Document of The World Bank Report No. 23094-SE PROJECT APPRAISAL DOCUMENT ONA PROPOSED CREDIT IN THE AMOUNT OF SDR 23.6 MILLION (US$ 30.0 MILLION EQUIVALENT) TO THE REPUBLIC OF SENEGAL FOR A HIV/AIDS PREVENTION AND CONTROL PROJECT IN SUPPORT OF THE SECOND PHASE OF THE US$500 MILLION MULTI-COUNTRY HIV/AIDS PROGRAM (MAP2) (APL) FOR THE AFRICA REGION December 20, 2001 Human Development II Country Department 14 Africa Region CURRENCY EQUIVALENT (Exchange Rate Effective December 17, 2001) Currency Unit = CFA Franc CFAF 727 = US$1 US$1 = CFAF 727 FSCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome APL Adaptable Program Loan ARV Anti-retroviral (Drugs) ART Anti-Retroviral Treatment ASPEN Africa Safeguard Policy Enhancement Team CAS Country Assistance Strategy CNLS Conseil National de Lutte contre le SIDA CBO Community-Based Organization CREA Center for Applied Economic Research CSW Commercial Sex Worker DAC Departmental AIDS Committee EA Environmental Assessment ECOMOG Economic Community of West African States' Monitoring Group FMA Financial Management Agent FHI/USAID Family Health International/ United States Agency for International Development FBO Faith Based-Organization FMR Financial Management Report GDP Gross Domestic Product HAART Highly Active Antiretroviral Therapy HIV Human Immunodeficiency Virus IBRD International Bank for Reconstruction and Development IDA International Development Association IEC Information, Education & Communication IDU Injection Drug Users IAPSO Inter-Agency Procurement Support Office ILO International Labor Organization ISAARV Initiative Senegalaise d'Acces aux Anti-retroviraux MAP II Multi-country HLV/AIDS Program II M&E Monitoring and Evaluation MOHP Ministry of Health and Prevention MSM Men Having Sex with Men NES National Executive Secretariat MTCT Mitigation of HIV/AIDS mother to child transmission NGO Non-Governmental Association NPV Net Present Value NSP National Strategic Plan 01 Opportunistic Infections PIP Project Implementation Plan POM Project Operational Manual PLWHA People Living with HIV/AIDS PMCT Prevention of Mother to Child Transmission PNA Phannacie Nationale d'Approvisionnement PNLS Programme National de Lutte Contre le SIDA PMR Project Management Report STI Sexually Transmitted Infection RAC Regional Aids Committee STD Sexually Transmitted Disease SWAA The Society for Women Against AIDS in Africa TB Tuberculosis TTL Task Team Leader UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Program UNICEF United Nations Children's Fund UNFPA United Nations Fund for Population Activities VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Callisto E. Madavo Country Manager/Director: John McIntire Sector Manager/Director: Alexandre Abrantes Task Team Leader/Task Manager: Anwar Bach-Baouab SENEGAL HIV/AIDS PREVENTION AND CONTROL PROJECT CONTENTS Page A. Project Development Objective 2 1. Project development objective 2 2. Key performance indicators 2 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported t 3 by the project 2. Main sector issues and Government strategy 3 3. Sector issues to be addressed by the project and strategic 5 choices C. Project Description Summary 1. Project components 9 2. Key policy and institutional reforms supported by the project 13 3. Benefits and target population 14 4. Institutional and implementation arrangements 14 D. Project Rationale 1. Project alternatives considered and reasons for rejection 19 2. Lessons learned and reflected in the project design 20 3. Major related projects financed by the Bank and other 22 development agencies 4. Indications of borrower commitment and ownership 24 5. Value added of Bank support in this project 25 E. Summary Project Analysis 1. Economic 25 2. Financial 26 3. Technical 27 4. Institutional 27 5. Environrental 29 6. Social 30 7. Safeguard Policies 31 F Sustainability and Risks 2. Critical risks 33 3. Possible controversial aspects 34 G. Main Loan Conditions 1. Effectiveness Conditions 34 2. Other 34 H. Readiness for Implementation 35 I. Compliance with Bank Policies 35 Annexes Annex 1: Project Design Summary 36 Annex 2: Detailed Project Description 42 Annex 3: Estimated Project Costs 48 Annex 4: Economic and Financial Analysis 49 Annex 5: Financial Summary 63 Annex 6: Technical Analysis 65 Annex 7: Institutional Analysis and Implementation 88 Arrangements Annex 8: Procurement and Disbursement Arrangements 99 Annex 9: Monitoring & Evaluation II1 Annex 10: Project Supervision Plan 115 Annex 11: Project Processing Schedule 117 Annex 12: Documents in the Project File 118 Annex 13: Statement of Loans and Credits 119 Annex 14: Country at a Glance 121 Annex 15: Senegal HIV/AIDS Brief 123 MAP(S) IBRD 31726 124 1 SENEGAL HIV/AIDS Prevention ad Control Project Project Appraisal Document Africa Regional Office AFTH2 Date: December 18, 2001 Team Leader: Anwar Bach-Baouab Country Director: John Mchntire Sector Manager: Alexandre V. Abrantes Project ID: P074059 Sector(s): HA-HIV/AIDS Lending Instrument: Specific Investment Loan (SIL) Theme(s): Health/Nutrition/Population Poverty Targeted Intervention: Y Program Financing Data [] Loan [XI Credit [I [I] Guarantee [I Other: Grant For Loans/Credits/Others: Amount (US$m): $30.00 Proposed Terms (IDA): Standard Credit Grace Period (years): 10 Years to maturity: 40 Commitment fee: Standard Service charge: 0.75% Financing Plan (US$m): Source Local Foreign Total BORROWER 0.73 0.09 0.82 IDA 21.73 8.27 30.0 COMMUNITY/NGO 1.39 0.00 1.39 Total: 23.85 8.36 32.21 Borrower: GOVERNMENT OF SENEGAL Responsible agency: MULTI-SECTOR GOVERNMENT AGENCIES Ministry of Health and Prevention Address: Building Administratif, Dakar, Senegal Contact Person: Dr. Mandiaye Loume, Director of Health Tel: (221) 860 3287 Fax: (221) 860 3287 Email:dirsante@sentoo.sn Other Agency(ies): Conseil National de Lutte Contre le SIDA Secretariat Executif Contact Person: Dr. Ibra Ndoye, Secretaire Executif National Tel: (221) 822 9045 Fax: (221) 822 1517 Email: INdoye@telecomplus.sn Address: HLM1 No. 147 Dakar B.P. 10403, Dakar, Senegal Estimated disbursements (Bank FYIUS$m): FY 2002 2003 2004 2005 2006 2007 Annual 2.1 6.0 7.0 5.5 7.2 2.2 Cumulative 2.1 8.1 15.1 20.6 27.8 30.0 Project Implementation period: January 2002-April 2007 Expected effectiveness date: April 2002 i Expected closing date: September 30, 2007 2 A. Project Development Objective 1. Project development objective: (see Annex 1) 1.1. The overall development objective of the project is to assist the Government in: (i) preventing the spread of H[V/AIDS by reducing transmission among high risk groups; (ii) expanding access to treatment, care and support for people living with HIV/AIDS (PLWHA) in Senegal to serve as a pilot for the implementation of Anti-Retroviral Treatment (ART) in Sub-Saharan Africa; and (iii) supporting civil society and community initiatives for HIV/AITDS prevention and care. The project will support the implementation of Senegal's strategic plan against HIV/AIDS for the period 2002-2006 (Plan National de Lutte Contre le SIDA-PNLS), and promote civil society and community initiatives for prevention and care, put forward by beneficiary groups selected on the basis of the technical quality and likely impact of their proposals. The plan's specific goals are to: * keep the prevalence level of HIV below 3% by 2006; * mitigate the health and socio-economic impact of HIV/AIDS at individual, household and community levels; and * create an enabling environment for a broader and stronger public/private partnership to implement the plan. 2. Key performance indicators: (see Annex I) 2.1. The following constitute the summary outcome and process indicators of the project. Given the nature of the epidemic and the experience in other countries, it would be difficult to achieve measurable impact in terms of reduction of HIV/AIDS prevalence in the overall adult population, or increased life expectancy, within the project period. However, measurable impact can be expected among certain target groups as set forth below in the outcome indicators. A more extensive list of indicators appears in the logical framework (Annex 1). a. Outcome indicators By 2006: * 65% of adult males report using a condom with a casual partner during their last sexual encounter; * 60% of women aged 20 to 49 report using a condom with an irregular partner during their last sexual encounter; * 80% of women aged 20 to 49 report knowledge of at least two methods of protection against HIV/AIDS; * 70% of commercial sex workers and 80% of the members of uniformed services report using condoms during their last sexual encounter with a non-regular partner; * by 2006, reduce the prevalence among commercial sex workers of Trichonomas from 15% to 10%, Gonococcie from 4% to 2% and Syphilis from 20% to 15%; * 60% of women attending pre-natal clinics accept voluntary testing for HIV; 3 * Increase the level of Voluntary Counseling and Testing (VCT) acceptance among the population by 10% every year; * Reduce the rate of mother to child transmission from 30% to 15%; b. Process/output indicators * 90% of all ministries have incorporated HIV/AIDS prevention in their work plans and budgets; * All levels and branches of education system implement the HIV/AIDS curricula; * 100% of health centers have improved blood safety and safe injection practices; * 80% of personnel in the health system are trained to provide comprehensive care of STIs and Ols; * HIV/AIDS reference facilities in all 10 regions of the Country, providing regular integrated treatment and care for Sexually Transmitted Infections (STIs), TB, opportunistic infections (Ols), mitigation of mother to child infection, and ARV treatment, with counseling and medication; * 95% of PLWHA are under ARV treatment receive psycho-social support; * 80% of registered orphaned children receive social support at community level; * 7,000 people have received ARV treatment. B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1) Document number: 17269-SE Date of latest CAS discussion: January 29, 1998 1.1. The 1998 CAS recognized that the low prevalence of HIV/AIDS offered no guarantee against an epidemic unless additional preventive measures were taken. It also encouraged the Government to increase per capita spending to that end. Preliminary consultations (May 2001) with regard to the CAS under preparation were conducted with focus groups in all of Senegal's 10 regions. These focus groups included youth, women, vulnerable groups, NGOs and regional and communal authorities. All groups clearly identified the need for an intensified HIV/AIDS prevention campaign, with advice and support available at the community level. 2. Main sector issues and Government strategy: 2.1. Senegal continues to shoulder a heavy burden of preventable HIV diseases. In this regard, it has implemented a policy shift toward the prevention of disease through the decentralization of health services and through the involvement of beneficiaries and NGOs, particularly in the management and implementation of programs. However, these effo, risk being undermined by Senegal's rapid population growth and still high but stable WHV prevalence rates among specific high risk groups [15% of Commercial Sex Workers (CSW) are sero-positive]. Furthermore, the extent of behavior change is limited compared to the high level of awareness. A significant effort for the promotion of safer sexual behavior is required, and, to raise the median age of first sexual contact. The population is expected to reach 16 million in 2020, almost doubling from 2000 (9.4 million), pushing the 4 urban population to about 9 million people. This increase will exert unrelenting pressure on social services, and in the event of weakening economic conditions, poses a major threat of increased prevalence of communicable diseases, notably fHV/AIDS. Senegal regards its development plan for the period 2002-2006 as the last reliable window of opportunity for full containment of HIV/AIDS and STDs. 2.2. Senegal has a reasonable chance of significantly reducing HIV infections during the next five years. Factors which have helped Senegal's success in maintaining one of the lowest prevalences in the region and which favor further reduction of new infections are: * strong commitment at the highest level of Government and civil society; * an early and unanimous decision (1986) to confront STD and contain HIV infections; * consistent and sustained strategic direction and management of the program; * a high level of sensitization to the issues on the part of civil society, the private sector and Government, leading to strategic alliances between Muslims and Catholics, the NGOs and key groups such as PLWHA, women, youth and high risk groups; * strong capacity for policy formulation and strategic planning; * a good network of primary, secondary and tertiary health care facilities; * tested delivery systems and increasingly robust mechanisms for M&E and grassroots participation; * the development of best practices with the assistance of major international research institutions, now disseminated widely in the Region. 2.3. The 2002-2006 National Strategic Plan Against HIV/AIDS in Senegal was developed and adopted through a multisectoral consultative process in 2001 and is considered by Government an integral part of the broader framework for poverty alleviation. It builds on the earlier National Strategic Plans, and constitutes a synopsis of sector strategic plans that were elaborated through a series of consultations within each sector. The multi-sector plan involves government ministries, private sector and civil society, and stresses the need for partnership among all the actors on the ground to ensure a coordinated, localized response to reducing the spread of HIV infections and the socio-economic impact of AIDS. 2.4. The Government has thus requested access to IDA resources within the framework of the second phase of the Multi-Country HIV/AIDS Program (MAP II) for the Africa Region to be presented to the Board of Directors in January, 2002. Senegal is eligible for MAP funding and has satisfied the four MAP eligibility criteria as follows: a) Senegal already has a coherent national strategy and has developed a comprehensive medium-term, multi-sector plan in a participatory manner with all concerned stakeholders; b) It has created a National HIV/AIDS Council chaired by the Prime Minister with broad representation from all sectors and civil society, including people living with HIV/AIDS, to coordinate the implementation of the national plan; c) The Government has agreed to use exceptional implementation arrangements to accelerate project execution by outsourcing implementation aspects such as 5 behavioral surveys, operational research, financial and program management, monitoring and evaluation; and d) The Government has agreed to use and fund multiple implementation agencies as reflected in its plans to channel funds directly to both public and private implementing agencies, civil society organizations, NGOs, associations of PLWHA, and to communities. 3. Sector issues to be addressed by the project and strategic choices: 3.1. An analysis of Senegal's HIV/AIDS program was carried out recently as part of the preparation process of the new strategic plan. The analysis was conducted in close association with all partners in the program including Government, bilateral and multilateral agencies, civil society and the private sector. Its main conclusion is that while Senegal has achieved remarkable progress to date in the fight against the disease with very limited resources, it needs a substantial injection of funds to consolidate and widen its program, and ensure its sustainability. The analysis identified three major areas where improvements are needed. While Government has already taken steps to put these improvements on a sustainable footing with the help of international donors, there are still gaps, and there is the need to finance future program directions, particularly community approaches to care and prevention, capacity building for civil society and taking ART beyond the pilot phase. The three areas for priority improvements are: (i) Weak institutional capacity and limited partnership with civil society. The intensification of the prevention effort and the introduction of patient and family support services will require significant strengthening and coordination of the concerned institutions, services and systems, notably: * systems and procedures for channeling funds more efficiently to the grassroots; * developing capacity at the regional and sub-regional level through accelerated training of technicians in the areas of VCT (especially for pregnant women), ART, treatment of Ols and STDs, procedures to ensure safe blood supplies and the safe handling of medical waste; * partnerships within the civil society to strengthen and develop local capacity to deliver prevention and care at a decentralized level; * monitoring and evaluation, which becomes more complex as a result of greater grassroots involvement; * research and dissemination activities: consolidation of the existing, successful collaborative research arrangements and enhancement of Senegal's role in disseminating best practices to other countries in the Region; * procurement of drugs, testing kits and related services to ensure that regional and district services are supplied efficiently and on time. 3.2. Sector Response. To address the issue of timely funding of grassroots activities, Senegal has decided to contract out the processing of grant requests and related disbursements on a competitive basis to a private sector Financial Management Agent. It will also ensure efficient partnerships with civil society in order to transfer and build local training and delivery capacity at the grassroots level. Additionally, Senegal will reinforce its M&E system; preparations are well advanced for deploying a second generation 6 surveillance system country-wide, which incorporates attitudinal and behavioral surveys. The system of notification of HIV/AIDS and STDs will also be reinforced to ensure full reporting and follow-up. (ii) The need to intensify prevention at the grassroots level. Prevention, which has been the main weapon of Senegal's fight against AIDS, has proven to be effective, as evidenced by the current prevalence rate. There is now broad agreement on prevention as a national priority and a high level of public knowledge about HIV/AIDS. However, much work is still to be done, particularly with regard to: * Youth, aged 15 to 19, whose numbers will increase dramatically through 2010, rising to 15% of the overall population. Educating them about disease transmission and protection, and raising the average age of the first sexual encounter are the highest priorities in terms of containment. To be effective, this group must be reached in the last years of primary school, before sexual activity begins. Specific activities must also be developed for those who have dropped out of the education system; * Women, who are particularly vulnerable because of the health risks related to genital mutilation (still a widespread practice), their generally low health status and their low rate of literacy; * Other vulnerable groups such as sex workers, homosexuals, transport workers and men and women in uniform (the latter are an important and a hitherto neglected target group, given Senegal's very active role in ECOMOG peacekeeping and in providing training infrastructure for other member countries); * Sustainability of prevention activities over the long term. The best prospect for this is sharing the burden of prevention among a greater number of actors in society and reinforcing grassroots capacity and responsibility. 