Document of The World Bank
FOR OFFICIAL USE ONLY Public Disclosure Authorized Report No: 323 19-MG
PROJECT APPRAISAL DOCUMENT
ON A Public Disclosure Authorized PROPOSED CREDIT
IN THE AMOUNT OF SDR 20.2 MILLION (USD30 MILLION EQUIVALENT)
TO THE
REPUBLIC OF MADAGASCAR
FOR A
Public Disclosure Authorized SECOND MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT
June 13,2005
Human Development 111 Country Department 8 Africa Region Public Disclosure Authorized This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS
(Exchange Rate Effective February 23,2005) Currency Unit = Ariary 1943.45 = USDl USD = SDR1
FISCAL YEAR January 1 - December 31
ABBREVIATIONS AND ACRONYMS AiDB African Development Bank M&E Monitoring and Evaluation AGF Agence de gestion Financikre (Financial Management Agency) MIS Management Information System AIDS Acauired Immuno Deficiencv Svndrome MoH Ministrv of Health and Familv Plannine
1 Organization) CPAR I Country Procurement Assessment Report I OSE I Organisme de Suivi & Evaluation (Monitoring & Evaluation Organization) CPFA Country Profile of Financial Accountability ovc %ham and Vulnerable Children CRESAN IDA-financed Health Sector Support Project PCN Project Concept Note crus Comiti Rigional de Lutte contre le SIDA (Regional AIDS Com.) PID Project Information Document csw Commercial Sex Workers PLWHA People Living With HIVIAIDS DHS Demographic and Health Survey PRSC Poverty Reduction Strategy Credit FAP Fond d’Appui a la Prevention (Fund for STI/HIV/AIDS PRSP Poverty Reduction Strategy Paper
Vice President: Gobind Nankani Country Managermirector: James Bond Sector Manager: Laura Frigenti Task Team Leader: Nadine T. Poupart
2 FOR OFFICIAL USE ONLY MADAGASCAR Second MultisectoralSTI/HIV/AIDS Prevention project
CONTENTS
Page
A . STRATEGIC CONTEXT AND RATIONALE ...... 8 1. Country and sector issues...... 8 2 . Strategic alignment with CAS. PRSP. and the health sector ...... 10 3 . Rationale for Bank involvement ...... 11 4 . Eligibility for Repeater Status ...... 11
B. PROJECT DESCRIPTION...... 14 1. Lending instrument ...... 14 2 . Project development objective and key indicators ...... 14 3 . Project components ...... 15 4 . Lessons learned and reflected in the project design ...... 17 5 . Alternatives considered and reasons for rejection ...... 18
C . IMPLEMENTATION ...... 19 1. Partnership arrangements: Progress towards the “Three Ones” ...... 19 2 . Institutional and ImplementationArrangements ...... 19 3 . Monitoring and evaluation of outcomes/results ...... 21 ... 4 . Sustainability ...... 22 5 . Critical risks and possible controversial aspects ...... 22 6 . Loadcredit conditions and covenants ...... 23
D. APPRAISAL SUMMARY ...... 23 1. Economic and financial analyses ...... 23 2 . Technical ...... 24 3 . Fiduciary ...... 24 4 . Social...... 25 5 . Environment ...... 27 6 . Safeguard policies ...... 27 1-1 7 . Policy Exceptions and Readiness...... 27
/This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed. without World Bank authorization. Annex 1: Country and Sector or Program Background ...... 28 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies ...... 35 Annex 3: Results Framework and Monitoring ...... 36 Annex 4: Detailed Project Description...... 41 Annex 5: Project Costs ...... 45 Annex 6: Implementation Arrangements ...... 46 Annex 7: Financial Management and Disbursement Arrangements ...... 51 Annex 8: Procurement Arrangements ...... 58 Annex 9: Safeguard Policy Issues...... 62 Annex 10: Project Preparation and Supervision ...... 63 Annex 11: Documents in the Project File ...... 65 Annex 12: Statement of Loans and Credits ...... 67 Annex 13: Country at a Glance ...... 69 Additional Annex 14: Detailed Monitoring and Evaluation Arrangements ...... 71 Additional Annex 15: Supervision Plan...... 75
Map: IBRD 34097
4 MADAGASCAR
SECOND MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT
PROJECT APPRAISAL DOCUMENT
AFRICA
AFTH3
Date: June 13,2005 Team Leader: Nadine T. Poupart Country Director: James P. Bond Sectors: Other social services (65%); Health Sector ManagerBIirector: Laura Frigenti (35%) Themes: HIV/AIDS (P); Other communicable diseases (P); Participation and civic engagement (S); Gender (S); Other social protection and risk management (S) Project ID: PO90615 Environmental screening category: Partial Assessment Lending Instrument: Specific Investment Loan Safeguard screening category: Limited impact
~~ Project Financing Data [ ] Loan [ XICredit [ 3 Grant [ ] Guarantee [ 3 Other:
For Loans/Credits/Others: Total Bank financing (USDm.): 30.00 Proposed terms: Financing Plan (USDm) Source Local Foreign Total BORROWERRECIPIENT 0.00 0.00 0.00 IDA GRANT FOR HIV/AIDS 24.70 2.30 30.00 Total: 24.70 2.30 30.00
Borrower: Government of Madagascar PrCsidence de la Republique Comite National de Lutte contre le VIH/SIDA Nouvel Immeuble ARO Ampefilola 2eme Ctage Antananarivo 10 1 - Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 Secretariat ExCcutif du CNLS : [email protected] Responsible Agency: Unite de Gestion du Projet Nouvel Immeuble ARO Ampefiloha, Escalier B 2 Antananarivo 101 - Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 u,m(ii.wanadoo.mrr
5 4nnual 6.00 8.00 8.00 8.00 0.00 0.00 0.00 0.00 0.00 kmulative 6.00 14.00 22.00 30.00 0.00 0.00 0.00 0.00 0.00
Expected effectiveness date: October 7, 2005 Expected closing date: December 3 1, 2009 Does the project depart from the CAS in content or other significant respects? [ ]Yes [XINO Re$ PAD A.3 Does the project require any exceptions from Bank policies? Re$ PAD D. 7 [ ]Yes [XINO Have these been approved by Bank management? [ ]Yes [XINO Is approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical risks rated “substantial” or “high”? [XIYes [ ]No Re$ PAD C.5 Does the project meet the Regional criteria for readiness for implementation? [XlYes [ ]No Re$ PAD D. 7 Project development objective. Re$ PAD B.2, Technical Annex 3 The MSPPII’s development objectives are the same as those ofthe MSPP. Those objectives are to support the Government of Madagascar’s efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory. To do so, the project will intensify and build capacity to carry out the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread of HIV/AIDS. In addition, the MSPPII will seek to improve the quality oflife ofpersons living with HIV/AIDS through increased access to quality medical care and to non-medical support services. Given the current epidemiological situation, the project will put an even stronger focus than the original project on at-risk groups in high prevalence areas, while moderately expanding services to other affected groups (e.g., orphans and other vulnerable children).
Project description. Re$ PAD B.3, Technical Annex 4 The proposed follow-on MSPPII will finance five components: 1) Harmonization, dono1 coordination, and strategies; 2) Support for health sector response; 3) Fund for STI/HIV/AIDS prevention and care-taking activities; 4) Monitoring and evaluation; and 5) Project managemenl and capacity building.
Component two is the only new component that was added to the project, in order to provide 2 stronger role to the health sector. Which safeguard policies are triggered, if any? Re$ PAD D.6, Technical Annex IO Environment: The proposed project has been classified as category “B” for environmental screening purposes, given the risks associated with the handling and disposal ofmedical wastes.
Safeguard policies: The only safeguard triggered is the environmental assessment, because i Medical Waste Management Plan (MWMP) is required. A full environmental assessment ofthe health sector, which included HIV/AIDS, was also carried out as part of the preparation of the IDA-financed Second Health Sector Support Project (CRESANII). A MWMP was developecl for the MSPP. and has been imdemented since Mav 2004. The MoH has installed 200 small-
6 scale bumers to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that bumers are used at the sites supervised (district hospitals of Ankazobe, Antanifotsy and Faratsiho). The construction of full incinerators at district level is underway; some ofthem should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out in Madagascar's different types of health facilities. The MoH has demonstrated the ability to plan for and prepare these activities, as well. Significant, non-standard conditions, if any, for: Re$ PAD C.7 Board presentation: None Loadcredit effectiveness: Recruitment of auditors acceptable to IDA Covenants applicable to project implementation: 0 Submission ofthe updated Project Implementation Manual, including updated administrative, accounting and financial Parts to IDA by August 3 1, 2005 0 Submission ofthe updated FAP procedures manual to IDA by September 30,2005 0 Finalization ofrevised National M&E Plan and validation by all stakeholders by June 30, 2005 0 Completion ofa technical audit ofFAP sub-projects by October 3 1,2005
7
A. STRATEGIC CONTEXT AND RATIONALE
1. Country and sector issues
The proposed Second Multisectoral STYHIV/AIDS Prevention Project (MSPPII) is a repeater of the IDA-financed Madagascar Multisectoral STI/HIV/AIDS Prevention Project (MSPP) that is supported by a USD20 million IDA credit, and is expected to close late 2005. This section highlights the key country and sector issues since the start ofthe original project in 2002.
Country Issues. Madagascar continues its recovery from a historical decline in per capita income until 2001. Since the 2002 political and economic crisis, the newly elected Government has embarked on many courageous reforms, which are unique to Madagascar in the post- independence period. These reforms have helped growth to rebound, to 9.8 percent in 2003. The macro-economic environment in 2004 was difficult, however. The year was marked by exogenous shocks which included two cyclones, the sharp depreciation ofthe exchange rate, and high inflation (27 percent). In spite of these setbacks, the Government has continued to steadily implement its reform program, and growth is still projected to be robust. Yet, Madagascar remains a poor country with a per capita income of USD300 (2004), and low social indicators. Poverty is mainly prevalent in rural areas with 77 percent of the rural population being poor in 2001 compared to 44 percent in urban areas.
Sector Issues. Until recently, Madagascar was considered an anomaly to HIV/AIDS epidemics in Sub-Saharan Africa: despite high sexually transmitted infections (STI) prevalence in approximately 20 at-risk zones countrywide, and risky sexual practices, HIV/AIDS prevalence among blood donors, STI patients,' and sex workers had remained remarkably low.2 However, infection rates have inexorably progressed (fiom 0.01 percent in 1996 to 0.15 percent in 1999 to 0.3 percent in 2001). HIV/AIDS prevalence rates may continue to grow unless Madagascar further strengthens its management efforts and targets the areas where HIV transmission is most likely to occur.
HIV/AIDS. Characteristic of low prevalence countries, Madagascar has lacked sufficient data to track the progression of the epidemic with precision. However, several recent studies and the initiation of a second generation surveillance system can now provide national and local authorities with current prevalence rates and behavioral data on at-risk groups. The first nationally representative survey, conducted in 2003 , indicates that 0.95 percent of pregnant women are infe~ted.~
' The proportion ofsex workers in the sample is not known, and may have been low. The apparent paradox between high STI rates (8% among pregnant women in 2003) and sexual promiscuity especially in some parts of the country on the one hand, and a low HIV HIV/AIDS prevalence rate on the other hand, may be explained by (i)circumcision which is generalized; (ii)limited transport infrastructure; and (iii)low herpes prevalence. The 2003 HIV-prevalence survey among pregnant women (Ministry of Health) shows a HIV/AIDS prevalence rate of 1.1%. However, this rate was not regionally weighted. It was recently (January 2005) corrected to 0.95%. HIViAIDS prevalence in the general adult population of Madagascar is most probably lower than among pregnant women. Sexually Transmitted Infections (STI). STI rates are extremely high in Madagascar. In 1998, active syphilis in pregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions. In a 2000 study of approximately 1,000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. Recent analysis of a sample of households surveyed for the Demographic and Health Survey (DHS) 2003-04 showed syphilis prevalence at 6.3 percent among adults aged 15-49.
Government Strategy. The Government, at the highest level, continues to be strongly committed to the fight against STI/HIV/AIDS. This commitment is a critical element behind the achievements of the MSPP. Over the past three years, the Government has taken the lead in mobilizing public opinion and organizing the Government’s response to the epidemic. At the end of 2002, the President of Madagascar established the National AIDS Commission (“Comite‘ National de Lutte Contre le SIDA” or CNLS) and appointed an Executive Secretariat to coordinate the implementation of the HIV/AIDS program. A thematic group, made up of representatives from the UN agencies and World Bank, was established under the auspices of UNAIDS to advise the Government in developing and implementing its response to the epidemic. A National Strategic Plan for HIV/AIDS (2001-2006) and a Monitoring and Evaluation (M&E) Plan have been adopted.
After a slow start and a mid-2003 re-structuring, the original project has rapidly increased its activities and has had a number of successes. More than 300 communal AIDS prevention committees, of which more than 25 percent have produced local HIV/AIDS plans, have been established. Some 850 sub-proj ects have been carried out, promoting preventive interventions across a range oftarget populations and sponsored by NGOs and community-based organizations (CBOs). About 400,000 STI kits have been distributed through both public and private channels. A comprehensive communications strategy has been developed, and is now being implemented.
The Government’s strategy is evolving in several ways in response to a better understanding of the epidemic and of STI/HIV/AIDS management. First, the initial mass media campaigns for HIV/AIDS focused on raising awareness and communicating basic messages about HIV/AIDS prevention to the population as a whole. With awareness now raised, the Government’s new HIV/AIDS communication strategy complements the original media campaigns by focusing more on interpersonal communication and actions that lead to behavior change and reduction of stigma. The use of local radios will be favored over print and television media, given radio’s relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement of influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers’ associations). The cinemobile strategy has recently been revised to become more interactive. Even in mass communication, interactivity through televised debates, hot lines, etc. will be introduced. Efforts to involve people living with HIV/AIDS (PLWHAs) in prevention efforts will also be intensified.
Second, under the local response (Fund for STI/HIV/AIDS prevention and care-taking activities) the MSPP supported general prevention efforts throughout Madagascar, with a loose focus on most at-risk zones. The Government recently recognized the need to strengthen its focus on at- risk communes and prioritize interventions in these communes on the most at-risk groups. This evolution is in line with evidence from other countries at the same stage of the epidemic that
9 shows that halting the spread ofthe infection among these groups significantly attenuates wider scale transmission.
Third, the Government has produced partial anti-retroviral (ARV) treatment guidelines, in collaboration with several partners. Until now, the treatment ofabout 29 AIDS patients has been supported by the Association Rive from the Rkunion. However, treatments are not standardized, and drugs are mostly non-combined drugs of many different types. This increases the risks of prescription errors, lack ofpatient compliance to treatment, drug resistance, and complicates the drug procurement and distribution process. Furthermore, the cost of treatment ranges from USD300 to USD6,000, which makes its use financially unsustainable if 3,000 new patients need ARV therapy each year, as projected. These factors do not allow rapid scaling-up of ARV treatment in the Malagasy context. The World Bank looks forward to receiving the complete Government’s ARV treatment guidelines that will address issues such as use of standardized treatment regimens and Fixed Dose Combination, management of medical supply cycle, compliance and adherence to treatment monitoring, capacity building program including for counseling. A medical and management expert committee should be set up to complete the guidelines.
Fourth, the Government and its partners have taken steps to tackle high STI prevalence under the MSPP by: (i)training both the public and private health providers in the syndromic approach nationwide; and (ii)developing STI treatment kits for several sets ofsymptoms, which have been sold at highly subsidized prices in public health facilities and in private facilities, through social marketing. Moreover, Population Services International (PSI) established a network of franchised clinics run by generalists specially trained in providing reproductive health care to the youth, including the treatment of STIs in several large urban centers (Antananarivo, Diego, Mahajanga, Tamatave). A syphilis elimination program targeting pregnant women and their spouses is also being set up in hospitals and 350 peripheral health centers.
There are a few areas of strategy that remains to be finalized. The Government has just produced a draft revised strategy for condom distribution (with USAID and SantCnet support), and a draft strategy on prevention ofmother-to-child transmission (MTCT). A committee has been set up to develop a strategy on care for orphans and vulnerable children. Finally, a strategy on blood transfusion will be prepared shortly in the context of an African Development Bank (AfDB) project which will finance the control ofcommunicable diseases.
2. Strategic alignment with CAS, PRSP, and the health sector
a) Strategic alignment with the CAS and PRSP
The Country Assistance Strategy (October 2003, p.17) recognizes that the Bank will continue to support the fight against HIV/AIDS through financing of the second phase of the MSPP. The MSPPII will directly support the PRSP’s third pillar, to foster and promote systems for ensuring human and material security, by managing the HIV/AIDS epidemic through implementation of the National Strategic Plan (NSP). Board discussions for the MSPP also highlighted the importance of effective containment of HIV/AIDS in Madagascar’s poverty reduction efforts. Both the MSPP and the MSPPII support Millennium Development Goals 7 and 8, which aim to halt and reverse the spread of HIV/AIDS and malaria and other diseases by 2015. Progress
10 towards these targets, in turn, will strengthen the human capital needed to achieve sustained reduction in poverty. Finally, the Secretariat of the New Partnership for Africa’s Development has specifically requested the Bank’s support in fighting HIV/AIDS in Africa since the project directly supports its goals.
b) Strategic alignment with the health sector
While the original project’s design considered the Ministry of Health and Family Planning (MoH) to be a clear project stakeholder, the Project Management Unit (UGP) and the MoH collaborated more than what was originally envisioned in the course of MSPP implementation. Specifically, the UGP and the MoHwere able to develop coherent and coordinated coverage of HIV/AIDS-related interventions in the health sector, especially on STI treatment. The MSPPII formalizes this collaboration through the creation of a stand-alone health component. Moreover, as the HIV/AIDS epidemic rolls out and more HIV positive persons are being diagnosed, including within the framework ofthe MTCT prevention, and treated, more resources need to be devoted to the MoH for diagnosis, ARV and opportunistic infection treatment as well as nutritional support for AIDS patients. Finally, since the management of medical waste and the implementation of universal precautions is lagging behind due to lack of funds as well as crowding of multiple priorities in the health sector, the MSPPII will devote resources to scaling up these interventions.
3. Rationale for Bank involvement
The rationale used to justify the Bank’s involvement in the MSPP remains valid for the MSPPII. While many donors support the Government’s efforts to expand the fight against HIV/AIDS, no partner other than the World Bank is able to mobilize resources sufficient to finance implementation of the key activities outlined in the NSP. The Bank’s financial support also provides the Government of Madagascar (GoM) with: (i)the credibility to leverage other partners’ resources, and (ii)flexibility in the allocation ofresources, as the donor oflast resort.
In addition, the Bank contributes its cross-country experience in the design, implementation and evaluation of Multi-Country AIDS Programs. Through its regional AIDS Campaign Team for Africa, the Bank is well-positioned to provide the GoM with regional and international experiences and share lessons learned. Moreover, through involvement in various sectors in Madagascar and experience in support to decentralized, community-based projects (e.g., the social fund and community nutrition projects), IDA is well placed to continue to assist the Government in its national effort to fight HIVIAIDS in a truly multi-sectoral and community- oriented manner. The Bank’s technical input to the revision of the NSP and the national M&E plan will be substantially increased under the MSPPII.
4. Eligibility for Repeater Status .
a) The MSPPII complies with general repeater requirements.
Project status report ratings. Since the project’s original institutional arrangements were modified in early 2003, implementation problems have been mostly resolved, and project status report ratings have consistently been satisfactory. At the project’s Mid-Term Review in
11 December 2004, the MSPP had: (i)disbursed USD12.2 million (54 percent of the credit); (ii) committed an additional USD5.0 million; and (iii)planned to disburse the balance of the credit by the end of2005.
