Documentof The WorldBank FOROFFICIALUSEONLY ReportNo: 29049-AFR PROJECTAPPRAISALDOCUMENT ON PROPOSEDGRANTS TO BURKINA FASOOF SDR 12.5 MILLION(US$18.1MILLIONEQUIVALENT),GHANAOF SDR 10.3 MILLION(US$14.9MILLIONEQUIVALENT), MOZAMBIQUE OF SDR 14.4MILLION(US$20.8 MILLIONEQUIVALENT),THEUNITEDNATIONSECONOMICCOMMISSIONFORAFRICA OF SDR 1.4 MILLION(US$2.0MILLIONEQUIVALENT),AND THEWORLD HEALTH ORGANIZATIONOF SDR2.8 MILLION(US$4.6MILLIONEQUIVALENT) (TOTALAMOUNT SDR41.4MILLION(USD 60 MILLIONEQUIVALENT)) FORA REGIONALHIV/AIDSTREATMENTACCELERATIONPROGRAM May21,2004 contents maynot othenvisebe disclosedwithout World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective April 30,2004) Currency Unit = XOF (Burkina Faso) -GHC (Ghana) -MZM(Mozambique) XOF 549 = US$l- GHC 8925 =US$ 1-MZM23300 =US$ 1 US$1.45133 = SDRl FISCAL YEAR January 1-December 31 ABBREVIATIONS AND ACRONYMS AAS African Solidarity Association/ Oasis Center JICA Japanese Intemational CooperationAgency AIDS Acquired Immune Deficiency Syndrome LC Letter of Credit AIDSETI AIDS Empowermentand Treatment Intemational LIB Limited Intemational Bidding ALAVI Association Laafi La Viim M&E Monitoringand Evaluation ANC Ante-NatalClinic MAP Multi-Country HIVIAIDS Programfor Africa ARV Anti-RetroViral MOH Ministryof Health ART Anti-Retroviral Therapy MEDIMOC National Medical Supplies Agency-Mozambiq. BMC Budget ManagementCenter MISAUPEN MinistryofHealth's Strategic Planto Combat CAMEG Central MedicalStores-BurkinaFaso STIIHIVIAIDS, 2004-2008 -Mozambique CAS Country Assistance Strategy MOU Memorandumof Understanding CBO Community BasedOrganization MSF Doctorswithout Borders CCM Ministry's Advisory Council(Conselho Consultivo MTCT Mother-to-ChildTransmission do Ministro) NACP National AIDS Control Program - Ghana CHAG Christian Health Associationof Ghana NAIMA NGO AIDS ImpactMitigationAssociation CHGA Commission on HIViAIDS and Govemancein Africa NCB NationalCompetitive Bidding CHN National Hospital NGO Non-GovernmentalOrganization CICDoc Information and counselingcenter on HN/AIDS and 01 Opportunistic Infection tuberculosis PADS Health District SupportProgram - BurkinaFaso CIDA Canadian Intemational DevelopmentAgency PA1 PharmAccessIntemational CMAM PharmaceuticalDepartmentfor Drugsand Medical PAMAC Associational andCommunitySupport Program Supplies - Mozambique Burkina Faso CMLS NationalAIDS Committee -Burkina Faso PA-PMLS HNiAIDS PreventionProject CMLS/Sante Ministry of HealthAIDS CommissionBurkinaFaso PEF Private EnterpriseFoundation- Ghana CMS Central Medical Stores - Ghana PEN NationalStrategic Planto CombatHIViAIDS - CMSC SainteCamille Medical Centre Mozambique CNCS NationalCouncil to CombatHIV/AIDS -Mozambi. PLWHA People LivingWith HN/AIDS CNLS-IST NationalCouncil to CombatHNIAIDS and STIs PMTCTt PreventionofMother To Child Transmission and DAM Directorateof Medical Services Family Support DEE Departmentof Epidemiology PRSP PovertyReduction Strategic Paper DEP National HMIS - BurkinaFaso PSI Population ServicesIntemational DF DirectorateofFinance PU ProcurementUnit DilD Departmentfor Intemational Development - UK RAP RegionalMulti-disciplinary Advisory Panel DGPML Departmentof Pharmacy, Laboratoriesand Drugs of RCCC RegionalClinical Coordination subcommittee the Ministryo fHealth-Burkina Faso RENSIDA Network of 18 PLWHA organizations DNS National DirectorateofHealth RMS RegionalMedical Stores DPC DirectorateofPlanning and Cooperation QCBS Quality and Cost Based Selection DRH HumanResourcesDepartment-BurkinaFaso SBD StandardBidding Documents DSF Directoratefor Family Health-Burkina Faso sc SpecialCommitment EPP Epidemic Projection Package SP-CNLS NationalAIDS Council-BurkinaFaso ESTHER Solidarity network of therapeutic hospital care for SP/CNLS-IST PermanentSecretariatof the BurkinaAIDS Council HN/AIDS STD/STI Sexually TransmittedDisease/Sexually Transmitted EU EuropeanUnion Infection FDB Foodand Drugs Board - Ghana SWAP Sector Wide Approach FHI Family Health Intemational - USA TB Tuberculosis FMA Financial ManagementAgent TOR Terms of Reference FMR Financial MonitoringReport TOT Training o fTrainers GAC GhanaAIDS Commission TTL Task Team Leader GACOPI Office of Intemational Cooperation, Ministry of Health TWG TechnicalWorking Group on ARV Therapy GARFUND GhanaAIDS ResponseFund UNAIDS JointUnitedNations Programmeon HNIAIDS GFATM Global Fund to fight HIVIAIDS, Tuberculosisand Malaria UNDP UnitedNations DevelopmentProgram GHS GhanaHealth Services UNECA UnitedNations Economic Commissionfor Africa HAART Highly Active Anti-Retroviral Therapy UNGASS UnitedNations General Assembly SpecialSessionon HA1 HealthAlliance International HNiAIDS HBC Home-BasedCare UNICEF UnitedNations Children's' Fund HN HumanImmunodeficiency Virus UNFPA UnitedNations Population Fund HMIS Health Management InformationSystem UNV UnitedNationsVolunteer ICB Intemational Competitive Bidding USAID United States Agency for InternationalDevelopment IDA Intemational DevelopmentAssociation VCT Voluntary Counselingand Testing IP ImplementingPartner WFP World Food Program ITAC Intemational TreatmentAccess Coalition WHO World Health Organization JHPIEGO Intemationalpublic healthorganizationaffiliatedwith Johns Hopkins University - Vice President: Callisto E. Madavo Country ManagedDirector: Pamela Cox Sector Manager: Keith Hansen Task Team Leaders: MichaelAzefor and ElizabethLule FOROFFICIAL USEONLY AFRICA RegionalHIV/AIDS TreatmentAccelerationProject(TAP) CONTENTS A STRATEGICCONTEXTAND RATIONALE . ................................................................ 3 1.Country andsector issues.......................................................................................................................... 3 2.Rationale for Bank involvement ............................................................................................................... 7 3.Higher level objectives to which the project contributes.......................................................................... 7 B.. PROJECTDESCRIPTION ............................................. .......................................... 8 1.Lending instrument................................................................................................................................... 8 2.Project development objective and key indicators..................................................................................... 8 3.Project components................................................................................................................................... 9 4.Lessons leamedandreflected inthe project design................................................................................ 12 5.Altematives considered and reasons for rejection .................................................................................. 13 C IMPLEMENTATION . .............................................................................................. 13 1.Partnership arrangements............................... ..................................................................... 2.Institutional and implementation arrangements...................................................................................... 14 3.Monitoring and evaluation of outcomes/results ...................................................................................... 16 4.Sustainability........................................................................................................................................... 16 5.Critical risks and possible controversial aspects..... ....................................................... 6. Loadcredit conditions and covenants...................................................................... ..................... 18 D APPRAISAL SUMiMARY . .......................................................................................... 18 1.Economic and financial an .................................................................................................... 18 2. Technical............................ ..................... ........................................ .................................................................................................... ....................................................................................................................................... 21 5. Environment............................................................................................................................................ 