3.3. Sector response. Senegal now seeks to carry prevention to a new level of intensity by implementing a multisectoral prevention program involving civil society, Government and the private sector based on Senegal's philosophy of "Faire Faire", e.g. active involvement of beneficiaries in the resolution of their own problems. The main thrust of the program is a grassroots effort in which even the smallest social units of civil society - local associations, villages, neighborhoods - assume responsibility for the fight against HIVIAIDS, assisted by an extensive network of action groups which have arisen since 1986. These include: NGOs (two federations of NGOs have been created to harmonize and improve prevention efforts), women's groups (there are over 300 in Senegal), youth associations and municipalities associations. In Government, the Ministry of Health and Prevention (MOBP), and all line ministries have a role to play in prevention. The MOHP plays a major role in prevention and treatment, notably through testing (particularly of pregnant women and treatment to prevent mother to child transmission), the diagnosis and treatment of STIs, improving safe injection practices and the provision of safe blood supplies, clinical care and epidemiological surveillance. It also has a major responsibility with regard to Information Education and Communication (IEC), ensuring that key messages are of high quality and providing information to users of health service facilities. Finally, MOHP plays a key role in backstopping the other technical ministries which are expected to play their part in prevention, not only with regard to their own staff but 7 through outreach programs and projects which reach out to specific segments of the population. Education provides a good example of a sector prevention program. With the support of the teacher's unions, prevention is already integrated into personnel management and the curricula of primary and secondary education incorporate modules on prevention. Further reinforcement of these programs offers one of the best ways of reaching the majority of youth before their first sexual experience (Senegal currently has a gross primary enrollment of 70% and targets 100% by school year 2009-2010). Education also reaches out to the informal sector, notably through the women and girls' literacy program. This program operates in all ten regions and has 200,000 participants. Its activities incorporate HIV/AIDS materials which are available in the eight national languages - a powerful tool for IEC. In other sectors, development projects can be a vector for reaching such diverse groups as rural and urban communities, farmers and transport workers. Finally, the private sector, working at the enterprise level or through trade associations, can obtain advice and matching grants to implement prevention measures, building on Senegal's experience with the provision of reproductive health services at work sites. Tourism is a particularly important private sector target for prevention since it holds out good prospects for investment and foreign exchange earnings. At the same time, it is often the interface between high risk groups and overseas visitors. Consequently, a "prevention conscious" tourism industry can only strengthen those prospects by inspiring international confidence. (iii) Inadequacy of treatment, care and support. While prevention has made significant progress, the burden of care and support for PLWHA and their families has largely fallen on the extended family, usually poor, eroding their already limited means and preventing them from obtaining the education and employment opportunities needed to escape poverty. The epidemiological monitoring system in Senegal shows a stable HIV population of approximately 80,000 HIV infected persons, most of whom are unaware of their condition. Data available for 2001 indicate that only 550 adults and 10 children are under Anti-Retroviral Therapy. While access to treatment has to be seen in the context of low prevalence, and the continuance of low rates (and therefore on the strengthening and reinforcement of prevention), access to ART must be gradually increased to mitigate to some extent, the socio-economic impact of the disease. 3.4. Sector response. An important element in Senegal's poverty reduction program is the alleviation of the financial burdens of over-extended families by providing care for those who are sick, counseling, support services and eventually economic opportunities, albeit initially in the form of limited pilot projects. In terms of care, ART will be provided to patients likely to benefit from the treatment offered by the public health system, based on an eligibility criteria and income level (see Annex 2 of Senegal PAD). In 2000, Senegal successfully introduced anti-retroviral drug therapies, on a pilot basis, in the public health system, and has negotiated favorable prices with five ART drug manufacturers with possible further reductions. Based on the positive results of the pilot phase, the medical authorities are taking up the challenge to strengthen the gains achieved so far and gradually expand access to ART over the next decade to selected clinical sites in all regions. Given the relatively low number of PLWHA (estimated in 2001 at 80,000 of the adult population), the financial burden, while initially high, may be less over the long term than the costs imposed by opportunistic infections which result in frequent and extended 8 hospitalization together with expensive medication. Other elements of the response are the treatment of 01, counseling and support services to PLWHA and their Families at the community level by the combined efforts of the health services and grassroots NGOs. Finally, special provision will be made for orphans. (The cumulative number of orphans is still manageable, around 20,000.) Orphans will be carefully followed by the social services, financial aid and home care will be granted to enable them to continue their schooling and access health care. Infected orphans will be guaranteed treatment since they impose only marginal additional costs for ART provision. 3.5. Strategic Choices. Senegal might have chosen to "rest on its laurels", confident that its current health-focused program and prevention campaign have sufficient momentum. However, recognizing the risk that the country might reach an exponential growth of HIV/AIDS in the event of an economic downturn coupled with rapid population growth, it has decided on an intensification of prevention activities, including the promotion of voluntary testing and counseling, an expansion of Anti-Retroviral Treatment, and community-based care and support programs to PLWHA. Hence, Government is taking steps to move toward a multisectoral approach while maintaining and reinforcing the leadership role played by MOHP. This approach is based on a stronger partnership with the civil society and communities, which will be called on to participate in key actions in IEC, the promotion of VCT, the prevention of mother to child transmission, access to condoms, and home care and support to PLWHIA and their families. Communities as well as NGOs, Community-Based Organizations (CBOs) and special interest associations will be more readily able to tap financial resources and technical support in order to ensure a timely and flexible response to these initiatives. 3.6. The Government also intends to promote and encourage the participation of private enterprises and their federated organizations in implementing the national strategy, including initiating a communication strategy aimed at sensitizing private sector leaders to the benefit of providing prevention and treatment services to their employees and their families. It will also test financial and administrative mechanisms for channeling resources efficiently to beneficiaries, notably by contracting out financial management of all initiatives by both public and private entities to a competitively selected private sector agency. The main thrust of the proposed program is to channel approximately 70% of IDA resources to the community level to finance activities aimed at: * the reduction and containment of HIV infection and transmission among women, newborns, adolescents and high risk groups; * improving access to prophylaxis and treatment of STIs, opportunistic infections and Anti-Retroviral Therapy for all people living with H1V/AIDS eligible for treatment according to national standards; * the provision of care, counseling and support to PLWHA, their families and orphans; * expanding and strengthening public sector health facilities for testing, treatment, safe blood supplies and safe injection practices; * strengthening the institutions responsible for M&E and consolidating existing collaborative research arrangements with regional and international institutions (Senegal is a key reference for the Region in terrns of best practice and a "living laboratory" for testing new approaches). 9 C. Project Description Summary 1. Project Components: (See Annex 2 of Senegal PAD for a detailed description and Annex 3 of Senegal PAD for a detailed cost breakdown.) 1.1. The project will support implementation of Senegal's strategic plan through a wide variety of public sector agencies, private and non-governmental organizations, and by community-based organizations. It will be executed over a five-year period extending from 2002 to 2006 to coincide with the national strategic plan and will complement other donor activities. The project aims to develop additional planning, implementation, monitoring and evaluation capacity of public and private entities, and expand existing prevention, treatment and mitigation programs. It will be implemented in close coordination with other bilateral and multilateral organizations. The project will be implemented through four major components as follows: Part A. Strengthening the capacity of implementing agencies and coordination structures (US$ 1.92 million) 1.2. This component is designed to reinforce the resource management, implementation and monitoring and evaluation capacity of government agencies, civil society and the private sector, and to strengthen the capacity of local organizations and rural communities in the design and implementation of demand-driven HIV/AIDS activities. The National HIV/AIDS Council, its Secretariat and its decentralized structures at the regional and district levels will also be provided technical, financial and material support to coordinate, monitor and evaluate implementation of the national strategic plan. More specifically, capacity-building support will consist of two sub-components: 1.3. Support to HIV/AIDS Units. This sub-component will cover the provision of technical support services and training to HIV/AIDS units of line ministries, NGO and CBO personnel, with an emphasis on project design, participatory planning, and monitoring of community-based activities. It will also train laboratory technicians, medical and paramedical staff and social workers to strengthen VCT, the prevention of mother to child transmission, the prevention and treatment of opportunistic infections (01) and tuberculosis, and the provision of ART. 1.4. Support to Monitoring and Evaluation. This sub-component will consist of the provision of technical support services, equipment and materials to implement a comprehensive Monitoring & Evaluation (M&E) plan. The National Executive Secretariat (NES) will coordinate and ensure implementation of the following M&E components, outsourcing them to Government and private agencies: (i) surveillance; (ii) epidemiological research; (iii) financial monitoring; and (iv) project monitoring. Surveillance comprises both biological and behavioral surveillance. Operations research will examine what is working and disseminate important lessons. The World Bank will support operations research, to ensure maximum cross project learning and dissemination. Financial and project monitoring will focus on NES's contracting and coordinating capacity and the relevance, quantity, quality and economy of public sector and civil society services. Structured reporting and assessment forms and procedures will be utilized to ensure sound project monitoring. Financial and project monitoring will generate verified 10 primary data to inform internal and external supervision. With regard to such financial and program management monitoring, Senegal has agreed to outsource the project's financial management to a single agency which will also be responsible for financial and program management monitoring and evaluation. Terms of reference were prepared and agreed upon during project preparation. Part B. Support to civil society and community-based initiatives in the area of prevention, care, social support and mitigation (US$ 12.5 million). 1.5. Using a grant mechanism, this component is designed to intensify prevention, care and social support to meet the needs of specific target groups, PLWHA and their families. It will ensure the continuity and expansion of successful HIV/AIDS mitigation activities adapted to local conditions and managed by grassroots organizations and communities. This component will also promote and encourage HIV/AIDS initiatives of private sector enterprises aimed at developing and implementing prevention, care and support strategies designed for their employees and their families. This will be done in close coordination and complementarily with the recently launched ILO-financed project with the Ministry of Labor. 1.6. A private Financial Management Agent (FMA) will be contracted to provide overall financial management for the project, including the management of grants for civil society activities. Funds will be channeled directly through grants to associations, religious organizations and communities, private enterprises, NGOs and community-based organizations to cover a wide range of activities including: (i) prevention and sensitization activities targeted at communities as well as specific groups at high risk and aimed at building awareness, reducing the stigma associated with HIV/AIDS and the adoption of safer sex behavior; (ii) provision of home and community-based care for AIDS patients; and (iii) social support to PLWHA, orphaned children and households affected by HIV/AIDS, through income generation activities and support to local caregivers. Grant recipient responsibilities will be specified in a contractual agreement signed before work begins. Eligibility criteria, norms and standards for implementation of sub-projects under this grant mechanism are described in more detail in Annex 2 of Senegal PAD and will be finalized in a specific module of the project operational manual. 1.7. With regard to activities aimed at helping orphaned children, the project will finance investments to improve their nutrition, their access to education and health care, as well as their integration into host Families and communities. Sub-projects proposed by civil society organizations and financed under the IDA Credit will complement and reinforce ongoing or new initiatives such as the Hope For African Children Initiative launched by Care, Plan International, Save the Children, The Society for Women Against AIDS in Africa (SWAA) and the World Conference on Religion and Peace. This Initiative has received a US$ 10.0 million grant from the Bill and Melinda Gates Foundation and has been endorsed by UNICEF, the World Bank and USAID. The project will ensure complementarities with the FHIIUSAID and other efforts by partners to support civil society in the fight against HIV/AIDS. 11 Part C. Support to Governmental Agencies Multi-Sector program (US$ 10.69 million). 1.8. The purpose of this component is to support a major expansion of HIV/AIDS activities implemented by government entities. Several ministries are in the process of developing detailed work plans and budgets and will be eligible for support under the project as of the first project year. These are the ministries in charge of health, women, youth, the interior, education, and technical and vocational training, literacy and national languages. Additional ministries and state enterprises will also have access to IDA funds once they develop their action plans. 1.9. Activities under this component cover the full spectrum of prevention, treatment, care and support and include: (i) IEC - the design, implementation and evaluation of information, education and communication (IEC) programs aimed at specific audiences such as adolescents (both genders) in and out of school, women, youth, and men in uniform; and high risk groups such as commercial sex worker (CSW) and men having sex with men (MSM); (ii) Social Marketing - promotion and distribution of condoms; (iii) MTCT - Mitigation of HIV/AIDS mother to child transmission (iv) VCT - promotion of and access to voluntary HIV counseling and testing (VCT); (v) Blood banks - screening of donors and quality control for transfused blood products; and (vi) Diagnosis, treatment and care of HIV patients, including clinical management of sexually transmitted diseases, opportunistic infections, TB, and pilot anti-retroviral infections. 