Impact. Project impact has generally been consistent with original PAD expectations, exceeding expectations on certain components while experiencing difficulties on others. In terms of knowledge change, the proportion of the population who knows of HIV/AIDS has progressed significantly since 1997: 79 percent of women know what HIV/AIDS is today, up from 69 percent in 1997. In terms of the treatment of STIs, a major driver of HIV/AIDS transmission, STI treatment protocols are now consistently applied, and STI treatment kits are widely available. These advances in the treatment of STIs may have resulted in the lowering of syphilis prevalence: at the time of the MSPP design, active syphilis in pregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions, while the 2003/04 DHS survey indicates that syphilis prevalence is now at 6.4 percent for women aged 15-49.
In terms of behaviour change, however, the initial project’s impact has been less apparent. Condom use remains extremely uneven despite the distribution of about 32 million condoms over the last four years, and the promotion of condom use in mass media campaigns and sub- project activities. In the general population, only 4 percent of men and 2.2 percent of women used condoms the last time that they had sex. In high-risk groups, condom use varies considerably: use by women with non-regular sex partners varies between a high of7 1 percent in Mahajanga to a low of 24 percent in Ilakaka. Condom use will need to be consistently higher in high-risk groups in order for HIV transmission to be effectively reduced.
Fiduciary, environmental, social and safeguard issues. There are no unresolved fiduciary, environmental, social or safeguard problems. An environmental assessment ofthe health sector, which included HIV/AIDS, was camed out as part of the preparation of the IDA-financed Second Health Sector Support Project (CRESANII). The assessment included preparation of a medical waste management policy and plan, which has been discussed with all stakeholders to ensure full ownership. The plan includes specific actions which need to be camed out in terms of medical waste disposal and management for the various types of health facilities in Madagascar. In addition, specific training programs are recommended for each type of health worker. The implementation of these waste management policies and actions started in May 2004.
Fund availability from other agencies, supplemental funding or cost savings. The CNLS has undertaken a mapping exercise, comparing estimated financial requirements with available resources. It has concluded that even with important contributions from the Global Fund (USD13.4 millions in 2004-06, with a possible addition of USD6 million in 2007) and the expected contribution from the AfDB (USD11 million in 2005-07), there is a funding shortfall of approximately USD31 million through 2007. There is not yet any clarity on the financial gap beyond that date. No other partner agency is currently able to scale up its activities or to make up for this funding shortfall, and the shortfall will have the sharpest impact in areas where the MSPP has already invested significant resources. Based on the fimding gap as well as past and projected MSPP expenditures, it seems clear that the MSPPII goals cannot be achieved via a supplemental credit or cost savings.
12 b) MSPPII complies with the MAP repeater requirements.
Strategy. In collaboration with UNAIDS, bilateral donors, NGOs and other civil society entities, the GoM prepared a draft NSP to combat HIV/AIDS in 2000. The NSP was refined through an intensive participatory process at the regional and community levels, and was adopted in 2002. Budgeted action plans have been completed, and were used in the financial mappinggap analysis. The NSP is currently being updated to take lessons learned into account, and to integrate new initiatives (e.g., the Global Fund’s project).
Coordination by the National AIDS CounciVlVational AIDS Secretariat. The CNLS and its Executive Secretary (SE) have been strengthened to carry out their coordinating role with the involvement of civil society and clear public accountability. After the 2002 political crisis, the Cellule de Coordination Nationale des Actions de Lutte Contre le VIHBIDA (CCN) was formally created to lead the development of the NSP and to coordinate the multi-sectoral HIV/AIDS effort. It has since been re-named the Comitb National de Lutte contre le SIDA (CNLS). The CNLS is made up of representatives of the public and private sectors and civil society organizations, and is now placed under the direct authority of the President of the Republic. In late 2003, the SE was appointed to manage the MSPP, which substantially improved project performance.
Management of fund for STmIV/AIDS prevention and care-taking activities. The Financial Management Agency (AGF) established under the MSPP has ensured both the timely processing of grant applications and the regular flow of funds. Since assuming the grant management responsibility in March 2003, the AGF has processed more than 850 sub-projects valued at more than USD7 million. More than 75 percent of approved sub-projects were for small grants of USD10,000 or less. The parallel establishment of a “Facilitating Organization” (OF) that helped CBOs to develop their sub-project applications reduced proposals’ revision rate from 60-70 percent of all proposals to 30 percent. Explicit measures linked disbursements to performance, although these tended to be more administrative in nature (i.e., submission of the requisite reports) than technical. The MSPPII will build on these strengths, while making improvements in the supervision and evaluation of sub-projects. Of all approved sub-projects, less than 10 percent were supervised and/or evaluated, primarily due to a shortage of personnel. To remedy to the lack of oversight of approved sub-projects, Regional Coordination Bureaus will take on greater responsibility for sub-project supervision under the MSPPII, and OFs will be awarded contracts by region, instead of nationally as under the MSPP. Contracting by region will place the OFs closer to the ground, increasing their ability to supervise sub-projects.
Technical support for sub-projects and public sector activities. Technical support for sub- projects is provided by different actors, depending on sub-project size. For example, CBOs and NGOs that apply for small sub-project funds receive assistance in developing their proposals from OFs, while proposals over USD100,OOO are reviewed by the technical sub-committee ofthe UNAIDS Thematic Group. The MSPP also provided technical support for the development of public sector strategies and pilot projects. There were significant difficulties in providing support to some ministries. Institutional issues related to the implementation of pilot projects reduced some ministries’ interest in the development of public sector strategies and pilot projects. Because the institutional issues are not likely to be resolved in the short- to medium- term, the MSPPII will initially focus on a limited number of sectors that were able to effectively
13 use MSPP technical support, and that play an especially important role in HIV/AIDS prevention or care-taking. These sectors have been identified primarily as health, education and security.
Monitoring and evaluation system. The MSPP financed a fully operational national M&E system. The M&E system was developed at two levels: (i)at the national level, through development of an M&E plan guided by the SE and Institut National de la Statistique Malgache (INSTAT); and (ii)at the project level, through the design and implementation of a management information system (MIS). Though significant strides in putting an M&E system into place were made under the MSPP, the composite parts ofthe MIS need to be fully integrated (in a common sofhvare platform); second generation surveillance data needs to be better used in national programming and project decision-making; and project activities need to be evaluated.
B. PROJECT DESCRIPTION
1. Lending instrument
The lending instrument is an investment credit with a medium-term focus (four years) to finance services, training, and goods in support of implementation of STI/HIV/AIDS interventions. The Country Financing Parameters, approved on May 12, 2005, allow for up to 100 percent project financing, including taxes. The financing parameters also allow for recurrent cost financing where required, provided that the implications ofrecurrent cost financing on Madagascar's fiscal situation and debt sustainability are taken into consideration.
2. Project development objective and key indicators
The MSPPII's development objectives are the same as those ofthe MSPP. Those objectives are to support the Government of Madagascar's efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory. To do so, the project will intensify and build capacity to carry out the national response to HIV/AIDS and STIs, a key risk factor for and contributor to the spread ofHIV/AIDS.
In addition, the MSPPII will seek to improve the quality of life ofpersons living with HIV/AIDS through increased access to quality medical care and non-medical support services. Given the current epidemiological situation, the project will put an even stronger focus than the original project on at-risk groups in high prevalence areas: while moderately expanding services to other affected groups (e.g., orphans and other vulnerable children).
The achievement of the development objectives will be measured by the following key indicators:
Decrease by 20 percent in syphilis prevalence among commercial sex workers (data pending).
Madagascar has experimented with the "PLACE" method, which uses local ethnographic and contextual data rather than blood testing in order to identify sites where HIV prevention activities could be particularly productive. A PLACEpilot study was camed out in May, 2003 in seven towns judged at high-risk for sexual transmitted infections because of their activities (e.g. mines, large cattle markets, tourism, ports.) Preparation of a 2005 PLACE study is ongoing.
14 0 Increase in percentage of people in high-risk groups (truck drivers, military, commercial sex workers) who can cite three methods of HIV/AIDS prevention, from 52 percent to 85 percent of truck drivers, from 48 percent to 85 percent of military, and from 50 percent to 75 percent for commercial sex workers.
0 Increase in percentage of people in high-risk groups (truck drivers, military, commercial sex workers) who reject two major misconceptions about HIV/AIDS transmission, from 60 percent to 90 percent of truck drivers, from 78 percent to 90 percent ofmilitary, and from 48 percent to 85 percent for commercial sex workers.
0 Increase in proportion of commercial sex workers reporting the use of a condom in their last act ofsexual intercourse with a client from 76 to 90 percent.
0 Decrease in percentage of men and women aged 15-49 who report having sex with a non-regular partner in the last 12 months, from 16.8 percent to 9 percent for women and from 38.1 percent to 20 percent for men.
Some key performance indicators were changed since the MSPP to reflect an increased project emphasis on high-risk areas and the behavior of people likely to frequent those areas. In addition, the MSPP Mid-Term Review found that some key MSPP indicators were too ambitious, inappropriate or unavailable. A more complete list of the indicators that were validated with the UNAIDS thematic group in April 2005 (as part of the revision of the M&E Plan) is presented in Annex 1.
3. Project components
The proposed follow-on MSPPII will finance five components. Component two is the only new component that was added to the project in order to provide a stronger role for the health sector. Details ofthe project components are described in Annex 2.
15 Component and Sub-components Indicative o/o of costs Total
~ (USDM) 1. Harmonization, donor coordination, and strategies 1.5 5 yo a) Harmonization and donor coordination 0.03 b) Updating ofthe national strategic plan 0.1 c) Implementing the STI/HN/AIDS communications 1.3 strategy and action plan d) Sector strategies and action plans 0.07 2. Support for health sector response 3.5 12% a) Support for STI control. 1.5 b) Support for care and treatment ofPLWHAs 1.4 c) Other health sector response activities 0.6 3. Fundfor STmIV/AIDS prevention and care-taking activities (FAP) 16.5 55% a) Sub-projects 14.5 b) Fund management 2.0 4. Monitoring and evaluation 2.9 10% a) Monitoring 1.20 b) Epidemiological data collection 1.20 c) Impact studies/Evaluation 0.5 5. Project management and capacity building 2.5 8 Yo
0.8 3 yo 2.3 7 yo 100% Total Financing Required 30.0 100%
Parameters for Madagascar.
Capacity implications of the scaled-up activities. There is little concern about whether the UGP has the capacity to scale-up project activities, as the MSPPII credit amount of USD30M is a reasonable progression from the MSPP credit amount of USD20M. The two areas in which the budget has been significantly increased from the MSPP to the MSPPII are the financing of the Fund for STI/HIV/AIDS prevention and care-taking activities (FAP), from USD13.9M to USD16.5M, and the support to the health sector component, which did not exist under the MSPP and will receive USD3M under the MSPPII. No significant problems are anticipated with the increase in volume ofthese activities.
There are two broader, capacity-related concerns, however. The first is whether the UGP will have the capacity to successfully re-orient a larger volume of finance towards high-impact activities in a much more limited geographic area (given the MSPPII's focus on core-transmitter groups within high-risk communes). The project will need to shift from supporting general knowledge-building activities to supporting knowledge and behavior change in Madagascar's high-risk areas. To manage this concern, the project has commissioned a demographic and epidemiological profile to identify "hot" communes on an empirically sound basis. It also will undertake an ex ante cost-effectiveness analysis to assess which of the eligible sub-project activities are likely to be the most effective in changing knowledge and behavior in high-risk
16 areas. Finally, it will provide support - potentially through the hiring of a “supra” facilitating organization - to facilitating organizations in how to best help CBOs to develop and carry out high-impact activities in high-risk communes.
The second concern is whether the UGP - and the CNLS more broadly - will be able to implement an M&E System which is more ambitious than under the MSPP. The MSPPII is expected to generate more monitoring data than did the MSPP. It will also aim to use the data in real-time project decision-making, which was not consistently done under the MSPP. To do so, data must be delivered to each level of CNLS or project management accurately and in a timely manner, and rapidly analyzed. The MSPPII will therefore place M&E specialists in the project’s Regional Coordination Bureaus to guide implementation ofthe M&E system at the sub-regional level and ensure good-quality data collection. The project will finance revisions to its MIS and data entry processes to speed data collection. Each year, the MSPPII will also hire a consultant to collaborate with the CNLS to analyze the data generated each year and make programmatic recommendations based on the data analysis. Data analysis and recommendations will be summarized in an annual report, Results and Strategic Re-Orientations.
4. Lessons learned and reflected in the project design
The MSPPII will draw on a number of lessons learned, from intemational experience and from the first MSPP. The intemational lessons emerge from the first generation of Multi-Country AIDS Programs (MAPs). Some of these lessons have been compiled in the Implementing Multi- Country HIUAIDS Programs (MAPS) in Africa report, while others have been highlighted through continued operational research on MAPs by the World Bank’s Development Research Group. The MSPP lessons were outlined in the Aide-Memoire for the MSPP Mid-Term Review Mission and in the Aide-Memoire for the MSPPII Pre-Appraisal Mission.
a) International lessons learned
Focus on high-risk zones in low prevalence countries. The first generation of MAP projects provided broad-based funding for HIV/AIDS prevention and care-taking activities. This model was well suited to countries with a high level of HIV prevalence where generalized prevention strategies were needed, and/or to creating a facilitating environment for highly targeted HIVIAIDS interventions. It is now recognized that HIV/AIDS response in low prevalence countries may be highly targeted to high-risk zones to reduce the risk ofHIV transmission in the areas where that risk is greatest. To take this lesson into account, the MSPPII will change its coverage strategy to focus on core-transmitter groups in the highest risk communes. An analysis of existing epidemiological, behavioral and population-based data is being financed under the MSPP to identify the high-risk communes. At least three-quarters ofthe MSPPII’s FAP will be invested in these high-risk areas.
A comprehensive approach in the fight against HIV/AIDS. When the World Bank first published Confronting AIDS in 1999, the annual cost of ARV therapy for one person (inclusive ofmedical costs) was estimated to be about USD10,OOO for a first-line ARV regimen. This cost was considered to be too high for the vast majority of developing countries to bear. Since 1999, however, the cost of ARV therapy has dropped considerably. Because the prices ofARVs have
17 decreased substantially, and the regimens have become simpler to adhere to, it is now feasible for more countries, including Madagascar, to support a comprehensive approach that includes offering prevention, care and treatment to those infected. The MSPPII will therefore make financing available to the health sector through its second component, for purchase of ARVs and drugs for opportunistic diseases. This financing will compliment funding of the purchase of ARVs by the Global Fund.
b) MSPP lessons learned
Stronger health sector involvement. The MSPP worked with sectors important to the prevention of HIV/AIDS to develop sector strategies and action plans for management of the epidemic. Though the project did emphasize a relationship with the health sector, its Mid-Term Review found that the Ministry of Health’s collaboration was strong, particularly on the STI kits, and highly complimentary to other MSPP activities. Given the strength ofthis collaboration, there is now a need to expand MSPPII to support medical care of PLWHAs. This support will be financed under a separate project component.
Stronger M&E system and more effective use of data. The MSPP financed a series ofnational epidemiological and behavioral surveys, in fill or in part. However, these data are not sufficiently used to reorient the strategy and actions. To address these issues, the MSPPII will: (i)continue to co-finance epidemiological and behavioral surveys; (ii)support collection of data in MSPPII project areas through sub-contracted Lot Quality Assurance Sampling (LQAS) to measure project-specific impact; (iii)finance annual analysis of all survey and operational data, and (iv) finance the development of an annual report, ResuZts and Strategic Re-Orientations, in close collaboration with CNLS staff, that will present the summary data analysis and recommendations for re-orientation of the National HIV/AIDS Program based on the data analysis. The report and its recommendations will be shared and discussed with development partners before implementation.
5. Alternatives considered and reasons for rejection
Two alternatives to the MSPPII were considered and rejected, before determining that a repeater project was the best approach:
1. The alternative of supplementinn the work done on HIVIAIDS under the on-noing Second Health Sector Support Proiect was not felt to be the most effective solution, given the closing date of the health project (already extended once to 2006) and the multi- sectoral nature of the HIV/AIDS problem. However, based on excellent previous collaboration between the two projects, MSPPII has developed an explicit health sector support component that involves the MoHin the project directly.
2. The alternative of including HIVIAIDS in the PRSC was rejected because ofthe reduced amount of PRSC2 financing made available for the key sectors of education, health and nutrition, and because ofthe need to earmark the use offinds for STI/HIV/AIDS.
18 C. IMPLEMENTATION
1. Partnership arrangements: Progress towards the “Three Ones”
Madagascar is making good progress towards the “Three Ones” approach to management of HIV/AIDS, which includes one national HIV/AIDS policy framework, one national coordinating authority, and one national M&E system. The country has one policy framework (2001-2006) and one national AIDS coordinating authority with reasonable technical capacity for coordination, M&E, resource mobilization, financial tracking and strategic information management. The CNLS has also developed a common M&E plan and a set of performance indicators with UNAIDS support. The performance indicators were validated by the UNAIDS thematic group in April 2005, and the MSPPII will use these indicators in its logical framework (Annex 2).
To further support the “Three Ones”, the project will: (i)revise the national strategic framework to incorporate the results of the recent studies, include the proposed interventions ofthe various partners, and serve as a consensus-based management tool for the period 2007-2010; (ii) maintain the institutional arrangements which were carehlly established during MSPP, but will revise the project’s operational manuals to reflect improved capabilities and streamline existing procedures; and (iii)ensure that the MIS hnded by MSPP serves the needs ofthe national M&E strategy as well as those ofall partners. The MSPPII will support revisions to the MIS system as needed.
Under component 1, MSPPII will also provide funding to strengthen harmonization and donor coordination for HIV/AIDS interventions. The CNLS has begun to map out the availability and distribution of funds according to the priorities ofthe NSP. While there is currently no intention of formally harmonizing or pooling funds, the MSPPII will seek to establish: (i)agreement on the annual work plan and outputs; and (ii)a detailed financing plan identifying specific activities to be funded by specific agencies and the GoM. Individual partners’ financing will be “earmarked” in the annual work plan. However, it is understood that the IDA contribution will be flexible, and used as funding oflast resort.
Finally, the MSPPII will continue to submit bi-annual program monitoring reports for review by the CNLS and its financing partners. Reporting formats (including summary reports on activity outputs, financial statements, and procurement) will reinforce the “Three Ones” and will be agreed on by CNLS and its partners. Adjustments to the annual work plan will be jointly agreed upon at bi-annual reviews.
2. Institutional and implementation arrangements
The institutional arrangements for the National HIV/AIDS Program and the MSPPII are similar to those used under the MSPP.’ The responsibility for the oversight of the National HN/AIDS Program rests with the CNLS at the central level; the Regional HIV/AIDS Prevention Committee (CRLS) at the regional level; and the Local HIV/AIDS Prevention Committee (CLLS) at the
A detailed description ofthe differences between the MSPP and MSPPII institutional arrangements is provided in Annex VI.
19 commune level. These committees are made up of HIV/AIDS stakeholders, including representatives from Government, PLWHAs, NGOs, the private sector, and religious and CBOs.
At the central level, the CNLS was created by Government decree in October 2002. The mandate ofthe CNLS is to: (i)coordinate the national fight against HN/AIDS; and (ii)guide the implementation of the NSP. The CNLS is made up of an Executive Secretariat (SE) and a plenary committee. In addition to the day-to-day management ofnational HIV/AIDS prevention activities, the SE provides political and strategic support to the Govemment’s fight against HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection ofrights. The SE also oversees implementation of the MSPP, with the Executive Secretary serving as project director.