22 6. Safeguardpolicies................................................................................................................................... 22 7. Policy Exceptions and Readiness ...................................... ........................................................... 22 ANNEXES Annex 1-A: Country and Sector or Program Background . Faso................................................. Burkina 23 Attachment to Annex 1-A: Implementation Partners inBurkina Faso....................................................... 35 Annex 1-B: Country and Sector or Program Background . ............................................................ Ghana 37 Attachment to Annex 1-B: Implementation Partners inGhana .................................................................. 52 Annex 1-C: Country and Sector or Program Background . ................................................. Mozambique 54 Attachment to Annex 1-C: Implementation Partners inMozambique........................................................ 67 Thisdocumenthas a restricteddistributionand may be used by recipients only in the performance of their official duties I t s contents may not be otherwise disclosed . without World Bank authorization . Annex l-D:Country and Sector or ProgramBackground. ........................................................ UNECA 72 Annex l-E: Country and Sector or ProgramBackground. WHO............................................................. 76 Annex 2: Major RelatedProjects Financedby IDA and/or other Agencies ............................................... 81 Annex 3: Results FrameworkandMonitoring............................................................................................ 85 Key Performance-Based Indicators ............................................................................................................ 91 Annex 4: Detailed ProjectDescription....................................................................................................... 92 Annex 5: Total Project Costs.................................................................................................................... 100 Annex 6: ImplementationArrangements .................................................................................................. 101 Annex 7: Financial Management and Disbursement Arrangements......................................................... 110 Annex 8: Procurement Arrangements ....................................................................................................... 129 Annex 9: Economic and FinancialAnalysis ............................................................................................. 139 Annex 10: Safeguard Policy Issues........................................................................................................... 141 Annex 1l:Project Preparation and Supervision ........................................................................................ 142 Annex 12: Documentsinthe Project File................................................................................................. 146 Annex 13: Statement of Loans and Credits .............................................................................................. 148 Annex 14: Countries at a Glance .............................................................................................................. 150 Burkina Faso............................................................................................................................................. 150 Ghana........................................................................................................................................................ 152 Mozambique ............................................................................................................................................. 154 MAPS Burluna Faso ....................................................................................................................... IBRDNo.32317 Ghana .................................................................................................................................. IBRDNo.26553 Mozambique ........................................................................................................................ IBRDNo.29996 Date: May 21, 2004 Team Leaders: MichaelAzefor and ElizabethLule Country Director: Pamela Cox Sectors: Other social services (40%), Health(60%) Themes: Other Sector Managermirector: KeithHansen communicable diseases(P), other social protection andrisk Project ID: PO82613 management (S), Gender (S) Lending instrument:IDA Grant Environmental screening category: B Safeguard screening category: B FinancingPlan(US$m.) Source Local Foreign Total RECIPIENTS Government o f BurkinaFaso 00.00 00.00 00.00 Government o f Ghana 00.57 00.00 00.57 Government o fMozambique 00.74 00.00 00.74 WHO 00.00 00.00 00.00 UNECA 00.22 00.00 00.22 IDA 34.05 25.95 60.00 Others 1. Total 35.58 25.95 61.53 BorrowerRecitient: Governments o f B la Faso. Ghana anc Mozambique. WHO andUNECA FY 2005 , 2006 2007 1 I I I Annual 119.87 23.53 I16.61 1 (incl. 3 countries &WHO. Cumulative '19.87 43.40 60.00 I Does the project depart from the CAS incontent or other significant 0 )Yes X N o respects?Ref: PADA.3 Does the project require any exceptions from Bankpolicies? Ref: PAD D.7 3 ) Y e s X N o Have these been approved by Bank management? 9)Yes X N o I s approval for any policy exception sought from the Board? 3 )Yes X N o 1 Does the project include any critical risks rated "substantial" or "high"? X Y e s oNo 2. Re$ PAD C.5 Does the project meet the Regional criteria for readiness for implementation? Ref: X Yes o No PAD D.7 Project development objective Re$ PAD B.2, TechnicalAnnex 3 The primary goal o f the TAP is to pilot strategies for strengthening each country's capacity to scaleup comprehensive programs providing care and treatment, whch i s effective, affordable, and equitable. It will pilot treatment systems which ensure that PLWHA and their immediate families benefit from care and treatment which has beendemonstrated to: (a) enable infected persons to live longer, healthier and more productive lives and to care for their dependents; (b) be effective inpreventing maternalto child HIV transmission and indecreasing the risk o f sexual transmission; and (c) diminishthe stigma ofHIV/AIDS. Project description [one-sentence summary of each component] Re$ PAD B.3.a, TechnicalAnnex 4 - Component 1: Testing approaches for scaling-up service delivery for HIV/AIDS care and treatment - ($38.82 million) (Burkina Faso $13.48 million; Ghana $9.86 million; and Mozambique $15.48 million) Component 2: Strengthening institutional capacity for HIV/AIDS care and treatment ($16.5 1 million) - (Burkina Faso $4.63 million; Ghana $5.72 million; andMozambique $6.16 million) Component 3: Facilitating regional learning from the TAP country experiences ($6.0 million) (WHO $4.0 million and UNECA $2.0 million) Which safeguard policies are triggered, ifany? Ref: PAD D.6, TechnicalAnnex I O The most important environmental issue for the TAP relates to medical waste management and as indicated by the paragraphs below, this issue has already beenresolvedby existing projects ineach country andTAP activities will be covered through those safeguards. Significant, non-standard conditions, if any, for: Ref: PAD C.7 Boardpresentation: June 17,2004 Grant effectiveness: September 15,2004 Covenants applicable to project implementation: - - Project OperationalManual (including fiduciary guidelines) would be completedby Effectiveness; Sub-grant Agreements satisfactory to IDA would be signedbetween each MOHand respective Ips as - agreed at negotiations before Grant Effectiveness; Opening o f Special Accounts before first disbursement. 2 A. Strategic context and rationale 1. Country andsector issues 1. Background. More than 50 millionAfricans have beeninfected byHIV since the start o f the epidemic, and three million people are newly infected each year. Through its impact on human capital, productivity, public services, and social cohesion, the epidemic represents the paramount threat to development on the continent. Within the past decade, however, a powerful new tool has emerged: HIV treatment with highly active antiretroviral drugs (ARVs). Inboth developed and developing countries, the use o f ARVs has reduced mortality by as much as 80 percent, prolonging the lives o f persons living with HIV and keeping them active members o f families, society, and the workforce. Yet despite these successes, the development o f simpler percent since 1996 - treatment coverage inAfrica remains negligible. Of the roughly 26 million drug regimens, and a dramatic reduction in cost - ARV drug prices have fallen more than 98 people living with HIV in Africa, an estimated four million have advanced to the stage where ARVs are necessary to forestall (or reverse) the onset of AIDS. Only 100,000 have access to treatment. 