Ghana - AIDS Response Fund (GARFUND) Project

Report No. PID9728 Project Name Ghana-Ghana AIDS Response Fund (GARFUND) Region Africa Regional Office Sector Non-Sector Specific Project ID GHPE71617 Borrower(s) GOVERNMENT OF GHANA Implementing Agency Address GHANA AIDS COMMISSION Ministry of Employment and Social Welfare P.O. Box CT 5169 Contact Person: Mr. Alhaji Muhammad Mumuni, Minister of Employment and Social Welfare Environment Category C Date PID Prepared November 30, 2000 Projected Appraisal Date October 18, 2000 Projected Board Date December 19, 2000 1. Country and Sector Background National awareness of the spread of HIV/AIDS dates back to the mid-eighties when the GOG established the National Technical Committee on AIDS. Soon after, the National AIDS/STD Control Program (NACP) was established within the MOH to coordinate the national response to the epidemic. However, its impact has been limited. Part of the reason is that prevention works primarily through behavior change, and the NACP/MOH has focused more on medical/clinical aspects. Although the MOH has developed some IEC programs and has worked on a limited basis with NGOs, it has been unable to mobilize civil society. An October 1999 mission of the International Partnership against HIV/AIDS in Africa noted the need for a multi-sectoral approach to increase the effectiveness of the GOG's response. The GOG established a multi-sectoral national commission to coordinate all HIV/AIDS activities in the country. It also assessed the adequacy of its response to the epidemic to date and based on the results developed a National Framework for HIV/AIDS in Ghana. It is estimated that at least 4.6 (1998 figures) of the adult population of Ghana is infected with HIV. At least 600,000 Ghanaians are estimated to be living with HIV. Prevalence almost doubled between 1994 and 1998. At current rates of infection, it is estimated that 1.2 million Ghanaians will be infected by the year 2005. Prevalence rates are highest among commercial sex workers, with rates as high as 82 percent in Kumasi in the Ashanti region. The actual number of AIDS cases is difficult to estimate given the strong stigma associated with the disease and the culture of silence it imposes. 2. Objectives The objectives of the proposed project (Ghana AIDS Response Fund, Garfund) are to reduce the spread of HIV infection, and reduce the impact of AIDS on those infected and their families by enabling the Government of Ghana (GOG) to implement a balanced, diversified multi-sectoral response,  engaging all relevant government sectors, non-governmental organizations and grassroots initiatives. The only sector not being financed is the MOH which is already receiving donor/IDA support through the Health Sector Program Support Project (HSPSP, Cr. 2994-GH). The project would support the implementation of the GOG's "Strategic Framework for HIV/AIDS in Ghana. 3. Rationale for Bank's Involvement Availability of sufficient funding for HIV/AIDS: Many donors are supporting Ghana's efforts to step up efforts to combat HIV/AIDS. However, no other donor is able to mobilize the amount of resources necessary for a fund which could finance the efforts of non-governmental and community-based groups as well as public agencies.Cross-country experience: The Bank is the largest financier of HIV/AIDS and STD control projects and has ample experience in the design, implementation and evaluation of these programs in all continents the Bank works in. Moreover, the Bank has ample experience in the management of investment and community development funds all over the world in which implementing entities are largely organizations of civil society and local district governments.Analytical capacity: The Bank has authored numerous studies analyzing HIV/AIDS and its impact, drawing upon knowledge in epidemiology, public health, and economics in order to make recommendations on defining priorities, strategies to confront it, and the measurement of its impact. The Bank can provide added value in its technical assistance on monitoring and evaluation. 4. Description The project would finance a US$25.0 million, 4-year component of the non-health components of the Government's Strategic Framework for HIV/AIDS. Garfunds's objective is to intensify multi-sector activities designed to combat the spread of HIV/AIDS and to reduce its impact on those already affected. To achieve its objective, the project includes support for the following activities:Prevention and Care Services (US$21.0 million) by financing governmental (excluding health) and non-governmental entities to provide a broad spectrum of preventive and care activities at national, regional and local levels. Approximately seventy-five percent of funding will be earmarked for non-governmental and community-based initiatives. The size of any single activity financed under the fund is not expected to be large (generally less than US$100,000). Prevention activities are designed to reduce high risk behavior and exposure to risk, and to reduce the vulnerability of those who are unaware of their risk by raising their awareness, and "de-stigmatizing" the disease so as to increase access to prevention and care. For families affected by HIV/AIDS, Garfund would reduce their vulnerability by financing services to protect their rights, income generation activities, care for orphans and home-based care for the ill.Strengthening Public/Private institutions for HIV/AIDS Control and Care Giving (US$2.4 million) by supporting training and technical assistance for institutions on technical and practical aspects of working with HIV/AIDS, and when required, some training on community participation and project management. Only entities implementing subprojects are eligible for training. The training will be subcontracted to NGOs and line ministries with expertise on the issue in question. Financing of this component will strengthen the impact