Implementation of the national HIV/AIDS program is coordinated at the regional level by the CRLS, which is responsible for (i)supervising and coordinating HIV/AIDS interventions; (ii) guiding implementation of the NSP; and (iii)liaising between the CNLS, the Local CLLS, and other STI/HIV/AIDS prevention actors in the region. At the commune level, the CLLS is responsible for: (i) developing the local plan in the fight against HN/AIDS; (ii) guidinglcoordinating implementation of the plan; and (iii)mobilizing the local population in the fight against HIV/AIDS.
Project Implementation Arrangements. The UGP is responsible for day-to-day management of the project. Its responsibilities include: (i)development ofthe annual work program and budget; (ii)management of project activities, financial management, procurement, administration and logistics; (iii)oversight of monitoring and evaluation (contracted to the Monitoring and Evaluation Organization or OSE); and (iv) periodic reporting to the World Bank. The UGP also serves as the Secretary ofthe MSPP Council, which provides oversight ofthe project as a whole. The Council reports directly to the President ofthe Republic and is made up offifteen permanent members, including one representative from each of the following: the Office ofthe President of the Republic; the Ministry of Finance; the Ordre des Experts ComptabZes de Madagascar; the NGO sector; the private sector; beneficiaries’ associations; and key sectors such as health, education, security and youth.
The UGP is supported by the OSE and the Technical Review Organization (ORT). The OSE is responsible for carrying out periodic project monitoring surveys and for supporting MSPP management to use data in project decision-making and strategic re-orientations. The ORT, under the auspices of the UNAIDS thematic group “dargie”, consists of designated partners within the group who review for technical quality all proposals over USD25,OOO and a sub-set of proposals over USDlO0,OOO submitted to the FAP.
At the regional level, the Regional Coordination Bureau (BCR) is responsible for MSPPII implementation. Each BCR covers one to three administrative regions, and is staffed by a Director and a Technical Coordinator. M&E Consultants will be assigned to each office to ensure high-quality regional data collection. Each region also has a Facilitating Organization (OF). The OF is an NGO contracted by the project to assist: (i)communes in the development of their local plans in the fight Against HIV/AIDS; and (ii)CBOs in the development and implementation ofthe technical aspects oftheir applications for Fund financing.
20 Lastly, a Financial Management Agency (AGF) is responsible for: (i)evaluating the financial viability of CBO applications to the Fund; (ii)returning financially weak proposals to the CBOs for revision; (iii)forwarding suitable proposals to the OF for technical review; and (iv) making payments to the CBOs for approved sub-projects. The AGF is also responsible for maintaining a database ofunit costs for the range ofactivities eligible under the Fund.
3. Monitoring and evaluation of outcomes/results
Though MSPP generally adhered to the arrangements described in the annex to the original PAD, two M&E specialists were insufficient to carry out the range of responsibilities described. Specific problems included: (i)the coherent functioning ofthe computerized MIS. The MIS is in place and operational at the UGP and AGF but, while some parts of the system work individually, only one (sub-projects) is fully automated and the parts do not function together as a whole; (ii)the lack of use of monitoring data in national programming or project decision- making; and (iii)the lack of impact evaluation(s) of project activities. The MSPPII M&E subcomponent will also ensure that the national M&E system used by all donors is in place and operational.
a) Monitoring
The MSPPII Monitoring Plan contains five parts. First, a monitoring framework identifies the key performance indicators associated with MSPP project inputs (Annex 2). Second, outcomes (i.e., behaviors and knowledge) in the project’s at-risk zones (as well as in a limited number of control areas) will be measured using LQAS for recurrent behavioral surveillance. Third, key performance indicators as well as financial, input and operational data will be consolidated in the project MIS, which will be improved to form a single, coherent system. Fourth, sub-project quality will be monitored more closely by placing M&E staff in the BCRs, verify the accuracy of monitoring data; monitor sub-project quality through periodic site visits; and share relevant data with regional partners. Fifth, monitoring data will be regularly released to development partners and the public, primarily in the form ofquarterly, biannual and annual reports.
b) Epidemiological data collection and special studies
The MSPPII will continue to contribute to the financing of a second generation surveillance system and other population-based surveys and large-scale studies. These include bi-annual behavioral surveys among high-risk groups (sex workers, sex workers’ clients, truck drivers, military and youth) and annual sentinel biological surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). The latter includes the cross-sectional HIV prevalence study (Enqugte Nationale de Sero-prevalence Auprks des Femmes Enceintes) first conducted in 2003; the 2008/09 Demographic and Health Survey; and the annual “PLACES” study ofhigh-risk sites and risk behaviors there.
c) Impact studies
The MSPPII will support one or more (pending the availability of funding) impact studies to measure, for example, changes in HIV/AIDS prevalence and incidence, changes in AIDS related mortality, social norms, coping capacity in the community, and economic impact. These impact
21 studies will be launched only after technical review confirms that the study design has sufficient statistical power to test the study hypothesis. The study methodology will be reviewed by the Global HIV/AIDS Monitoring and Evaluation Support Team.
d) Consolidated analysis to reorient the strategy
The project will also finance a consolidated annual report, ResuZts and Strategic Re-Orientations. The report will present: (i)an analysis of data generated and studies camed out in the course of the year, and (ii)recommendations on re-direction of the National HN/AIDS Program or the MSPPII. The report will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based on this analysis. The reports will then be disseminated to and discussed with the UNAIDS thematic group, with a view to regularly using monitoring and evaluation information in program decision-making.
4. Sustainability
Though perhaps less so in Madagascar than in neighboring countries, HIV/AIDS constitutes a pending natural disaster, to which response is well beyond the Government’s financial means. For the foreseeable fiture, there is general agreement within the international community that an effective and sufficient response to the epidemic is largely dependent upon the continued financial support of multilateral and bilateral donors. However, the project will try to build sustainability by measures such as advocating for budget lines for HIV/AIDS or assigning civil servants fill time to the fight against the epidemic.
5. Critical risks and possible controversial aspects
Risk Risk Rating Risk-Mitigating Measures For equity reasons, the UGP may not be able M The project will allocate 75 percent ofsub-project to focus the majority ofits resources on high- funds to identified “hot,” or high-risk, communes. risk areas, despite the pressing The Fund’s procedures manual will be revised epidemiological case for doing so. accordingly.
Despite Government’s efforts to mobilize M The MSPP has invested considerable resources in public opinion, some religious organizations reaching both religious and traditional leaders. The may continue to speak out against condom MSPPII will continue to do so, with an emphasis on use andor encourage stigmatization. continuing the dialogue with opposing groups. Within the project, communication regarding condoms will be less aggressive in mass media campaigns but intensified in communications with high-risk groups. In addition, the project will try to better leverage the President’s commitment to HIV/AIDS prevention to involve other national leaders in the promotion ofcondoms and the reduction ofstigma.
22 The capacity ofthe health care system to S The project description allows the project to be provide basic services for treatment of STI flexible in its support to the health sector, intervene and HIV positive patients (opportunistic where it sees that it will have the greatest impact, and infections, MTCT, ARVs), and for voluntary act in compliment to the CRESANII Project and counseling and testing is too weak to enable health-related activities supported by the PRSCs. the project to meet its health sector-related For example, it may finance the training ofhealth objectives. staff.
National NGOs may not have the expertise to M At least twenty percent ofthe regional OF contracts successfully assist CBOs in implementing will be awarded to international NGOs with a proven more technically sophisticated or socially track record. challenging sub-projects, such as home- based care or support to orphans and vulnerable children or PLWHAs.
6. Loadcredit conditions and covenants
(i)Conditions for effectiveness
0 Recruitment of auditors acceptable to IDA.
(ii)Covenants
0 Submission of the updated Project Implementation Manual, including updated administrative, accounting and financial Parts (with new Chart of accounts and Financial Monitoring Reports) to IDA by August 3 1,2005; 0 Submission ofthe updated FAP procedures manual to IDA by September 30,2005; 0 Finalization of revised National M&E Plan and validation by all stakeholders by June 30, 2005; and 0 Completion ofa technical audit ofFAP sub-projects by October 31,2005.
D. APPRAISAL SUMMARY
1. Economic and financial analyses
Detailed economic analysis on HIV/AIDS has been carried out under the Multi-Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR, paragraphs 76-78). The analysis demonstrates the impact ofthe epidemic on economic development and poverty as well as the cost-benefit offHIV/AIDS interventions.
The fiscal impact of the project is expected to be modest. Counterpart funds are not required and will therefore not impose a financial burden on the GoM. Civil works will be minimal and will be primarily restricted to the renovation of voluntary counseling and testing (VCT) facilities in existing health centers. The recurrent cost of maintenance for infrastructure built under the project is thus expected to be negligible. Finally, the MPPPII will finance expansion, staffing and operating costs of the BCRs. This will involve some supplemental costs relative to the original project. As detailed in the "sustainability" section above, however, the international community is expected to finance the response to the HIV/AIDS epidemic for the foreseeable
23 future. The slight additional costs ofnew BCRs should therefore not create any additional fiscal burden on the GoM.
2. Technical
The design of the MSPPII is based on the MSPP. The MSPP, in turn, relied on existing knowledge and experience gained in Madagascar and in other African and Asian countries. The preparation team relied heavily on the UNAIDS Thematic Group in Madagascar for the project’s technical content. The design follows the MAP principles and the NSP, which reflects a consensus among all stakeholders. In addition for MSPPII, UNICEF provided technical support for communication and on orphans and vulnerable children (OVC) activities. The design ofthe new health component is based on IDA’S experience with the health sector in Madagascar through successive health support projects, and from international experience in the financing of care and treatment for PLWHAs. The M&E component has been strengthened through the collaboration ofthe World Bank and USAID.
The M&E sub-committee ofthe UNAIDS Thematic Group will continue to advise the CNLS and UGP during implementation. The UGP will also continue to rely heavily on its partners for technical support on the Fund implementation. For example, before approval by the AGF, all sub-project proposals to the FAP above USD25,OOO will be reviewed by designated partners of the UNAIDS Thematic Group with comparative advantage in the type of activity proposed (Annex IV provides details). The UGP can at all times apply for technical support from the partners to the UNAIDS Thematic Group and/or from the UNAIDS Secretariat. Annual technical audits will be undertaken by independent consultants.
3. Fiduciary
Procurement. The third Country Procurement Assessment Review (CPAR) for Madagascar was conducted in November 2002. It was followed by a workshop in June 2003 that validated ajoint CPAR/ Country Profile of Financial Accountability (CPFA) action plan to ensure rapid implementation ofprocurement reforms. Key elements ofthe intended procurement reforms are: (i)revision of the draft procurement code to ensure transparency, simplify procedures, and comply with international standards; (ii)establishment of effective procurement institutions to ensure that the new regulations will be adequately applied, provide sufficient oversight and control, and improve efficiency through adequate delegation of responsibilities; and (iii) implementation of adequate training and capacity building to ensure the sustainability of the procurement reforms.
A new procurement code was enacted in July 2004. Since the texts for regulatory application are still under preparation, however, the existing Procurement Code of 1998 will continue to be applied. The World Bank ascertained that deficient features identified in the 1995 CPAR have been properly addressed. IDA standard bidding documents are widely used. An area ofconcern, however, is the cumbersome and overly bureaucratic approval process for contract signing by the Government, which causes unnecessary delays. In addition, insufficient programming and procurement planning contribute to delays in project implementation resulting in slow disbursement. To mitigate risks of delays for the proposed project, proper prerequisites for the
24 use of Bank standard bidding documents, including evaluation reports for national competitive bidding procedures, have been agreed upon with Government during negotiations. The Project Implementation Manual will be updated.
A procurement capacity assessment ofthe UGP, including training needs and arrangements, was conducted as part of project preparation. On the basis of the initial assessment, an action plan was drafted to address areas where the UGP needs to be strengthened. The action plan includes: (i)a specific section on procurement in the Project Implementation Manual to be updated by August 3 1, 2005; (ii)the improvement of organization of the filing of procurement-related documents, including within the regional offices; (iii)procurement training sessions for project staff; and (v) the financing ofindependent procurement and technical audits to be carried out on a regular basis.
Financial management (FM). In accordance with Bank policy and procedures, the financial management arrangements of the UGP responsible for the implementation of the MSPPII have been reviewed to determine whether they are acceptable to the Bank. This review is an update, since the FM system of this entity has already been assessed in the context of the MSSP. The conclusion of this review rated the project FM system "globally satisfactory". However, the following measures need to be taken to ensure adequate recording of project transactions and timely production of financial reports required for managing and monitoring MSPPII activities: i)review of the project Chart of accounts to reflect components and activities to be financed under MSPPII credit; ii)determination of the format and contents of the financial and physical progress reports to be agreed by August 3 1,2005; and iii)recruitment, on a competitive basis, of an accounting assistant to better handle the high volume of transactions and activity, and ensure appropriate segregation of duties. All these recommendations should be implemented by early July 2005.
The project financial statements will be audited annually by independent and qualified auditors acceptable to IDA, in accordance with International Standards of Auditing. The auditors should be recruited prior to effectiveness. The audit report will be submitted to IDA not later than six months after the end of each fiscal year. The content and format of the new financial management reports (FMRs) will be agreed before effectiveness. No significant problems have been encountered in terms ofaudit covenants: the MSPP and all other Bank-financed projects in Madagascar have consistently submitted their audit reports in due time.
4. Social
4.1 Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes.
Madagascar is still at an early stage in the epidemic and is therefore in the fortunate position to be able to curb its spread. The project is designed to reach the most at-risk groups, which include sex workers and their clients, migratory workers, youth, etc. It will empower these groups to undertake HIV/AIDS activities, reduce transmission and ultimately avoid the severe socio-economic impact of HIV/AIDS that is seen in countries with high prevalence rates. Recent
25 studies on sexual and socio-cultural behavior will be used to fine-tune project-financed activities for STI/HIV/AIDS prevention and treatment.
4.2 Participatory Approach: How are key stakeholders participating in the project?
The original project was developed on the basis of the government's NSP and in close consultation with key government, NGO and elected representatives as well as international stakeholders. Different focus group discussions were conducted at the central level and local levels. In addition, several regional meetings were carried out with the participation of local development actors and potential beneficiaries to develop regional and sectoral HIV/AIDS strategies. Technical assistance was provided to assist the government in empowering the communities and NGOs to actively participate in designing and implementing the national HIV/AIDS program through the PRSP process. During the pre-appraisal mission (March 2005), the proposed repeater project was discussed with the Partners Forum. The project design reflects input from its members.
Finally, representatives of FIFAFI, Madagascar's only association ofPLWHAs, are members of the MSPP Council, the CNLS, and the Country Coordinating Mechanism (CCM). Four PLWHAs are currently working in the CNLS and the UGP.
4.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations?
To date, 850 sub-projects requested by NGOs and CBOs have benefited from funding from the Fund. A consortium of three international NGOs was also hired to provide technical support to the NGOs or CBOs that submitted sub-project proposals under USD25,OOO. With the increase in volume of component 3 (the FAP), NGOs and CBOs will continue to be eligible to request sub- project funding. Those NGOs with specialized capacity and experience in the fight against HIV/AIDS will be contracted as OF to assist: (i)communes in the development of their local plans in the fight against HIV/AIDS; and (ii)CBOs or NGOs in the development and implementation of the technical aspects of their applications for Fund financing. There will be 22 OF contracts, one for each region of Madagascar. Up to 80 percent ofthe contracts may be won by national NGOs.
4.4 What institutional arrangements have been provided to ensure that the project achieves its social development outcomes?
At the central level, the CNLS oversees the national, multi-sectoral HIV/AIDS prevention efforts. The mandate of the CNLS includes attention to social development objectives and the involvement of PLWHAs in the National HIV/AIDS Program and MSPP in particular. At the regional and local levels, the project facilitates achievement of social development outcomes through its Fund, which seeks to empower local communities by allowing them to apply for funds for and implement their own STI/HIV/AIDS activities. On the supply side, as above, the MSPPII provides the opportunity for national NGOs to develop their ability to facilitate STI/HN/AIDS prevention and care-taking activities by acting as OFs.
26 4.5 How will the project monitor performance in terms of social development outcomes?
The MSPP is a social development project. Its M&E arrangements are described in brief in the "Monitoring and Evaluation of Outcomes and Results" section, M&E indicators are listed in Annex 2, and in detail in Additional Annex 14 on Detailed Monitoring and Evaluation Arrangements.
5. Environment
The proposed project has been classified as category B )) for environmental screening purposes, given the risks associated with the handling and disposal ofmedical wastes.
6. Safeguard policies
The only safeguard triggered is the environmental assessment, because a medical waste management plan (MWMP) is required. A full environmental assessment of the health sector, which included HIV/AIDS, was also carried out as part of the preparation of the IDA-financed Second Health Sector Support Project (CRESANII).
A MWMP was developed for the MSPP, and has been implemented since May 2004. Since that date, the MoH has installed 200 small-scale burners to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that burners are used at the sites supervised (district hospitals ofAnkazobe, Antanifotsy and Faratsiho). The construction of full incinerators at district level is underway; some of them should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out in Madagascar's different types ofhealth facilities. The MoHhas demonstrated the ability to plan for and prepare these activities.
Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP/GP 4.01) [x 1 [I Natural Habitats (OPBP 4.04) [I [ XI Pest Management (OP 4.09) [I [ XI Cultural Property (OPN 1 1.03, being revised as OP 4.1 1) [I [ XI Involuntary Resettlement (OP/BP 4.12) [I [ XI Indigenous Peoples (OD 4.20, being revised as OP 4.10) 11 [ XI Forests (OP/BP 4.36) [I [ XI Safety ofDams (OP/BP 4.37) [I [ XI Projects in Disputed Areas (OP/BP/GP 7.60)* [I [ XI Projects on International Waterways (OP/BP/GP 7.50) [I [I
7. Policy Exceptions and Readiness
The proposed project does not require any exceptions from Bank policies on repeater projects.
* By supporting theproposedproject, the Bank does not intend to prejudice the final determination of the parties' claims on the disputed areas
27 Annex 1: Country and Sector or Program Background MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
1. Current Dimensions of the HIV/AIDS Epidemic in Madagascar
HIV was first diagnosed in Madagascar in 1984. In 1998, 37 AIDS cases and 233 HIV positive cases were reported to the World Health Organization (WHO). While sparse study results indicated that HIV had more than doubled in three years, from 0.07 percent (1996) to 0.15 percent (1999), it is only in 2003 that the first national representative survey showed that HIV prevalence was 0.95 percent.6 Based on the HIV rate differential between pregnant women and the general population observed in other country studies, HIV prevalence in the general adult population of Madagascar is probably lower than among pregnant women. The estimated number ofreported deaths due to AIDS in 2003 was 24, and the number ofpeople known to be living with AIDS was 68.7 Current estimates suggest that there are at least 35,000 HIV positive people in Madagascar. Studies conducted in 2001 estimated that 96 percent of HN infections were acquired through sexual transmission.
2. Risk and Vulnerability Factors
Extremely high STZ rates. Rates of sexually transmitted infections (STI) are extremely high in Madagascar. Because ulcerative genital disease, such as herpes genitalis and syphilis, increases the risk of HIV transmission by 50 to 300 times (male to female), control of STIs through condom use with irregular partners and the availability ofprompt and affordable STI treatment is particularly critical in the fight against HIV/AIDS in Madagascar.