2. Most developing countries have been reluctant to begin scaling up treatment. Little o f the money committed under IDA'SMulti-Country HIVIAIDS Program (MAP) for Africa, for instance, has been devoted to treatment thus far. To encourage greater attention to this issue, IDA, UNAIDS, the Global Fundto Fight AIDS, Tuberculosis and Malaria and major bilateral donors have recently committed to increasing treatment, and WHO has declared access to ARVs a global health emergency, setting a target of treating three million people in developing countries by the end o f 2005'. Ultimately, achieving universal coverage will require addressing the chronic weaknesses that beset health systems, particularly inAfrica. But accelerating access to treatment needs to begin now to accumulate enough lessons o f experience so that subsequent scaling up can proceed effectively and quickly. Deferring treatment expansion until all conditions are optimal would result in countless unnecessary deaths, and would also encourage the development o f an unregulated market in contraband and counterfeit ARV drugs, which would have serious consequences on HIV drugresistance andpublic health. 3. In support of these overall goals and the "3 by 5" objectives in particular, three pilot countries (Burkina Faso, Ghana, and Mozambique) have agreed to participate in the proposed Treatment Acceleration Program (TAP) to pilot the feasibility o f scaling up existing treatment initiatives. The countries were selected based on the existence o f promising ongoing treatment activities andto include a representative variety o f systems and epidemiologic conditions. While the three participating countries do not present the entire range o f potential characteristics for accelerating treatment, they offer suitably different contexts for: (a) assisting governments and their NGO/private sector partners to refine national treatment policy and adapt WHO-approved treatment protocols to country situations; (b) supporting decentralized, cost-effective, and equitable treatment activities managed by NGOs and other private sector partners; and (c) learning important lessons for scaling up treatment programs in other countries. TAP would offer these countries a flexible financing instrument to strengthen the evolving institutional relationships for providing care. 'The"3 by 5" Initiative, 3 4. The Region originally explored usingMAP operations directly to achieve these ends, but determined that a short-term, complementary and nested instrument would be necessary. Countries have thus far chosen to commit the vast majority o f MAP resources to prevention, care, and support. As these foundations provide essential underpinnings for treatment and have been chronically under funded, it would be counterproductive to divert resources away from them. In addition, countries remain hesitant to embark on widespread public sector treatment with MAP (and other donor) support until more is known about how programs can be safely scaled up. This underscored the importance o f designing a learning-based initiative focused on treatment. Such an initiative might have been possible by promoting separate MAP-supported undertakings in several countries. But this would have taken longer and made it far more difficult to ensure comparability o f results. Accordingly, the Region concluded that the public goods aspect o f this work would best be achieved through an integrated, synchronized, inter- country program that could ensure consistent methods and simultaneous results, as well as facilitating regional learning by doing. This would also enable the formal, funded involvement o f WHO in the program, which is essential to ensure technical standards and region-wide application o f lessons learned. MAP resources will be used, however, to: (a) mobilize communities to reduce stigma around HIV counseling and testing, (b) create community awareness regarding treatment, and (c) develop support services for those tested for HIV and/or on treatment. Thus TAP would serve as a nested experimental initiative with some o f its activities already integratedwithin MAP, while others would be progressively mainstreamedinto MAPSas knowledgeis gained. 5. Key strategic elements. Each o f the proposed TAP countries has approved a Poverty Reduction Strategy Program (PRSP) acceptable to IDA and a Country Assistance Strategy (CAS) emphasizing the importance o f preventing the spread o f HIVIAIDS and expanding care and treatment for persons living with HIV/AIDS (PLWHA). Each o f the countries: is currently implementing a national HIV/AIDS project supported by IDA under the MAP; has adopted a national HIV/AIDS policy or strategy to expand treatment o f PLWHA and to assist households and communities affected by the pandemic; and has applied for or received funds from the Global Fund. In addition, there are a handful o f treatment scale-up partnerships in other countries supported by other donors. TAP would therefore support the CAS objectives, complement existing MAP arrangements, coordinate with other treatment partnerships, and strengthen the countries' ability to absorb increasing amounts o f aid for treatment through the Global Fund, the PRSCs and other initiatives. 6. The TAP would be patient-centered, and meet the treatment needs o f PLWHA and their families. By using nongovernmental, private and community-based support activities, it would complement public sector-based treatment activities and provide a continuum o f care for the poor in urban and rural low-income settings. The program design has sought to help countries pilot various means o f scaling up treatment and leam lessons from the process that would be widely disseminated. The TAP would be used as a vehicle for refining roles andresponsibilities, rapidly developing appropriate and scientifically sound tools and mechanisms for scaling up treatment, and sharing lessons and results across countries. Individual country treatment programs would differ but would be mutuallyreinforcing as each country learns from the others. 7. The overall objective o f the TAP is to strengthen individual country capacity to provide comprehensive, quality care and treatment, which i s effective, affordable, and equitable for 4 PLWHA. TAP funds would primarily be: (a) channeled through sub-grants managed by NGOs or private sector entities working in partnership with the public sector; and (b) used to expand and strengthen a continuum o f care and treatment activities. In addition, TAP would support ministries o f health in building national capacity for efficient management o f HIV/AIDS treatment, particularly in regulating public/NGO/private partnerships, strengthening public hospitals serving as treatment referral centers, upgrading human resources, and monitoring program implementation. Finally, TAP would provide a framework for: (a) cross country learning by doing; (b) strengthening partnerships with WHO in design, implementation and evaluation; and (c) applying lessons leamed across a broader group o f countries to accelerate the scaling-up o f treatment programs usingMAPand other financing. 8. Specifically, TAP would strengthen the foundation for treatment and increase the number o f persons being treated through: (a) the development of services provided by associations o f PLWHA in Burkina Faso; (b) the extension o f company treatment benefits to include all members o f the surrounding communities in Ghana as well as by the associations o f PLWHA andNGOs; and (c) the expansion o f treatment services provided by international NGOs within public sector health facilities in Mozambique. TAP would ensure government oversight o f the treatment expansion process through its support for a National Treatment Committee established bythe Ministry o fHealth ineacho fthe pilot countries. 