS. Expected key outcomes by end of the project include: - ability of 50 percent of the target population to cite at least two acceptable ways of protecting themselves from HIV; - 50 percent reported condom use among the target population, - a 20 percent decrease of reported non regular sexual partners; and - an increase of appropriate STD case management to 70% of those individuals seeldng STD care.  4 Project Description: 8. Prevention of Seiual Transmission of HIV (US$35 Omillion) would be achieved through promotion of safer sexual behavior, increased condom availability and usage and provision of care and treattnent of STDs. Promotion of safer sexual behavior would be achieved through awareness and mass mobilization campaigns, community mobilization campaigns and targeted behavioral interventions and services. Through an intense behavior modification program the project is expected to influence changes in the sexual practices of target populations. Increased use of condoms is expected and the project would make them widely available. Condoins would be provided through multiple channels including government and NCQO health facilities; NGO and CBO programs; organized groups like the Army and Police; and, Social Marketing Programs. The proiect supports the care and treatment of STDs, including behavioral change, drugs and diagnostics and training for health personnel. 9. Mitigation of the Personal Impact of AIDS (US$22.4 million). This component finance drugs, protection supplies and health care services to mitigate the personal impact of AIDS. The AIDS epidemic results in overstretching of existing hospital capacity to provide health care in Uganda. Many AIDS patients need social and counseling services that cannot be provided by government facilities. Numerous NGOs and CBOs are involved in supporting HIV/AIDS patients, but they often lack fuids to meet the full extent of the reeds or provide services which are not cost-effective and sustainable. Famnilies providing care at home for their relatives, as well as other selected care providers, will be identified by the District Health Team (DIT) and supported by this project. The project would finance contracts between DHTs, NGOs and CBOs to imp.ement home and community care of patients with AIDS. Patients with AIDS are immuno-depressed and contract opportunistic infections easily. This component provides support for drugs and clinical and protective supplies. From a public health standpoint, the most serious of the many HIV related infections is tuberculosis. People who are immuno depressed contract tuberculosis easily and in turn infect those with whom they are in close contact. Already in Uganda, the number of tuberculosis cases has risen dramatically. The project supports the diagnosis and care management of tuberculosis. 10. Institutional Development (US$10.7 million). This comlponent will fnance incremental salaries, local and overseas training, technical assistance, office supplies and vehicle running and maintenance costs. The component would help develop the capability of districts to plan and implement STD/AIDS activities thereby ensuring stronger local commitment to disease control efforts. At the same time the role of the National level would change from day to day program implementation to one of technical support and training. The project will help evolve the new roles and responsibilities of the national and district-levels. At the same time activities such as surveillance, operations research, monitoring and evaluation are nationwide in scope and will be nationally implemented. The results of these activities will enable the project to be responsive to the changing patterns of STIs. Funds are also provided for innovative NGO cfivities. Often with small sums of money NGOs are able to develop and try out new approaches  S Project Financing: 11. Total project cost is US$ 73.4 million, including US$5.2 million for contingencies. The IDA credit of US$50 million (S;)R 36.3 million) would cover about 68% of the total projvnt cost or 73% of the foreign exchange costs and 53% of the local cost net of duties and taxes. In addition to donors cofinancing, as outlined para 1, WHO pal ticipated in the design and appraisal of the project and is expected to continue its support through implementation. USAID will provide technical