1.10. IEC. The IEC program which will be supported under this component aims at maintaining awareness of HIV/AIDS risks and protection measures. It will promote behavior change for safe sex practices and risk reduction, and advocate among public and private leaders with respect to human rights protection, abolition of discriminatory practices and learning to live with PLWHA. Use of the mass media will be an important channel of communication. A communication strategy will be put in place to ensure effective communication to all sectors of the public and civil society. 1.11. Social Marketing. This component will support the use of social marketing for condom promotion and distribution. Peer groups, vending machines and other social marketing strategies will also be used to make condoms accessible to all segments of the adolescent and adult population. Each ministry can choose its strategy to make condoms available and accessible to its staff and clients, and visible access to condoms in public places will be encouraged. 1.12. Mitigation of HP//AIDS Mother to Child Transmission. The project will support the decentralization of the MOHP pilot Prevention of Mother to Child Transmission (PMCT) program to at least one clinical site in each of the ten regions of the country during the period 2002-2006. The objective is to achieve a level of 80% awareness of mother to child transmission among women aged 15 to 49, and to reduce the transmission 12 rate from 30% to 15%. Ninety percent of children born to HIV-infected mothers will be provided with care and treatment at the end of the project. 1.13. Specific activities will consist of: a) the gradual establishment, training and equipping of multidisciplinary teams in each of the ten regions of the country under the supervision of a national team composed of leading gynecologists, pediatricians, biologists and social workers; b) implementation of a program of pre-test and post-test counseling and the voluntary testing of a target total of 58,000 pregnant women in pre-natal consultations during the period 2002-2006; c) expanding access to short regimen treatment using Zidovudine or Nevirapine drugs; d) expanding access to Anti-Retroviral Treatment therapy in accordance with national standards; e) the development and implementation of specific psycho-social support and LEC activities targeting HIV-infected pregnant women covering topics such as nutrition, breast feeding practices and the use of milk substitutes; and f) the establishment of a supervision and monitoring system to ensure effective control and quality of implementation of PMCT protocols and guidelines, and efficient follow-up and monitoring of patients. 1.14. Diagnosis, Treatment and Care of HIV/AIDS Patients. This will be based on the expansion of ISAARV (Initiative Senegalaise d'Acces aux Antiretroviraux). Launched in 2000 and currently limited to the city of Dakar, ISAARV will be progressively decentralized to the main cities of the country (Saint Louis, Kaolack, Ziginchor and Tambacounda). For this purpose, the project will strengthen voluntary counseling and confidential testing and laboratory capacity to help scale up the diagnosis, treatment and care for HIV/AIDS patients. This is part of the MOHP's objective to reduce HIV transmission, reduce worker disability and improve the quality of life for HIV/AIDS patients. This component will also support activities aimed at improving the diagnosis and treatment of sexually transmitted diseases, opportunistic infections, and tuberculosis. It will contribute, as needed, to the strengthening of drug management, patient management (eligibility, clinical and biological follow-up) and psycho-social and economic support to PLWHA. Bio-medical equipment will be purchased to monitor the immunology and virology parameters of HIV infection. Financing will be made available to cover the costs of minor renovations in selected laboratory facilities, the procurement of reagents and drugs for the treatment of STIs, OIs, TB and other HIV-related illnesses. In May 2000 the Government joined the Accelerated Access Initiative launched by the pharmaceutical producers of anti-retroviral drugs and indicated its intention to continue its ARV drug procurement plan under an arrangement with those companies which provided price reductions (up to 95%). It is worth mentioning that two producers have agreed to donate Nevirapine and Flucanazole, two of the drugs used in the ART regimen in Senegal. Funds under the IDA Credit will also be made available, as necessary, to supplement Government financing of ARV drug procurement. Part D. Support to project management and administration (US$ 2.82 million). 1.15. This component will provide support to facilitate the programming, coordination, and monitoring of project operations, including support to the National AIDS Council (Conseil National de Lutte contre le SIDA - CNLS) and NES, to ensure complementarity and efficient coordination of activities by all concerned parties, and to consolidate activity plans, budgets and progress reports. This component will support the deployment of 13 skilled and experienced manpower to staff essential coordinating structures, and will fund services of a Financial Management Agent, technical and financial audits, logistic support to facilitate project supervision and reporting, and the organization of CNLS/NES regular meetings and annual project reviews. Cost Summary Table Indicative % of Bank- % of Component Sector Costs Total financing Bank- (US$M) (US$M) financing A. Strengthening capacity of 1.92 5.9 1.92 100 implementing agencies and coordinating structures B. Support to civil society and 13.88 43.1 12.50 90 community-based organizations initiatives C. Support to Government 11.40 35.4 10.69 93.7 Agencies Multi-Sector Programs D. Support to Project 2.93 9.1 2.82 96.2 Management and Administration E. Unallocated 2.08 6.5 2.08 100 Total Project Costs 32.21 100.0 30.00 93.1 Total Financing Required 32.21 100.0 30.00 93.1 - Costs do not include taxes - Costs in this table and subsequent tables do not include parallel financing from other donor agencies. - Costs only include IDA, Government and community financing. 2. Key policy and institutional reforms supported by the project: 2.1. The project supports the implementation of Senegal's comprehensive National Strategic Plan against HI-V/AIDS (PNLS) which aims to achieve a major shift towards a multisectoral and decentralized program that treats HIV/AIDS as a development priority. The Government's creation of a multisectoral National AIDS Council [Conseil National de Lutte Contre le SIDA (CNLS)] under the chairmanship of the Prime Minister is a clear recognition that the HlV/AIDS epidemic is a fundamental national priority that has to be addressed as a multisectoral issue. The project also reflects the Government's new policy direction towards a broader decentralized community-driven approach involving community-based organizations, non-governmental organizations and the private sector, with about 85% of project resources being targeted towards regional, district and commune levels. In order to implement this approach, the project will support key institutional reforms that will facilitate the implementation of a multisectoral, beneficiary-driven WHV/AIDS program as well as the establishment and operation of CNLS, NES, the Regional and Departmental Committees, the HIV/AIDS units within the line ministries, and the outsourcing of financial management and M&E to private sector firms and research organizations. 14 3. Benefits and target population: 3.1. Benefits: By scaling up ongoing efforts in the fight against HIV/AIiDS, involving all sectors and players at all levels of society, the project is expected to have a major impact in reducing the further spread of HIV/AIDS, improving care of PLWHA and mitigating the social impact of the epidemic. 3.2. The project will provide the following benefits to Senegal: a) Reduce the number of new HIV/AIDS cases, by reducing the rate of transmission of fIHV through: (i) changing HIV-related behaviors, particularly in target groups; (ii) improving accessibility to condoms; (iii) reducing the rate of sexually transmitted diseases; (iv) improving blood safety and safe injection practices; and (v) reducing the number of HIfV infections transmitted from mother to child and expanding voluntary counseling and testing services; and b) Extended productive life of people living with, or affected by, AIDS by: (i) improving the prevention and treatment of opportunistic infections, particularly TB; (ii) providing ARV drug treatment for PLWHA; (iii) improving the care for AIDS orphans; and (iv) provision of psychological and social support for PLWHA and their families. 3.4. Target population: The project would directly benefit: (i) high-risk groups; (ii) PLWHA; and (iii) the entire population of Senegal. 4. 1. Target groups include: (i) youth (in and out of school); (ii) women; (iii) commercial sex workers; (iv) population with signs and symptoms of STIs; (v) workers; (vi) armed forces; (vii) migrants; (viii) health workers; (ix) MSM; and (x) other groups. 4. Institutional and implementation arrangements: Institutional arrangements (i) Project coordination. Overall coordinating responsibility for the PNLS will be undertaken by the National HIV/AIDS Council (CNLS) established by presidential decree. The CNLS members include representatives from all government ministries, the private sector, an observer designated by the group of international donors and representatives of the civil society including youth, women, religious groups, PLWHA, NGOs, regional and local communities as well as recognized experts in HIV/AIIDS that the CNLS may deem necessary to call upon for advice (non-voting). The Prime Minister will assume the chairmanship of the CNLS and chair its meetings. The Minister of Health will assume its vice-chairmanship. The number of CNLS members will be limited to a maximum of 30 persons. It will meet once every six months or, exceptionally, at the request of its chairperson and/or one third of its members. The CNLS will be responsible for: (a) advocacy, strategic direction and policy coordination to ensure conformity with the PNLS; (b) mobilization of financial, human and physical resources necessary to carry out the PNLS; 15 (c) oversight of the plans for implementation of the PNLS throughout the country; (d) ensuring the legal and ethical aspects of the fight against HIV/AIDS. 41.2. The CNLS will execute its mandate through the National Executive Secretariat (NES) which will have responsibility for overall management of the PNLS. The NES will have a perrnanent core of executive staff including an Executive Secretary, an Administrative and Financial Officer, and three Program Coordinators. The NES Executive Secretary will be the Project Director and will report to the Minister of Health and Prevention, as vice- chairperson of CNLS. The NES will be responsible for: (a) Recording decisions taken during meetings of the CNLS and ensuring their execution; (b) Overseeing the contracts and conventions signed between the Financial Management Agent and the implementing agencies, and ensuring their overall execution and quality assurance; (c) Representing the CNLS in meetings with various levels of government and other partners; (dl Ensuring the provision of technical assistance and quality assurance to partners involved in the national responses; (e) Ensuring monitoring and evaluation of sector and local plans; (f) Presenting the annual financial statements and program reports to the CNLS; kg) Organizing occasional meetings between all the partners in the program; (h) Coordinating with the Financial Management Agent (FMA) in addition to chairing the national selection committee for civil society projects that are above a specified ceiling or have national coverage; (Ii) Ensuring overall monitoring, evaluation and coordination of the program. 4 i. [te NES will coordinate with other I)A-funded projects and with HIV/AIDS related ,nnaoects financed by other bilateral and multilateral agencies. The NES will meet regularly v rLh thL IUNAIDS Theme Group and participate in meetings of HIV/AIDS donors led by N' N?E)P iii Project Implementation. The project will finance a series of HIV/AIDS action plans presented by line ministries, as well as projects proposed by a large number of civil society orearnizations, including NGOs, faith based-organizations (FBOs), women's groups, ,tssociations, unions, private enterprises and community-based organizations (CBOs). 4.4. Line ministries andparastatals. These will receive approximately 40% of project ,unds, These funds will be complemented by contributions from line ministries or p.aastatal budgets, including provision for a Focal Point or HIV/AIDS unit that will be r esponsible for policy coordination, monitoring and reporting on the sector response to H1V-RAIDS. Line ministries will implement their respective plans through their existing central. regional and departmental units. They will provide administrative and technical support to their implementation units, including relevant guidelines, training and monitoring and evaluation. They will also ensure that appropriate financial, human and )hysicWa resources are channeled to regional and departmental authorities to carry out a uccentralized response to HIVAIDS. They will ensure active involvement and 16 representation of the public sector in the regional and departmental HIV/AIDS committees. A formal contract, including a work program and budget with agreed input and output indicators, will guide the relationship between line ministries, the NES and the FMA. The NES will be responsible for providing technical assistance and quality control to line ministries. (The breakdown of project funds is provided in Annex 3 of Senegal PAD.) 4.5. All line ministries will reinforce existing coordinating units at the central level and ensure participation of their staff at regional and departmental levels in AIDS control comrnmittees (CRLS, CDLS). There is also the need to set up a communication plan for prevention campaigns in the respective sectors; NES will coordinate a comprehensive communication plan to be contracted out to specialized social marketing agencies. (Details concerning the various participating line ministry plans are contained in Annex 2 of Senegal PAD.) 4.6. Civil Society. Civil society will directly receive approximately 40% of project funds through sub-projects proposed and implemented by a variety of organizations. Civil society organizations will include NGOs, CBOs, private sector enterprises, associations, women's groups, labor unions and other legally constituted civil society organizations who wish to carry out activities in the fight against HIV/AIDS among their target beneficiaries and communities. With respect to the NGOs, a roster of over 200 civil society organizations working in HIV/AIDS has been established in Senegal, and reflects different categories of NGOs and CBOs, classified according to their experience, geographic coverage, target beneficiaries and ability to carry out HIV/AIDS projects. Each civil society organization will submit an action plan and budget for financing projects to the FMA at the national or regional level according to the level of financing proposed and the geographic coverage of the project. The FMA will organize regular meetings of the selection committees, to be presided over by the NES or regional HIV/AIDS Committees according to the proposed project's scope and scale. The selection committee will receive a report from the FMA and approve or reject the proposals according to the criteria set out in the operational manual. The NES and its regional equivalent will also ensure that proposals fall within the scope of the NSP and ensure the technical quality of the proposals. 4.7. The NES will work with the regional and departmental HIV/AIDS committees to analyze the technical assistance requirements of civil society organizations to improve their capacity to undertake effective projects in the fight against HIV/AIDS. It will develop a Capacity-Building Plan that must be completed within the first six months of the project and implemented within the first year of the project. (See Annex 2 of Senegal PAD for further details.) 4.8. The project will be implemented in an incremental manner starting with those line ministries, parastatals and civil society organizations that already have HIV/AlDS work plans and projects. Coverage will be extended to other sectors and organizations of civil society as implementation capacity is strengthened and work plans and projects are prepared. Line ministries and their regional and district structures will prepare work plans and budgets for each fiscal year on an annual basis. 17 4.9. By effectiveness, the Borrower will have adopted a project implementation plan (PIP), including a detailed work plan for the first year of the project and a project operational manual (POM), including all implementation arrangements, administrative, financial and accounting procedures. The manual will set out the functional relationships between the different organs in the institutional framework, the criteria and guidelines for allocation of funds, including under the grant mechanism, as well as accounting norms and reporting requirements for all responsible implementing agencies. 4.10. External technical and financial audits of the project will be carried out regularly by the Government in order to ensure financial and technical compliance and quality control. 4.11. Financing for the project will be mobilized through public sector budget contributions (investment and recurrent expenditure), current resources committed by bilateral agencies and multilateral organizations and international NGOs, and private sector donations. IDA resources through the MAP II will serve to complete the HIIV/AIDS program financing plan. In order to ensure a multisectoral and local response in the fight against HIV/AIDS, resources from IDA will be allocated approximately in the following manner: * 45% of the Project's resources will be directed towards the public sector and 45% to the civil society and the private sector; * 85% of Project resources will be targeted towards the community and regional levels, and 15% to the national level; * 10% of the total credit will go towards project management, including the fee of the Financial Management Agent, independent financial and technical auditors, operating costs of the NES and administrative support to the Regional and Departmental Committees. (iii) Project monitoring, supervision and evaluation. It is proposed that surveillance and epidemiological research will be managed by the HIV/AIDS unit of the MPOH, assisted by the Epidemiology Group, the Bacterial-Virological Laboratory and research institutions. Financial and program management monitoring will be combined and delegated to one agency, for effective financial program cross-verification. Structured reporting and assessment forms and procedures will be developed to ensure sound program monitoring. Financial and program monitoring will generate verified primary data to inform internal and external supervision. 