9. Key issues. Despite the positive clinical results o f many treatment pilot programs, coverage remains low because o f technical, political, and financial challenges. TAP preparation in each of the participating countries has addressed these challenges as the basis for strengthening country capacity to expand treatment. 10. Weaknesses of the health care delivery system. Several weaknesses limit the quality o f health care in the three countries. Facilities are ill equipped and poorly staffed, diagnostic services are rudimentary, supply chain systems are weak and operating budgets are inadequate. Government efforts to address these weaknesses are hampered by an acute shortage o f qualified health personnel and lack o f financial resources. In the three countries, governments have recognized these weaknesses, and have leveraged resources from NGOs, private sector and networks o f associations o f PLWHA to scale up comprehensive treatment. InBurkina Faso, the number o f health districts providing treatment services would increase from 10 to 20 (of 54); in Ghana the number o f districts would increase from 7 to 17 (of 140); and in Mozambique the number o f treatment facilities would increase from 60 to 200. Sufficient and optimal use o f humanresources is critical to the success o f expandingcare andtreatment. 11. Human Resources. The human resource crisis in the health sector has long been recognized as a major barrier to scaling HIV/AIDS programs. Consequently, TAP would support different approaches (both short and long term) to address the chronic shortage o f qualified personnel. In the short term, TAP would increase the range o f professionals and paraprofessionals by encouraging creative recruitment and incentives; explore the feasibility of developing a new cadre o f health workers trained over a short period o f time and build skills through training and pilot different skill mix. TAP is an opportunity to gain insight through operational research examining these unique humanresource models. With UNECA and WHO assistance, TAP countries will be supported in ongoing personnel planning and supervision for treatment. The TAP will provide data to enhance global dialogue on the health sector human 5 resource crisis and facilitate policy choices for addressing the acute shortage o f health personnel at the country and regional level. 12. Drug Availability. The persistent declines in the cost o f drugs, thanks to increasing availability o f generic versions; the pre-certification (by WHO) o f generic manufacturers and lower prices negotiated by the Clinton Foundation on behalf o f low income countries, with a number o f suppliers would help TAP countries, substantially reduce the shortage o f drugs, a constraint to comprehensive andquality care and treatment on a large scale. 13. Weaknesses in patient management and tracking. As TAP countries are poised to increase the number o f HIV/AIDS patients under treatment, clinical procedures and patient tracking systems need to be strengthened and improved to ensure proper monitoring for compliance. This is essential for identifying and dealing with potential resistance. Results from this collective learningwould enhance operational research and learning inHIV/AIDS treatment. Improved clinical patient management would help TAP countries ensure that the supply chain for drugs and medical supplies is strengthened to guarantee quality care and comprehensive treatment. WHO support in this area is provided for under the TAP and strong collaborative learning among the three countries would facilitate cross-country fertilization, which UNECA would facilitate. 14. Inadequate attention to issues of inclusion and gender equity. Although expansion o f treatment requires buildingthe capacity of additional partners to reach the affected families and communities, few countries have taken adequate advantage o f potential partnerships with the private sector, NGOs, faith based organizations, and associations o f people living with . HIV/AIDS. TAP preparation has involved National AIDS Councils, relevant government ministries, the medical professions, and groups o f PLWHA to promote a more collaborative approach. Participatory processes involving all stakeholders have been and would continue to be usedthroughout the process o f implementation, scaling up andmonitoringand evaluation. 15. In addition, TAP preparation has examined gender issues in view o f the fact that in Africa, nearly 60% o f PLWHA are women, and women aged 15-24 are 2.5 times more likely to be infected than men in the same age bracket. TAP would enhance women's access to prevention, care and treatment, primarily through V C T for women receiving antenatal care, prevention o f mother-to-child transmission (PMTCT) services, and, ifclinically eligible, through treatment for themselves, their infants and for their partners. The program would also address policy issues andprovide support inpolicy implementation. 16. Financial accessibility. The cost of HIV treatment is now crossing the threshold of economic viability, but has not yet reached the point o f individual affordability for most Africans, for whom drastically reduced anti-retroviral drugprices still constitute a major barrier. Only a small proportion o f the patients inparticipating countries will be able to afford treatment for some time to come. Until prices fall further, extemal hding (from IDA and others) will continue to play the predominant role in fbnding treatment for the poor. TAP will promote accessibility in this way, as well as by ensuring a larger and more reliable market for drug manufacturers and thereby inducing further price reductions. The April 2004 agreement by the World Bank, UNICEF and the Global Fund to support drug procurement at heavily discounted prices under agreements negotiatedby the Clinton Foundation represents a major step forward in this respect. 6 17. TAP funding would enable the Ministry o f Health to improve services at district and regional public hospitals. As drug costs continue to decline, improvements to quality o f treatment would play a key role in sustaining donor support in the medium to long term. This will lay the groundwork for sustainable scale-up o fnationwide programs. 2. Rationale for Bank involvement 18. There are three compelling reasons for IDA involvement. First, as AIDS is now the foremost threat to development in Africa, IDA support for treatment is an integral part o f its efforts to promote long-term economic and social progress. Both IDA's expertise in implementation and its experience in coordinating multiple partners are necessary to help countries address the systemic, structural, fiduciary, and logistical issues that proper treatment will require. No other entity possesses this full set o f attributes, and partners in AIDS- including the Global Fund-are depending on IDA to provide them. Second, IDA finance represents a crucial contribution to the global funding of HIV/AIDS efforts, which will depend on extemal resources for years to come. Third, scaling up HIV treatment would help protect IDA's existing portfolio inAfrica, inwhich investments inmultiple sectors are under threat from AIDS. The TAP would also strengthen MAP projects, by providing governments and others with the knowledge for effective use of MAP resources to increase treatment and sustain VCT activities. 3. Higher level objectives to which the project contributes 19. In the MAP, IDA has defined the development objective of dramatically increasing access to HIV/AIDS prevention, treatment, care and support in countries. Inparticular, MAP2 called for the scaling up o f anti-retroviral therapy (ART) in selected countries. The TAP was envisaged in the Ghana CAS No. 27838-GH o f February 20, 2004 (paragraph 97) and in the Mozambique CAS No. 26747-MOZ o f October 20, 2003 (paragraph 57). Although TAP preparation was initiated after the Board approved the Burkina Faso CAS No. 25458-BUR o f March 12, 2003, the TAP responds to the CAS option to choose ways o f increasing support through ARV therapy (paragraph 72). 20. The proposed TAP would fill a gap not yet addressed under the MAP by: (i) supporting innovativepartnerships to pilot treatment scale up; and (ii)providing the opportunity for regional information exchange and learning about the development o f treatment initiatives. The proposed TAP is entirely consistent with national HIV/AIDS programs finded through the MAP, the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), bilateral donors, other multinational agencies andthe government's own resources. By contributing to the development of essential elements for scaling up treatment, TAP would increase the pilot countries' ability to absorb significantly greater resources from such partners for treatment. 