assistance and training outside the project. The Government, NGOs and CBOs contribution of US$7.4 million would finance about 10% of the total project cost. The project has been listed as "core" in the country's development estimates. Counterpart funding is assured. A breakdown of costs and the financing plan are shown in Schedule A. Amounts and methods of procurement and disbursements, and the disbursement schedule are shown in Schedule B. A timetable of key prccessing events and the status of Bank Group operations in Uganda are shown in Schedule C and D, respectively. More detailed information is provided in the Staff Appraisal Report No. 12630. Project Implementation: 12. The Ministry of Health will be responsible for overall project coordination. The Permanent Secretary (PS), MOH will be the Project Director in charge of coordination and implementation. The bulk of project activities will be implemented through district level organization, community groups and NGOs. The AIDS Control Program will provide strong technical backstopping to the districts. The Director of ACP will have responsibility for the technical aspects of the project. A Project Steering Committee, chaired by the PS, MOH with representatives from the MOH, MOI, MOLG, MOFP, UAC, NMS and ACP will be established to act as an advisory body to the implementing parties. NGOs; other ministries and specialized divisions within the MOH (MCH, PHC, etc.) will be invited to participate in the Committee whenever necessary. The Project Coordinator will be the Secretary of the Steering Committee. The projec., which would be coordinated by the Ministry of Health, would use government, NGOs, CBOs, private sector contractors, training and research institutions to implement the proposed project. 13. At the disti,-,t level, the District Medical Officer will be responsible for coordinating project activities. In the decentralized districts he will work closely with the DES who will be the accounting officer. He will work closely with NGOs active in the district as well as with members of the District Health and Development Committees (DHC and DDC), and community groups to ensure that services are provided to the largest groups of peoples within the district that could play an active role in the control of STIs. 14. A project Coordinator, (a Ugandan national), has been appointed and will be located in the PIU of the First Health Project. The Project Coordinator will work in close cooperation with the Director of the ACP. Accountants, procurement specialists, and  6 other support staff already in place for the First Health Project will support this project as needed. Depending on the need, financing of these will be taken over by the project when the First Health Project comes to an end. An evaluation officer will be appointed for this project. Short-term consultancies will be approved by IDA as required on an ad hoc basis. The role of the PCU will be to facilitate the implementation of the project, including handling the administrative requirements of IDA. Local and international contracting will be utilized to the maximum extent for several implementation actions, e.g. procurement of drugs and condoms. All project activities will be undertaken by existing units or offices of the health system. No new government office will be created though provision does exist for the expansion of successful NGOs. Supplies such as condoms, drugs, diagnostics and protective items are to be procured by initially the NMS following procedures agreed on with IDA. Supplies will be distributed according to the workplans of the respective program offices. Project Sustainability: 15. The recurrent cost implications of the project are small. No new buildings are being constructed, and no additional staff are likely to be hired. Government will finance the maintenance costs of new equipment purchased, through the MOH budgetary allocation. These costs are estimated at 5% of purchase price annually. The project will be managed by staff already in place except for a project coordinator, secretary and driver. Most ACP staff are already on MOH payroll. Other PIU staff are being funded through the First Health Project. Given that the health sector has been seriously underfunded over the past several years, the MOH has been unable to finance the purchase of