4.12. Line ministries and other implementing agencies will supervise their own activities at all levels within their respective sector mandates. They will provide the NES and FMA with information on a number of agreed variables, on a quarterly basis. Regional and departmental HIV/AIDS committees representing each sector and incorporating community-based and civil society organizations will supervise project activities at departmental and community levels. Analyses will be conducted by the FMA to assess the financial and administrative performance of community based organizations and other civil society entities as needed. 4.13. The NES core team will supervise overall project implementation and will assess effectiveness and efficiency of implementation at central, regional and departmental levels, 18 working in close collaboration with the FMA under its defined terms of reference for program management monitoring. It will consolidate progress reports, organize regular meetings of NES members to discuss progress for each type of implementing agency. It will organize the annual project reviews, the mid-term review and the project completion review to assess the performance of the project, its components and its contribution to the national strategic goal of reducing the spread and impact of HIV/AIDS. The project's annual stakeholder meetings will form the basis for the following year's annual work program and budget. The project operational manual provides a detailed description of the project monitoring and evaluation. (See Annex 4 of Senegal PAD for a summary). (iv) Procurement procedures. Line ministries will procure works, goods and services related to the respective activities, in accordance with the Bank's Gu/delines: Procurement under IBRD Loans and IDA Credits (January 1995 and revised in January and August 1996, September 1997 and January 1999), in particular section 3.15, Community Participation in Procurement. Consulting services by firms, organizations or individuals financed by IDA will be contracted in accordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997, revised in September 1997 and January 1999). 4.15. The Government will contract with the Pharmacie Nationale dApprovisionnement (PNA), a public autonomous drug procurement agency, to carry out procurement of large items and packages such as diagnostic kits, reagents, pharmaceutical products and drugs for the diagnosis and clinical management of HIV/AIDS, sexually transmitted infections and other opportunistic infections including tuberculosis. United Nations procurement agents may also be contracted for the procurement of specific items such as condoms. 4.16. Communities will use the Bank's Simplified Procurement and Disbursement Procedures for Community-based Investments to procure goods and services needed to implement their respective HIV/AIDS initiatives. Since each sub-project costs would be modest, local shopping will be a standard procurement method. 4.17. To facilitate speedy import of items valued at less than US$ 100,000 equivalent, and which are required urgently for diagnosis, treatment or institutional strengthening, contracts may be prepared according to international shopping and national shopping procedures, or through procurement from the United Nations. 4.18. Project procurement and disbursement arrangements are detailed in Annex 8 of Senegal PAD and will be detailed in the Project Operational Manual. (v) Financial management and disbursement. Financial management of the project and the monitoring and evaluation of program management will be contracted out to a private sector Financial Management Agent (FMA) selected on a competitive basis. This is in line with MAP best practice to ensure the most rapid, flexible and efficient mobilization of resources to the beneficiaries of the project. As part of its contract with the Government, the FMA will be required to develop a fully integrated financial and accounting system using appropriate software as well as a detailed manual of financial procedures and chart of accounts, including the format, content and periodicity of the various financial statements 19 to be produced. The FMA will also be required to set up an appropriate financial and accounting system at a regional level. Transfer of funds to line ministries, NGOs, CBOs and private sector organizations and mechanisms for tranche releases and the scaling up of successful projects will be made by the FMA in accordance with eligibility standards and implementation procedures as described in the project operation manual and guidelines. For each category of applicants there will be clear eligibility criteria, thresholds as well as requirements for contributions, depending on size, experience and sector. For all applicants, no more than 20% of any funding can be used for overhead. The FMA will analyze applications and submit reports to the monthly selection committees chaired by the NES or regional equivalents for consideration (depending on the scale and scope of the application). (See Annex 2 of Senegal PAD for further details.) 4.19. By effectiveness the Borrower will have adopted the project operational manual (POM), including all administrative, financial and accounting procedures and installed a financial management system satisfactory to IDA. The objective is to put in place sound financial management and output monitoring systems and to introduce the World Bank Financial Management Initiative to administer the credit. However, in its initial phase, the project will operate under traditional disbursement procedures until its financial management is deemed satisfactory by IDA to fulfill the requirements of PMR-based disbursement. Government will open a Special Account at a commercial bank and all disbursements will be fully documented at the time of submission of withdrawal applications, except for expenditures made against Statements of Expenditures (SOEs). D. Project Rationale 1. Project alternatives considered and reasons for rejection: Choice of instrument 1.1. Taking into account the likely timeframe for containing HIV/AIDS, consideration was given to employing the "vertical", multiphase APL instrument within Senegal. This has the advantage of a phased approach signaling Bank commitment and attracting donor support in Senegal over the medium to long term. Notwithstanding, three factors support proceeding with a specific investment loan (SIL), namely: a) the low level of HIV/AIDS prevalence coupled with the country's well-documented successful experience in the design and implementation of HIV/AIDS programs; b) Senegal's adoption of a five-year plan 2002-2006 for mitigation of HIV/AIDS which provides a sound policy and implementation framework as well as reasonable targets for the proposed operation; and c) other donor plans to support the national strategy (UNICEF, UNDP and UNFPA) country strategy plans also cover the same five-year period. A further advantage is that the national plan period overlaps with the Medium Term Expenditure Framework agreed upon with Senegal, thus ensuring close attention to the efficiency of both budget procedures and expenditures. This is especially important since the multisectoral character of the project is posited on adequate budgets for HIV/AIDS at the level of the technical ministries and on the efficiency of their expenditures. 20 Financing of ART 1.2. At first glance, the high costs of ART initially and over time might appear to militate against its inclusion in the project. Senegal seeks to emulate several other countries at a similar prevalence level (Barbados, Chile, Morocco and Vietnam) which have decided to provide ART to selected patients on both humanitarian and economic grounds. Their decision - and Senegal's - is based on partnership with the pharmaceutical companies, the relatively low number of treatable cases, the anticipated savings in terms of lower costs related to treatment of Ols (including TB), and the reduced negative economic impact on the families of PLWHA. However, to be effective ART provision must meet generally recognized preconditions: trained personnel and the necessary clinical facilities and laboratory infrastructure must be in place as well as effective measures for monitoring drug resistance, patient counseling and follow-up. The Government's ongoing medium-term health sector reform and investment program broadly supported by multilateral organizations and bilateral agencies, will help satisfy these preconditions. Most importantly, the Government has established an institutional mechanism (the ISAARV commission) for the fair selection of patient access to ART in the public sector according to clear medical and income criteria in accordance with WHO/UNAIDS guidelines for the introduction of ART in resource limited settings. In addition, Senegal has pioneered implementation of the Pharmaceutical Companies Access Initiative in Africa and entered into an agreement with five pharmaceutical companies for the supply of anti-retroviral drugs at reduced price. Choice of Senegal as MAP2 Pilot 1.3. Senegal was chosen to accompany MAP2 as the pilot country for two main reasons. First, Senegal is the most advanced in respect of readiness for ART, as discussed above. It has conducted a number of clinical trials which have produced results in terms of continuity and clinical outcomes similar to those achieved in the EU and USA. The project will now scale up the trials to cover other regions. The second reason for Senegal accompanying MAP II is to show the Bank's willingness to support countries with a low HlV/AIDS prevalence in order to maintain this low prevalence or avoid significant increases. 2. Lessons learned and reflected in the project design: 2.1. The National Forum on HIV/AIDS held in December 2000 clearly identified the successes and failures of the national program in place since 1986, drawing lessons for project design. Findings from the evaluation of MAP I as well as from other country experiences were also incorporated into project design. These lessons include: Political leadership and commitment. 2.1. Political "champions" are key to mobilizing national and donor resources for the fight against the HIV/AIDS epidemic. The Government of Senegal has been a model of early, high-level leadership given its firm commitment to the fight against HIV/AHDS. The Government recognizes the social as well as the economic imperatives to keep a very low HIV/AIDS prevalence and therefore is committed to supporting a sustained program and is 21 now establishing a national council for HIV/AIDS control (CNLS), chaired by the Prime Minister. Need for a multisectoral approach and community participation. 2.3. Experience in many countries demonstrates the fact that the health sector alone is not capable of winning the war against AIDS on a sustained basis. There is need for a multisectoral approach involving key ministries in Government at all levels, the private sector and the non-government/community sector. For the Senegal MAP, a multisectoral team - including civil society representatives - was involved in project design from the beginning. At the same time, the role of the Ministry of Health and Prevention is recognized as pivotal, particularly with respect to treatment of STIs, OIs, provision of ART, MTCT treatment, VCT, blood transfusion services, procurement, epidemiological surveillance and general health-related technical training and oversight. All coordination and management structures of the Senegal project are multisectoral. 22 3. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned) Latest Supervision (PSR) Ratings Sector Issue Project (Bank-fina ced projects only) Implementation Development Progress (IP) Objective (DO) Bank-financed HNP and Reproductive Health Cr. 2985-SN: Integrated U S Health Sector Development Program (Closed June 30, 2003) Endemic Diseases Cr. 2951-SE: Endemic U 5 Disease Control Project (Closed Dec. 31, 2002) HN-Nutrition Cr. 2723-SN: S S Community Nutrition I Project (Closed June 30, 2001) Social Protection Cr. 3446-SE: Social S S Development Fund Project (Closed Dec. 31, 2004) Other development agencies AfDB Social Development, Health infrastructure E.U. EDF support to Decentralized Rural Development IDB Program, support (HIV NDF AIDS Sub-projects: JICA US$1.0 Million) KFW The Kingdom of Belgium Program Support to The French Cooperation HIV/AIDS The Netherlands Cooperation Taiwan USAID/FHI/CDC UNICEF UNFPA IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HlU (Highly Unsatisfactory) 23 Contracting out of Financial Management. 3.1. Lessons from MAPs to date indicate the importance of contracting out financial management in order to maximize effective and rapid access to funds by the various stakeholders, particularly those which are community-based. Eligibility criteria must also be made clear and transparent to all potential implementing agencies. In particular, high priority must be put on financing "software" rather than "hardware" - funding people directly involved in HIV/AIDS activities rather than equipment and civil works. 3.2. In the Senegal project, all financial management will be contracted out to a private sector Financial Management Agent (FMA) and no major civil work program is envisaged. The FMA will be responsible for disbursements to all civil society applicants, as well as the public sector in the implementation of their sector plans. The Government has also agreed that M&E of program management will be contracted out. Financing and Capacity Building Mechanisms for Civil Society. 3.3. In order to ensure a widespread, sustained and cost-effective response to the disease, it is imperative that the community take primary responsibility for prevention and care of orphans and PLWHA. Much has been learned with regard to the mobilizing and financing of community-based initiatives over the last few decades. Senegal already has a highly active civil society with over 200 NGOs involved in HIV/AIDS and 300 women's groups. In the Senegal MAP, at least 40% of project funds will be channeled directly to civil society. Need for strengthening capacity of implementing agencies. 3.4. Based on past experience, greater priority needs to be given to enhancing the capacity of institutions in program management, procurement, financial management, monitoring and evaluation. Component 1 will provide significant capacity building for implementing agencies, the NES and regional and community equivalents. At the technical level, training of health personnel in both the technical and psycho-social dimensions of HIV/AIDS form a key subcomponent of the project. Importance of Monitoring and Evaluation. 3.5. Monitoring and evaluation of project activities is important in assessing progress and the impact of interventions as well as identifying corrective measures in the course of implementation. The HIV/AIDS surveillance systems need to be strengthened for effective monitoring and evaluation of H[V/AIDS epidemic trends to identify areas that need to be tackled for the greatest impact. Senegal has a developed M&E surveillance system that has provided critical data for identifying high risk groups and tracking PLWHA. The MOHP is reinforcing its second generation surveillance system by expanding it to all regions during the Project. The project will contract out project management monitoring and evaluation and there will be an independent performance review and audit of the NES and Financial Management Agent. Civil society is involved in M&E through its roles in the 24 CNLS, NES and regional/community equivalents, and will also participate in the annual supervision missions. Importance of clarifying roles. 3.6. It will be important to delineate the roles of different agencies. Experience from other countries has demonstrated that the principal entities can be made ineffective and/or become overly bureaucratic if roles are not clearly defined, including functions in relation to other key players. In Senegal, clear terms of reference for the CNLS, the NES and the regional and community equivalents will be fully developed in the Project Implementation Plan (PIP). Vulnerability Factors and high risk groups are key to future success. 3.7. The HIV/AIDS epidemic is driven by underlying vulnerability factors among populations and high risk groups. The combination of poverty, illiteracy and gender disparities exacerbate exposure to the virus. For this reason the project will look at targeting these groups with differential information geared to behavior change and will also pilot some income-generating activities. It will also support efforts to reduce stigmatization of PLWHA and homosexuality in order to bring these in line with Senegal's progressive approach to CSW. This project will specifically focus on vulnerable groups, including youth (in and out of school), women, workers, CSW, MSM, armed forces, PLWHA, prisoners and others. Good Donor Coordination. 3.8. This can significantly reduce the Government's transaction costs for management of externally funded programs. Common arrangements for program reviews, monitoring and evaluation, planning of financial and technical assistance, support missions, funding of programs or program components are all areas that will be pursued in close cooperation with UNAIDS and other cooperating partners. The UNAIDS (WHO) representative has been part of the project design team and the project will benefit from the strong donor coordination and complementarily that exist already in Senegal. Other donors may also elect to utilize the FMA as a vehicle for channeling their funds to Senegal's 1HV/AIDS program. 