7 B. Project Description 1. Lendinginstrument 21. IDA proposes a three-year Regional HIV/AIDS Treatment Acceleration IDA Grant. Grant funds would be provided to recipient countries, which would pass significant parts on in the form o f sub-grants to NGO/associations and private company clinics to finance scale-up o f ongoing treatment activities and to drive a regional learning process on the lessons o f scaling up treatment. To address a potential risk o f the loss o f Implementing Partners, part of the Grant will fund district or regional public hospital service improvements to serve as referral facilities for Implementing Partners. NGOs, networks o f associations, faith-based and private company clinics already managing HIV/AIDS treatment programs in the three TAP countries submitted proposals which were evaluated on the basis o f TAP criteria spelled out during project preparation and agreed upon with Governments. These will be funded through sub-grant agreements between each Implementing Partner and the respective Ministry o f Health. Part o f the grant would fund specific MOH program oversight structures, support and coordination, monitoring and evaluation; activities to strengthen referral services to back-up selected private/NGO treatment centers funded under the TAP as well as measures to strengthen the learningframework for HIV/AIDS treatment. 22. The TAP would also finance the facilitation o f the TAP'Sregional learning process. This would include in-country technical support o f TAP activities by WHO and the cross-country consultation and learning through a multi-disciplinary Regional Advisory Panel (RAP) organized through UNECA. This cross-country learning facilitation would include support to operational research identified by the RAP on issues o f importance intreatment. WHO and UNECA would be grant recipients for these regional learning activities onbehalf o f the three TAP countries. 2. Projectdevelopmentobjectiveand key indicators 23. The primary goal o f the TAP is to pilot strategies for strengthening each country's capacity to scale up comprehensive programs providing care and treatment, which is effective, affordable, and equitable. It will pilot treatment systems which ensure that PLWHA and their immediate families benefit from care and treatment which has been demonstrated to: (a) enable infected persons to live longer, healthier and more productive lives and to care for their dependents; (b) be effective inpreventing maternal to child HIV transmission and in decreasing the risk o f sexual transmission; and (c) diminish the stigma o f HIV/AIDS. Thus, in addition to the lives that would be directly saved, households would also benefit by prolonging income, education, andnutrition andreducing the numbero f orphans. 24. Substantial benefits for the health sector would also result from the increased availability o f effective care and treatment, including: (i) reduced incidence o f opportunistic infections and associated lower medical costs; (ii) revitalized prevention efforts as antiretroviral therapy may serve as an incentive to implement more vigorous HIV prevention programs; (iii) strengthened capacity o f the health system to deliver comprehensive services; (iv) improved morale and reduced attrition in health services; and (v) increased experience with treatment which can be shared with other countries. 8 25. The implementing partners (Ips), inconjunction with MOH authorities, have established baseline information and targets; they would sign agreements indicating progress to be achieved andoutcomes to bemonitoredandbe evaluated regularly relative to the initialbaseline. 3. Project components 26. The proposed IDA Grant o f $60 millionwould finance a three-year HIV/AIDS Treatment Acceleration Program (TAP) to support national-level implementing partners (IPS) in Burkina Faso, Ghana, Mozambique, and the international facilitating partners WHO and UNECA, for the purpose o f implementing elements o f the program that would benefit IDA'Sless developed members. At the country level, TAP would: (i) scale up ongoing treatment programs through agreements with existing NGO andprivate sector service providers; and (ii) strengthen the health system's capacity for expandingtreatment through support to Ministries o f Health for improving infrastructural and logistical support and for managing the complex issues related to treatment in resource-limited settings. At the regional level, TAP would facilitate: (iii) in-country technical and clinical support through WHO to intensively monitor and evaluate country-level program experience and regional coordination and knowledge sharing through U N E C A to rapidly exchange and disseminate the lessons and implementation tools to other African countries involved intreatment. Component 1: Testing approachesfor scaling-up service delivery for HIV/AIDS care and treatment ($38.82 million) (Burkina Faso $13.48 million; Ghana $9.86 million; and Mozambique $15.48 million) 27. The TAP activities comprise: (a) piloting scaling up existing care andtreatment programs managed by selected ImplementingPartners to ensure the delivery o f the full continuum o f care,; and (b) piloting efforts to significantly increase the number o f patients needing care and treatment at different stages. The TAP would focus on five elements o f treatment: Voluntary Counseling and Testing (VCT); Home-Based Care (HBC); Prevention o f Opportunistic Infections (01); Anti-Retroviral Treatment (ART); and Prevention o f Mother to Child Transmission (PMTCT andPMTCT-Plus). 28. Voluntary Counselingand Testing(VCT). The quality o f VCT services for each o f the entry points for HIV-infected people (VCT centers, pre-natal care sites, STI and TB clinics, and hospital in-patient services) would be upgraded. This would include : (a) rehabilitation and expansion o f the number o f VCT and antenatal sites; (b) promotion o f greater demand for VCT services through local information campaigns and community meetings; and (c) improvement in the quality o ftesting and counseling services byprovidingtraining andlaboratory equipment and supplies. 29. Home-based patient care and family support. TAP would finance the training o f community counselors, home-based medical and psycho-social support, and nutritional education; where feasible, TAP preparation has attempted to coordinate treatment sites with food aid programs to ensure nutritional supplementation where appropriate, and would build the capacity o f associations as first line providers o f services intheir communities. 30. Treatment of opportunistic infections. Under TAP, prevention and treatment of opportunistic infections would be included as a standard element o f care. Treatment would be 9 expanded to district referral to secondary or tertiary health facilities, as it is expanded to community health centers and associations where innovative techniques facilitate the rational use o f existing resources, especially for case management. The organization o f appropriate ambulatory and referral services o f care would be strengthened. Increased training and use o f traditional healers in the referral system would be promoted. TAP would pilot formal relationshipsbetweenpublic hospitals and associations and community health centers. 31. ART. The provision o f ART by Implementing Partners would be in accordance with government approved guidelines and protocols within nationally structured patient monitoring and evaluation systems. 32. PMTCT and PMTCT-Plus. Training activities for birthattendants insimple practices to reduce PMTCT at birth, administration o f ARV at birthto the mother and the newborn baby, and the prevention o f transmission o f the virus through breastfeeding, would be financed and needed drugsto prevent mother to childtransmission would be provided. 