drugs or pay a living wage to its staff. It is expected that Treasury allocations for health will increase. At the same time a number of cost recovery measures as well as decentralization of health services are being introduced. These issues are being addressed through the proposed District Health Services project currently under preparation and expected to be appraised during this fiscal year. 16. Expenditures on condoms and STD drugs are substantial and likely to remain high over the medium term. Donor funding for these commodities will be necessary for the foreseeable future. The cost of maintaining new equipment purchased through the project is expected to be 5% of the purchase price annually. These amounts will be included in the annual budgetary allocations of the MOH. At the district level there will be increased costs of travel for health staff following up STD and Tuberculosis cases. With decentralization, districts will be empowered to allocate their budgets in accordance with health care priorities. It is also envisaged that, wherever possible, charges will be made for condoms and STD drugs, The proceeds of these charges will be retained within the district health budget. 17. Many of the consumable items being funded are investments in human capital, and will r.store good health or prevent illness. Condoms, drugs for TB treatment and gloves for health workers are examples. Provision of these items reduces rather than incurs recurrent costs in the health sector: every TB patient treated, or every HIV-infection  7 averted, reduces the number of future potential patients seeking health care. Left unchecked, STD infections in men cause mild to severe genital or urinary tract problems and can cause infertility. The consequences for women, who are often asymptomatic and therefore unaware of the infection, include adverse outcorint- of pregnancy for mothers and newborns, infections in newborns and infants, infertility, cervical cancer, and in some cases death. These impose vastly higher costs than STD treatment. The direct drug costs of presumptive treatment of the most common STD syndromes are US$2.91 (for Genital Ulcer Disease), US$3.43 (for urethral discharge) and US$4.23 (for vaginal discharge). Viewed another way, it has been estimated that at US$10/hour for clinic time, in a country with an HIV seroprevalence rate of 5% (less than half the seroprevalence rate in Uganda), treatment of a core group of high-risk STD patients costs between US 11 c and 96c per healthy life year saved, and is an extremely cost-effective health intervention. Lessons from Previous IDA Involvement and Linkages with Sector Policy: 18. IDA is financing an ongoing Fi'st Health Project which became effective in 1988. The project had a slow start, l'ra' . .. to shortcomings iri ;oject administration, many of which are common to otlitt -. *;; 3d rroject in Uganda. The initial difficulties have been overcome and thoug' -. rie problems remain the project is expected to be completed on schedule. Discuss:o., on health policy reform have resulted in efforts to develop a new project. The proposed Community Health and AIDS Project (CHAP) was to address health policy issues and to support efforts to contain the growing AIDS epidemic. As preparation proceeded it was felt that the project as designed would be extremely complicated. Accordingly a decision was made to split CHAP into 2 projects - an STD/AIDS project and a District Health Services Project. IDA has been closely involved in the AIDS sector since 1988. In 1990, IDA jointly with WHO and UNDP, led a multi-donor mission to review the AIDS situation in Uganda. Since then, support has been given for the establishment of the UAC by funding the post of Director-General. More recently savings from the First Health Project have been committed for procurement of STD drugs and condoms. The project is designed to be flexible and innovative so as to encourage community initiatives. Hence, by its vety design, several activities will be "pilot" in nature. 