4. Indications of borrower commitment and ownership: 4.1. Senegal was the first country in Africa to mount an HIV/AIIDs prevention campaign. With high level and broad political support, matched by a significant financial effort, it has maintained and intensified that campaign regularly over the past ten years. A comprehensive medium-term - 2002-2006 strategic framework and action plan have been developed with effective participation of all line ministries and the civil society. Program oversight and coordinating structures previously located in the MOHP are now being moved to the Office of the Prime Minister. In addition, the Government is committed to putting in a large proportion of the financing itself; it is scaling up the MOHP budget to reach a 15% share of the recurrent budget and other ministries are expected to provide matching funds to those which will be made available under the IDA credit. 25 5. Value added of Bank support in this project: 5. 1. The project allows IDA to provide continued support to a successful program, promotes Senegal as a flagship of good performance to date, and points to future directions for others in sub-Saharan Africa (with MAP2). However, this requires building on successes, and ensuring program sustainability and effectiveness. Senegal so far has done a great deal with limited resources involving high transaction costs. This project under MAP2 will significantly reduce the costs of raising (and coordinating) financial resources. IDA support is also important because Senegal needs substantial new funds to solidify and widen the program, particularly to fill existing gaps and finance future directions to strengthen weak elements of its program, such as: * the limited multisectoral approach to date; * the under-resourced decentralized/community approach to care and prevention; * weak project management capacity of both the public sector and the civil society; * the need to scale up a number of successful pilot activities; * taking ART beyond the pilot phase (including testing the hypothesis ART reduces overall treatment costs); * financing research in needed areas; * combating stigmatization (homosexuality, workplace treatment of PLWHA). 5.2. Bank support will complement other development partners, including pharmaceutical companies, in a joint effort to support the national program of H1V/AIDS containment and eventual marginalization. It brings to the table substantial financing required to intensify HIV prevention, scale up the treatment of AIDS and Ols as well mitigate the socio- economic impact of the disease. With the Bank's good working knowledge of the other sectors, it can assist in making the technical ministry programs more effective. Finally, by promoting emphasis on monitoring and evaluation as well as research and dissemination, it will assist Senegal in maintaining its all important "success story" - a powerful example for other countries in the sub-region which are struggling with significantly higher levels of prevalence as well as those who wish to retain a low prevalence level. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8 of Senegal PAD) 1. Economic (see Annex 4 of Senegal PAD): 1.1. A detailed economic analysis on HIV/AIDS was carried out for the first phase of the MAP and applies to this project. It includes an overall assessment of the impact of HIV/AIDS on economic development and a cost-benefit analysis of HIV/AIDS interventions. This report highlights the following key findings: * HIV/AIDS negatively affects an economy by reducing productivity, domestic savings and overall economic growth; * HIV/AIDS increases the burden on the health budget and risks crowding out other key programs such as vaccination, the fight against malaria and other parasitic diseases; 26 * care and treatment of AIDS patients imposes high costs on families and at the same time reduces their earning capacity; * family coping strategies may result in children abandoning school or the family reducing other health expenditures below an acceptable minimum. 1.2. The economic benefits of Senegal's national program are multifold: * new infections will be significantly reduced; * the treatment costs of opportunistic infections will be reduced, possibly outweighing the cost of ART; * AIDS patients will have longer and more productive lives due to improved care overall, including ART; * the economic prospects of families and orphans will be improved; * Senegal's profile for attracting tourists (a major contribution to GDP) and foreign investment will be enhanced or at a minimum, not diminished. 1.3. The cost-benefit analysis suggests that the five-year project lifecycle could avert infections among 21,292 cases. In dollar terms, this would translate to about US$ 36 million of benefits through averting productivity losses and through averting costs of care. The net present value NPV for the first five years from the inception of the project is US$ 4.5 million and the IRR is 26 percent. However, the situation changes a year after that when NPV is almost US$ 20 million and IRR is 53 percent. The NPV and IRR grow positive and increase beyond project lifetime. 1.4. The analysis also shows that the HIV/AIDS prevention project can slow down the growth in the epidemic. However, the extent to which the epidemic can slow down depends on the effectiveness of the prevention program. Given the above scenarios, the impact of the project is low in the first five years of the project lifecycle; however, the impact increases beyond the fifth year. The hypothetical situation demonstrates that the benefits can be far greater from the HIV/AIDS prevention project, if there is a larger slowing down in the growth of the epidemic due to the project, which is also dependent on the intervention programs. The cost-benefit analysis therefore supports the implementation of a HIV/AIDS prevention project. 2. Financial: (see Annex 5) 2.1. A specific analytical concern of the project is to track the cost-effectiveness of different interventions, including ART treatment regimens. The annual cost of ART and the relevant laboratory exams in Senegal are still high. This raises the concern that expanding the program without careful monitoring of the cost effectiveness of different regimens, and their impact on equity, might put at risk the financial sustainability and economic efficiency of the whole program. Senegal's Center for Applied Economic Research (CREA) at the University of Dakar has the technical capacity to undertake this work, as well as monitor the longer term economic impact of the program through tracer studies of the employment and income of PLWA and their families. 27 Fiscal Impact: (see Annex 5) 2.2. The fiscal impact of the project is likely to be small. The amount to be disbursed annually under the project is estimated at US$ 6.0 million representing less than 0.05% of the total Government budget in FYOO/O1. Counterpart funds are not expected to be unduly heavy as civil works and operational costs represent a small proportion of the project costs. Civil works will be limited to minor renovation of existing laboratory facilities. Major management activities will be outsourced, thus limiting requirements for recurrent cost support in the future. The project will cover some of the incremental operating expenses, estimated to be 10% of total project cost. The actual fiscal impact is further minimized since almost 40% of the project will be directly channeled to NGOs, private sector organizations and CBOs which will be required to generate their own counterpart contributions (ranging from 10% to 40%, in-kind or in cash) of the cost of their proposed sub-projects. Nevertheless the Government will be expected to assume full responsibility for the maintenance of many project investments at the closure of the project. To ensure adequacy and availability of operating and maintenance costs, the Government has agreed under the ongoing IDA-supported health sector investment program to gradually increase the proportion of the MOPH's recurrent budget allocated to operation and maintenance to 15% of the annual recurrent budget. 3. Technical: (see Annex 6) 3.1. The technical design of the project has benefited from lessons learned in Senegal's fourteen-year old campaign, the evaluation of MAPI project implementation, and from international experience. New dimensions of the program supported by the proposed project are: early attention to capacity-building in project implementation to ensure timely start-up of activities; M&E; the provision of ART treatment; enhanced treatment of Ols with particular attention to TB prevention and treatment; and a local response to family support for PLWHA. 4. Institutional: (See Annex 7) Success will depend on the effective collaboration between the NES, line ministries, NGOs, private sector and other partners at national, regional and district levels. This will require sound financial management and clear accountability as well as technically sound outreach strategies. It is believed that the recruitment of a financial management agent and a clear understanding of the role of policy coordination and monitoring by the CNLS under the chairmanship of the Prime Minister will facilitate project implementation and timely resolution of problems which might arise in execution of activities by multiple ministries and the civil society. 4.1 Executing Agencies The NES will be responsible for overall project management and coordination of the implementation of project activities by the public sector and the civil society. It will coordinate closely with the FMA and will report to the CNLS. Each participating ministry (through its own HIV/AIDS unit), parastatal, and civil society organization will manage its 28 own HIV/AIDS activities and report regularly on agreed input and output performance indicators to the FMA and NES. 4.2 Project Management Project supervision will be regularly conducted by NES which will organize two semi-annual program reviews involving all parties in the partnership against HIVIAlDS in Senegal. These reviews will focus on progress made in achieving the PNLS objectives and constraints faced in its implementation. A consolidated yearly financial and progress report will be prepared by NES and FMA for the CNLS annual meetings. 4.3 Procurement Issues A timely and sustained supply of reagents, ART and 01 drugs is a sine quta non for this component. Some procurement of laboratory equipment and bio-medical supplies is expected. Any breakdown in the supply of materials or laboratory facilities for testing which results in a program stoppage, simply cannot be tolerated. This issue was given special attention at pre-appraisal to assess the volume and adequacy of needed supplies. The project will provide assistance to the MOHP to help improve drug purchasing strategies as the international market evolves. No major civil works activities are envisaged under the project. 4.4 Financial management issues The Financial Management Assessment for the Senegal HIV/AIDS Prevention and Control Project was conducted based on the Guidelines to Staff issued by the Financial Management Sector Board, dated June 30, 2001. The objective of the assessment is to determine whether the entities responsible for the implementation of the HIV-IAIDS Prevention and Control Project have acceptable financial management arrangemnents as required by the Bank policies, including system of accounting, reporting, auditing and internal controls. The formal assessment was carried out in the field during the period of Novemlber 19-24, 2001. But it also takes into account outcomes of discussions and reviews carried out during the preparation and pre-appraisal phases. The financial management arrangements of the HIV/AIDS Prevention and Control Project are characterized mainly by the decentralized approach in the implementation of the project's activities whereby most of the activities will be implemented by the end beneficiaries (governmental agencies and civil society). The overall financial managemcent responsibility will be contracted out to a Financial Management Agent. The review of the proposed financial management arrangements made it possihle reach an agreement with the Borrower's representative on the flow of funds, the overall financial management responsibility for the project, the accounting, reporting, intemal and external auditing systems to be put in place as well as a time-bound action plan. 29 One Special Account will be opened and managed by the Financial Management Agent at the central level. Sub-accounts of the Special Account will be opened and managed at the regional level by the regional representative of the Financial Management Agent to finance activities implemented at the regional level, namely sub-projects submitted by local civil society organizations. Regarding government agency action plans, advance account mechanisms will be used to finance related activities on the understanding that the large procurement will be handled by the FMA. Given this framework, the scope of the assessment was basically limited to the Financial Management Agent, the civil society organizations and governmental agencies. As the Financial Management Agent is not yet in place, it is not possible, at this stage, to assess its capacity to meet the project's needs based on the arrangements described above. The assessment was therefore focused on determining whether the overall financial management arrangements are appropriate for the needs of the project and whether the required conditions are met to fully and satisfactorily implement these arrangements by credit effectiveness at the latest. An agreement was therefore reached on the terms of reference, the evaluation criteria and the shortlist for the selection of the Financial Management Agent. Regarding the civil society organizations and Government agencies, a full-fledged assessment of their financial management capacity is not possible given the demand-driven approach of the project, which does not make it possible to have a pre-defined list of organizations that will be involved in the implementation. The approach taken is rather to ensure that all selection criteria of civil society organizations include an assessment of their financial management capacity. Furthermore consideration was given to the monitoring by the Financial Management Agent of the appropriate use of the project's resources by recipients. It was decided that this monitoring will be linked to disbursements of funds. The project's financial management system is not yet in place since it depends on the Financial Management Agent which is not yet recruited. As a result, the current situation of the project's financial management system does not meet the Bank's minimum financial management requirements as specified in OP/BP 10.02. However, these requirements are expected to be met once all measures defined in the agreed action plan are completed. 5. Environmental: Environmental Category: B (Partial Assessment) 5.1. Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. 5.2. The project is not expected to have major adverse environmental impact. However, there are risks attached to the handling and disposal of HIV/AIDS infected materials. These risks potentially affect: personnel in hospitals, health centers and municipalities who handle waste, families whose income is derived from the triage of waste and also the general public to the extent that waste is not disposed of on site or safely contained in protected areas. A draft medical waste management plan was prepared by the Government 30 and reviewed during appraisal. Institutional arrangements and the cost of its execution will be financed under the ongoing health sector investment program. The plan will be finalized before credit effectiveness and will include the proper disposal of hazardous bio- medical waste, a bio-safety training program for the staff of all hospital, health center and community-based programs, including traditional midwives and practitioners who may be involved in testing and treatment. The training program will include specific instruction on the triage, transport and disposal of waste. In addition the project implementation manual will include guidelines to ensure that environmental considerations are taken into account in the selection and design of project activities. With the assistance of the Africa Safeguard Policy Enhancement Team (ASPEN), TORs have been prepared for such a plan which will be reviewed by the Bank prior to credit effectiveness. The task team organized a presentation on medical waste management, attended by members of the Senegalese project preparation team and a follow-up half-day workshop is envisaged in the near future. 6. Social: 6.1 Key Social Issues The project will have a very positive social impact by raising the awareness level of specific segments of the population who are at high risk of infection (particularly women and youth), and encouraging safe sex behavior among the population in general. Furthermore, expected increases in access to VCT, availability of ART treatment and care and support at the family level should have a positive impact on the social environment by assisting and empowering people and institutions to deal more effectively with the disease burden. Socially marginalized groups, such as MSM, commercial sex workers, inmates and PLWHA and their families whose economic and human rights are subject to violation will also receive support through the project. In addition, a monitoring process using quantitative and qualitative research among specific groups is built into the project design to ensure periodic assessment of social impact and to take corrective actions for social issues which might arise during implementation. 6.2 Participatory Approach The preparation process of the PNLS was highly participatory with extended consultations with various stakeholders at several national and regional fora and workshops leading to the preparation of a medium-term strategic framework and program design. In order to obtain consensus on project content and implementation arrangements, the Borrower's project preparation team included representatives from line ministries, the civil society and local and regional authorities. Prior to project conception, a series of workshops and strategic plans were developed by various sectors (e.g., youth, women, NGO, traditional healers, education) and consolidated into a national strategy at the National Forum held in December 2000. In each case, representatives from the Government and the civil society actively participated. Partners from all sectors will also participate in the program structures, including the CNLS, the NES and the various regional and local HIV/AIDS Committees. Approximately fourteen key Ministries will establish HIV/AIDS units and will obtain matching funds through the project to implement their HIV/AIDS programs. As a result, the Borrower has succeeded in securing a 31 consensus on project content and implementation arrangements, among its partners and beneficiaries. 