33. PMTCT-Plus activities, which include: (a) family centered care linked to the local community; (b) continuity o f care drawing on a multi-disciplinary team o f providers, and long term retention o f patients; (c) psychosocial support, treatment o f STIs and depression; and (d) interventions to integrate treatment adherence with other programs such as family planning and reproductive health, would be funded. Component2: Strengthening institutional capacityfor HIWAIDS care and treatment ($16.51 million) (Burkina Faso $4.63 million; Ghana $5.72 million; and Mozambique $6.16 million) 34. To ensure effective public oversight o f the treatment scale-up process, TAP would: (i) strengthen the capacity o f the National Treatment Committee, established in each country by the Ministry o f Health, to provide technical guidance and quality control; (ii) coordinate program expansion through improved planning o f infrastructure, human resource development, and drug procurement; and (iii) monitor the accessibility, quality, and results o f treatment with particular attentionto the poor. 35. Strengthening the capacity of the National Treatment Committee. Each o f the pilot countries has established a National Treatment Committee. Among other responsibilities, these committees would: (a) refine national treatment policy and adapt WHO recommended treatment protocols to their individual situations; (b) assess and accredit the fiduciary and clinical qualifications o f institutions seeking to provide treatment and/or expand services; (c) review and approve progress reports (and potentially future proposals) submitted by the Implementing Partners; and (d) supervise the delivery o f treatment services. TAP would provide resources for the National Treatment Committee and working groups, and for the coordinating secretariats. TAP would finance selected activities related to national treatment policy, accreditation and approval o f providers, and program reporting and monitoring. It would also finance limited office equipment and transport as well as operational costs, including assistance for financial management, auditing, and monitoring and evaluation. 36. Coordination of program expansion. In each country, MOH would coordinate the implementation o f treatment scale-up initiatives, both in terms o f policy formulation and in the areas o f physical infrastructure, training needs, drugs logistics, and IP initiatives. TAP would 10 use existing MOH structures with experience in managing IDA funds (either through health projects or through the MAP). Implementingpartners would be responsible for coordinating their activities per their approved action plan (sub-grant proposals) among their member associations and report to the MOH. The drugs procurement and distribution agency would ensure a regular supply of ARVs and related supplies by coordinating its planning, procurement and logistics activities with the TAP coordination unit. WHO would support technical coordination of program activities in and among the TAP countries, and UNECA would support regional coordination oftreatment acceleration initiatives. 37. To facilitate the TAP coordination unit ineachcountry, the project would support regular stakeholder meetings and annual meetings involving the development partners. The Treatment Committee activities in each country, which would include programming, clinical and fiduciary reporting, regular supportive supervision and treatment center inspection, would be funded. The project coordination unit in the MOH will be supported with necessary human resources, equipmentandmaterials. 38. Monitor the quality and disseminate the results of treatment. While patient tracking methods in the TAP countries have been judged adequate for the current number o f PLWHA under treatment, systems for monitoring compliance, identifying potential resistance, and integrating the results into operational research and learning require improvement. The TAP would fund feasibility studies to determine the most appropriate patient tracking systems. Funds have also been allocated for equipment and technical support to increasenationalcapabilities for monitoring resistance. WHO would provide technical support indeveloping quality systems for patient tracking and assist TAP countries carry out operations researchusing TAP funds. Such research will include analysis o f equity o f access. At the country level, regular consultations between M O H and P s would: (a) review and evaluate progress and to address implementation difficulties, and (b) periodicallyrevise treatment guidelines andprotocols. Component 3: Facilitating regional learningfrom the TAP country experiences ($6.0 million) (WHO $4.0 million and UNECA$2.0 million) 39. To support in-country learning, TAP would fund WHO technical support activities, through its headquarters and regional offices, and within each MOH TAP unit: (i) refining and implementingtreatment guidelines and protocols; (ii) developing national standards, criteria and assessment tools for accrediting laboratories and treatment sites; and (iii) setting up quality assurance systems for drug procurement and testing. WHO would also provide additional technical assistance in: (i)developing curricula and pedagogical methods for the training of medical and paramedical staff; (ii) strengthening program monitoring and evaluation; and (iii) establishing methods for managing patient compliance and evaluating treatment outcomes and potential drugresistance. 40. To support cross-country learning, the TAP would establish a regional multi-disciplinary advisory panel (RAP) to promote the rapid incorporation of lessons from the TAP into MAP, Global Fund and other donor-fimded programs. RAP would meet at least semiannually; participants would include, inter alia, representatives from each TAP country; IDA; WHO- Geneva and WHO-AFRO; UNICEF; all PS;and other interested partners. UNECA would establish a Secretariat for the RAP and coordinate follow-up on recommended improvements from lessonsemergingfrom TAP countries. 11 41. UNECA, in cooperation with WHO and the World Bank, will facilitate regular consultation and learning among TAP countries. As the regional secretariat for the United Nations system and a source o f analysis, learning, and support for African implementation o f socio-economic policies, and as the host o f the Commission on HIV/AIDS and Governance in Africa (CHGA), UNECA would provide: (i)support on HIV/AIDS issues; (ii)access to important regional development statutory bodies; and (iii) organization and hosting o f regular multi-country expert meetings. A small TAP coordinating unit would be established within the CHGA to serve as the secretariat for the RAP and regional liaison for TAP activities in collaboration with WHO (HQGeneva, Regional WHO/AFRO and WHO country offices) and the country TAP Coordinators with regardto learning activities. Lessons learned from the TAP would be incorporated directly into the work o f the CHGA and other fora as well inAfrica. 42. The RAP would establish a regional clinical coordination sub-committee (RCCC) to work with the International Treatment Coalition (ITAC) and WHO to maintain regular review o f treatment regimens and protocols as lessons from country treatment programs are gathered and shared at the regional level. The RCCC would comprise clinical experts recognized for their work inHIV/AIDS treatment, to enable African countries to share experiences, to review clinical results, and to recommend policy reforms in participating countries. WHO would serve as the rapporteur o f the RCCC. The project would finance costs associated with the regular review and evaluation o f country results as well as for periodic workshops to exchange information and coordinate strategies for implementing lessons learned. 4. Lessons learned and reflectedinthe project design 43. Lessons learned both from previous pilot studies o f care and treatment and from the implementation o f MAP projects have been incorporated into the design o f TAP, particularly with respect to ARV treatment, which has had a dramatic impact in reducing mortality in resource limited settings. There are impressive results from Brazil, where universal access to treatment has reduced HIV-related mortality by 50% since 1996. Improvements insurvival rates have also been reportedfrom Mozambique, Haiti, South Africa and India. 