Syphilis and gonorrhea rates, in particular, are among the highest in the world. In 1998, active syphilis in pregnant women was as high as 14.8 percent, and was over 35 percent among sex workers in some regions. In a May 2000 study of approximately 1,000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. The first nationally representative survey carried out in 2003 found that active syphilis was 8 percent among pregnant women.* Recent analysis of a sample of 2003104 DHS showed syphilis prevalence at 6.3 percent among adults aged 15-49.
The 2003/04 DHS confirmed most ofthe findings of the national survey ofpregnant women, and provided more insight into the variations in syphilis prevalence: (i)the highlands (Antananarivo and Fianarantsoa) are less affected than the coastal areas; (ii)while the capital city has a very low prevalence rate, the other cities have a slightly lower prevalence than the rural areas which are the most affected; and (iii)there is a clear inverse relationship between syphilis prevalence and welfare (the poorest being 5.9 times more likely to be positive than the richest), and syphilis prevalence and education (those with no education are 3.5 and 5.7. times more likely to be infected than those who have had some primary and secondary education, respectively).
6 The previous national prevalence figure of 1.1% was subsequently corrected to take into account the proper weighting of the different provinces. ’Project data. The analysis on the raw data however ignored the different weight attached to the sample groups. For example, young rural women were not weighted in relation with their representation in the actual population.
28 High-risk sexual behavior and misconceptions. The median age at first sex in women has remained constant at around 17.5 years over the past years.' Fifty one percent of women and 61 percent ofmen know that condom protect against HIV. But this proportion is lower among the youngest: only 44 percent of young girls who knew about HIV/AIDS and were sexually active, know that condoms protect against HIV (DHS 2003/04). Sixty percent ofwomen and 73 percent of men knew that limiting the number of sexual partners could protect against HIV. This knowledge has dramatically increased, especially among women, compared to DHS 1997 (38 percent ofwomen).
Nevertheless, when it comes to the behavior, 17 percent ofwomen and 38.1 percent of men said they had high-risk sexual behavior during the past 12 months. There is a great variation of behavior depending on social, demographic and geographical characteristics: men in general and single women tend to have more high-risk sexual behavior. In Antsiranana and Toliara, multiple sexual partners are more common. Risky behavior is particularly high among the youngest (43 percent among the 15-19 year old girls, and 89.2 percent among the 15-19 year old boys). The use of condom also remains very low (5.4 percent for girls, 12.2 percent for boys). Moreover, there are still about 25 percent ofmen and women who have had an STI and who did not look for treatment or counseling. lo
Misconceptions regarding STI/HIV/AIDS are consistently reported, including among youth (15- 19 years of age). This includes the belief that HlV/AIDS can be transmitted by insect bites, and by sharing dishes with someone with AIDS, as well as that a person looking healthy cannot be HIV positive. Cultural bamers and misconceptions about transmission may help to explain why condom use remains very low. A large proportion of those interviewed stated that they know what a condom is but would not propose the use ofone during occasional sex. Condoms are also source of misconceptions such as causing uterine cancer and leading to infertility and people often consider that condoms are less important than fidelity. Qualitative research shows that talking about sex remains taboo. The influence of parents seems to remain very high in Madagascar (53 percent of interviewees stated that they are mostly influenced in their behavior by their parents), but most parents are reluctant to discuss sexuality with their children. On the other hand, virginity is considered less important now throughout most ofthe country and there is a strong link between material or financial compensation and sex. This link has led, in some instances, to an easy transition to commercial sex. Despite the strength ofreligion as reflected in the level ofchurchgoers, the clergy seem to have little influence on sexual behavior' * .
3. Strategic Axes
Communication. The project will support a reorientation of communication activities from top- down mass communication (which will be reduced) to grassroots communication using participatory methods (which will be intensified). Even in mass communication, it will be important to introduce interactivity though televised debates, hot lines, etc. Efforts to involve
DHS 2003. Nevertheless there is a general opinion that DHS overestimated the median age which could be closer to 13. loDHS 2003 11 Synthesis Report : Society, culture and HIV-AIDS in Madagascar. MeiZegers. April, 2003.
29 PLWHAs in prevention efforts will also be intensified. The use of radio will be favored over print and television media, given radio’s relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement of influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers’ associations). The project will support training and capacity building of these different groups.
Local response. The MSPPII will continue to finance the Fund created under MSPP to support the local response, and the Fund will continue to be managed by an independent AGF. During the MSPP, nearly 850 sub-projects run by local NGOs and CBOs have contributed to the implementation ofprevention programs across the country. Under the MSPPII, CBOs will take over ofthe local response to HIV/AIDS from the NGOs, under the leadership ofthe CLLS. The local response will include: (i)condom distribution in identified high-risk communes; (ii) HIV/AIDS peer education and training of community counselors, with a special emphasis on communication for behavior change; (iii)home delivery of treatment and non-medical care- taking services to PLWHAs (activities could include psycho-social and nutritional support); (iv) orphans and vulnerable children activities; (v) awareness-raising in high-risk groups and areas to increase the demand for HIV/AIDS services; (vi) reinforced communication to reduce stigma and discrimination towards PLWHAs, including greater focus on elimination of misperceptions about PLWHAs; and (vii) HIV/AIDS in workplace programs both in the public and the private sector.
Technical coordinators at the regional level, assisted by OFs, will supervise the preparation of the local plans to fight against HIV/AIDS and the implementation of the plans by CBOs (in the form of local response activities). There will be up to twelve regional coordinators in Regional Coordination Offices, and twenty-two OF contracts, one for each of Madagascar’s regions. The OF will be local or international NGOs. Twenty percent of the regional contracts will be awarded to international NGOs.
Several steps will be taken to enhance the effectiveness oflocal response activities. The terms of reference of the AGF and the OF will be revised in order to enhance the coordination between them. As a result, the AGF (whose number ofregional offices is likely to grow in the future) will start keeping a database ofunit costs and will adapt the latter to the regional contexts, as needed. The menu of standard sub-projects will also be revised and tailored to CBO capacities. In addition, a second menu will be elaborated to address the needs in the lower risk areas. Finally, the Fund’s procedures manual will be modified in order to improve CBO selection criteria, and encourage a sub-program approach (long-term) versus a sub-project approach (short-term) at the commune level.
Sexually transmitted infections (STIs). A broad national STI control program was launched in 2003. The strategy is based on the syndromic approach,12 which promotes the subsidized sale of two standardized STI treatment kits through the public and private sectors (the latter through
’’ STIs are classified by syndrome. Each syndrome is made up of a combination of symptoms and clinical signs identified upon examination. The four main symptoms are (i) urethral discharge for men; (ii)lower abdominal pain for women; (iii) vaginal discharge for women; and (iv) genital ulcers for both men and women.
30 social marketing in pharmacies and pharmaceutical wholesalers; see Box 1.l).13 The high prevalence of STIs, combined with the high percentage ofthe poor who cannot afford to pay for STI treatment, provides the argument for subsidizing STI treatment andor making treatment available at no cost to the very poor (“indigents’y. In addition, PSI has established a network of franchised clinics run by general practitioners (GPs) in several towns (Antananarivo, Diego, Mahajanga, Tamatave). The GPs are specially trained in providing STI treatment and other health care to youth. A recent Government decree allows GPs to provide their STI patients with STI treatment kits directly. Finally, as syphilis treatment for pregnant women has been shown to be highly cost-effe~tive,’~a syphilis campaign for pregnant women will start in regional and district hospitals as well as in about 350 rural health centers.
Box 1.1: STI Treatment Kits
While HIV prevalence in Madagascar is still low compared with other Sub-Saharan African countries, rates of chlamydia, gonorrhea and syphilis are high. Studies in Tanzania and Uganda have demonstrated that improved STI treatment can reduce HIV transmission by up to 40 percent in countries or areas where, like Madagascar, HIV prevalence is low and STI prevalence is high. Because STI treatment not only prevents but lowers the risk of HIV infection, such treatment has strong, positive spillover effects whichjustify focused public attention and subsidy.
Since the public sector alone cannot fill the need for the STI treatment nationwide, Population Services International (PSI) has set up a program to distribute subsidized pre-packaged STI kits in the public and private sectors, with assistance from USAID and the World Bank-financed CRESANII and MSPP project. STI kit distribution is coupled with promotional and educational activities, and training for health professionals.
I The pre-packaged therapy contains antibiotics to treat the STI; sufficient condoms for the duration of treatment; partner referral cards; and educational and informational leaflets. In the last two years, 360,000 CURA 7 kits (to treat infections with genital discharge symptoms) and 78,000 Genicure kits (to treat ulcerative infections) have been sold. The luts have proven to be the preferred treatment option for STIs, with CURA 7 kits selling at 135 percent of projected volume for the period and Genicure luts selling at 205 percent of projected volume.
(Source: Preventing HIV through Social Marketing of Pre-Packaged Sexually transmitted Illness treatment kits, 2004, as cited in “Performance ofthe Madagascar health sector: Current situation, constraints and policy recommendations,” under preparation by the World BanWAFTH3).
Condom promotion. Awareness of the importance of condoms in protecting individuals from HIV has increased considerably since 1997. The 2003/04 DHS shows a 30 point increase in the percentage of women who know that condom use can protect against the virus (from 27.2 percent in 1997 to 50.8 percent in 2003). Increased awareness ofthe importance of condoms has not been matched by increased condom use, however. Condom use in the general population is low (2.2 percent of women and 4 percent ofmen used a condom the last time that they had sex). Although it is consistently higher among populations with non-regular sex partners, condom use in this population varies widely by region: condom use by women with non-regular sex partners varies between a high of 71 percent in Mahajanga to a low of 24 percent in Ilakaka, a “Wild West” type mining area.
l3Cura-7, a kit combining ciprofloxacin and doxycyclin for genital discharge and Genicure combining ciprofloxacin and penicillin. Both kits are fitted with ad hoc information, simple instructions for using the drugs, illustrations showing several pictures ofthe respective syndromes including genital diseases that are not cored by the kits as well as waming cards for the sexual partner(s). For detailed information see box “STI kits”. l4Is antenatal syphilis screening still cost effective in sub-Saharan Africa. Sex Transm Infect. 2003 Oct; 79(5):375-81. Terris- Prestholt F. et al.
31 Social marketing has facilitated condom access: over 32 million units were distributed from 2000 to 2004 through more than 25,000 retail points nationwide, at the cost of almost USD0.20 each. Nonetheless, gaps in condom access persist in the general and in high-risk areas. To address these gaps, a new brand of luxury condom will be launched, with a projected distribution offive million the next few years, and 15 million basic quality condoms will be distributed for free in high-risk areas.
Voluntary counseling and testing (VCT), prevention of mother-to-child transmission (MTCT), and safe blood transfusion. The country currently has 49 VCT centers for a population of 17 million, mostly located in the province of Antananarivo (22 VCT). The other provinces respectively have 3 to 8 VCT centers (8 in Toliara, 7 in Antsiranana, 5 in Fianantsoa, 4 in Toamasina, 3 in Majunga province). Nevertheless free testing is the rule in only three provinces (Fianarantsoa, Toamasina, Mahajunga). In the province ofAntananarivo, only 11 out of22 VCT centers provide free testing. Compared to 6 to 7 in Antsiranana, and 6 to 8 in Toliara).
UNICEF finances HIV screening for pregnant women and the prevention of MTCT in 11 Hospitals and 14 health centers. With the support of UNICEF and the Global Fund (USD13.4 million), the Government is planning to significantly expand the number ofVCT centers over the next few years. The MSPPII will complement these efforts where necessary. Currently, given the overall low prevalence and the fear of stigmatization, few people actually use these services. It is expected that the utilization rate of the VCT services will be boosted once ARV and adequate lab testing for ARV follow-up will be made available as planned by the MoH and coordinated by the CNLS, and as communication campaigns help to reduce stigmatization.
Properly tested blood transfusions are available on demand, using family relatives as donors in all hospitals practicing surgery. Outside Antananarivo and a few other cities, blood banks are not yet functional. The ADB is launching a USDl1 million project to strengthen the safety of blood transfusion and implementation ofuniversal precautions countrywide. Finally, the MoHis currently organizing a circuit to collect medical waste in peripheral health centers and is building “Montfort” incinerators at the district hospital level to properly to manage medical waste. Again, the project will complement these efforts where necessary.
Anti-retroviral treatment. Currently, treatment of AIDS cases is fully supported by the Association Rive from the Reunion. The association is providing technical and laboratory assistance, as well as generic and brand name ARV drugs. However, the ARVs are prescribed according to French treatment protocols, which are not adapted to a developing country environment. Moreover, drugs that will be ordered shortly are mostly not fixed-dose combinations of ARV. This choice increases the risk of prescription errors, poor adherence to treatment (too many pills to take, mono or bi-therapy, increase in drug resistance) and drug management risk (drug forecasting, expiration date, stock out).” All these factors are likely to hamper health services quality and prevent from a rapid scaling up of antiretroviral therapy all over the country of Madagascar. Moreover, while the current cost of treatment under these protocols remains affordable due to the very limited number ofpatients served, it will be beyond
l5Sources: (i)OMS, 2003; (ii)MSF “two pills to save lives, fixed-dose combinations ofARVs”, February, 2004.
32 Madagascar’s financial means to treat AIDS patients under these protocols as the number of patients seeking treatment increases.16
Treatment guidelines. In 2004, the MoH developed PLWHA treatment guidelines, including treatment protocols for opportunistic infections at the different levels of the health system (primary health care centers, district hospitals, referral centers). However, these protocols did not take into account the limited laboratory infrastructure of the health facilities (testing equipment, laboratory monitoring). The MoHrecently developed draft treatment guidelines that are closer to WHO recommendations. The draft guidelines were partially approved by the Partners’ Forum which requested that these also address issues such as the use of standardized first and second line regimen^,'^ the use ofFixed Dose Combinations ofARVs,” when to start ARV therapy and when to change regimen, clinical and laboratory monitoring, drug resistance monitoring, management of the medicine supply cycle, lab analysis and ihfrastructure management (taking into account the existing capacity in health facilities), capacity building program including counseling and treatment adherence, and strategy for setting up of the ARV prescribing sites. These guidelines are expected to follow international recommendations for countries with limited resource^.'^
Monitoring and evaluation of ARV treatment would be carried out by the treating doctor who would track: (i)treatment tolerance and toxicity; (ii)clinical and immunologic response to treatment; and (iii)treatment adherence. This last point could be promoted by the use of Fixed Dose Combinations but will also require strong education campaigns carried out by treating doctors, counselors, health workers, and voluntary organizations working close to patients’ home. Patient follows-up should also be put into place to evaluate the treatment efficiency, and monitor toxicity and emergence ofdrug resistance.
Medical and management expert committee. In January 2003, the GoM established a technical committee on drug management, which includes laboratory analysis experts, representatives of the National Referral Laboratory, and some health partners. A national coordinator for drug procurement planning and distribution was recently appointed. A sub-committee including experts from technical and financial partners has been asked to finalize the guidelines taking into account international recommendations as soon as possible. However, there is no formal
l6 It is expected that approximately 3,000 new patients will need ARV therapy each year, which will quickly increase the financial burden ofproviding such treatment. In 2003, the WHO recommends for the first line regimens: d4T/3TC/NVP or ZDV/3TC/NVP or d4TI3TCIEFV or ZDV/3TC/EFZ. EFV should not be given to pregnant women and ZDV requires haematologic monitoring. 2e line regimen: TDF or ABC+ddI+LPV/r or SQV/r or NFV if no cold-chain available. In Annex D of the WHO document, 2003, there is a list of Fixed Dose combination of ARVs that are available and pre-qualified by the WHO. The list of WHO pre-qualified manufacturers is continuously updated and is available at : ~~~W.Who.iiit,:”edicines. l9WHO 2003. Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach. WHO recommendations for initiating antiretroviral treatment therapy are the following ones: (i)if CD4 testing available, offer ARV to patients with either WHO stage IV disease irrespective of CD4 cell count, or WHO stage I11 disease and CD4 cell count below 350/mm3, or WHO stage 1 or I1 disease with CD4 cell count below 200/mm3; (ii)if CD4 testing unavailable, offer treatment to patients with WHO stage IV or I11 disease, irrespective of total lymphocyte count, or WHO stage I1with a total lymphocyte count below 1200/mm3.
33 committee of national medical and management experts in charge of the development of the national treatment guidelines.
Consequently, the GoM will need to establish a national committee consisting ofmedical experts on the one hand, and drug and laboratory monitoring management on the other hand. The medical sub-committee would consist of two or three referring physicians specialized in HIV/AIDS treatment, and who have an expertise in public health in developing countries. This committee would act as a medical reference for prescribing physicians all over the country, especially regarding more complex clinical cases, and could provide counseling to the CNLS and the MoH on national medical issues linked with diagnosis, treatment and follow up of AIDS patients.
The sub-committee for drug and laboratory monitoring management should include experts with strong knowledge of the national health system capacity to better address logistical bottlenecks. This committee should work in close collaboration with the medical expert sub-committee. The project will strengthen the capacities of this sub-committee through technical support provided by organisms with background in developing countries with a similar epidemiologic and socio- economic profile or through periodic clinical training seminars that follow international recommendations for resource-limited settings.
Orphans and vulnerable children (OVC). According to the latest UNICEF estimates,20 100,000 orphans live in Madagascar, and 30,000 of them are AIDS orphans. About 2,400 orphans are estimated to be orphans of both parents. In an effort to avoid further discrimination and stigmatization vis-&vis AIDS orphans, the implementation and respect of all OVC rights will need to be assured throughout the country.
In order to develop appropriate programming for orphans OVC, a needs assessment ofMalagasy orphans and other vulnerable children will be undertaken. The needs assessment will: (i)identify different categories of OVC; (ii)compile an inventory of formal and informal services that currently address these children’s needs; (iii) develop profiles of the types of families most likely to become foster or adoptive families at present; and (iv) analyze the challenges particular to OVC care in community settings. The needs assessment will be used to identify the policies and programs that are most urgently needed for OVC children. In terms ofprogram options, the “extended family” model should be preferred to programs involving the creation of children’s homes or the identification ofnon-family-related foster parents. The extended family model has consistently been shown to be the most effective and cost-effective intervention in terms of children’s welfare.
In addition, a network oftechnical assistance for all national OVC support programs and services should be established (the creation of a National Steering Committee for OVC is currently underway). Finally, existing norms and guidelines regulating public and private institutions for orphans and abandoned children will be revised, and minimum standards of services concerning early childhood care and development are likely to be developed.
2o UNICEF Children on The Brink 2004 : 26
34 Annex 2: Major Related Projects Financed by the Bank and/or other Agencies MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
The Multisectoral STI/ HIV/AIDS Project (World Bank, USD20 million credit). This project was approved in November 2001, and is expected to close around December 2005, i.e. a year ahead oftime. Its development objective is to support the Government ofMadagascar’s efforts to promote a multi-sectoral response to the HIV/AIDS crisis and contain the spread of HIV/AIDS on its territory. To do so, the project builds capacity and scales up the national response to HIV/AIDS and STIs, a key risk factor and contributor to the spread of HIV/AIDS. The project has financed, inter alia, sector strategies and pilot projects, including communication campaigns, the implementation ofthe local response, and M&E activities. It is rated satisfactory on both IP and DO ratings.
The Second Health Sector Support Project (World Bank, USD40 million credit). The project was approved in November 1999, and a supplemental credit (USD22 Million) is under preparation. Health services are provided at approximately 2,500 health facilities nationwide (public sector and NGOs). Approximately 60 percent ofthe population is estimated to live within a five-kilometer radius of a public facility. An emerging but limited private health sector operates essentially in urban and suburban centers. Quality of services is below standard and the supply ofbasic medicines and supplies has been poor. The project objective is to contribute to the improvement ofthe health status ofthe population through more accessible and better quality health services. The project is rated satisfactory on both IP and DO ratings.