19. An intensive dialogue with the Ministry of Health on health policy reform is ongoing. In June 1993, several senior MOH officials attended a workshop in Washington on the World Development Report 1993: Investing in Health. Subsequently the MOH prepared a Policy Paper on Health Policy, incorporating several WDR recommendations, which has been approved by the Cabinet. Parliament has also passed a Decentralization Biil thereby providing a legal basis for the decentralization of health services. Further work on the reform is continuing and wvill be a part of the proposed District Health Services Project to be appraised later this fiscal year. A letter of Sector Policy is being developed as part of preparation of that project. The proposed Sn project closely follows the decentralized approach.  8 Rationale for IDA Involvement and Country Assistance Strategy: 20. The AIDS epidemic is already having a severe impact on the economy, especially since so many of its victims are just reaching the prime of their active economic lives. The Government is keen to have the Bank play a kLy role. Expenditures needed for AIDS interventions are substantial and it has been demonstrated over the years that the AIDS Control Program has been severely underfunded. Other donors have previously been reluctant to finance the costs of treatment of STDs despite the high payoff noted above. IDA is willing to finance the operating unit costs of treatment as an investment in human capital. IDA would also be able to ensure that appropriate policies such as decentralization and palliative home care are adopted. Finally, IDA would play a highly effective role in addressing the implementation problems of the AIDS program as well as act as a catalyst to attract additional donor funding. The objectives of the proposed project are consistent with the Country Assistance Strategy for Uganda discussed by the Board on May 20, 1993 which emphasizes poverty alleviation. The preventive component will help the population avoid AIDS-related poverty, while the mitigation component will assist those who are afflicted. Agreed Actions: 21. Prior to negotiations the Government implemented the following measures: prepared and submitted to IDA sample tender documents for drugs, diagnostics and condoms; appointed a suitably qualified and experienced project coordinator; appointed a project steering committee; and submitted a draft implementation manual. 22. During negotiations agreement was reached that: (a) a timetable for airing of TV and Radio materials be submitted to IDA annually by March 31 each year; (b) the production of TV and radio materials would be undertaken by through open competition; (c) all biomedical research proposals be reviewed by an independent panel; (d) progress reports and beneficiary assessment data be consolidated by the ACP and submitted to IDA every 6 months; (e) work plans be submitted to IDA by March 31 annually; (f) the annual district health plans include activities and earmarked funds for drugs to be distributed by NGOs and CBOs; (g) a mid-term evaluation of the project be held in 1996 and that a project completion report be prepared by the Government within 6 months of the closing date of the project; and (h) all project accounts be audited by the Auditor General and that all audited accounts, together with the auditors report, be submitted to IDA not later than six months after the end of each goverment fiscal year. 23. As conditions of credit effectiveness, the MOH would invite all broadcast media entities to submit proposals to air programs for the first year of the project. The Government would have contracted suitable organizations to distribute condoms to NGOs throughout Uganda. A project implementation manual would be furnished satisfactory to the Association. As a condition of disbursement, the Mnistty of Health would ensure that district health teams include in their submission of the initial annual district health plan, activities and earmarked funds for drugs to be distributed by NGOs and CBOs.  9 Environment Assessment: 24. The project is classified as category C, with no adverse impact on the environment. Benefits: 25. The project would have an immediate impact by making STD care available nationally. It would strengthen the Government's ability to deal with opportunistic i.ifections such as TB. Through the provision of condoms, the project would have an immediate effect on the transmission of STDs. In the medium term the project will directly benefit 66500 tuberculosis patients and their families, fellow-workers and others who would be at risk of infection through contact with them. It will provide condoms to an estimated 4 million persons, thus protecting them and their sexual partners from the risk of contracting HIV and STDs. The project will furnish sufficient diagnostics to test every pregnant women who seeks care from syphilis during the life of the project, benefiting them and their unborn children. More than 1.5 million people with FHV will receive care for various infections. Protective supplies will safeguard an estimated 7000 health workers from the risk of HIV and tens of thousands of patients from nosocomiat and iatrogenic infections. 