6.3 Consultations or collaboration with NGOs or other civil society organizations NGOs and CBOs, among other civil society organizations, are currently involved in project design and are expected to play an active role in project implementation. Their involvement will consist primarily of assisting communities to facilitate the design, implementation and monitoring of community-led, community-owned initiatives. Resources will also be provided to NGOs and CBOs using simple contractual agreements to enable them to conduct specific sub-projects on a larger scale and to cover their participation in evaluation and research. 6.4 Institutional arrangements to ensure social development outcomes The participatory approach used in project preparation will be continued during project implementation. Two beneficiary assessments will be conducted, once at project mnid-term and again at the end of project. In addition, the PNLS coordinating structures (i.e., the CNLS, the NES and the regional and district committees) will include representatives from government agencies, civil society and different associations of special interest groups. 6.5 Performance in terms of social development outcome monitoring Indicators of beneficiaries' satisfaction will be included in project design and regularly monitored during project implementation. Moreover, technical reviews will be conducted under contractual arrangements with selected private sector firms to assess NGO and CBO performance and take corrective action. 7. Safeguard Policies: 7.1 Do any of the following safeguard policies apply to the project? Policy Applicability Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) Yes Natural Habitats (OP 4.04, BP 4.04, GP 4.04) No Forestry (OP 4.36, GP 4.36) No Pest Management (OP 4.09) No Cultural Property (OPN 11.03) No Indigenous Peoples (OD 4.20) No Involuntary Resettlement (OD 4.30) No Safety of Dams (OP 4.37, BP 4.37) No Projects in International Waters (OP 7.50, BP 7.50, GP No 7.50) Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60)* No 32 F. Sustainability and Risks 1. Sustainability: 1.1. The project is built upon the established partnership between Govemment and the civil society, their past and current collaboration in various social sector projects and their strong ownership of the national multi-sector plan against HIV/AIDS. The project will expand and intensify existing programs by mainstreaming prevention care and support activities of several line ministries and the civil society, and by tapping and reinforcing community resources and community organizations' potential for mobilization. The govemment policy of decentralization and the project's emphasis on capacity building at all levels of project implementation would also enhance sustainability. 1.2. A specific analytical concern of the project is to track the cost-effectiveness of different interventions, including ART treatment regimens, to ensure the financial sustainability and equity of the whole program. Senegal's Center for Applied Economic Research (CREA) at the University of Dakar will undertake this work, as well as monitor the longer term economic impact of the program through tracer studies of the employment and income of PLWHA and their families. 33 2. Critical Risks (reflecting the Failure of critical assumptions found in the fourth column of Annex 1): Risk Risk Rating Risk Mitigation Measure From Outputs to Objective Coordinating capacity of NES is weak M Competitive staffing of NES based on experience and technical competences. Poor inter-sector and public/private S Role and mandate of coordinating and collaboration at national and regional implementing agencies are clearly defined in levels implementation manual; dissemination of operational guidelines and criteria to all actors; consistent monitoring and performance evaluation by NES. From Components to Outputs Implementation capacity of government M Capacity-building activities including agencies and NGOs is weak technical support and on-the-job site training are an important component of the project and will be provided early during project implementation. Lack of interest and commitment from M Strong motivation by senior government and local government, communities and civil society leadership; effective participation beneficiaries by civil society and local government in policy formulation, project design and implementation, and IEC activities to promote the project and explain its financing mechanisms and benefits. NGOs, CBOs and communities lack of S On-the-job technical assistance and training by capacity to propose and implement sub- major NGOs/CBOs to assist smaller projects organizations and communities to ensure quality of design and efficient implementation; contracting out to experienced NGOs, sensitization work and regular monitoring and supervision of activities at community level in most parts of the country. Reluctance of some ministries to commit M Key ministries have been involved in project resources design; location of program in Prime Minister's office; technical support from MOHP; matching financial support. Capacity to effectively administer ART S Provision of necessary materials and technical is weak training incorporated into project. NES and other institutions become too S Commitment to core staff only, with most bureaucratic and controlling functions - financial management, project management, M&E - contracted out; recurrent expenditure financed by counterpart. Overall Risk Rating M Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk) 34 3. Possible controversial aspects: The project was designed by a multisectoral team and no controversial aspects are anticipated. G. Main Loan Conditions 1. Effectiveness Conditions. The Borrower has: a) established the accounting and financial management system for the project; b) opened the Project Account; c) appointed a Financial Management Agent for the Project; d) adopted the Project Operational Manual and the Project Implementation Plan, both in form and substance satisfactory to IDA; e) furnished to the IDA the plan of actions and the procurement plan for the first year of Project implementation; f) furnished to the IDA a medical waste management plan, in form and substance satisfactory to IDA; and g) appointed the staff of the NES, an Executive Secretary, 3 Program Coordinators and a Financial Controller, all with experience and qualifications satisfactory to IDA. 2. Dated covenants. The Borrower shall, not later than April 30, 2002: a) establish, restructure or strengthen, as the case may be, NES and the regional and department level HIV/AIDS Committees; b) furnish to the Association a monitoring and evaluation action plan for the Project; c) appoint an in-house Accountant within each Line Ministry or government agency eligible to receive proceeds of the Credit under the Project. The Borrower shall, not later than June 30, 2002, furnish to the Association a detailed strategic action plan for its IEC campaigns against HIV/AIDS under the Project. The Borrower shall, not later than September 30, 2002, appoint and thereafter maintain throughout Project implementation, a Technical Auditor with experience and qualifications satisfactory to the Association and who shall be responsible for preparation of a technical audit report, satisfactory in form and substance to the Association, to be furnished annually by the Borrower to the Association. 35 H. Readiness for Implementation 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. X 1. b) Not applicable 2. Preparation of the procurement documents for the first year's activities is well advanced and requires minimal additional work to be ready for the start of project implementation. 3. The Project ImplementatidSn Plan has been appraised and found to be realistic-and of satisfactory quality. (See paragraph 4 below) X 4. The items below are referred to in Section G "Main Loan Conditions" (above). These materials were reviewed during negotiations. They were found to be a good technical quality, although requiring some additional information on cost and implementation to be satisfactory to IDA. It was agreed that the following would be finalized before Credit Effectiveness: a) The final project operational manual; b) The final project implementation plan; c) The final procurement plan; and c) The final plan of action for bio-medical waste management. I. Compliance with Bank Policies X The project complies with all applicable Bank policies. _ _ _r_-_ _ _ _ _ _ __ _ Anwar Bach-Ivaouab Alexandre V(Abrantes John McIntire Team Leader Sector Manager Country Director 36 Annex 1 Project Design Summary SENEGAL: HIV/AIDS Prevention and Control Project Key Performance Dati Collection Hierarchy of Objectives_ Indicators Strategy Critical Assumpftons Sector-related CAS Goal: Sector Indicators: _ector country (from Goal to Bank r .s.reorts Msio) Reduce poverty Human development UNDP annual report Adoption of the National indicators, including the and household Strategic Plan for HIV/AIDS poverty profile surveys and its integration in the poverty reduction program Reduce and contain Prevalence rate remains Epidemiological Adequate and sustained HIV/AIDs below 3% by 2006 Bulletin financing of the Plan Strengthen the involvement At least 90% of the Ministerial budget Commitment of the technical of the technical ministries in ministries concerned reports. Ministry of ministries prevention have allocated annual Finance's analytical budget to the fight report against HIV/AIDS Key Performance Data Collection Hierarchy of Objectives Indicators Strategy Critical Assumptions Project Development Outcome / Impact Project reports: (from Objective to Goal) ObJective: Indicators: I. Prevent spread of HIV By 2006: by reducing transmission among high risk groups (i) Promote sexual behavior 70% of boys aged 15 Second Generation IEC impacts successfully on that reduces the risk of tol9 report using a Surveillance System behavior patterns. transmitting HIV/AIDS condom during their last Availability of condoms sexual encounter 30% of women aged 20 Second Generation to 49 are familiar with Surveillance System the female condom. 80% of women aged 20 Second Generation to 49 know at least two Surveillance System methods of protection against HIV/AIDS. 65% of adult males Second Generation Involvement of all partners reported using a condom Surveillance System concerned with an irregular partner during the past 12 months 60% of women aged 20 Second Generation to 49 report using a Surveillance System condom with an irregular partner during the last 12 months 37 80% of men in uniform Second Generation Commitment of the highest use condoms with Surveillance System authorities of the military, irregular partners police, customs and fire _________________ departments (ii) Strengthen HIVIAIDS Prevalence of STIs Prevalence surveys. Availability and accessibility controls for commercial sex among commercial sex STI surveillance of condoms and IST workers workers falls from: - 15 medication to 10% for Trichomonas; - 4 to 2% for Gonococcie, and 20 to 15% for Syphilis Percentage of Second generation Involvement of leaders of commercial sex workers surveillance system commercial sex workers tracked report using a groups. condom during their last Involvement of police sexual encounter: authorities - increases from 56 to 70% with a regular partners (not client) - is over 95% with clients 30% of commercial sex Activity reports Availability of female workers tracked use condom female condoms (iii) Reduce risk of people Reduce by 50 percent Prevalence survey receiving blood products blood product related and Surveillance HIV/AIDS infections system Key Performance Data Collection Hierarchy of Objectives Indicgtors Strategy Critical Assumptions Output from each Process/output Project Reports From Oitputs to Objecfive Component indicators .._ . . _- A. Strengthening the Capacity of implementing Agencies and coordination structures 1. Support to HIV Units 90% of target Ministries, Project monitoring Political commitment from state enterprises have a reports leaders of different ministries functioning coordination and state enterprises committee, a designated Government budget focal point, an HIV action plan, and a budget to finance the relevant HIV action plan 90 % of CSOs and Project monitoring Contracted agencies able to NGOs involved in reports provide the relevant capacity project implementation building have received capacity building in the areas of 38 sub-project design, participatory planning and monitoring of CBO initiatives 80 % of relevant Project monitoring MOH and contracted personnel in health reports agencies have the capacity to system trained in a) train the target personnel syndromic treatment of STIs, b) oportunitistic infections, c) TB, d) prevention of mother to child transmission, and e) ART management 2. Support to Monitoring Biological surveillance Project monitoring Capacity of MoH and and Evaluation system in place, covering reports contracted agencies 10 regions, disseminating relevant reports quarterly 80% of national and Epidemiological Capacity of national, regional regional referral centers bulletin and referral centers notify AIDS cases Behavioral surveillance Project monitoring Capacity of contracted system in place, reports agency disseminating annual reports Epidemiological bulletin Epidemiological Capacity of contracted published every two bulletin agency years 75% of research project Project monitoring identified as priority reports have been financed 39 B. Support to Civil Society and Community Based Initiatives in the area of prevention, care and mitigation Number of CSO and Project monitoring Capacity of relevant CBOs CBO sub projects: reports and CSOs a) received, b) approved, c) financed, and d)successfully concluded Number of VCT Project monitoring Capacity of relevant CSOs centers managed by reports CSOs 80% of registered Epidemiological Capacity of relevant CBOs orphans have received Bulletin and project and CSOs social support at monitoring reports community level C. Support to Governmental Agencies Multi-sector Programs 1. IEC Information, HIV education Ministry of Commitment of leadership at Education and curricula implemented Education curricula MoE Communication at all levels and branches of education system 2. Social Marketing of Condoms available at Project monitoring Capacity of MoH, contracted condoms 80 percent of public report CSOs and CBOs baths 3. MTCT - Mitigation 95% of children born Epidemiological Capacity of MoH or HIV mother to child to HIV infected bulletin and project contracted agencies Transmission. mothers will be monitoring reports provided with the relevant treatment and care 4. VCT - Voluntary VCT centers in 10 Project monitoring Capacity of MoH or counseling and Testing regions report contracted agencies Utilization of VCT up Project monitoring Capacity of MoH or by 10 percent every report contracted agencies, and _____________________ year impact of IEC campaigns 40 5. Blood banks Blood banks in Bakel, Project monitoring Capacity of MoH Kedougou, and Fatick report 100% of blood banks Epidemiological Capacity of MoH ensure systematic bulleting and testing of donors for project monitoring H[V, hepatitis B and reports Syphilis, and 100% of transfused blood has been tested for those infections 6. Diagnosis, treatment Reference Facilities in Project monitoring Capacity of MoH or and care of HIV/AIDS 10 regions, providing reports contracted agencies patients standard integrated diagnosis, treatment and care for HIV/AIDS, including a) VCT, b) STIs, c) opportunistic infections, d) TB, e) prevention of mother to child transmission and f) ARV and the relevant medication 50% reduction in Project monitoring Capacity of MoH or stock-outs of HIV report contracted agencies related medications. 