Intensification of the fight against HIV/AIDS: (Global Fund, USD13.4 million grant). The goal ofthis project (November 04 - October 06) is to maintain a low level ofHIV infection in 20 high-risk districts by: (i)increasing access to VCT services in 20 high-risk areas; (ii)improving access to prevention opportunities of transmission from mother to child in healthcare facilities; (iii)reinforcing existing prevention measures by the application of universal precaution measures, reinforcing transfusion safety and free access to condoms in public healthcare facilities; (iv) assuring proper care ofpersons suffering from HNthrough the establishment of a technical platform in three regions, the supply oftests for biological examinations, and the social and community care; and (v) improving the care oforphans ofAIDS, reinforcing the capacity of associations of persons living with HIV, and host families and by assuring the care of basic needs ofthe orphans.
Project to Support the Control of Communicable Diseases (STI/HIV/AIDS/Tuberculosis (African Development Fund, OPEP, UNAIDS, USDll million). The project is under preparation and is expected to be approved shortly. It will be implemented over a five-year period. The specific objective is to ensure safe blood transfusion and improve the population’s access to preventive and curative care with respect to communicable diseases, notably HIV/AIDS, STI and tuberculosis. The project includes: (i)the establishment of an operational blood transfusion network; (ii)improving the populations’ access to services for the prevention, diagnosis and treatment of communicable diseases (STI/HIV/AIDS, tuberculosis and hepatitis); (iii)national capacity building for epidemiological surveillance; and (iv) capacity building for the management ofthe project.
35 Annex 3: Results Framework and Monitoring MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Results Framework
To SUDDO~~the Govemment ,f Madagascar’s efforts to commercial sex workers I communication strategy is effective romote a multi-sectoral or needs modification. esponse to the HIVIAIDS :risis, and to contain the Determine if targeting strategy (both :pread of HN/AIDS on its high-risk groups and communes) emtory needs to be changed. 2. Percentage of respondents who can both correctly identify ways of preventing the sexual transmission of Provide data for impact evaluation HIV and reject major misconceptions about HN studies. transmission and prevention (by age group and gender)
3. Percentage of people in high-risk groups (commercial sex workers, truck drivers, military), who can cite three methods of HN/AIDS prevention .
4. Percent of youth 15-24 exposed to STI/HIV/AIDS communication activities/products in the previous 6 months (by source of information)
dtitude Indicator 5. Percentage of population aged 15-49 who do not express discriminatory attitudes towards PLWHA (by age and gender)
lehavior Indicators 6. Percentage of youth aged 15-24 reporting the use of a condom in their last act of sexual intercourse with a non-regular partner in the last 12 months
7. Percentage of men and women aged 15-49 who report having sex with anon regular partner
8. Percentage of men and women aged 15-49 reporting the use of a condom in their last act of sexual intercourse with a non-regular sexual partner in the last 12 months
9. Percentage of commercial sex workers reporting the use of a condom in their last act of sexual intercourse with a client
10. Percentage of truck drivers and military reporting the use of a condom in their last act of sexual intercourse with a non-regular sexual partner in the last 12 months
36 Intermediate Results One per Component Component One: Component One: Component One:
1, Coordination among donors and 1.1. The National Strategic Plan for HIV/AIDS is 3ighlights donor duplication of 3artners on contribution to the revised and disseminated by the end of 2006 :fforts and identify gaps. iational HIVIAIDS strategy 1.2. Annual reporting allows identification of donor Racks coherence between strategies contributions to the program in a coherent manner md activities.
1.3. The national communication plan is updated according to recommendations of the midterm evaluation Component Two: Component Two : Component Two:
2. Strengthened the capacity of the 2.1 Number of STI treatment kits distributed to Tracks availability ofcondoms and health sector to effectively provide MOHper year and sold in public and private sectors STI kits to determine adequacy of :are and support to PLWHA. per year nesponse
2.2. Number of condoms distributed and sold Ensure adequacy of treatment through the public sector and NGO programs per year
2.3. ARV Treatment Guidelines are adequate and implemented Component Three: Component Three: Component Three:
3. Sub-projects promote behavior 3.1. Seventy five percent of the FAP resources are Flags problems with increased change and implement support and allocated to hot places commune-level activities. Tracks care activities mainly in at-risk targeting ofmost at-risk zones areas. 3.2. Number ofCLLS implementing and monitoring their PLLS on a monthly basis
3.3. Number of interpersonal communication activities camed out per year in hot spots
3.4. Number ofbeneficiaries reached by group
3.5. Number ofCBOs receiving capacity building in STVHIV/AIDS by OFs
Component Four: Component Four: Component Four:
4. The MSPPII monitoring and 4.1. Annual operational plan reflects Provides data to MSPPII management evaluation system provides data recommendations ofConsolidated Annual Report for decision making. that is used to orient programming and funding decisions.
Component Five: Component Five: Component Five:
5. Capacity ofregional 5.1. Capacity building plan is produced and Highlights project staff weaknesses so coordinating staff to manage implemented annually as to improve skills at the regional MSPPII activities is increased. level.
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SI Annex 4: Detailed Project Description MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
PROJECT COMPONENT 1: Harmonization, donor coordination, and strategies (USD1.5 million equivalent). Under MSPP, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This was generally due to the low priority given by the sectors which did not see much benefit in developing sector plans, given the limited resources provided to implement pilot activities. This component will be revised to include donor coordination, the updating ofthe national strategy, and a more selective support to sectors. This component will emphasize four activities:
Harmonization and donor coordination: This activity will support practical mechanisms of coordination among donors to ensure better impact and cost-efficiency of HIV/AIDS interventions. Although Madagascar has achieved two of “Three One principles” (one national authority for HIVIAIDS, and one strategic framework) donor coordination needs to be intensified, particularly on the M&E system.
Updating of the NSP. The current plan covers the period through the end of 2006, and will need to be updated and re-validated thereafter, based on recent knowledge about the disease and the evaluation ofpast activities.
Implementing the STI/HIV/AIDS communications strategy and action plan. Though knowledge of HIV and information on prevention is now relatively ~idespread,~~actual sexual practices remain risky,25 and stigma strong. The project will maintain mass media campaigns, but will place more emphasis on activities that facilitate dialogue and action on prevention and stigma reduction at the grassroots level. This sub-component will finance mass communication activities initiated by the UGP and communication materials and toolkits for NGOs and CBOs that will implement grassroots communication sub-proj ects under the Fund. Ifneeded, the existing communications strategy (October 2004) may be updated based on the evaluation ofcommunication activities.
Support for the development of sector strategies and action plans. This sub-component will finance an assessment of “impact effectiveness” of the support received by key line ministries and public sector agencies fiom the MSPP. It will also finance sector strategies and/or action plans for a limited number of sectors (two to three) which focus on high-risk groups (e.g. education for the youth, security for the solders, prisoners, police personnel etc.), and which has been found to be most effective. If implementation of the public sector response progresses satisfactorily, the number or sectors may be expanded during the course of the project. To address the limitations found in the public sector response under the MSPP, the project will try to institutionalize the relationships with the sectors (e.g. periodic
24 The DHS 2003-04 showed that knowledge of HIViAIDS satisfactorily progressed since 1997 from 69% to 79% for women and it is at 88% for men in 2003. 25 The 2004 pilot PLACE survey among risk groups in certain hot spot areas showed that condom use by women with non- regular partners varies between highs of71% (Mahajanga) and lows of24% (Ilakaka).
41 working groups, participation ofthese groups in strategic decisions such as the revision ofthe NSP etc.)
PROJECT COMPONENT 2: Support for health sector response (USD3.5 million equivalent). Under the MSPP, the MoH was involved in the implementation of a major STI program, and of the medical waste management plan. The involvement of the health sector in the fight against STI/HIV/AIDS will be strengthened under the MSPPII, which will complement general funding to the sector provided by CRESANII (USD40 million for the original credit and USD22 million for a supplemental credit that will be submitted to the Board in early FY06).26 This component will finance a range ofactivities, including the revision ofthe health strategy for the prevention of HIVIAIDS. The UGP and the MoHmay decide together to sub-contract some ofthese activities to NGOs and the private sector.
a) Support for STI control. MSPP made a significant effort to control STIs by financing (a) training based on the syndromic approach, and (b) the sale of two STI treatment kits at subsidized prices in both the public and in private sectors.27 MSPPII will expand these activities in high-risks places or groups, particularly for pregnant women by supporting a program ofsyphilis elimination. b) Support for care and treatment of PLWHAs. Based on the preliminary experience ofthe IDA-financed Regional Treatment Acceleration Program, and on the interim review of the MAP Program in Africa, MSPPII will help the MoHestablish a range ofcomplementary ser- vices such as: (a) expansion of the VCT centers in all 111 district hospitals and in health centers in high-risk areas28. These VCT will be staffed by one nurse or laboratory technician and one counselor; (b) psycho-social, nutritional, and other support for persons infected and affected by HIVIAIDS; and (c) treatment of PLWHAs (ARVs, CD4 count), prevention of MTCT, and treatment of opportunistic infections (diagnosis tools and pharmaceutical products). This financing will compliment financing by the Global Fund.
c) Other health sector response activities. MSPPII will provide complementary funding for other activities as needed, such as laboratories (mainly supported by the Global Fund) or blood transfusion (mainly supported by the AfDB), training of health staff, and medical waste management.
PROJECT COMPONENT 3: Fund for STI/HIV/AIDS prevention and care-taking activities (USD16.5 million equivalent). Under MSPP, some 850 NGO, CBO, and association- sponsored sub-proj ects have contributed to a range of preventive interventions. These local response activities will be scaled up with a stronger focus on places where the population is at greatest risk ofbeing infected or of transmitting the infection. Seventy five percent of the Fund
26 The objective of this project is to contribute to the improvement of the health status of the population through more accessible and better quality health services. 27 More than 400,000 STI kits for genital discharge were sold in 2004 at approximately USDO.5 through social marketing in the private sector and at USD0.35 in the public sector. STI kits for genital ulcer are being commercialized through social marketing and will soon be available in the public sector at the same price. However, this activity has not been evaluated. 28 Along with the reconstructionirehabilitation of 300 health centers, a comprehensive needs assessment was recently performed at district (first-referral) level providing the needed information to prioritize the creation of VCT centers and the strengthening of lab facilities.
42 resources will be allocated to these places, which will be identified using the PLACE methodology (already piloted) and the LQAS. This component will finance the following activities: a) Sub-projects. Sub-projects will include: (i)condom distribution through social marketing and promotional distribution; (ii)grassroots communication activities that shift the focus from general knowledge about the epidemic to behavioral communication for change; (iii) home-base care and other support for PLWHAs and associations ofPLWHAs; (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for HIV/AIDS services; (vi) training of peer educators and community-based counselors; (vii) activities that aim at reducing stigma and discrimination against PLWHAs; and (viii) workplace HIV/AIDS plans for the public sector. b) Fund Management. This component will finance fund management by the AGF, the OFs and the ORT. The AGF reviews sub-project proposals for the strength of financial management arrangements, and transfers funds from the project to organizations who have received approval for the sub-project proposal. The OFs will i) support the CLLS in incorporating STI/HIV/AIDS activities into their Communal Development Plans in the highest risk areas; and (ii)strengthen CBO capacity to develop and implement sub-projects. This sub-component will also finance the updating of the list of the standardized activities eligible under the Fund and developed under the MSPP. Under the MSPP, the list of the standardized activities was used to increase the effectiveness of Fund-financed activities and to avoid over-programming of geographic areas and/or target populations. The updating will refine this instrument and its mode d’emploi so that it can be used as effectively as possible in the MSPPII’s high-risk communes.
Operation ofthe fund. As under the original project, the management of the Fund will be contracted out by the UGP to an AGF using a performance-based contract. The AGF will have representatives in each province and will be responsible for (i)processing requests for financing; (ii)approving requests under USD100,000 using selection criteria; (iii)submitting requests above USD100,OOO to the Conseil for approval; (iv) notifying applicants of financing decisions; (v) disbursing approved financing; and (vi) providing necessary data and information to auditors for annual technical and financial reports, and to UGP on a regular basis. The AGF will receive training on HIV/AIDS.
Proposals under USD100,OOO will be automatically approved by the regional office ofthe AGF according to agreed upon criteria, as outlined in the procedures manual. Proposals over USD100,OOO will be submitted by the regional office of the AGF to the Conseil for approval after technical review by the technical sub-committee of the UNAIDS Thematic group. In all cases, the regional office of the AGF is responsible for contracting the implementation of the approved project and disbursing approved financing. All proposals over USD25,OOO and a sub- set ofproposals over USD10,000 will be submitted for technical review to designated partners of the UNAIDS Thematic Group.
A beneficiary contribution will be requested in-kind or in-cash for sub-project costing more than USD10,OOO. This contribution will amount to 3 percent of sub-project cost (for proposals costing
43 between USD10,OOO and USD25,000), 5 percent (for proposal costing between USD25,OOOO to USD100,000), and 10 percent for proposals costing between more than USDlO0,OOOO).
PROJECT COMPONENT 4: Monitoring and evaluation system (USD3.0 million equivalent). In accordance with the “Three Ones” principle, the MSPPII project will support the national M&E plan to which all HIV/AIDS partners in the country adhere. This component provides support to a single M&E system, and has four objectives: (i)ensure that the national M&E system is operational; (ii)develop a functional monitoring system (including MIS) to measure and manage the performance ofthe MSPPII project; (iii)track the evolving status ofthe HIV/AIDS epidemic in Madagascar; and (iv) learn how government policy can slow the epidemic and mitigate its consequences, drawing from the Malagasy experience. The M&E component will have three parts: monitoring; epidemiological studies; impact studies and consolidated annual report. More details on this component are provided in Additional Annex
Monitoring: The project will support implementation of a five-part monitoring plan. The monitoring plan is designed to generate and/or collect key performance indicators, financial, input and operational data for the project; consolidate this data in a fully functional MIS; and use the data collected in project decision-making. LQAS will be used for quality data collection of a sub-set ofkey performance indicators.
Epidemiological surveys: The component will continue to finance a series of second generation surveillance surveys and other population based surveys. These include bi- annual behavioral surveys among high-risk groups (sex workers, truck drivers, military and youth); annual sentinel surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). The latter includes the cross- sectional HIV-prevalence study (Enqugte Nationale de Sero-prevalence Aupr2.s des Femmes Enceintes) first conducted in 2003; the 2008/09 DHS; and the annual “PLACES” study ofhigh-risk sites and risk behaviors.
Impact studies and consolidated annual report: The MSPPII will support one or more impact studies. The project will also develop a consolidated annual report, in close collaboration with the CNLS. The report will provide a summary analysis of data collected in the course ofthe year and recommendations on re-orientation of the national HIV/AIDS program, based on the data analysis. The study methodology will be reviewed by the Global HIV/AIDS Monitoring and Evaluation Support Team.
COMPONENT 5: Project management and capacity building (USD2.5 million). MSPPII will support the institutional arrangements and operational modalities established under MSPP, at the central level (CNLS, MSPPII Council, and UGP), and the new structures established at the regional level (BCR), following the creation of regions mid-2004.29 This component will finance part of each level’s staff, equipment and operating costs, vehicles, periodic technical assistance, and some training based on annual capacity building plans.
29Under MSPPI, UGP had an office in each ofthe six provinces. Under the MSPPII, this arrangement will be replaced by an office in each of the 22 regons.
44 Annex 5: Project Costs
MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Table 5.1: Project Costs by Component
Local Foreign Total Project Costs By Component or Activity USM USM Component 1: Harmonization, donor coordination and strategies 1.45 0.05 Component 2: Support for health sector response 2.50 1.oo Component 3: Fund for STI/HIV/AIDS prevention and care-taking activities 16.50 0.00 16.50 Component 4: Monitoring and evaluation 2.25 0.65 Component 5 : Project management and capacity building 2.00 0.50 2.50 Total Baseline Cost 24.7 2.2 Physical Contingencies 0.7 0,1 Price Contingencies 0.1 2.2 Total Project Costs 25.5 4.5 30.0 1 Interest during Construction Front-end Fee Total Financing Required 25.5 4.5 30.01 'Identifiable taxes and duties are USDO, and the total project cost, including taxes, is USD30 million. Therefore, the share of project cost including taxes is 100 percent.
Table 5.2: Disbursement Schedule (in USD million)
IDA FY 2006 2007 2008 2009 Annual 6 8 8 8 Cumulative 6 14 22 30
45 Annex 6: Implementation Arrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
1. Institutional and implementation arrangements
The institutional arrangements for the National HIV/AIDS Program and the MSPPII remain similar to those used under the MSPP, and are charted in Figure 6.1. Generally speaking, the institutional arrangements for the National HIV/AIDS Program and the MSPPII Project are complimentary. This is consistent with the “Three Ones” approach to management of the HIV/AIDS epidemic, in which a common approach to management ofthe epidemic is seen as the most coherent, cost-effective means ofcontaining the virus.
Figure 6.1 : National HIV/AIDS Program and MSPPII Project InstitutionalArrangements
I MSPPII Operational I National HIV/AIDS I I Arrangements I Propram Arrangements
Council
...... I......
However, there will be four significant institutional changes between the MSPP and the MSPPII. First, the National3 Coordinating Committee (Comitk de Coordination Nationale, CCN) was a temporary committee mandated to guide definition ofnational HIV/AIDS priorities in the lead- up to the MSPP, and was described as such in the MSPP project appraisal document. The committee was formalized as the National HIV/AIDS Prevention Committee (Cumitk National de Lutte contre le VIH/SIDA, CNLS) during the MSPP and is now consistently referred to as the CNLS. Second, the UGP was moved under the under the direction ofthe Executive Secretary of
46 the CNLS in December 2003. This has allowed an improvement in coordination and a more steady response of actions. Third, Madagascar is in the process of decentralizing and has recently created 22 regions, between the province and district levels. To accommodate regionalization, the MSPPII will increase the number of Provincial HIV/AIDS Prevention Committees (Comitks Provinciaux de Lutte contre le VIH/SIDA, CPLS) from six to up to twelve; the name ofthese committees will be changed to the Regional HIV/AIDS Prevention Committee (Comitks Rkgionaux de Lutte contre le VIH/SIDA, CRLS); and the CRLS will be expected to cover a set ofregions rather than provinces. Fourth, the project adds contracting ofa monitoring and evaluation organization (Organisation de Suivi et Evaluation, OSE). The OSE is responsible for carrying out periodic project monitoring surveys and for working with the CNLS and MSPP management to use data in project decision-making and strategic re-orientations.
a) Institutional arrangements for the national HIV/AIDS program
The institutional arrangements for the National HIV/AIDS Program include the CNLS at the central level; the CRLS at the regional level; and the Local HIV/AIDS Prevention Committee (CLLS) at the commune level.
Central level. The CNLS was created by Government decree in October 2002. The mandate of the CNLS is to (i)coordinate the national fight against HIV/AIDS and (ii)guide the implementation ofthe National Strategic Plan.
The CNLS is made up of an Executive Secretariat (SE) and a plenary committee. The SE has day-to-day management of national HIV/AIDS prevention activities and provides political and strategic support to the Government’s fight against HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection of rights. The SE also oversees implementation ofthe MSPP, with the CNLS Executive Secretary serving as project director. The plenary committee is responsible for overseeing implementation of the NSP. It is made up of eighty stakeholders, including representatives from Government, PLWHAs, NGOs, the private sector, and religious and CBOs.