26. The TB control program will have received drugs and supplies needed to treat all identified cases, follow-up patients to help ensure compliance with treatment, trace contacts, and verify suspected cases and refer them for treatment. The project witl help to avert a major resurgence of TB incidence. Prevention of STDs and HV will result in large savings in sickness care expenditures. The drain on society by the loss of life from AIDS is staggering in human, social and economic terms. Investment in reducing STDs and HIV will produce savings and increased economic activity through carefully targeted interventions. For instance a Nairobi program found that 6,000 to 10,000 new HIV infections a year were averted at a cost $0.50 per Disability-Adjusted Life Year (DALY) gained. Palliative home care costs between $30 and $75 per DALY gained. Curing each case of gonorrhea in a core group saves 120 DALYs, at a cost well below the $1 per DALY gained if the benefits of fewer secondaiy cases and the reduced risk of HIV transmission are included. Thus the project will be an effective means protecting large numbers of Uganda's labor force against the disease, and their dependents against AIDS- related poverty. Risks: 27. The principal risk for the project is that the incidence rates of HIV, STDs or TB, all high already, may increase so quickly as to overwhelm even the integrated and intensified effort of Uganda's STI program. The only way of averting this risk is to mount the most inclusive, cost-effective program possible in the shortest time. A secondary risk is that the health services may lack sufficient experience and capacity to implement an effective STD screening and prevention program. The project provides for traiDing of  10 health workers in STD diagnosis and treatment. There is also some risk that sufficiently broad Government support may not materialize. Public commitment to STI control is an important aspect of program success, especially in spreading accurate and timely information. Given the high public awareness about STDs, Government's forthright treatment of the issue and integrated effort (including IEC) already underway, this risk is regarded as small. Another risk is that the ACP capacity may prove inadequate to cope with the complexity and size of the coordinating task involved. A project coordinator will be appointed and short-term technical assistance provided as necessary. A final risk is that the behavioral changes the STI program seeks to promote are likely to prove difficult to achieve. Through annual work plans and a mid-term review a process of continuous monitoring will be established to enable modification of strategies as appropriate. Limited experience in other countries, however, suggests that the literal life-and-death choice posed by the proliferation of STIs has proven compelling enough to override even the inherent resistance to change. Recommendation: 28. I am satisfied that the proposed credit would comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve it. Lewis T. Preston President Attachments Washington, D.C. March 9, 1994  1) Schedule A SEXUALLY TRANSMITTED INFECTIONS PROJECT Estimated Costs. Financing Plan and IDA Disbursements Estimated Costs Project Components Local Foreign Total - US$ million Prevention of Sexual Transmission of HIV 8.3 26.7 35.0 Mitigation of the Personal Inpact of AIDS 1.5 21.0 22.5 Institutional Development 6.8 3.9 10.7 Total Base Cost 16.6 51.6 68.2 Contingencies 1.3 3.9 5.2 TOTAL PROJECT COST 17.9 55.5 73.4 Financing Plan (US$ Million) Expendture Categry IDAISIDA KIW ODA Govt Total Drugs & Equipment 17.9 5.0 22.9 Supplies 20.4 1.8 4.2 26.4 IEC Materials 8.8 8.8 Local Training 0.2 3.3 3.5 Technical Assistance 0.4 0.4 Vehicles 1.9 1.9 Allowances 0.0 0.9 