90% of referral centers Project monitoring Capacity of MoH or possess ART kits to report contracted agencies treat accidental exposure 7,000 HIV/AIDS Epidemiological Capacity of MoH or patients have received Bulletin and project contracted agencies ARV treatment monitoring reports 95% of PLWHA under Epidemiological Capacity of MoH services ARV treatment receive Bulletin and project psycho-social support monitoring reports D. Support to Project Management and Administration 100% of activities in PIP planned activities concluded 100% of project funds disbursed No misprocurement 41 [ Hierarchy of Objectives Key Performance Data Collection Critical Assumptions Indicators Strategy Project Components and Inputs Project Reports (from Components to Subcomponents __ _ Outputs) A. Strengthening the US$2.0 million Project data Capacity of NES Capacity of implementing Agencies and coordination structures B. Support to Civil US$12.5 million Project data Capacity of NES, CSO and Society and Community CBO, quality of capacity Based Initiatives in the building actions area of prevention, care and miitigation C. Support to US$12.5 million Project data Capacity of NES Governmental Agencies Multi-sector Programs D. Support to Project US$3.0 million Project data Capacity of NES Management and Administration 42 Annex 2 Detailed Project Description SENEGAL HIV/AIDS Prevention and Control Project The project will support implementation of Senegal's strategic plan by a wide variety of public sector agencies, private and non-governmental organizations, and by community-based organizations. It will be carried over a five-year period extending from 2002 to 2006 to coincide with the strategic plan's duration and will be complementary to other donors activities. The project aims at building additional planning, implementation, monitoring and evaluation capacity of public and private entities and expanding existing prevention, treatment and mitigation programs. It will be implemented through four major components as follows: Project Implementation by Component: Part A - Strengthening the capacity of implementing agencies and coordination structures (US$ 2.0 million) This component is designed to reinforce the resource management, implementation and monitoring and evaluation capacity of government agencies and civil society (including the private sector), and to strengthen the capacity of local organizations and rural communities in the design and implementation of demand-driven HIV/AIDS activities. The national HIV/AIDS Council, its Secretariat and its decentralized structures at the regional and district levels will also be provided technical, financial and material support to coordinate, monitor and evaluate implementation of the national strategic plan. More specifically, capacity-building support will consist of two sub-components: Support to HIV/Units. This sub-component will cover the provision of technical support services and training to HIV/AIDS units of line ministries, parastatals and civil society organizations with an emphasis on project design, participatory planning, and monitoring of community-based activities, and the training of lab technicians, medical and paramedical staff and social workers to strengthen VCT, the prevention of mother to child transmission, the prevention and treatment of opportunistic infection and tuberculosis and the provision of ART; the sub-component will also cover the provision of capacity building services to civil society by (i) the project structures including the FMA (for financial management) and (ii) NGOs and other agencies who can supply reputable capacity building services to other civil society organizations. Support to Monitoring and Evaluation. This sub-component will consist of the provision of technical support services, equipment and materials to implement a comprehensive Monitoring & Evaluation plan consisting of epidemiological surveillance and research, behavior surveys, financial and program management and operation research to ensure maximum program learning and dissemination. Senegal has excellent capacity and established international partnerships in both biological and behavioral surveillance and epidemiological research. In contrast, program management capacity which relates to 43 the relevance, quantity and quality of public sector and civil society services is less developed. Consequently, this sub-component will have more of a major focus on the latter element of the M&E plan and will complement and draw upon the insights of ongoing surveillance activities in support of efforts by the Ministry of Health and Prevention to progressively expand coverage nationwide. The scope of research activities to be funded under this sub-component include social and economic impact studies, HIV/AIDS household impact and cost effectiveness of HIV/AIDS interventions, situation analysis and assessment of knowledge, attitudes and practices in sexual behavior and attitude toward PLWHA. The number of epidemiological sentinel sites will be expanded from 5 to 10 locations to ensure nation wide coverage by the end of project year two. On financial and program management monitoring, Senegal has agreed to outsource the projects financial management to a single agency which will also be responsible for financial and program management monitoring and evaluation. terms of reference were prepared and agreed upon during project's preparation and a firm will be appointed before credit effectiveness. Part B - Support to civil society and community-based initiatives in the area of prevention, care, social support and mitigation (Total Grant US$ 12.5 million). Using a grant mechanism managed by the FMA, this component is designed to intensify prevention, care and social support to meet the information needs of specific target groups and PLWHA and their families, and to ensure continuity and expansion of successful HIV/AIDS mitigation activities adapted to local conditions and managed by grassroots organizations and communities. The component will also promote and encourage initiatives of private sector enterprises to develop and implement prevention, care and support strategies designed for their employees and their families. Funds will be channeled directly through grants to associations, religious organizations, private enterprises, NGOs and community-based organizations to cover a wide range of activities including: (i) prevention and sensitization activities targeted to specific groups at high risk and aimed at raising awareness and changing behavior including IEC activities at job sites; (ii) provision of home and community-based care for AIDS patients; and (iii) social support to PLWA, orphans and households affected by HIV/AIDS. Activities include nutrition, income generation activities support to school enrollment of orphans. Government's and grants recipients' responsibilities will be embodied in a contractual agreement signed before works start. Eligibility criteria, norms and standards for implementation of sub-projects under this grant mechanism are described in a specific module of the project operation manual but are summarized below: Within the Civil Society organizations, NGOs have been classified according to experience and capacity and this classification will act as a guide to eligibility under the project for different levels of financing. The maximum amount was set at US$ 200,000 per applicant for national projects (more than one region). Each civil society organization will submit an action plan to the financial management agency at the national or regional level according to the level of financing proposed and the geographic coverage of the project: 44 * If the project covers more than one region and its budget is over US$ 30,000, the application must be sent to the national office of the fiduciary agency with a copy sent to the NES. * If the project covers one region or many departments in one region and its budget is less than US$ 30,000, the application must be sent to the regional office of the financial management agency with a copy sent to the RAC. * If the project covers one department or a number of rural communities in one region and its budget is less than $10,000, the application must be sent to the regional office of the financial management agency with a copy sent to the DAC. The projects will be analyzed by the fiduciary agency according to the eligibility criteria set out in the cahier de charge and manual of procedures (e.g. legal status, bank account, management ability and experience). The fiduciary agency will organize regular meetings of the selection committees to be presided over by the NES or regional AIDS Committee according to the project's scope and scale. The selection committees chaired by the NES or regional AIDS Committee will receive a synthesis report from the fiduciary agency and approve or reject the proposals according to criteria set out in the manual of procedures. The NES, RAC and DAC committees will also ensure the proposals fit within the scope of the NSP and ensure the technical quality of the proposals. The fiduciary agency will establish contracts with the implementing agencies under delegated authority from the NES and disburse according to procedures in the manual of procedures. It will also ensure the collection and analysis of project financial reports for submission to the NES. All procedures will have detailed timeframes to be specified in the Project Operational Manual. Part C - Support to Governmental Agencies Multi-Sector program (US$ 10.7 million). The purpose of this component is to support a major expansion of HIV/AIDS activities implemented by government entities. Several ministries are in the process of developing detailed work plans and budget and will be eligible for support under the project as of project year one. All line ministries will reinforce existing coordinating units at the central level and ensure participation of their staff at regional and departmental levels in AIDS control committees (CRLS, CDLS). They also expressed needs to set up a communication plan for prevention campaigns in their respective sectors and the NES will coordinate a comprehensive communication plan that will include civil society need and be contracted out to specialized social marketing agencies. Line ministries also have specific activities described below: * The Ministry of Health's activities are already covered in the main body of the PAD * The Ministry of Youth will reinforce the capacity of staff in departmental youth centers to address issues related to HIV/AIDS and integrate AIDS prevention activities in ongoing programs such as existing counseling centers (Centres 45 d'Ecoutes/Conseil) created to improve access of young people to reproductive health services. * The Ministry of Education will strengthen its efforts to include HIV/AIDS prevention messages in primary and secondary school curricula as well as vocational training centers materials. Standardized training modules are already available and will be distributed throughout the country using IDA funds. * The Ministry of Women will work with the Ministry of Social Development to include HIV/AIDS prevention activities in existing women's' groups' plans of action, focusing on gender-related issues and socio-cultural barriers that could increase the spread of AIDS. * The Ministries of Army and Interior developed an integrated plan of action that will prevent the spread of HIV/AIDS and develop care and support activities targeted at people in uniform and their families. * The Ministry of Labor recently developed a strategy in partnership with ILO to address legal aspects of AIDS and related stigmatization in the workplace and promote implementation of AIDS prevention activities by enterprises and labor unions. To expand this public sector response, the NES will conduct information and advocacy activities towards other ministries, such as the recently created Ministry of Tourism, to develop AIDS control action plans. Additional ministries and state enterprises would also have access to IDA funds once they develop their own plans with activities and budgets. Activities under this component cover the full spectrum of prevention, treatment, care and support and include: * IEC - the design, implementation and evaluation of information, education and communication (IEC) programs aimed at specific audiences such as adolescents (both genders) in and out of school, women, youth, and men in uniform; and high risk groups such as commercial sex worker (CSW) and men having sex with men (MSM); * Social Marketing - Promotion and distribution of condoms; * MTCT - Mitigation of HIV/AIDS mother to child transmission; * VCT - promotion of and access to voluntary HIV counseling and testing (VCT); * Blood banks - screening of donors and quality control for transfused blood products; and * Diagnosis, treatment and care of HIV patients, including clinical management of sexually transmitted diseases, opportunistic infections, TB, and pilot anti-retroviral infections. IEC. The IEC program which will be supported under this component aims at maintaining awareness of HIV/AIDS risks and protection measures. It will promote behavior change for safe sex practices and risk reduction, and advocate among public and private leaders with respect to human rights protection, abolition of discriminatory practices and learning to live with PLWHA. Use of the mass media will be an important 46 channel of communication. A communication strategy will be put in place to ensure effective communication to all sectors of the public and civil society. Social Marketing. This component will support the use of social marketing for condom promotion and distribution. Peer groups, vending machines and other social marketing strategies will also be used to make condoms accessible to all segments of the adolescent and adult population. Each ministry can choose its strategy to make condoms available and accessible to its staff and clients, and visible access to condoms in public places will be encouraged. Mitigation of HIV/AIDS mother to child transmission. The project will support the decentralization of the MOHP pilot PMCT program to at least one clinical site in each of the ten regions of the country during the period 2002-2006. The objective is to achieve a level of 80% awareness of mother to child transmission among women aged 15 to 49, and to reduce the transmission rate from 30% to 15%. Ninety percent of children born to HIV- infected mothers will be provided with care and treatment at the end of the project. Specific activities will consist of: a) the gradual establishment, training and equipping of multidisciplinary teams in each of the ten regions of the country under the supervision of a national team composed of leading gynecologists, pediatricians, biologists and social workers, b) implementation of a program of pre-test and post-test counseling and the voluntary testing of a target total of 58,000 pregnant women in pre-natal consultations during the period 2002-2006; c) expanding access to short regimen treatment using Zidovudine or Nevirapine drugs; d) expanding access to Anti-Retroviral Treatment therapy in accordance with national standards; e) the development and implementation of specific psycho-social support and IEC activities targeting HIV-infected pregnant women covering topics such as nutrition, breast feeding practices and the use of milk substitutes; and f) the establishment of a supervision and monitoring system to ensure effective control and quality of implementation of PMCT protocols and guidelines, and efficient follow-up and monitoring of patients. Diagnosis, treatment and care of HIV/AIDS patients. This will be based on the expansion of ISAARV (Initiative Senegalaise d 'Acces aux Antiretroviraux). Launched in 2000 and currently limited to the city of Dakar, ISAARV will be progressively decentralized to the main cities of the country (Saint Louis, Kaolack, Ziginchor and Tambacounda). For this purpose, the project will strengthen voluntary counseling and confidential testing and laboratory capacity to help scale up the diagnosis, treatment and care for HIV/AIDS patients. This is part of the MOHP's objective to reduce HIV transmission, reduce worker disability and improve the quality of life for HIV/AIDS patients. This component will also support activities aimed at improving the diagnosis and treatment of sexually transmitted diseases, opportunistic infections, and tuberculosis. It will contribute, as needed, to the strengthening of drug management, patient management (eligibility, clinical and biological follow-up) and psycho-social and economic support to PLWHA. Bio-medical equipment will be purchased to monitor the immunology and 47 virology parameters of HIV infection. Financing will be made available to cover the costs of minor renovations in selected laboratory facilities, the procurement of reagents and drugs for the treatment of STIs, Ols, TB and other HIV-related illnesses. In May 2000 the Government of Senegal joined the Accelerated Access Initiative launched by the pharmaceutical producers of anti-retroviral drugs and indicated its intention to continue its ARV drug procurement plan under an arrangement with those companies which provided price reductions (up to 95%). It is worth mentioning that two producers have agreed to donate Nevirapine and Flucanazole, two of the drugs used in the ART regimen in Senegal. Funds under the IDA Credit will also be made available, as necessary, to supplement Government financing of ARV drug procurement. Part D) - Support to project management and administration (US$ 3.0 million). This component will provide support to facilitate the programming, coordination, and monitoring of project operations, including support to NAC and NES to ensure complementarity and efficient coordination of activities by all concerned parties and to consolidate activity plans, budgets and progress reports. The component will support the deployment of skilled and experienced manpower to staff essential coordinating structures and will fund services of a financial management agent, technical and financial audits, logistic support to facilitate project supervision and reporting, and the organization of CNLS/NES regular meetings and annual project reviews. 48 Annex 3 Estimated Project Costs SENEGAL HIV/AIDS Prevention and Control Project Local Foreign Total Project Cost By Component US $million US $million US $million Component 1 1.77 0.00 1.77 Component 2 13.88 0.00 13.88 Component 3 3.69 7.15 10.84 Component 4 2.59 0.14 2.73 Unallocated 1.33 0.72 2.05 Total Baseline Cost 23.28 8.00 31.28 Physical Contingencies 0.32 0.36 0.68 Price Contingencies 0.26 0.00 0.26 Total Project Costs1 23.85 8.36 32.21 Total Financing Required 23.85 _ 8.36 32.21 Local Foreign Total Project Cost By Category US $million US $million US $million Civil Works 0.92 0.00 0.92 Drugs and Bio-medical Equipment 0.00 7.17 7. 1 7 Equipment (Other) 0.96 0.47 1.44 Services 4.95 0.00 4.95 Operations 1.77 0.00 1.77 Grants 13.88 0.00 13.88 Unallocated 1.36 0.72 2.08 Total Project Costs 23.85 8.36 32.21 Total Financing Required 23.85 8.36 32.21 49 Annex 4 Economic and Financial Analysis SENEGAL HIV/AIDS Prevention and Control Project This section analyses the benefits and costs of the HIV/AIDS Prevention project in Senegal. The total cost of the project is US$ 30.0 million over 5 years (2002-06). The data for prevalence rates for HIV/AIDS and deaths related to AIDS is estimated using information from the UNAIDS website, and from the Bulletin Epidemiologique HIV, Comite National de Prevention du SIDA CNPS, Senegal, 2000. The data for population and other economic indicators are from WDI, World Bank, 2001. The population annual growth rate for year 2000 is 2.4 percent. The annual GDP per capita growth rate is 2.6 percent. The following formula' has been applied to estimate the prevalence of HIV/AIDS in Senegal between 1999 and 2040: (1) Prevalence = h = H * exp (aO + al* t) / (1 + exp (aO + al*t) Where: h=country specific prevalence rate, H= max prevalence rate of 40 (and varied assumptions have been used), t=years from first incidence of AIDS case reporting (1984). aO and al are the coefficients from the regression of log (h/(H-h)) taking three reported points in time 0.19% for 1984, 1.44% for 1994, and 1.77% for 1999. Figure 1 plots the results of formula 1. The top solid curve is the growth in prevalence rate without HIV/AIDS intervention programs, and taking the maximum prevalence (P) that a country could have as 40. The next solid curve marked as "current" is the growth in prevalence rate in Senegal, but taking the maximum prevalence of 30. This line also represents the current HIV/AIDS prevalence rate of 1.77 percent reported for adults in 1999 by Senegal. The other curves reflect the growth in prevalence rate after the introduction of intervention programs. These various curves reflect the reduced prevalence rates between 5 and 32 percent. In order to maintain a prevalence rate of 3 percent in 2006, the HIV/AIDS prevalence would have to decline by over 30 percent between 2001 and 2006. This is indicated in Figure 1 by the solid line with a maximum prevalence of 20 percent. For this simulation, an assumption is taken that the intervention program will reduce HIV/AIDS prevalence by 10 percent between 2001 and 2006. This curve is indicated by an arrow and marked as "Project" in Figure 1, and with a maximum prevalence of 27 percent. l Robalino, David, Carol Jenkins and Karim El-Maaroufi. 