The Partners’ Forum (Forum des Partenaires) enhances the dialogue between the CNLS and the major bilateral and multilateral donors and NGOs. Coordinated by the Executive Secretary ofthe CNLS, Partners’ Forum provides the CNLS a venue to monthly inform all major donors on its current and future activities. Donors participating in such periodic reunions have the opportunity to offer their feed-back to the CNLS and express their possible concerns over existing issues identified within the scope ofthe project implementation.
The Country Coordinating Mechanism (CCM) was recently added at the Global Fund’s request. The mandate of the CCM is to submit, monitor, and evaluate activities on AIDS, Tuberculosis and Malaria to be financed by the Global Fund. The CCM is coordinated by the CNLS, and includes representatives of major donors, Government, NGOs, CBOs, Academia, the private sector, and PLWHAs. The CCM meets on a monthly basis and has become very active.
The CNLS also houses a UNAIDS Thematic Group, which is made up ofrepresentatives of UN agencies and the World Bank. The group meets on a monthly basis to provide support and
47 advice to the Government on HIViAIDS. The group has prepared an Inter-Agency Program to support the Government’s NSP, in which each UN agency outlines their support to the NSP.
Regional level. Implementation of the national HIV/AIDS program is coordinated at the regional level by the CRLS. Up to twelve CRLS will be formed during the MSPPII implementation period.30 The CRLS is responsible for (i)supervising and coordinating HIV/AIDS interventions; (ii)guiding implementation of the NSP; and (iii)liaising between the CNLS, the CLLS, and other STI/HIV/AIDS prevention actors in the region. As with the CNLS, CRLS members include representatives from a range of public, private and non-governmental organizations implicated in the fight against HIV/AIDS.
Local level. At the commune level, a CLLS is responsible for: (i)developing the local plan in the fight against HIV/AIDS; (ii)guidingcoordinating implementation of the plan; and (iii) mobilizing the local population in the fight against HIV/AID.S. Again, as with the CNLS, the CLLS is made up ofrepresentatives from a range ofpublic, private and NGOs implicated in the fight against HIV/AIDS.
b) Project implementation arrangements
The implementation arrangements for the MSPPII include the UGP, the Technical Review Organization (ORT), the Monitoring and Evaluation Organization (OSE), and the MSPPII Council at the central level, as well as the Regional Coordination Bureau (BCR), the Facilitating Organization (OF) and the Financial Management Agency (AGF) at the regional level. Given the Government long-term commitment to the fight against HIV/AIDS, the option ofeliminating the UPG and merging its functions under a Multi-Sectoral Response Unit of the CNLS will be explored during project implementation.
Central level. The UGP is responsible for day-to-day management of the project. Its responsibilities include: (i)development of the annual work program and budget; (ii) management of project activities, financial management, procurement, administration and logistics; (iii)oversight of monitoring and evaluation (contracted to the OSE); and (iv) periodic reporting to the World Bank, and integration of data into project decision-making. The UGP also serves as the Secretary ofthe MSPP Council.
An MSPP Council provides oversight of the project as a whole. Its responsibilities are to: (i) approve the UGP’s annual work program and budget; (ii)approve requests to the Fund over USD 100,000; (iii)ensure that the project-financed activities achieve the project development objective; (iv) approve annual technical and financial audits; (v) adopt and approve the procedures manual of the Fund and the Project Implementation Manual, and approve modifications to them; (vi) evaluate the perfonnance of the UGP based on performance indicators, in consultation with IDA; and (vii) approve the recruitment ofthe AGF. The Council also includes an audit committee, whose role is to facilitate the work ofexternal project auditors, review auditors’ findings, and ensure the implementation ofsuch recommendations.
30 Prior to the recent creation ofMadagascar’s regions, responsibility for coordination and oversight of HIV/AIDS prevention efforts at the sub-national level fell to the Comitb Provincial de Lutte contre le VIHSIDA (CPLS).
48 The Council reports directly to the President ofthe Republic. It is made up offifteen permanent members, including one representative from each ofthe following: the Office ofthe President of the Republic; the Ministry of Finance; the Ordre des Experts Comptables de Madagascar; the NGO sector; the private sector; beneficiaries’ associations; and key sectors such as education, security and youth.
The UGP is also supported by the ORT, under the auspices of the UNAIDS Thematic Group. The ORT, made up of designated partners, undertakes a technical review of all proposals over USD25,OOO and a sub-set ofproposals over USD100,OOO submitted to the FAP to ensure quality and provide recommendations for improvement, as necessary.
Regional level. In addition to its responsibilities within the CNLS, the BCR is responsible for ensuring MSPPII implementation at the regional level. Each BCR covers one to three administrative regions, and is staffed by a Director and a Technical Coordinator. The Director (i)coordinates project implementation by component; (ii)liaises with development partners across sectors in order to ensure effective project implementation and maximum complimentarity with other STI/HIV/AIDS activities in the region; and (iii)supervises the work of the OF and AGF in his or her region(s). The Technical Coordinator is responsible for supervising the development of local plans in the fight against HIV/AIDS, with the assistance ofthe OF, and the technical quality of the work performed by the OFs. The Technical Coordinator also plays an active role in implementation ofquality activities under the project’s other components.
Each region also has an OF. The OF is an NGO contracted by the project to assist: (i)communes in the development of their local plans in the fight Against HIV/AIDS; and (ii)CBOs in the development and implementation of the technical aspects of their applications for Fund financing. Particular emphasis will be placed on the use of key messages focusing on all three means ofpreventing HIV transmission - abstinence, fidelity and condom use - and not a sub-set of those messages. There will be 22 contracts available under the MSPPII, one for each of Madagascar’s 22 regions. An OF may hold a single contract to cover one region, or may hold several contracts. In order to ensure the continued transfer of technical expertise to national NGOs and CBOs, 20 percent ofregional contracts will be awarded to international NGOs for at least the first two years ofthe project.
Finally, an AGF is responsible for: (i)evaluating the financial viability of CBO applications to the Fund; (ii)returning weak proposals to CBOs for revision; (iii)forwarding suitable proposals to the OF for technical review; and (iv) making payments to CBOs for approved sub-projects. The AGF is also responsible for maintaining a database of unit costs for the range of activities eligible under the Fund. A single AGF is engaged by the project; it is expected to have eight regional offices.
c) Implementation arrangements for monitoring & evaluation
The UGP is responsible for monitoring project performance and contracting out the impact evaluation studies. The M&E Unit is currently staffed by two M&E specialists; a third staff member (or long term consultant) will be hired to perform spatial analyses of data using a Geographic Information System. Funds are budgeted to contract consultant services
49 internationally and nationally to provide the necessary support to the team’s approach to M&E and its instruments. Additional M&E staff will be contracted and placed in eight regional MSPPII offices to perform periodic spot checks of subprojects and to monitor the data collected and compiled at the local level. These staff will report to the UGP M&E team and will be technically qualified to provide continuous M&E presence in the field to supplement the intermittent site visits by the UGP M&E staff.
50 Annex 7: Financial Management and Disbursement Arrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Country issues
Several diagnostic works carried over the last two years31 confirmed the weak capacity of the country public financial management system. To increase the quality and success ofMSPPII, it is more efficient to entrust the implementation ofthis project to the UGP which had already a strong experience in managing World Bank funds.
The CPFA (Country Profile of Financial Accountability) carried out in September 1998 established also the weak capacity of the accounting profession in Madagascar: a number of accounting firms were operating below the international standards due to the lack of regulatory framework, proper auditing standards, clearly defined guidelines and procedures for systematic peer reviews, continuing education requirements, quality control mechanisms to harmonize methodology. To improve the capacity and the competitiveness of the local auditing firms, the following measures have been taken: (i)obligation for local auditors to enter into partnership with international accounting firms while auditing Bank/IDA financed projects in order to improve the quality of audit reports and ensure practical training and real transfer of methodology in the areas of organization and execution of audit assignments; (ii)effective participation ofthe international accounting firm while carrying out audit works in the field and submission ofaudit report jointly signed by the local and international audit firms.
Table 7.1: I; sk Analysis Risks Risk Risk Mitigation Measures rating Implementing Enti@ Low Stafflng Low NIA Funds Flow. Rsk of delays in Moderate Establishment of a bank account in the name of the payment ofNGOs, CBOs each regional AGF, with an initial deposit covering and other partners (associations, three months of expenditures (Special Account 90- communes) working at the day advance procedure). regional. Maintain good liquidity level both at central and regional levels by: (i)a close monitoring of cash forecast prepared on a quarterly basis; (ii)regular submission (at least on a monthly basis) of withdrawal application to replenish regional bank accounts and project special accounts.
Accounting Policies Low NIA and Procedures
31 Country Financial Accountability Assessment (CFAA), Country Procurement Assessment Report (CPAR), HIPC-Assessment and Action Plan, IMF Technical Assistance Report, European Union Financial Audit and Public Expenditure Review.
51 Intern a1 Audit Low NIA External Audit: The CPFA Substantial Local auditors who intend to audit the financial (Country Profile of Financial statements of Bank financed projects should Accountability) carried out in enter into partnership with international auditing September 1998 established the firm to strengthen their capacity. weak capacity of the accounting profession in Madagascar. The Effective participation of the international CFAA conducted in 2003 auditing firm in the fieldwork. confirmed that the country public financial management Reinforcement of the accounting profession after poses a major fiduciary risk. the completion ofthe ROSC mission.
Monitoring and Reporting NIA
Information Systems NIA
Implementing entities
The UGP is responsible for coordinating project implementation, and managing procurement, financial management, disbursement, project monitoring, reporting and evaluation. It will assure the record-keeping of transactions under the components 1, 2, 4 and 5 as well as the consolidation of project accounts and the production of quarterly Financial Monitoring Reports (FMRs) in compliance with international accounting standards and IDA requirements. Implementation of project activities under the component 3 will be sub-contracted to existing structures such as NGOs, CBOs and other associations whereas the financial management of funds financing these activities will be contracted to the existing AGF. Procedures and modalities for selection and contracting ofthese executing agencies are described in details in the operation manuals. The AGF will keep an accounting system satisfactory to IDA and will prepare its own financial statements as well as other financial and technical reports as required by the UGP. Each of the AGF’s regional offices has an accountant responsible for regional accounts as well as the electronic transmission ofregional accounts to the central level, using the existing computerized accounting and financial management system.
Strengths and weaknesses
The UGP has strong experience in managing World Bank funds for being in charge of the implementation ofMSPP. The accounting/budgeting system is adequate and the internal control procedures appropriate. It has also qualified and trained accounting staff who are very knowledgeable about Bank procedures. However, to further strengthen the project financial management system, some measures need to be taken. The following table provides relevant measures to address main deficiencies identified in the UGP financial management system.
52 Table 7.2: Measures to address deficiencies of financial management svstem Significant Weaknesses Resolutions Chart ofaccounts not reflecting yet the new components Review ofthe chart ofaccounts to reflect new and activities to be executed under MSPPII project components/activities eligible under MSPPII credit to satisfy reporting requirements
Accounting manual of procedures not being updated to Update of the accounting manual ofprocedures include the new chart of accounts and the models of to facilitate adequate record keeping ofMSPPII financial and physical progress reports required for transactions, and satisfy reporting requirements managing and monitoring MSPPII activities
Inadequate number ofaccountant commensurate with the Recruitment ofa qualified and skilled accounting volume oftasks to be coped with. assistant in conformity with the Bank procedures
Auditors in charge ofthe review ofMSPPII accounts Recruitment ofan accounting firm acceptable to have not been recruited yet IDA to carry out the audit ofMSPPII accounts
Funds Flow
The flow of funds from IDA is presented as follows:
World Bank (Credit)
(Special Account A) Central AGF l-7 (Special Account B) I I I
Regional AGF (Special sub-account)
Grants to recipients (NGOs, CBOs, other associations) for provision ofgoods and services
I I Suppliers of goods and services I
53 Staffing
The UGP’s accounting staff is qualified. However due to the volume of project transactions and activities and to ensure appropriate segregation of duties in financial management area, the Bank recommended to recruit an accounting assistant in conformity with the Bank procedures. The recruitment ofthis second accountant has been completed prior to negotiations.
Accounting policies and procedures
The accounting system in place is in compliance with generally accounting standards and IDA requirements and capable of producing timely financial information required for managing and monitoring project activities. The project accounting manual of procedures needs to be updated to include the new Chart of accounts as well as the models of financial and physical progress reports to be produced.
Internal audit
To ensure consistent application of the procedures and efficient use of finds by executing agencies, the accounting firm Delta Audit Deloitte and Touche in collaboration with the UGP M&E staff will continue to play the role of internal auditors. All issues identified during internal audit should be addressed quickly to improve the project performance.
External audit
The project financial statements will be audited annually by an international private accounting firm acceptable to IDA, in accordance with International Standards of Auditing and the new Guidelines describing Audit Policy and Practices for World Bank-financed Activities. The auditors will provide a single opinion on the annual financial statements, stating whether the financial statements fairly present the financial transactions and balances associated with the implementation of the project, and if the expenditures financed by the credit were appropriate. The auditors will be also required to carry out a comprehensive review of the internal control procedures and provide a management report outlining any recommendations for their improvement. The audit report will be submitted to IDA not later than six months after the end of each fiscal year. The auditors should be recruited prior to effectiveness.
Reporting and monitoring.
To monitor project implementation, the UGP will produce the following reports that should be prepared in compliance with international accounting standards:
Annualfinancial statements comprising:
a) Summary of sources and uses of funds (by components/project activitiedcredit category and showing all sources of finds); b) Project Balance Sheet;
54 0 QuarterZy FMRs: The FMRs includes financial reports, physical progress reports and procurement reports to facilitate project monitoring. The FMRs should be submitted to IDA within 45 days ofthe end of the reporting period (quarter). The form and content of FMRs has been determined as part ofproject appraisal and will be agreed at negotiations. Models of these reports will be presented in the project accounting manual ofprocedures.
Information systems
The UGP and AGF are using an integrated financial management system capable of recording and producing in a timely manner all financial reports required for managing and monitoring project activities.
Impact of procurement arrangements
Procurement arrangements do not present substantial risk.
Action plan
The present action plan agreed with the borrower describes main actions to be taken to strengthen the MSPPII financial management system.
Table 7.3: Action plan for strengthening MSP: 11 financial manag ment system
Actions Date due by Responsible 1 Update of the project Chart of accounts to reflect 06/15/05 UGP/AGF new components and activities to be financed under MSPPII;
2 Submission of the content of FMRs to be agreed at 0613 1/05 UGPIAGF negotiations.
Recruitment of auditors in charge of the audit of UGP MSPPII accounts: 0 Agreement on Terms ofreference
0 Submission of the technical and financial 06/ 15/05 proposal to the VPM; 0713 0105 0 Negotiations Submission of contract to IDA for non 08/06/05 objection 081 lolo5 Award of the contract to the auditors. 08/20/05 Production of the first FMRs and submit them to the 0 710 610 5 Bank.
55 Disbursement from IDA credit
For the implementation of MSPPII the following bank accounts will be opened in local commercial banks under conditions satisfactory to IDA:
0 Special Account A: Denominated in USD, disbursements from the IDA credit will be deposited on this account to finance MSPPII activities under expenditure categories 1 (Goods and Works), 2 (Consultant Services, Training and Workshops), and 4 (Operating Costs) in accordance with the disbursement percentages indicated in the DCA. 0 Special Account B: Denominated in USD, disbursements from the IDA credit will be deposited on this account to finance MSPPII activities under expenditure category 3 (Grants to Sub-Projects) in accordance with the disbursement percentages indicated in the DCA.
Funds deposited in these accounts will be used to ensure timely payments of (i)suppliers of goods and services, and (ii)contractors (NGOs, CBOs, other organizations) in conformity with the terms of the contract signed by the parties concerned. The project implementation and accounting manuals describe in details all procedural aspects regarding financial management (payments, replenishment, reporting, internal control) and reference to the procedures outlined in these manuals will be indicated in the DCA.
Disbursement arrangements
Method of Disbursement. The project would follow the transaction-based disbursements procedures (traditional mode) outlined in the Bank's Disbursement Handbook. The use ofreport- based disbursements could be possible thereafter if requested by the borrower and if the following criteria are met: (i)the FM rating has been maintained at satisfactory level; and (ii)the submission ofat least three quarterly satisfactory FMRs that could be relied upon for purposes of disbursement. Detailed disbursement procedures will be described in the project accounting manual ofprocedures.
Minimum of Application Size. The minimum application size for direct payments, to be withdrawn directly from the Credit Account, and special commitments is 20 percent of the amount advanced to the related special account.
Use of Statements of Expenses (SOEs). Withdrawals are to be made on the basis of SOEs for the following cases: 0 Contracts for equipments and goods in an amount inferior to USD150,OOO; 0 Contracts for works in an amount inferior to USD200,OOO; 0 Contracts for consulting services, training by firms ofless than USD 100,000; 0 Contracts for consulting services, training by individual ofless than USDl00,OOO; 0 All incremental operating expenses; and 0 Miscellaneous training expenditures (ie., those not subject to contract) Special Accounts. To ensure that funds will be available when needed, two special accounts in USD will be established in a local commercial bank under conditions satisfactory to IDA. The special account A, in the amount of USDl.O million, will be opened in the name of the UGP,
56 whereas the special account B in the amount of USD1.25 million will be in the name of AGF. The amounts have been estimated to cover about four months of expenditures and would be withdrawn from the credit account after effectiveness.
The special accounts would be replenished on the basis of documentary evidence of payments required by IDA, made from the special accounts, eligible for financing under IDA Credit. All SOEs supporting documentation will be kept by the executing agencies and made available for review by bank supervision missions and external auditors.
Allocation of Credit Proceeds
I Amountin Financing
4. OPERATING COSTS 2.1 100% foreign UNALLOCATED 3.1
Total Project Costs 30.0
57 Annex 8: Procurement Arrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
A. General
Procurement for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004; and "Guidelines: Selection and Employment of Consultants by World Bank Borrowers'' dated May 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to be financed by the Credit, the different procurement methods or consultant selection methods, the need for pre- qualification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
Procurement of Works: Works procured under this project would include: the rehabilitation of VCT centers and incinerator construction. The procurement will be done using the Bank's Standard Bidding Documents (SBD) for all International Competitive Bidding (ICB) and National SBD agreed with or satisfactory to the Bank. Since no major works are expected for this Project, for contract estimated to cost less than USD200,OOO equivalent per contract, civil work procurement may be carried out through National Competitive Bidding (NCB) and contracts for small works, estimated to cost less than USD50,000, will be procured through quotations procedures. Nevertheless, for minor works to be procured under sub-projects, specific procedures details can be found in the Manual ofProcedures for the FAP (Annex 7).
Procurement of Goods: Goods procured under this project would include: print media furniture, reproduction of movies, fmiture for STI control, medical treatment for PLWHA, equipment for VCT centers, vehicles, office equipment, and IT and software. The procurement will be done using the Bank's SBD for all ICB and National SBD agreed with or satisfactory to the Bank. To the extent practicable, contracts shall be grouped into bid packages estimated to cost the equivalent ofUSDl50,OOO or more and would be procured through ICB procedures. For contract estimated to cost less than USD150,000 equivalent per contract, procurement of goods may be carried out through NCB procedures and purchase of small furniture estimated to cost less than USD30,OOO will be conducted through prudent shopping procedures. Vehicles, ARV and medical treatment may be procured from UN agencies. STI kits may be procured from SALAMA, Madagascar Central Purchasing Agency for Essential Medicines and Medical Material. SALAMA procurement procedures have been assessed by the Bank and found to be acceptable.
Procurement of non-consulting services: distribution of kits for CBOs, and TV and radio broadcast. The project will contract NGOs and TV and radio using Direct Contracting methods.