0.9 Research & Monitoring 5.1 5.1 Studies 0.3 0.3 Recurrent Costs 0 3.2 3.2 Total 55.0 6.8 4.2 7.4 73.4  12 Schedule B Page 1 of 2 Uganda Sexually Transmitted Infections Project Procurement Arrangements (US$ million) (IDA Contributions Shown in Brackets) ProjectElement ICB LCB Other NB? Total Drugs & Equipment 16.4 1.5 S.0 22.9 (16.4) (1.5) (0.0) (17.9) Supplies 18.9 1.0 0.5 6.0 26.4 (18.9) (1.0) (0.5) (0.0) (20.4) IEC Materials 8.8 0.2 9.0 (8.8) (0.2) (9.0) Local Training 3.3 3.3 (0.0) (0.0) Technical Assistance 0.4 0.4 (0.4) (0.4) Vehicles 1.9 1.9 (1.9) (1.9) Allowances 0.9 0.9 (0.0) (0.0) Research/Monitoring 5.1 5.1 (5.1) (5.1) Studies 0.3 0.3 (0.3) (0.3) Recurrent Costs 3.2 3.2 (0.0) (0.0) TOTAL 46.0 1.0 11.3 15.1 73.4 (46.0) (1.0) (8.0) (0.0) (55.0) a NBF: Not Bank Flnanced Credit. b Cofinanced in parallel by KfW and ODA; procd with KfW and ODA regulations.  13 Schedule B Page 1 of 2 Allocation and Disbursement ofthe World Bank Credit (US$ million) Disbursement Category IDA Allocation % of Expenditure US$ million to be Financed 1. Drugs, Supplies and 33.3 100% of foreign expenditures, 100% of Equipment ex-factory local expenditures and 90% of local expenditures for other items procured locally 2. IEC Materials 5.5 90% of all expenditures. 3. Training 0.2 90%/O of all expenditures. 4. Technical Assistance 0.4 100% of all expenditures. 5. Vehicles 1.9 100% of foreign expenditures. 6. Monitoring/Research 4.5 90% of all expenditures. 7. Studies 0.3 100% of all expenditures. 8. Unallocated 3.9 TOTAL 50.0 Estimated Disbursements of IDA Credit (T_S$ milion) FY 1995 1996 1997 1998 1999 2000 Annual 5.0 8.0 8.0 12.0 11.0 6.0 Cumulative 5.0 13.0 21.0 33.0 44.0 50.0  14 Schedule C Timetable of Key Events Time Taken to Prepare 14 months Task Manager Vulimiri Jagdish Team Members Beatrice Helbling (Operations Officer) Yordi Seium (Costing Specialist) Deborah Rugg (Monitoring & Evaluation) Ros Widy-Wirsky (STD Specialist) Eric Blas (AIDS Specialist) Rudolph Schumacher (PH Specialist) Karin Edstrom (PH Specialist) First IDA Mission September 1992 Appraisal Mission Nov. 1993 Negotiations Jan. 1994 Planned date of Effectiveness July 1994 Relevant PCRs/PPARS None  Is STATUS OF BANK GROUP OPERATIONS IN UGANDA Schedule D A. STATEMENT OF BANK LOANS AND IDA CREDITS Page 1 of 3 (a of Decmber 30, 1993) Thirty (30) edt flly disbursed, 761.46 of which SECAL., SALa and Program LoanCredits a/ Cr.12520 1982 Uganda Reconstuction Cr. It 70.00 Cr.13280 1983 Uganda Agdc. Rehsb. 66.17 Cr. 14740 1984 Uganda Rconstructin m 50.00 Cr.A0340 1988 Uganda Economic Recovery Credit 24.00 Cr.18440 1988 Uganda Economic Recovery Credit 65.00 Cr.18441 1989 Uganda Economic Recovy Credtl 1.70 Cr.18442 1989 Uganda Economic Recovey Credit 25.00 Cr.A0341 1990 Uganda Economic Recovery Credit 12.80 Cr. 18443 1990 Ugand Economic Rovery Credt 1.50 Cr.20871 1991 Uganda Economic Rcovery U 2.00 Cr.20872 1992 Uganda Economic Recovery U 1.60 Cr.23141 1993 Ugand SAC I 1.40 Cr.20870 1990 Uganda Economic Recovey Credit 125.00 Cr.14340 1984 Uganda TAS I 15.00 Cr.15390 1985 Uganda Agriculral Doveopmnta 10.00 1.50 Cr.15600 1985 Uganda Socid Power 28.80 0.62 Cr.15610 1985 Uganda Petrolkum Exploration Prom S.10 1.41 Cr.18030 1987 Uganda Fourthlilghway 18.00 1.84 Cr.18240 1987 Uganda Forcesy Rehabii 13.00 1.16 Cr.18690 1988 Uganda, South West Ag. Rehab. 10.00 6.35 Cr.18930 1988 Uganda Sugar RaIlkaon 24.90 6.S2 Cr.19340 1988 Uganda Headth Roc. 42.50 14.03 Cr.19510 1988 Uganda Tech. Asmt. m 18.00 0.62 Cr.19620 1989 Uganda Public Entes 15.00 5.39 Cr.19650 1989 Uganda Education IV 22.00 6.05 Cr.19910 1989 Uganda Telecom U 52.30 9.39 cr.20880 1990 Uganda Poverty & Soc. Costs 28.00 9.40 Cr.21240 1990 Uganda Water Supply 1 60.00 56.47 Cr.21760 1991 Ugand LIvestoc 21.00 20.21 Cr.21900 b/ 1991 Uganda Ag. Sector Adj. Credit 100.00 34.76 Cr.22060 1991 Uganda Urban I 28.70 22.29 Cr.22680 1991 Ugnda Power m 125.00 110.70 Cr.23140 b/ 1992 Uganda SAC I 125.00 27.10 Cr.23150 1992 Uganda Enterprise Dovelopment 65.60 64.55 Cr.23620 Im Uganda Northemn Reconstrc. 71.20 67.05 Cr.24180 1993 Uganda Econ. & Finac Managemnt 29.00 22.60 Cr.24240 1993 Uganda Agric. Extsion Prog. 15.79 13.84 Cr.24460 1993 Uganda Agric. Res. & Trg. 25.04 23.58 Cr.24930 1993 Uganda Primary Educ. 52.60 48.24 Cr.24960 b/ 1993 Uganda Financial Sector Adjutmet Cr. 100.00 99.00 Total 8.40 1882.99 674.67 of which repaid 8.40 34.84 Total hd by Bank & IDA 1848.15 Amount sold 8.32 of which repaid 8.32 TOTAL Undisbursed 674.67 at Approved after FY80. b/ SAL, SECAL or Program Loan/Credit. 