2001. Assessing Potential Economic Impact of HIV/AIDS in the MENA Region. Working Paper, World Bank. 50 Figure 1: Senegal HIV/AIDS Prevalence Rates (1984 - 2040) 0.4500 0.4000 ,No Project (Max P=40%) 0.3500 / _ Max P=32% _ 0.3000 urrent -Max P30% x,, 0.2500 / X 0 -Max P-27% > 0.2000 //// Max P=20 - Max P=25% - - {AX / i Max P=20% - 0.1500 0.0 / - f ---Max P=15% i 0.1000 0.0500~~~~ -- ----- Mvax P I 9%/ -Max P-=5% 0.0000- -- Year 1980 1990 2000 2010 2020 2030 2040 2050 Source: Author's calculations using formula (1), idea adopted from Confronting AIDS: Public Priorities in a Global Epidemic. A World Bank Policy Research Report. World Bank, Washington, DC, 1997. For purposes of analysis, two hypothetical scenarios are developed. Table I shows the baseline prevalence rates for Senegal without the new project interventions (case I with a max P=30). Table 2 displays the results when the prevalence rate is reduced by 10 percent from case 1 due to project intervention (case 2 with a max P=27). This is a conservative estimate selected for this simulation, and marked by an arrow in Figure 1. The footnotes of these Tables I and 2 give the assumptions of the simulations. The results follow: The simulation in case I (no project intervention) reports that the incidence rate of HIV/AIDS increased from 4,906 annual new adult cases per million population in 2001 to 9,714 annual new adult cases per million population in 2006. The prevalence rate increased from 1.7 percent of adults in 1999 to 2.3 percent of adults in 2001 to 5.0 percent of adults in 2006. The simulation in case 2 is the situation where an intervention project is introduced in 2002, and reports that in the five year project lifecycle, the incidence for HIV/AIDS increased from 4,906 annual new adult cases per million population in 2001 to 8,628 annual new adult cases per million population in 2006. The prevalence rate for HIV/AIDS increased from 1.7 percent of adults in 1999 to 2.3 percent of adults in 2001 to 4.4 percent 51 of adults in 2006. This is an overall decline during the project lifetime in prevalence of 10 percent from case 1 (no project intervention). Given the above scenarios, the impact of the project is low in the first five years of the project lifecycle. However, the impact increases beyond the fifth year, and shows a marked reduction in the number of new cases and the prevalence of HIV/AIDS. Table 3 provides an estimation of the project benefits from the HIV/AIDS prevention. The simulation assumptions are as follows: (i) on average, averting HIV/AIDS infection buys an individual 10 more years of productive life, (ii) a patient who gets infected will live for 5 more years with adequate care, (iii) the average annual cost of care per patient is US$ 79 (excluding HAART), and (iv) project benefits accrue from second year of project inception. The results of the simulation show that the 5 years project lifecycle could avert infections among 21,282 cases. In dollar terms, this would translate to about US$ 36 million of benefits through averting productivity losses and through averting costs of care. Table 4 shows the net present value (NPV2) and the internal rate of return (IRR3) over the project lifecycle and beyond the project lifetime. The NPV for the first five years from the inception of the project is US$ 4.5 million and the IRR is 26 percent. However, the situation changes a year after that when NPV is almost US$ 20 million and IRR is 53 percent. The NPV and IRR grow positive and increase beyond project lifetime. Table 5 provides the summaries of the sensitivity analysis - the switching values of critical items. The results of the simulation are as follows: * A delay in the project benefits from year 2 to 3, reduces the IRR, although it remains positive beyond project lifetime; however if project benefits are accrued in the first year of the project, then IRR increases to 45 percent at the end of the project lifetime; and * IRR increases several folds as a result of the slowing down of the HIV/AIDS epidemic, and a reduction of the prevalence rate by 15 percent instead of by 10 percent due to project intervention. Although, if the prevalence rate does not reduce by 10 percent, and instead reduces by only 5 percent, then the IRR at the end of the five years is 0, but improves beyond the lifetime of the project. The Cost-Benefit Analysis shows therefore that the HIV/AIDS prevention project can slow down the growth in the epidemic. However, the extent to which the epidemic can slow down depends on the effectiveness of the prevention program. Given the above scenarios, the impact of the project is low in the first five years of the project lifecycle; 2 The Net Present Value (NPV) of a stream of costs and benefits is a number that results from discounting the values of the stream at a given discount rate. The NPV value of a stream is equivalent to the amount that would have to be invested today in order to obtain a return r for N years. In short, NPV is the sum of discounted net benefits over time. Belli, Pedro, et. Al., Economic Analysis of Investment Operations: Analytical Tools and Practical Apnlications. The World Bank Institute. WBI Development Studies. The World Bank. 2001 ' The intemal rate of return (IRR) of an income stream is that discount rate that makes the stream of net retums equal to a present value of zero. The IRR is then compared with the market rate of interest to determine whether a proposed project should be undertaken. Ibid. 52 however, the impact increases beyond the fifth year. The hypothetical situation demonstrates that the benefits can be far greater from the HIV/AIDS prevention project, if there is a larger slowing down in the growth of the epidemic due to the project, which is also dependent on the intervention programs. The cost-benefit analysis therefore supports the implementation of a HIV/AIDS prevention project. Sustainability of the HAART About 20 percent (or 15,560) of the HIV/AIDS patients are expected to require HAART treatment in 2000. In order to cover all the patients who require HAART, the government would require about US$ 168 million between 2002 and 2006. The budget for covering all HIV/AIDS patients requiring HAART is enormous, and by 2006 could take up as much as 26 percent of the public sector health budget, or 0.7 percent of GDP. In 2000, HAART is expected to be used by about 3,890 HIV/AIDS patients (or 25 percent of those who required the HAART treatment). This would make up about 2.8 percent of public sector health expenditure, and 0.07 percent of GDP. This is a large amount of the budget being spent for prolonging life of only a few individuals. A larger proportion of the population die due to communicable diseases and due to peri- natal/maternal causes, and the intervention programs supporting reproductive health and IMCI sub-components are far more cost-effective (ranging between $ 4 and $ 38 per life year saved in Kenya). Whereas, averting deaths of HIV/AIDS patients are much higher. In the case of Kenya, HIV/AIDS community-based interventions were $ 69 per life year saved, preventive interventions were $ 128 per life year saved, and curative interventions were $ 6,338 per life year saved. The annual cost of the HAART drugs in Senegal is approximately US$ 1000 per person per year, and the average annual GDP per capita is about US$ 512. Currently, the government subsidizes the costs of HAART to patients from 0 to 100% based on the income of the household. If the government maintains the current balance, then between 2002 and 2006, about 41,000 patients are expected to be provided with the HAART treatment with a cost of US$ 41 million. This will make up about 6 percent of the public sector health budget and 0.16 percent of GDP in 2006. This raises some concerns. First, the figures -which are underestimated as they do not take into account the cost of lab exams-show that the public sector is likely to have difficulties in sustaining the enormous cost burden of HAART, as it may not be fiscally sustainable. Second, most patients who are expected to access the HAART treatment/services are most likely to be living in urban areas, and are therefore likely to belong to the relatively better off income and education groups. The poor of Senegal- those living in rural, remote and under-served areas- are less likely to receive the treatment, or are less likely to comply with the treatment as they already have lower access to basic health care than richer groups. This will lead to equity concerns. Finally, in order for the government to subsidize HAART, the limited public resources may be substituted away from other illnesses. In particular, if chronic and critical ailments, such as cervical cancer, 53 and others, do not benefit from comparable subsidy, this will create an additional inequity of a different nature, inequity between patients vis a vis health care. During the project lifetime, further economic analysis will be required, as much information is not available on the costs and benefits of the HIV/AIDS. Some of the potential research areas are as follows: (i) cost-effectiveness analysis of the prevention, treatment, and care programs for opportunistic infections; (ii) cost-effectiveness of the prevention, treatment (anti-retroviral drugs and therapies) and care of HIV/AIDS; (iii) drug efficacy and increase in survival due to prevention and treatment form HIV/AIDS, especially HAART, (iv) fiscal sustainability and equity concerns regarding the provision of HAART, (v) a systematic review of the access of AIDS patients to different types of preventions (e.g. VCT), treatments or therapies provided by the public or private sectors, what are their likely gaps and benefits; (vi) socio-economic profile of the high risk and AIDS patients, (vii) the impact of AIDS on the poorest households, (viii) the costing and financing of opportunistic infections and HIV/AIDS, and (ix) surveillance system and reporting of incidence, morbidity and mortality. 54 Table 1: Senegal, HIV/AEDS Prevalence Rate Increases following historical growth trend (with no project intervention max P=30%) Year Population (excL AIDS Incidence Prevalence Adults Adult Incidence deaths) Adults Deaths Rate Total Adults Number Percent Adults (15-49yrs) of Cases (per _million) 1999 1.70 9,285,310 4,272,563 12,755 72,803 _3,640 2,985 2000 2.00 ___ 9,522,100 4,380,360 18,415 87,578 __ 3,640 4,204 2001 2.34 9,768,462 4,494,548 22,051 105,250 __ 4,379 4,906 2002 2.74 10,016,380 4,608,558 26,153 126,140 5,262 5,675 2003 3.19 10,263,588 4,722,227 30.882 150,715 6,307 6,540 2004 3.71 10,505,902 4,833,631 36,220 179,400 __7,536 7,493 2005 4.30 10,739,124 5,057.464 47,176 217,605_ _ 8,970 9.328 2006 4.97 10,977,799 5,169,330 50,214 256,939 10,880 9,714 2007 5.72 11,220,959 5,283,711 58,093 302,185 ____ 12,847 10,995 2008 6.55 11,469,552 5,400,647 66,755 353,831 15,109 12,361 2009 7.47 11,723,232 5,519,958 76,124 412,263 17,692 13,791 2010 8.47 ___ 11,982,077 5,838,308 102,756 494,407 __ 20,613 17,600 2015 14.44 13,301,310 6,683,387 495,133 964,819 _ 24,720 74,084 2020 20.65 14,575,202 7,547,280 641,911 1,558,489 48,241 85,052 2025 25.30 15,708,772 8,420,759 649,829 2,130,393 77,924 _ 77,170 Source: AIDS Prevalence and death are for 1999 and are from UNAIDS, 2000; AIDS adult Incidence and adult AIDS related deaths are from Senegal andfor .2000; Population from WDI, World Bank, 2001 Assumptions: (I) Population Annual Growth Rate=2.4%, and the deaths due to AIDS (t-1) have been subtracted from the population (t); 55 (ii) Prevalence rate increases taking past prevalence for 1984, 1994 and 1999, and then regressed at log (h/(H-h)) to estimate future prevalence, The formula is: h =( H * e(aO+alt)) / (1+e(aO+alt)), where t=time, h=current prevalence, H is max. prevalence=40, aO and al are regression coefficients; and Source: Robalino, Jenkins and El-Maaroufi. 2001. Assessing Potential Economic Impact of HIV/AIDS in the MENA Region. Working Paper, World Bank. Table 2: Senegal, HIV/AIDS Incidence Rate Reduced by 5 percent during the project lifetime (project intervention redu es prevalence by 10 percent) Year Population (excd. AIDS Incidence Prevalence Adults Adult Incidence deaths) Adults Deaths Rate Total Adults Number Percent Adults (15-49yrs) of Cases (per million) 2002 2.43 __ I10.017.345 4.608.838 23,231 112.0393 _ 4.674 5.040 2003 2.83 10.264.749 4,722,602 27,432 133,869 5,602 5,809 2004 3.30 _ I O 10.507.294 4.834.117 32.175 _ 59.351 - _ 6.693 6.656 2005 3.82 10.740.787 5.058.307 41.917 193.300 7.968 8.287 2006 4.41 10,979,778 5,170,297 44,610 228,245 9,665 8,628 2007 5.08 11,223,358 5,284,890 51,615 268,448 11,412 9,767 2008 5.82 11,472,384 5,402,045 59,313 314,339 13,422 10,980 2009 6.63 11,726,562 5,521,606 67,642 366,264 15,717 12,250 2010 7.52 11,985,975 5,840,283 91,309 439,260 18,313 15,634 2015 12.82 13,305,850 6,685,687 439,910 857,207 21,963 65,799 2020 18.34 14,580,645 7,550,037 570,344 1,384,690 42,860 75,542 2025 22.47 15,719,394 8,426,140 577,879 1,893,335 69,235 68,582 Source: AIDS Prevalence and death are for 1999 and are from UNAIDS, 2000; AIDS adult Incidence and adult AIDS related deaths are from Senegal and are for year 2000; Population from WDI, World Bank, 2001 Note: HIV/AIDS Data is for end of the year 56 Assumptions: (I) Population Annual Growth Rate=2.4%; and the deaths due to AIDS (t-1) have been subtracted from the population (t) (ii) Due to project intervention, the rate of growth in AIDS epidemic slows down, and is estimated (conservative) at about 10% lower than the expected prevalence if no project (see Table 2, year 2006). Prevalence therefore reduces to a diffusion level of P=27%. Incidence in year (t) = Prevalence (t) - Prevalence (t-1) + Deaths (t); and (iii) HIV/AIDS related adult Deaths (t)=5% of adult prevalence (t-1) of HIV/AIDS, and of all deaths is 10% of adult prevalence (t-1). Table 3: Senegal Estimating Project Benefits (project inter ention redu es prevalence by 10 percent) Year HIV Years of Averted ($) Total Infections Life Productivity Cost of Benefits Averted Saved Losses Care ($) among adults _ _ 200(2 213 1.930 ____ __ __ 2.9'1 2.92' 1,615.282 '_ 2003 5053 50_ 3,448 6.369 _ 3,613.751 4,119.482 2004 826.775 _ _ _ _ __4.043 10.413 6,061.412 6.888.188 20(05 I .244.975 _ _ _ ____ _ _ _ 5,267 15.680 __ 9.364,710 __ 10.609.685 2006 1.689.789 5.602 21 .282 13. 3041.074 14.730.863 2007 2,204,100 ___ ___ 6,477 27,759 17,452,580 19,656,680 2008 2,794,926 7,441 35,201 22,706,284 25,501,211 2009 3,468,336 8,481 43,682 28,909,741 32,378,077 2010 4,377,512 11,451 55,132 37,436,719 41,814,231 2015 7,072,424 55,223 89,073 68,766,279 75,838,703 2020 10,067,127 71,567 126,790 111,288,320 121,355,447 2025 11,395,226 ____ _ 71,950 143,517 143,220,032 154,615,258 Total (yrs 2-6) 4,499,200 Total__yrs 2-6) 21,282 56,665 33,696,229 36,348,217 Source. Author's calculations. 57 Assumptions: (i) Infections Averted is the difference in the incidence between tables 1 and 2; (ii) On average, averting HIV infection buys an individual 10 more years of productive life; (iii) average annual productivity is valued at GDP per capita (US$ 512 in 1999), with a growth rate of 2.6% annually; (iv) a patient who gets infected will live for 5 years with adequate care; (v) benefits do not accrue the first year of the project; and (vi) the average annual cost of HIV/AIDS interventions in Senegal has been estimated using the following variables, and is US$ 79/person/year (excluding HAART, but including the following: clinical management of OI=US$ 247/person/yr, home-based care of HIV/AIDS patient=US$ 63/person/yr prophylaxis for 01 = US$ 30/person/yr, palliative care=IJS$21.50/person/yr., psychosocial support (VCT)=US$ 3/person/yr. Assumptions for HIV infected cases: 20% require clinical management of 01, 20% require home-based care. 35% require prophylaxis for 01, 30% require palliative care, and 15% require psychosoical management). Source: Costs of Scaling HIV Program Activities to a National Level in Sub-Saharan Africa: Methods and Estimates. AIDS Campaign Team for Africa (ACTafrica), World Bank, Nov. 17, 2000 58 Table 4: Senegal, Internal Rates of Return (project intervention reduces Prevalence by 10%) Year Project Project Project Discount Discounted NPV IRR Costs Benefits Net FMActor Net $ (%/) $ $ Benefits (r=5%) Benefits 2)02 3.100.000 _ 1.00 (3.100.000) . __ _________(3.1 00.000) _ _ _ __ 2003 7.000.000 1.05 (2,743.350) _____ 4,119.482 (2.880.518) __ (5.843.350) 2004 7.200.000 1.10 l 282.823) _______ 6.888.188 (311.812) ___ _(6.1'6.173) _ 2005 5.500.000 1.16 4.413.938 -8.2 O 10.609.685 5.109.685 _ _ (1.712 .235) _ 2006 7.200.000 1.22 6,195.659 25.700Q !4,730.863 7.530.863 _________ 4.483.424 2007- - 1.28 15,401,523 53.2% __ __ _ 19,656,680 19,656,680 _ ______19,884,947 _ 2008 0 1.34 19,029,396 65.5% ___ ___ 25,501,211 25,501,211 _ ____ _ __ 38,914,343 2009 0 1.41 23,010,495 72.0% _ ___ _32,378,077 32,378,077 ____ __ ____ 61,924,838 ___ _ 2010 0 1.48 28,301,517 75.8% _ _ ___ 41,814,231 41,814,231 _ _ 90,226,355 __ _ 2015 0 1.89 40,218,883 80.6% 75,838,703 75,838,703 270,635,665 2020 0 2.41 50,425,695 81.0% 121,355,447 121,355,447 505,429,164 2025 0 3.07 50,338,291 81.0% 154,615,258 154,615,258 758,479,892 Source: Author's calculations. Note: Because of discounting, the present value of the benefits tapers off rapidly over time, therefore the stream of benefits is supposed to last for several years after project closing. 59 Table 5: Senegal, Change in IRR as Project Parameters Change Project Parameters IRR at the end f the # ofyear, from project inception 5 10 15 Average (2006) (2012) (2017) Stream of Costs remain as is, but Stream of Benefits varies, and begins in: Begin in Projectyear2 26% 79% 81% 62% Begin in Project year 1 45% 9__ 99% 100
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Senegal - HIV/AIDS Prevention and Control Project
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