44. Brazil has used public and private sector partners within its national health security system to provide universal care to all HIV/AIDS patients. Benefits have been recorded in increased health services funding, improved health care, and cost savings for companies and their employees. In Uganda, strong political leadership and community mobilization led to a substantial increase in patients receiving ARV therapy, while in Ghana, a district-level pilot provided an empirical basis for a structured scale-up plan. Further, evidence from Cote d'Ivoire's electricity corporation shows that the introduction o f comprehensive care and therapy for employees increased VCT five-fold, reduced absenteeism by 94% and decreased HIV/AIDS- related hospitalization by 81%. Preliminary results from other African, Caribbean and Asian countries have achieved outcomes for patients that compare favorably with those achieved by patients inmore developed countries. Inall cases, these positive results highlight the importance o f strengthening community-based adherence support systems. Careful and sustained patient monitoring has produced strong adherence and less drug resistance. Effective and careful preparation and counseling o f patients prior to starting treatment, funding essential elements o f treatment including the training o f family members to support patients, and building up community support, assures good results. 12 45. TAP preparations reviewed lessons learned from MAP operations inthe three countries with special focus on more efficient mechanisms for speeding up and tracking the use o f TAP funds and correcting constraints which initially slowed MAP disbursements and using recent improved MAP implementation procedures. 46. TAP would strengthen the functioning o f existing national treatment committees within MOHto build an effective institution for quality assurance, program supervision, monitoring and evaluation so that all complications and adherence problems are tackled early. To improve dialogue and collaboration between private and public sector service providers, association and community organization representatives would be formal members o f this treatment committee. TAP would strengthen management procedures, and would support efforts by the local associations and organizations to keep civil society advocates involved duringimplementation. 5. Alternatives consideredandreasonsfor rejection 47. Two options were considered for the design o f the program, each with different implications for the administrative costs, appropriate IDA grants, and for the speed o f disbursements. Using available MAP resources was considered, but for the reasons outlined above (see para. 4), this was found sub optimal. 48. Another option considered was to limit TAP to funding AltVs. For clinical efficiency and to ensure comprehensive treatment, the TAP opted for five elements o f treatment. This promotes patient participation in their own treatment, harnesses local health, community and international technical competencies to delay progression o f the virus to full-blown AIDS. In this context, TAP opted for public-private partnership, which involves and strengthens a broad spectrum o f co-producers in different treatment components, including centers o f excellence, NGOs, associations o f PLWHA, faith-based organizations, regional and district hospitals, traditional healers, midwives andbirthattendants, and the private sector. 49. The Global Environment Facility Medium Sized Grants, the Global Distance Learning Initiative, and the sub-regional IDA grant for combating H N / A I D S in the Abidjan-Lagos Transport Corridor were all considered, and elements o f each have been incorporated into the TAP design. C. IMPLEMENTATION 1. Partnershiparrangements 50. TAP implementation would involve three sets o f partners: the Government (represented by the Ministry o f Health), the implementing partners (IP), and international facilitators (IF- WHO and UNECA). In collaboration with MOH, the IPSwould deliver HIV/AIDS treatment outreach programs. The IPS would be local and/or international NGOs, working with communities, associations o f PLWHA, faith-based organizations, the private sector, and/or public/private partnerships. I F s have recognized competence in HIV/AIDS treatment coordination (WHO) and coordination o f inter-country learning (UNECA). IFs would use IDA funds for in-country technical support andcross-country activities. 13 51. Partnerships have been established in each country with a range of organizations to improve andexpand HIV/AIDS treatment, care, and support activities. Ineach country, IPSwere selected for the first phase of the TAP on the basis o f on-going treatment programs they manage. Additional IPSmay be added in future, in accordance with the guidelines established by the National Treatment Committee and with a no objection from IDA. The National Treatment Committee would review and approve fbture IP sub-grant requests, review regular reports, and monitor and evaluate the performance o fthe Lps. Initially identifiedIPSinclude: o BurkinaFaso: AIDSETIwith its network of 5 associationsofPLWHA; CICDOC with 4 other NGOs; andSt Camille; o Ghana: PEF/PAIinassociationwith 10-15private companies; o Mozambique: ComunitAdi St. Egidio, HealthAlliance International, and Pathfinder International. 52. Roles, responsibilities and collaborative mechanisms among the IFs were finalized at negotiations, and it is envisagedthat the RAP and the RCCC would serve as the framework for regional learningand provide scientific oversight for country treatment programs. The proposed coordination unit at UNECA would strengthen regional ownership o f the program, promote operational research, and give the TAP visibility through the Conference o f African Heads o f State. 53. IDA'S TAP Task Team and respective MAP Task Team leaders would backstop implementation in each participating country. TAP would also incorporate a number o f the implementation support tools initiated by ACT Africa, particularly cross-country leaming, regional HIV/AIDS training, and monitoring and evaluation. WHO has agreed to provide technical support in monitoring and evaluation in each country, using senior health specialists, external specialists andPLWHA, andto coordinate regional leaminginthis area. 54. Through the RAP-RCCC, TAP country experiences will be shared with partners supporting treatment expansion in other countries. Regular consultation with partners such as the Global Fund, the Gates Foundation, and the Clinton Foundation will complement ongoing exchange o f lessons. 2. Institutionaland implementationarrangements 55. Overview. While the situation differs from country-to-country, certain features for each of the national programs are common: 0 M O H has the responsibility for overseeing all treatment programs. In collaboration with the National AIDS Council and National AIDS Secretariat, it has defined the institutional framework within which TAP activities would be carried out andwould ensure full consistency with activities under the MAP; 0 All TAP-financed activities ofthe MOHare integral partsofMOH's sector action plans under the MAP and would be implemented using existing M O H units. Additional funding to support the M O H unit coordinating TAP activities would beprovided; 14 0 IPSwould receive funds under terms set forth in a sub-grant agreement between the IP andthe MOH; 0 Monitoring and evaluation (M&E) systems would be strengthened in the three countries with technical support from WHO and would be used to document data for decision-making, to enhance the learning processes, and to improve the quality of services; Regional learning andcoordinationwill be supportedbyUNECA; 0 IDA supervision will be ledbyMAPtask team leaders and coordinatedwith TAP countries, WHO and UNECA. 56. Each TAP country has established an advisory National Treatment Committee reporting to the MOH to oversee expansion o f treatment programs, monitor TAP implementation, and rapidly disseminate useful information among countries inthe region. 57. Project management (finance, disbursement, and procurement) and implementation coordination would use existinginstitutional arrangements for the MAP inthe health sector and the IDA-supported health sector project inGhana. A TAP coordinator position would be funded by the TAP to strengthen the capacities of these units and 2-3 designated technical specialists would provide operational support. The project coordination unit would serve as the secretariat of the National AIDS Treatment Committee. The institutional arrangements and organizational relationships are presented in the country descriptions (Annex 1) and summarized in the implementation arrangements (Annex 6). 