01-21-94  16 ScbeduleD Page 2 of 3 B. STATEMENT OF IPC INVESTNENTS DN UOANDA (as of December 30, 1993) 1993 ABP-Clovergem Canniag Preserv & Proc.. 0.85 0.00 0.85 1993 AEF-NOE-OB Canning Prserv & Pros 0.65 0.00 0.65 1994 AEP-SKYBLUE Hots & Resutauants 0.51 0.00 0.51 1985,1993 DFCU Developmeat Fiwe Companks 0.00 0.98 0.98 1993 JUBUIE 0.00 0.10 0.10 1965 MULCO Spinig, Weaving & FinIshing 4.32 0.71 5.03 1984 TAMTECO Mfg of Food Producs NEC 1.62 0.00 1.62 1972 TPS Tourbm Services 1.11 0.00 1.11 1984 UgandR Sugar Ccoma Chocolate, Sugar 8.00 0.00 8.00 1985 Uganda Tea F&od Product NEC 2.81 0.00 2.81 Total gross conuitmeuts 19.87 1.79 21.66 Les: ROpayments, cancelatons, exchange adjusents, tenrinatios and daes 9.16 0.71 9.87 Tota Commitments now held by IFC: 10.71 1.08 11.79 Total Undisbursed 2.01 0.00 2.01 Total Outsanding IFC 8.70 1.08 9.78 01-224-94 ug2edl.wkl  17 Schedule D Page 3 of 3 DISBURSEMENT ISSUES 1. The active IDA portfolio for Uganda at the end of December 1993, consisted of 27 projects for a total commitment of US$1.09 billion, with US$674.6 million undisbursed. This included 24 investment projects for a total of US$796 million committed and US$514 million undisbursed. Over the last five years, the investment portfolio has shown a trend of rapidly increasing undisbursed balance, growing at an average rate of 17% per year, whereas disbursements remained at about US$68 million per year on average - with US$78.8 million disbursed in FY93. The corresponding disbursement factor (ratio of disbursements to cumulative net undisbursed balance at the beginning of the FY) declined from an average of about 20% for FY89-91 to about 15% in FY92-93. Meanwhile, problem projects increased from 14% in FY92 to 19% of the portfolio in FY93. 2. The portfolio's modest disbursement performance is due in part to its relatively young age structure (average of 4.8 years). However, as suggested by the increasing number of problem projects, there are also other issues which have undermined progress. 3. The major issues are: (a) shortage of counterpart funds resulting from poor mobilization of domestic resources and an excessive portfolio of externally funded projects; (b) weakness in project management and initial delays in meeting conditions of effectiveness; and (c) other deficiencies regarding procurement, management of special accounts, and compliance with audit covenants. 4. An in-depth Public Expenditure Review (PER) will be carried out in FY94, following upon a similar exercise in FY93 to reach agreement on a core investment program for which the Government will provide adequate counterpart fimding (even if this means postponing or canceling non-core projects). Thereafter, the CPPR (Country Portfolio Performance Review) will finahze restructuring of the Bank s portfolio on the basis of the framework provided by the PER. At the same time, Govemment and the Bank will review progress in overcoming generic implementation issues identified during previous CPPRs. Other plans for FY94 include: (a) organization of Sector Implementation Reviews in association with the responsible project managers; (b) provision by the Resident Mission of greater support to project managers on procurement, special accounts, disbursements, and auditing; and (c) continuation of the practice of preparing implementation mamuals for new projects.  IBRD 2505 SUDAN UGANDA / 5 t g R X ~t t RIERS * FALLS T. t- g /q. R. t f j I ' ' ' l KOnDo FERRIES ZAIRE ~~~~~~~~~~~~~~~~~~~~~-PRJMARY BITUMEN ROADS |O -AIRE @ _ - 4 +FPRiMARY GRAVEL ROADS UNSURFACED ROADS >amR, - - g eii*\ RAILROADS o SELECTED TOWNS AND VILLAGES K~~~~~~~~~~~~~~~~~ DISTRICT CAPITALS * NATIONAL CAPITAL - DISICT BOUNDARIES REGION BOUNDARIES lb-.-INTERNATIONAL BOUNDAPIES _4 DmA,t 50 sc,deo dho a0 m.S FoO Ffd i. D0 CI Kobi e DiatfENt. MUBENDE l~~~~~~~~ ~~~~~~~~~~~a-ooab,o 50 100 ISO man; ;o~~5 100 LAKE V CTORbs f ai E -d ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~- WMAN~~~~~~~~~~~~~~~~~~~~~~~~~GN I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~AO - aRWANDA -R LI6~ - u= e -.J | , , .!:. 1 - = | - | ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~JULY 199.