of activities financed under Component l.Knowledge Management (US$1.4 million) by providing support for the establishment of a - 2 -  mechanism/strategy to collect, organize and disseminate up to date information on AIDS prevention and care, best practices of existing projects, research results, and any reports that would be useful to implementing entities. It would also finance activities to bring together subproject representatives to share experiences with subprojects with similar orientations. Financing of this component will strengthen the impact of activities financed under Component l.Project Management and Monitoring and Evaluation (US$3.0 million). The project would finance the establishment of a monitoring and evaluation system which will assess the progress attained in the fight against AIDS nationwide on the basis of the targets defined in the Strategic Framework and will monitor the advance of Garfund financed activities. 5. Financing Total ( US$m) Total Project Cost 27.8 GOVERNMENT 1.8 IDA 25.0 Community/NGOs 1.0 6. Implementation The credit is would be disbursed over a four year period. IDA would retroactively finance expenditures incurred up to 12 months prior to credit signing, including those relating to the setting up of the GAC Secretariat and its premises (rent, office equipment, supplies, salaries), and any other necessary preparatory activities including the setting up of Garfund's financial management system, up to an amount of US$1.5 million (or 6% of the value of the credit). The proposed project would be placed under the authority of the Ghana AIDS Commission (GAC) which would be in charge of the definition of broad priorities for action, the selection of eligible proposals, and the monitoring of the performance of those receiving funding. The Secretariat of the GAC would implement the GACs decisions. The GAC includes high level representatives of all line Ministries that can play a role in the fight against HIV/AIDS, religious, occupational, NGO affiliations, women's and student organizations and other interest groups. It is located in the Presidency under the chairmanship of the President. The vice-chairmanship of the GAC will rotate every year. The current vice-chair is the Minister of Employment and Social Welfare.Garfund will employ a fund mechanism to finance subprojects executed by a wide range of organizations at the national, regional and local levels. The GAC will select a technical subcommittee to review and select subproject proposals on a semiannual basis and to submit their recommendations to the GAC for their final endorsement. The Secretariat would be responsible for the financial and administrative aspects of Garfund, as specified in a detailed operational manual. It would contract the necessary technical support to guide executing entities in preparing proposals and implementing subprojects. It would prepare and administer contracts to selected executing entities and monitor their technical and financial performance. The Secretariat would provide financial and technical reports on a quarterly basis to the GAC, and prepare annual reports for financing agencies. 7. Sustainability Sustainability is more likely to result from: selecting low-cost, preventive interventions and thus reducing the number of people who - 3-  contract HIV/AIDS which would require more expensive treatment; and strengthening capacity to deliver cost-effective interventions, especially at the local level, and with major involvement of NGOs and community organizations. The project will prevent substantial expenditures on treatment of AIDS cases in the public sector, by virtue of the number of HIV infections that are averted. Managerial sustainability would be enhanced by strengthening the capacity of the Ghana Aids Commission to oversee the program, and strengthening implementation capacity in the public, private and NGO sectors at federal, state, and especially at local level. The project would include capacity building. 8. Lessons learned from past operations in the country/sector The project design reflects key lessons learned from international experience with HIV/AIDS. Key lessons learned are:n aggressive, preventive interventions are required to slow the spread of HIV;n interventions targeted to high risk behaviors and groups, within a broader campaign,are the most cost-effective way to reduce transmission and the best way to protect lower risk groups from infection;n information acquired through personal contacts is the most effective in promoting behavior change;n targeted interventions need to be complemented by broader advocacy, awareness and information campaigns which inform and protect the general population, build support for the program, and reduce the stigmatization of those infected or members of marginalized groups;f and advocacy and coordination across multiple sectors, including the NGO and private sectors, is needed to stem the epidemic.The experience in Uganda, where an advanced epidemic has been brought under control, and in Senegal, where a generalized epidemic has been prevented, demonstrate that HIV can be controlled through aggressive action combining strong government commitment, energetic prevention programs targeted at high risk behaviors, and sufficient resources from multiple sectors and sources. 9. Program of Targeted Intervention (PTI) N 10. Environment Aspects (including any public consultation) Issues The proposed project does not raise any major environmental issues. No construction activities are planned. 11. Contact Point: Task Manager Sandra Rosenhouse The World Bank 1818 H Street, NW Washington D.C. 20433 Telephone: (202) 473-2747 Fax: (202) 522-3135 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 - 4 -  Note: This is information on an evolving project. Certain components may not be necessarily included in the final project. This PID processed during the week ending December 1, 2000. - 5 -