Selection of Consultants: technical assistance, training and workshops, operationalization of cinemobiles, films production, financial management agency (AGF), data collection and surveys, financial and technical audits, and capacity building. Short lists of consultants for services
58 estimated to cost less than USD100,OOO equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines if a minimum of three qualified ones are available. Wherever applicable, public training institutions such as INSPC and INSTAT, and NGOs may be hired for capacity building and surveys. Firms will be recruited on the basis of the Quality and Cost Based Selection (QCBS) method, using the Bank’s Standard Request for Proposals. Selection based on consultants’ qualifications (CQ) can be used for the recruitment of training institutions and for assignments that meet criteria set out in para. 3.7 of the Consultant Guidelines. Single source selection can be used to contract firms for assignment that meet criteria set out in para. 3.9 to 3.13 ofthe Consultant Guidelines and for contract which amount do not exceed USD100,OOO.
Operating Costs: The project will finance project management unit and regional office management salaries, incremental costs, CNLS salaries, and capacity building for project staff. All staff selection within this category shall be done according Section V of Consultant Guidelines.
Others: The Manual ofProcedures ofthe FAP will govern sub-project financing in high-risk and rion high-risk communes.
The procurement procedures and SBDs to be used for each procurement method, as well as model contracts for works and goods procured, are presented in the Project Implementation Manual
B. Assessment of the agency’s capacity to implement procurement
Procurement activities will be carried out by the UGP which includes a Procurement Officer and a Procurement Assistant. An assessment of the capacity of the UGP to implement procurement actions for the project has been carried out by Sylvain Rambeloson (Sr. Procurement Specialist) in April 2005. The assessment reviewed the organizational structure for implementing the project and the interaction between the project’s Procurement Officer and the Ministry’s relevant central unit for administration and finance.
The key issues and risks concerning procurement for implementation ofthe project have been identified and include the phasing of activities to be undertaken and possible emerging of emergency cases. The corrective measures which have been agreed are the close follow-up ofthe agreed procurement plan and activity scheduling. A procurement action plan will be fine-tuned quarterly and the main procurement plan will be up-dated accordingly.
The overall project risk for procurement is Average.
C. Procurement Plan
The Borrower, at appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan has been agreed between the Borrower and the Project Team on May 23, 2005 and is available at UGP. It will also be available in the project’s database and in the Bank’s external website. The Procurement Plan will
59 be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.
D. Frequency of Procurement Supervision
In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the Implementing Agency has recommended annual supervision missions to visit the field to carry out post review ofprocurement actions.
E. Details of the Procurement Arrangements Involving International Competition
1. Goods, Works, and Non Consulting Services
(a) List ofcontract packages to be procured following ICB and direct contracting:
1 2 13 4 5 6 9
Ref. Contract Estimated Procurement P- Domestic Expected Comments No. (Description) Method Preference by Bank Bid- cost Q (yes/no) (Prior / Post) Opening
I.3.3.1 Billboard 144,000 Direct No No Prior Oct 07 production contracting
installation t.1.1 Social 1,400,000 ICB No No Prior Feb 06 0.35KUSD marketing of per year for STI treatment four years luts (purchase
distribution) - L2.1 Medical Direct No No Progressive treatment for 990,100 contracting and w/UN PLWHA - agencies L3.1 Incinerator 250,000 Direct No No Construction Contracting - 5.1.3.1 Vehicles Direct No No IAPSO gL 175,000 contracting 5.3.2.1
(b) ICB contracts estimated to cost above USD200,OOO for works and USD150,OOO for goods per contract and all direct contracting will be subject to prior review by the Bank.
60 2. Consulting Services
(a) List ofconsulting assignments with short-list ofinternational firms.
1 2 13 14 15 5 7
Ref. No. Description of Estimate Selection Review Expected Comments Assignment d Method by Bank Proposals cost (Prior I Submission Date 1.32 Production ofradio To be hecontract programming determined with phases (programs, spots and :client flashes) satisfaction) 3.1.1 Agence de Gestion 663,000 QCBS Prior Dec 05 The actual Financiere 4GF will 3perate to Jun 36
3.1.2 Organization____ of 1,084,0001 QCBS Prior Sept 05 Annual facilitation 1 1 4.1.2 LQAS baseline, mid- 588,000 CQS/QCBS Prior Feb 06 point and final surveys, analysis and dissemination 4.1.3.1 Technical audit 92,000 IC Prior JulO5 I 4.2.1 ImDact studies (TBD) I 500.000 I OCBS I Prior Oct 05 4.3.2.1 HIV/AIDS Prior To be Year 1 will be Epidemiological IC determined covered by Situation report I 5.4.1 Financial Audit 104,600 LCS Prior Dec 05 5.4.2 CNLS capacity 105,000 CQS Prior Feb 06 building and workshop on M&E data use I (b) Consultancy services estimated to cost above USD 100,000 per contract and single source selection of consultants (firms) and for individual consultants assignments estimated to cost above USD50,OOO will be subject to prior review by the Bank.
(c) Short lists composed entirely of national consultants: Short lists of consultants for services estimated to cost less than USD100,OOO equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.
61 Annex 9: Safeguard Policy Issues MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
The project is rated as category B. The Borrower has demonstrated the capacity to properly develop and implement a medical waste management plan (MWMP). The MWMP is the only safeguard-related study required for this project.
A MWMP was developed for the MSPP, approved and has been implemented since May 2004. It was disclosed under the MSPPII prior to project appraisal, in-country and in the Infoshop. The existing MWMP includes proper disposal of hazardous bio-medical waste and a bio-safety training program for the staff of all hospital, health centers and community-based programs, including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and treatment.
Under the MSPP, three different agencies were responsible for, respectively: (i)ensuring development and implementation of the MWMP; (ii)implementing the plan; and (iii) supervising implementation ofthe plan at the provincial and district levels.
Ensuring development and implementation of the plan. The UGP has been responsible for ensuring development and implementation of the MWMP. The UGP has satisfactorily hlfilled this role, supervising implementation of the MWMP according to the agreed-upon calendar and undertaking additional activities in support of implementation of the plan (national kick-off ceremony, annual evaluations ofthe plan).
Implementing theplan. The MoHhas been responsible for implementation ofthe MWMP, and has demonstrated capacity to properly implement the plan. Since May 2004, the MoH has installed 200 small-scale bumers to bum medical wastes. in all 200 health centers rehabilitated under the CRESANII Project. Recent supervision found that burners are being used at the CHD of Ankazobe, Antanifotsy and Faratsiho. The construction of full incinerators at district level is underway, and some of them should be functional by June 2005. The Plan also includes specific medical waste disposal and management actions, to be carried out in Madagascar’s different types of health facilities. The MoH has demonstrated the ability to plan for and prepare these activities, as well.
Supervising implementation of theplan: The Office for the Environment ofthe Ministry ofthe Environment (MINENV) has been responsible for supervising its implementation at the provincial and district level. It has performed this role satisfactorily.
62 Annex 10: Project Preparation and Supervision MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Planned Actual PCN review 0 1/ 12/05 0 111 2/05 Initial PID to PIC 02/01/05 0210 1/05 Initial ISDS to PIC 03/07/05 03/07/05 Appraisal 05/06/05 0 3114/05 Negotiations 0 512 3IO 5 06/02/2004 BoardRVP approval 07/07/07 Planned date ofeffectiveness 10118/05 Planned date of mid-term review 07/07/07
Key institutions responsible for preparation ofthe project: - in Government : CNLS, MSPP UGP, Ministry ofHealth - Donor partners included: UNICEF, and USAID
Bank staff and consultants who worked on the project included:
____ Name Title Unit Nadine Poupart Sr. Economist, TTL AFTH3 Jean-Pierre Manshande Sr. Health Specialist AFTH3 Hope Neighbor ET Consultant AFTH3 Mead Over Lead Health Economist DECRG Joseph Valadez Sr. Monitoring and Evaluation Specialist HDNGA Nancy Lemay Monitoring USAID Michele Tarsilla Consultant AFTH3 Anne-Claire Haye Consultant AFTH3 Peter Bachrach Consultant AFTH3 Etienne Poirot Orphans and vulnerable children UNICEF Diane Coury Orphans and vulnerable children UNICEF Farellia Venance Tahina Communication UNICEF Manuella Varasso Communication UNICEF Gervais Rakotoarimanana Sr. Financial Management Specialist AFTFM Sylvain Rambeloson Sr. Procurement SpeciaIist AFTPC Hisham A. Abdo Kahin ET Consultant LEGAF Sameena Dost Counsel LEGAF Michael Fowler Sr. Finance Officer LOAG2 Maryanne Sharp Operations Officer AFTH3 Astania Kamau Team Assistant AFTH3 Andrianina Nor0 Rafamatanantsoa Team Assistant AFTH3 Joan MacNeil Sr. HIVIAIDS Specialist & Peer Reviewer HDNGA John May Sr. Population Specialist & Peer Reviewer AFTH2
Patricio~ Marauez Lead Health Specialist & Peer Reviewer ECSHD
63 Bank funds expended to date on project preparation:
1. Bank resources: USD95,OOO 2. Trust funds: USDO 3. Total: USD95,OOO
Estimated Approval and Supervision costs:
1. Remaining costs to approval: USD30,OOO 2. Estimated annual supervision cost: USDl80,OOO
64 Annex 11: Documents in the Project File MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
In addition to the documents mentioned in the PAD ofthe original project, the following documents are available in the project file:
A. Project Documents Manuel d 'exe'cution du Projet, Septembre 2002 e Manuel de proce'dures pour le financement des organismes communautaires de base, DCcembre 2003 e Vers une compe'tence locale en matiBre de VIH/SIDA :Les Principes Gkne'raux, 2004 . Vers une compktence locale en matikre de VIH/SIDA : Guide pratique a 1 'usage des institutions et organismes chargks d 'appuyer les communes dans la Eutte contre le VIH/SID, Septembre 2004 Prbparer la rbponse locale face aux IST/VIH/SIDA Ci Madagascar, Madagascar, Octobre 2003 e c&feilleures pratiques )) pour la lutte contre les IST/VIH/SIDA et de'termination de leur niveau optimum par zone d 'intervention, Madagascar, Juin 2003
B. Bank Staff Assessments
BanWGovernment Aide Memoires: Mid-Term Review December 2004 Project Concept Note January 2005 Pre-Appraisal Mission March 2005
C. Other
Madagascar National HN/AIDS Strategies: Plan Stratkgique National de Lutte contre le VIH/SIDA 2001 -2006, Madagascar 200 1 Politique nationale de prise en charge des personnes vivant avec le VIH/SIDA, Ministkre de la SantC, Madagascar, Mars 2003 Strate'gie Nationale de Communication face aux IST/VIH/SIDA, Madagascar 2004-2006 Mise en oeuvre de la Stratkgie Nationale de Communication face aux IST/VIH/SIDA, Pre'sidence de la Rkpublique, CNLS, 2004 Plans Stratkgiques Locaux des CLLS, USAID, Madagascar, Novembre 2004 Notes de prksentation sur le programme PTME relative aux besoins d 'extension des sites pour 1 'annbe 2004, Madagascar, Septembre 2004 Priorities for Local AIDS Control Efforts (PLACE), USAID, May 2004 Document de Programme Conjoint d'Appui a la Lutte contre le VIH/SIDA Ci Madagascar, Groupe Thkmatique Nations Unies pour le VWSIDA, Madagascar, Avril2005 Stratbgie Nationale de la PlaniJication du PrbsewatiJ; Madagascar,' DCcembre 2003
Madagascar HN/AIDS related studies and activities ofNGO and civil society e Etude sur les problkmes des relations sociales des personnes vivant avec le VIH/SIDA, Madagascar, Octobre 2002
65 Une se'rie d 'outils pour la facilitation de discussions participatives sur les IST curables et le VIHSIDA, International HIV/AIDS Alliance, Mai 2005 e Integrating Service Delivery and Behavior Change Communication to Improve Adolescent Reproductive Health in Madagascar, PSI Madagascar, Decembre 2004
National HIV/AIDS Surveys EnquZte De'mographique de Sante' 2003-2004, Madagascar, Avril2005 Enqukte de Surveillance Comportementale sur les Camionneurs h Madagascar, Madagascar 2004 EnquZte de Surveillance Comportementale sur les Travailleuses du Sexe a Madagascar, Madagascar 2004 e EnquZte de Surveillance Comportementale sur les Jeunes h Madagascar, Madagascar 2004 e Enqukte de Surveillance Comportementale sur Ies Militaires h Madagascar, Madagascar 2004 Annuaire des Statistiques du Secteur Sa&, Ministhe de la Sant6 de Madagascar 2002
General Documents Assessing Community Health Programs: Using LQAS for baseline surveys and regular monitoring, USAID January 2003 Activite's PTME re'alise'es au niveau des formations sanitaires, Ministere de la Sante, Madagascar, Mars 2005 Access des Personnes vivant avec l'infection h VIH/SIDA aux ARV h Madagascar, Madagascar, Fevrier 2005 The Guttmacher Report on Public Policy : A policy Analysis for the ABC Approach to HIV Prevention, Washington DC, December 2003 Guide pour la prise en charge de l'infection h VIH chez 1 'adulte et l'enfant h Madagascar, Ministbre de la Sant6, 2004 AIDS in Africa: Three Scenarios to 2025, UNAIDS, March 2005 Madagascar: epidemiological fact sheets on HIV/AIDS and sexually transmitted infections, UNAIDS, September 2004 Report on the Global AIDSpandemic, UNAIDS, 2004 Reaching out to African Orphans, A framework for public action, African Region Human Development Series, World Bank 2004
66 Annex 12: Statement of Loans and Credits MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Difference between expected and actual Original Amount in USD Millions disbursements
ProjectID FY Purpose IBRD IDA SF GEF Cancel. Undisb. Orig. Frm. Rev’d
PO74236 2004 MG-GEF Environment Program 3 (FY04) 0.00 0.00 0.00 9.00 0.00 8.70 0.83 0.00 PO74448 2004 MG-Govemance & Inst Dev TAL (FY04) 0.00 30.00 0.00 0.00 0.00 29.84 3.21 0.00 PO74235 2004 MG-Environment Program 3 (FY04) 0.00 0.00 0.00 0.00 0.00 37.92 -0.98 0.00 PO82806 2004 MG-Transport Infrastr Invest Pi(FY04) 0.00 150.00 0.00 0.00 0.00 146.71 27.96 0.00 PO73689 2003 MG-Rural Transport APL 2 (FY03) 0.00 80.00 0.00 0.00 0.00 61.39 -1.27 0.00 PO76245 2003 MINERAL RESOURCES GOVERNANCE 0.00 32.00 0.00 0.00 0.00 28.39 0.38 0.00 PROJECT PO72 160 2002 MG- PSD 2 0.00 23.80 0.00 0.00 0.00 19.48 9.20 0.00 PO72987 2002 MG-MultiSec STI/HIV/AIDS Prev APL 0.00 20.00 0.00 0.00 0.00 10.49 -5.95 0.00 (FY02) PO55166 2001 MG-Community Development Fund SIL 0.00 110.00 0.00 0.00 0.00 37.41 -74.04 -23.15 (FYOl) PO51922 2001 MG-Rural Development Support SIL 0.00 89.05 0.00 0.00 0.00 64.42 -38.47 -6.08 (FYOl) PO51741 2000 2nd Health Sector Support 0.00 40.00 0.00 0.00 0.00 6.72 0.03 0.00 PO52208 2000 MGTransp Sector Reform & Rehab 0.00 65.00 0.00 0.00 0.00 9.63 4.55 0.00 PO52186 1999 MICRO FINANCE 0.00 16.40 0.00 0.00 0.00 5.30 4.22 0.00 PO0 1559 1998 Educ. Sector Dev. 0.00 65.00 0.00 0.00 0.00 7.48 6.27 0.16 PO01564 1998 RURAL WATER SEC.PIL0 0.00 17.30 0.00 0.00 0.00 6.05 5.46 0.00 PO01568 1998 2nd Community Nutrition 0.00 27.60 0.00 0.00 0.00 6.89 -3.92 0.00 PO48697 1997 URBAN INFRASTRUCTURE 0.00 35.00 0.00 0.00 0.00 3.44 3.06 3.16 PO01533 1996 MG-Energy Sec Dev Prj (FY05) 0.00 46.00 0.00 0.00 0.00 6.95 9.69 9.68 Total: 0.00 847.15 0.00 9.00 0.00 497.21 - 49.77 - 16.23
MADAGASCAR STATEMENT OF IFC’s Held and Disbursed Portfolio In Millions ofUS Dollars
Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic. Loan Equity Quasi Partic. 1997 AEF GHM 0.73 0.00 0.00 0.00 0.73 0.00 0.00 0.00 1995 AEF Karibotel 0.20 0.00 0.00 0.00 0.20 0.00 0.00 0.00 1992 Aqualma 0.00 0.61 0.00 0.00 0.00 0.61 0.00 0.00 1991 BNI 0.00 2.61 0.00 0.00 0.00 2.61 0.00 0.00 2000 BOA-M 0.00 0.82 0.77 0.00 0.00 0.82 0.77 0.00 2004 Cottonline 5.00 0.00 0.00 0.00 1SO 0.00 0.00 0.00 1983189 Nossi-Be 0.00 0.14 0.00 0.00 0.00 0.14 0.00 0.00 Total portfolio: 5.93 4.18 0.77 0.00 2.43 4.1 8 0.77 0.00
67 ~ Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic 2004 BP Madagascar 0.00 0.00 0.00 0.00 2001 Besalampy 0.02 0.00 0.00 0.00 2001 COTONA 111 0.01 0.00 0.00 0.00 2004 LGA 0.01 0.00 0.00 0.00 Total pending commitment: 0.04 0.00 0.00 0.00
68 Annex 13: Country at a Glance MADAGASCAR SECOND MULTISECTORAL STI/HIV/AIDS PREVENTIONPROJECT Sub- POVERTY and SOCIAL Saharan Low- Madagascar Africa income Development diamond' 2003 Population, mid-year (mi//ions) 6.9 703 2,30 Life expectancy GNI per capita (Atlas method, US$) 290 490 450 GNI (Atlas method, US$ billions) 4.9 347 1038 - Average annual growth, 1997-03 Population (%$ 3.0 2.3 19 Laborforce(%) 3.2 2.4 2.3 GNI Gross per primary Most recent estimate (latest year available, 1997-03) capita nrollment Poverty (% of population below nationalpo verty line) 71 ' /' Urban population (%of total population) 27 36 30 Life expectancyat birth (years) 55 46 58 1 Infant mortality(per 1,OOOlive births) 84 a3 82 Child malnutrition (%of children under5) 33 44 Access to improvedwater source Access to an improvedwtersource (%ofpopulation) 47 58 75 Illiteracy(%ofpopu/ation age 159 35 39 Gross primaryenrollment (%of school-age population) 04 87 92 -(-Madagascar Male 06 94 99 - Low-income group Female 02 80 85
KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1983 1993 2002 2003 Economic ratios* GDP (US$ billions) 3.5 3.4 4.4 5.5 Gross domestic investmentlGDP 8.4 114 14.3 n.9 I Exports of goods and services/GDP 0.6 15.3 16.0 215 Gross domestic savings/GDP 14 2.1 7.7 7.8 Gross national savings/GDP -14 3.6 8.4 119 Current account balancelGDP -7.1 -7.4 -6.2 -6.0 Interest paymentslGDP 0.9 0.8 0.7 16 Total debt/GDP 58.1 tT2.9 02.7 83.8 Total debt serviceiexports 20.9 Q.3 9.6 Q .O Present valueof debWGDP 318 43 A Present value of debtlexports 184.8 2002 Indebtedness 1983-93 1993.03 2002 2003 2003-07 (average annual groMh) -Madagascar GDP 14 2.5 -Q.7 9.8 6 .7 GDP oercaoita -13 -0.5 -15.2 6.8 4.1 Lowincome group
STRUCTURE of the ECONOMY 1983 1993 2002 2003 (%of GDP) Agriculture 35.8 28.7 317 29.2 Industry 13.5 119 14.4 15.4 I Manufacturing .. 9.9 Q.5 13.7 Services 50.7 59.4 53.8 55.4 Private consumption 69.0 90.0 84.1 83.0 General government consumption 9.6 7.9 8.2 9.2 Imports of goods and services V.5 24.6 22.6 316
1983-93 1993-03 2002 2003 Growth of exports and imports (%) (average annualgrovdh) Agriculture 2.5 19 -16 13 Industry 2.1 2.4 -20.8 14.5 P Manufacturing 0.5 2.9 -18.3 P.8 50 Services 11 2.9 -15.4 9.5 0 Private consumption 0.3 2.9 -6.9 8.6 -50 3 General government consumption -0.3 2 .7 -13.5 28.8 -100 5.1 7.1 -314 57.2 Gross domestic investment -*--Exports --O--lrrQOrtS imports of goods and services -0.8 7.6 -310 129.8
69 PRICES and GOVERNMENT FINANCE 1983 1993 2002 2003 Inflation (%) Domestic prices 1 (%change) I2020 Tj I Consumer prices 9.2 15.8 -0.8 15 Implicit GDP deflator 2 15 P.1 25.3 2.8 10 Government finance 5 (%of GDP, includes current grants) 0 Current revenue 116 8.8 13.1 -5 Current budget balance -16 -15 17 Overall surplus/deficit -0.1 -6.8 -6.5 I ----GDPdeilator -e-CPI I
TRADE 1983 1993 2002 2003 Export and import levels (US$ mill.) (US$ millions) Total exports (fob) 30 332 499 852 1,500 T Coffee 113 40 3 4 Vanilla 62 34 PO 85 Manufactures I75 227 551 Total imports (cif) 4% 599 729 1,300 Food 73 51 61 16 Fuel and energy 98 85 217 184 Capital goods 90 140 92 217 97 98 99 00 01 02 Export price index (895-WO) 90 77 02 09 Import price index(895=WO) 89 92 113 %ports Q lTQ0rtS O3 Terms of trade (895=x]O) 87 ni 96 I
BALANCE of PAYMENTS 1983 1993 2002 2003 Current account balance to GDP (Oh) (US$ millions) Exports of goods and services 368 56 730 1l71 Imports of goods and services 509 86 1029 1,720 Resource balance -121 -300 -299 -549 Net income -118 -134 -71 -80 Net current transfers -0 184 99 302 Current account balance -249 -250 -272 -327 Financing items (net) 228 270 218 344 Changes in net reserves 21 -20 53 -n Memo: Reserves including gold (US$ millions) 81 363 397 Conversion rate (DEC, /oca//US$j 430.4 2914.3 6.832.0 6.816
EXTERNAL DEBT and RESOURCE FLOWS 1983 1993 2002 2003 (US$ millions) Composition of 2003 debt (US$ mill.) Total debt outstanding and disbursed 2,04 1 3,805 4,518 4,590 IBRD 30 l7 0 0 G 231 IDA 223 932 1,652 1,804 Total debt service 83 78 73 142 IBRD 3 4 0 0 IDA 2 12 6 34 Compositionof net resourcefiows Official grants 77 257 66 Official credit0 rs 218 97 149 P8 Private creditors 74 -8 0 -8 Foreign direct investment 4 15 8 Portfolio equity 0 0 0 World Bank program Commitments 62 85 130 222 4 - IBRD E- Bilateral Disbursements 37 47 63 174 3-IDA D-Otkmltilatetal F-Rivate Principal repayments 2 8 6 22 3-IMF G- Shart-term
70 Additional Annex 14: Detailed Monitoring and Evaluation Arrangements MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
Subcomponent 4.1 Monitoring
The MSPPII Monitoring and Evaluation (M&E) subcomponent will ensure that the national M&E system used by all donors is in place and operational. The subcomponent will finance the following five activities: (i)a set ofproposed indicators to measure project performance and to track the epidemiology ofthe virus; (ii)introduction of LQAS to collect a subset ofthe project’s key performance indicators; (iii)revision of the project’s MIS to effectively organize indicators ofoutput, outcome and impact as well as financial, input and operational data; (iv) monitoring of sub-project quality; and (v) reporting and use ofmonitoring data.
Proposed indicators. The proposed MSPPII indicators include several of the performance indicators used during the MSPP project (Annex 1). The other indicators from the original project were dropped because they were either inappropriate, or data was not available. All proposed outcome indicators for MSPPII are aligned with the national M&E plan and with indicators used in primary data sources to ensure that data will be available.
An important difference in the indicators proposed for MSPPII is that they provide a comprehensive picture of the outputs and outcomes associated with knowledge, attitude and behavior change in high-risk groups (commercial sex workers, truck drivers and miners) and in the population as a whole. The indicators also include indicators on youth (girls 10-14 years old and boydgirls 15-24 years old) and on risk groups, neither ofwhich were included in the MSPPI M&E plan. This change reflects the need to monitor HIV/AIDS knowledge, behavior and ultimately prevalence among the specific population groups where the epidemic is currently concentrated.
Lot Quality Assurance Sampling (LQAS). Under this sub-component, the MSPPII will support the collection of outcome and impact level, in part using LQAS methodology. According to the MSPPII intervention strategy, a limited number of at-risk areas will be selected where HIV transmission is suspected, or documented, to be high. These will be the priority intervention zones for the project where the project will measure outcomes using LQAS. Data will be collected at an aggregate level among intervention zones rather than at the commune level. Because MSPPII will provide a small amount of funding for general behavior change for communication activities in non target areas, a set ofthese communes will be selected as control areas for the measurement ofoutcomes. The control areas will be sampled to ensure that the data can be aggregated to represent the national catchments area. Data sources for all outcome indicators are displayed in Annex 1.
Management Information System (MIS). The MIS will build on the project’s existing MIS, which is in place at the UGP but not fully operational. There are two main problems with the project’s existing MIS system. The first is the process for collecting data to input to the system: regional data is collected by the AGF, which takes extensive time to verify data quality, and which then provides monthly, quarterly and annual reports to the project. The data collected by the AGF is outside ofthe MIS. The project M&E team then manually inputs the AGF data into
71 the UGP central MIS. This process is laborious and time-consuming. The second problem is that the MIS is not fully functional. While some parts of the system work individually, none are fully automated and the parts do not function together as a whole (see footnote).32 As a result, information does not flow effectively, there is incomplete data at the central level, and there are delays in producing reports.
A series of changes will be made to the MIS to allow it to function more effectively under the MSPPII. These include:
0 Dataflow. The MSPPII will correct the database problems in order to address most of the problems associated with the lack of full automation of the MIS and the lack of a single, functioning system. The MSPPII will also address related problems in data flow, including delays in submission ofdata (particularly the operational plan module) and inadequate use of data at all levels ofthe system. 0 Financial, input and Operational datu. The current MSPP project will finance strengthening ofits existing MIS to allow for a more detailed analysis of data below the province level, and to permit the consolidation of,all data at the MSPP central office. Through this process, the MIS sub-systems will be adapted to include the new project activities and indicators in MSPPII and to eliminate its duplication of the accounting system. The MIS will also be modified to include health center and VCT data to monitor access to HIV/AIDS services - acquisition ofthese data will be coordinated with the Global Fund. 0 Outcome and impact datu. The introduction of LQAS will allow the project to collect key outcome and impact data for its intervention areas. Use of LQAS will allow the MSPPII to rigorously collect these indicators at minimum cost. A separate database will be developed to hold outcome and impact level data33 that can be exported and merged with the existing MIS.
Monitoring of sub-project quaZity. Much effort is currently placed on monitoring the cost and completion of sub-project activities, but not much emphasis is placed on monitoring the quality ofthese activities.
At the most basic level, because most output data have not been entered in the system at the level of the MSPP, the MIS is currently used mainly to track inputs. In the MSPPII, the MSPP team will focus on using their output data to better manage the project. In addition, a technical M&E staff member will be hired and placed in eight of the regional offices to serve as an extension of the UGP M&E office. These staff will be responsible for: (i)verifying the accuracy of the data submitted by promoters and CBOs; (ii)monitoring the quality of subprojects through periodic site visits and formative supervision; and (iii)sharing relevant data with partners in the region.
32 The main issues are related to problems with the database design and functions and problems with the flow of information within the system. The MIS currently consists of four sub-systems: 1) sector plans - well designed subsystem with very little data because, except for the labor sector, sector plans have only recently been finalized; 2) sub-projects - data exist and are current at the central AGF but are not yet consolidated at the MSPP level due to numerous problems with the design of this subsystem; 3) program operations - this subsystem could work well except for problems assigning the correct timeframe to the annual operational plans; for now the M&E team performs systematic tracking of annual plans by hand; and 4) structures - detailed financial data are available on the AGF, NGOs, subproject technical review organism; the subsystem functions well except that the monetary unit is still in Fmg rather than Ariary. 33 Impact level indicators will be monitored based on epidemiological and behavioral data coming from other surveys.
72 Reporting and use of data. The M&E unit will ensure that monitoring data are routinely reported to the public and to partners of the HIV/AIDS program through regular dissemination workshops and distribution of trimester, 6six month and annual monitoring reports. Regional UGP M&E staff will be responsible for conducting regular (six monthly) sessions with regional coordination staff to promote the use of project output data for management decisions. To ensure that outcome and process data are used for decision making by the UGP, annual operational plans will be supported from data assembled from the MIS and associated databases. Similarly, MIS data will form the basis of quarterly and annual reviews of project activities and progress. Monitoring data will also be used in the annual “situation analysis” and policy recommendations, described in the following section.
Subcomponent 4.2 Epidemiological data collection special studies, and situation analysis
This sub-component includes two parts. The first is the project’s contribution to a second- generation surveillance system as well as other population-based surveys and large-scale studies; the second ,is the development of an annual “Results and Strategic Re-Orientations” report, which will compile data from the year’s surveys and make programmatic recommendations based upon analysis ofthat data.
Second generation surveillance; other population-based surveys and large-scale studies. Madagascar’s second generation surveillance system includes biannual behavioral surveillance surveys among high-risk groups (commercial sex workers, truck drivers, military, and youth) and the annual sentinel surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and commercial sex workers). Its population-based surveys and other large-scale studies include the cross-sectional HIV prevalence study (“Enquete Nationale de Sero- prevalance azipris des Femmes Enceintes”) first conducted in 2003, the DHS planned for 2008/2009, and the annual replication of the “PLACES” study, which maps high-risk sites and monitors risk behaviors in Madagascar’s at-risk communes. The MSPPII will finance a portion of each ofthese studies. The project will also support the inclusion of an HIV/AIDS module in the survey instruments of large scale surveys and studies undertaken by agencies external to the MSPP.34
Report on “Results and Strategic Re-orientations ”. This sub-component will also support the development of annual CNLS reports which will provide: (i)a consolidated technical analysis of data generated and studies carried out in the course of the year; and (ii)recommendations on policy re-directions based on the technical analysis. Each report will address the following issues: 1) estimates of HN and STI prevalence in Madagascar and their variation by age, sex, risk group, location and educational status; 2) best estimates and description of the trends in the prevalence data; 3) summary information from sub-component 4.1 MIS data and national MIS data on the intensity of prevention interventions in the identified risk groups; 4) a judgment regarding the success or lack ofsuccess ofprevention programs in the various demographic and
34 The first application of the MSPPiHIViAIDS module was included in the 2003/4 DHS. However, the questions proposed by CNLS and MSPP were not compatible with MacroDHS survey formats. It is strongly recommended that future auxiliary survey instruments and methodologies be reviewed in collaboration with Macro or other agencies specializing in large-scale surveys, and that they are complimentary to the main survey instead of overlapping with it.
73 risk groups and in the various parts of the country; and 5) implications for reorienting HIV/AIDS policy and programs.
The entire report, and in particular the last section, will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based on this analysis. The reports will then be disseminated to and discussed with development partners, with a view to implementation ofthe report’s recommendations.
Subcomponent 4.3 Impact studies
For the benefit of the national fight against HIV/AIDS, as well as for global knowledge creation, the MSPPII project will support one or more (pending the availability of fhding) impact studies. Theses studies will measure, for example, changes in HIV/AIDS prevalence and incidence, changes in AIDS related mortality, social norms, coping capacity in the community, or the economic impact. The study will be awarded only after technical review confirms that the study design has sufficient statistical power to test the study hypothesis.
74 Additional Annex 15: Supervision Plan MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project
General Supervision Strategy
The project will require intensive supervision. A budget ofUSD180,OOO is allocated to supervise the project during the first 12 months ofproject implementation. It is multisectoral, with multiple players operating at the national and decentralized levels. At the decentralized level, it will be implemented largely by many entities only recently established and whose capacity will need strengthening.
The skills required for supervision are varied, given the multisectoral nature of the project and the diversity of issues surrounding HIVIAIDS. It is, therefore, proposed to establish a core supervision team, enhanced by specialists and other inputs on an as needed basis. The core supervision team will be in the field twice a year and would rely on UNAIDS Thematic Group partners for supervision of activities during and between missions. A supervision mission would take, on average, three weeks, and include about five people.
Specialized inputs will be provided as required. Task team leaders of related sectoral projects (mostly education and health) will be asked to devote at least half a day during each of their supervision mission on the MSPPII.
At the same time, the core supervision team will rely heavily on the technical inputs and collaboration ofits partners in the UNAIDS Thematic group and the team may tap into UNAIDS expertise for the specialized inputs. Project progress reviews will be held annually to assess the performance of the project and its contribution to the national effort to reduce the spread and impact of HIV/AIDS. They will be held jointly with the Conseil du PMPS and the UNAIDS thematic group. M&E information and conclusions of site visits conducted by the supervision team will form the basis ofthe discussions.
Progress reviews would include a presentation by the UGP on progress attained, problems encountered, and hture steps. A progress report will be prepared for annual review attendees to be distributed at least one week prior to the meetings. The presentation will employ data derived from the project MIS and observations made during site visits. Other information available at the time, including studies conducted by the project or other donors will be employed to complement MIS data. Progress reviews will culminate in stakeholder meetings that will form a basis for re- planning for the next two years. These meetings will be used to share information on trends, best practices and to provide general technical information.
Given the key role that MoHactivities have on the success ofthe government's efforts to reduce the spread of HIVIAIDS, supervision missions will coordinate closely with the MoH's ongoing CRESANII Project.
Supervision Objectives
The core team will be primarily responsible for the review of: (i)quality ofproject management and implementation, and adherence to the procedures and implementation manuals; (ii) monitoring and evaluation results; (iii)financial management, including AGF performance,
75 procurement procedures, and technical and financial audits; (iv) spot-check quality, relevance and location of sub-projects financed under the Fund component; (v) adherence to ARV treatment and STI treatment guidelines; (v) adherence of health sector activities with health sector policy; and (vi) progress on NSP update, communication action plan, and sector strategies and action plans.
Supervision Requirements
Core team: The core team would consist of staff from the Washington office and from the country office. The following skills would be included: (i)task team leader; (ii)a health specialist; (iii)a procurement specialist; (iv) a financial management/private sector specialist; and (v) team counterpart in country. A health specialist based in the field will participate in missions, and will focus year-round on the collaboration with the MoH. During the first two years, a monitoring and evaluation specialist should be part ofthe core team.
For the first and second years, 24 Washington-based staff weeks and 18 country office staff weeks are planned for the core team; to be gradually reduced in the third and fourth year.
Enhanced specialists and additional support: The core team will be enhanced by other specialists on a needed basis and at the discretion of the task team leader. These specialists would be responsible for the following: (i)provide strategic support to the revision of the NSP; (ii)quality of communication activities as a whole; (iii)occasional in-depth review of particular subprojects focusing on specific target groups; and (iv) impact evaluations.
For the first year, seven Washington-based staff weeks and six country office staff weeks are planned on an ad-hoc basis. Collaboration will be sought with the team leaders of relevant sectoral projects to provide time on MSPP during each supervision mission in the field.
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MADAGASCAR
12° SECOND STI/HIV/AIDS PREVENTION PROJECT 12° ANTSIRANANA
PAVED ROADS ALL-WEATHER ROADS DIANA RAILROADS RIVERS Ambilobe Iharana SELECTED CITIES Mahavavy Vohimarina REGION CAPITALS
PROVINCE CAPITALS Ambanja NATIONAL CAPITAL ANTSIRANANA 14° REGION BOUNDARIES 14° PROVINCE BOUNDARIES SAVA Sambava Bealanana
Analalava Andapa Antsohihy Antalaha
SOFIA Befandriana Maroantsetra Boriziny Sofia MAHAJANGA Mandritsara MAHAJANGAAnjombony Mampikony 16° 16° Mitsinjo Marovoay Soalala Bemarivo
Mahajamba Mananara BOENY Ambato Boeni
Besalampy ANALANJIROFO Boinakely Tsaratanana Soanierana- Andilamena Ivongo Ambodifotatra Maevatanana
Vohitraivo Mozambique Betsiboka Kandreho Vavatenina MELAKY Andriamena Manambaho BETSIBOKA Fenoarivo-Atsinanana Amparafaravola Lake Ambatomainty Alaotra
Morafenobe Ambatondrazaka Channel Vohidiala 18° 18° Maintirano Bemahatazana ALAOTRA Ankazobe Mahavavy MANGORO Fenoarivo be TOAMASINA ANALAMANGA Fanandrana Anjozorobe BONGOLAVA TOAMASINA Antsalova ANTANANARIVO Tsiroanomandidy ANTANANARIVO Miarinarivo Perinet Ampasimanolotra Manja- kandriana Moramanga Manambolo ITASY ATSINANANA Andramasin
Faratsiho Anosibe Miandrivazo Vatomandry Belo Canal Tsiribihina Mandoto Antanambao-Manampotsy Antanifotsy Tsiribihina VAKINANKARATRA Mangoro Antsirabe 20° MENABE Mahanoro 20° Marolambo Morondava Mahabo Fandriana Morondava Malaimbandy AMORON' MANIA Ambatofinandrahana Ambositra Manandriana VATOVAVY Nosy Varika INDIAN FITOVINANI Vohilava
Ambohimahasoa Pangalanes Vohiparara Ikalamavony Alakamisin’ Manja Ambohimaha Mananjary FIANARANTSOA Ifanadiana Irondro OCEAN Beroroha HAUTE MATSIATRA Morombe Mangoky FIANARANTSOA Ambalavao 22° 22° TOLIARA IHOROMBE Ankarmena Ikongo Ankazoabo Manakara atm. Ihosy Vohipeno Ivohibe ATSIMO ANDREFANA Vondrozo Sakaraha Farafangana Iakora ATSIMO Fiherechana Betroka TOLIARA Benenitra ATSINANANA Vangaindrano Midongy-du-Sud Onilahy Betioky ANOSY Befotaka 50° 24° 24° TANZANIA 45° 50° Berakete Bekily COMOROS Antsiranana Manantenina Mayotte (Fr) E U Ampanihy Mandrave 15° IQ 15° B Mahajanga ANDROY M Amboasary- ZA O l Sud M e n n R a Toamasina Beloha Tolagnaro h A C C ANTANANARIVO S Ambovombe e 20° u A 20° Androy q Tsihombe i b G
m A Fianarantsoa a z D o
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M JUNE 2005 shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any KILOMETERS endorsement or acceptance of such boundaries. 25° 25°
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