58. WHO would be responsible for backstopping in-country technical capacity building, monitoring and evaluation, working in collaboration with IDA'SGlobal AIDS Monitoring and Evaluation Support Team (GAMET). At the global level, as part o f the 3 by 5 initiative, WHO would assist TAP countries to build their capacity to provide ART and to adopt WHO generic guidelines to local realities for an effective ART program with appropriate monitoring and evaluation. WHO would take the lead inassisting TAP countries to adapt the tools used inother countries to local situations and to apply global experiences to strengthen implementation. For each TAP country the WHO Representative, working in conjunction with WHO/AFRO, would develop an annual plan o f action. WHO administrative procedures would be followed in the management o f these resources with annualreporting, and audit reports provided to IDA. 59. UNECA would be responsible for facilitating regional knowledge sharing among technical experts and policy makers. Providing HIV/AIDS treatment and care to people living with AIDS andto their families requires a broad range o f services that includes not only medical care and pharmaceuticals, but also supportive services to assure adequate nutrition; psychological and social support; and prevention messages wherever the opportunity arises. To date, these issues have not been addressed in large scale and the experience from various research projects is limited. UNECA would establish a small coordinating unit at its headquarters, comprising two technical professionals and an administrative staff member to facilitate the knowledge sharing among TAP countries and throughout Africa. TAP would provide an operational budget for three years to permit the unit to organize intra and inter- country learning and knowledge sharing and operational research commissioned by the RAP. UNECA administrative procedures would be followed in the management o f these resources with annual reporting, andaudit reports providedto IDA. 15 3. Monitoring and evaluation of outcomedresults 60. The TAP will fund on-going efforts to streamline M&E and track progress, identify problems, build databases for impact analysis, and disseminate results. TAP would support M O H efforts to integrate all treatment programs within national M&E systems for HIV/AIDS treatment and would facilitate collaboration between TAP country efforts and those led by WHO, UNAIDS andIDA'SGlobalHIV/AIDSMonitoringandEvaluationTeam. 61. During negotiations, a set of performance indicators selected from national programs were retained and will need further refining to facilitate timely and consistent collection o f comparable performance data within eachTAP country. These include the number of: 1)persons utilizing VCT services; 2) persons receiving prophylaxis/treatment for opportunistic infections; 3) HIV infected women receivingtreatment to prevent mother-to-child transmission; 4) persons on ARV treatment; 5) number of people receiving home-based care; 6) facilities providing treatment inrural, peri-urbanand poor urban areas; 7) people eligible for treatment who cannot afford it but are exempted from user fees (where fees are levied) for Ghana; and 8) regional publications reflecting lessons learned and best practices disseminated among TAP countries. These indicators would be disaggregated by age and gender to determine if women, children, youthandthe poorhave accessto treatment. 62. Additional information on the TAP learningprocesswould be generatedfrom operational research to be commissioned by the regional multi-disciplinary advisory panel (RAP)/ clinical coordination sub-committee (RCCC). Such research would focus on clinical aspects and other non-clinical areas (access, equity, costs, etc.) which are relevant to treatment outcomes and impact. 63. TAP would fund the semi-annual meetings o f the RAP and RCCC which would be the vehicle for sharing implementation experiences, and recommendations on programmatic changes. The RAP and the RCCC would collaborate with ITAC and serve as scientific oversight organs for ensuring that HIV/AIDS treatment in TAP countries meets international scientific standards. 4. Sustainability 64. As a complement to ongoing MAPS,the TAP would be the first IDAproject inAfrica to focus primarily on treatment. It would strengthen the adaptation and use of WHO treatment guidelines within the "3 by 5" initiative. Treatment results from pilot initiatives in TAP countries are promisingbut Governments still lack the tools, resources, organizational set-up and experience to scale up treatment on a sustainable scale. The project would build both the institutionalinfrastructure for expandedtreatment and strengthen the trust and partnershipamong Government, communities, NGOs, the private sector, and the international community that would strengthen sustainability. 65. By expanding treatment through delivery mechanisms that are pro-poor, TAP contributions would enhancethe effectiveness o f other investments inprevention, counseling and testing, care and treatment, as well as effective systems for addressing safety net issues. While the targetedbeneficiaries will not be able to cover the full costs o f treatment for the foreseeable 16 future, declining drug costs and technological developments augur well for reduced costs per patient. 66. By identifying and testing promising approaches to effective treatment and related services, and by sharing information across countries and in different operational settings, the likelihood increases that such activities will be scaled up and attract additional funding from many sources including donors, the Government, and implementing partners. TAP would also lay the groundwork for the next phase o f MAP support, enabling MAP projects to apply the lessons o f TAP to scale up treatment in a wide range o f countries - including the TAP pilot countries. This would ensure uninterrupted financing from IDA over the mediumterm, as TAP activities would be folded into MAPSat the program's close. This would also provide adequate time for governments to mainstream treatment scale-up intheir development plans andbudgets. 5. Critical risks and possible controversial aspects 67. The critical risks associated with the implementation o f TAP and the proposedmitigation measures are presented inthe following table: to treatment, which can leadto drug resistance. weakness or failure. existing capacities to deliver, sustain, monitor and evaluate treatment activities. Increasednational capacity would be ensured by the TAP via close operational support, which would enable government to take over treatment activities o fTAP IPSinthe event that the latter canno longer offer treatment and care services. Delays insustaining the flow of drugs Each country would use its national drugs agency and simplified to patients. Interruptions indrug mechanisms such as envisaged under the ClintonFoundation supplies, a common feature incountries H Agreement. Eachcountry would maintain an adequatebuffer stock covered, poses a risk to the continuity o f drugs and monitor it regularly. o f treatment required. Mutual distrust between governments Transparent consultations during preparation have reducedmistrust. and associationsof PLWHA. MOHservices wouldbe strengthened inthe TAP for effective collaboration withNGOs, and simplified accreditation systems to improve publidprivate partnership inservice delivery. Compromised patient confidentiality Strong community-based support systems beingput inplace inthe as information is shared among TAP TAP and effective M& EsupportedbyWHO would ensure countries. This could limitthe number M adequate patient confidentiality. Service provider training for ofpatients coming forward to seek increased confidentiality would be provided at all levels. treatment. Slow implementation due to H Detailedclarification o f roles and responsibilities during 17 complexity o f roles andresponsibilities negotiations involving all parties and intensive supervision. ofmultiple implementing parties Inequitable selection of beneficiary Beneficiary areas were selected because they were identified as high areas priority areas inthe national HIV/AIDS strategic plans, on the basis S o fhigh prevalence rates and accessibility to the poor and vulnerable groups. Government selected ImplementingPartners on the basis o f agreed criteria. These criteria will be maintainedfor the selection o f future IPS. Delays causedby weaknesses of the The use o f private non-governmental service providers with proven health care delivery system ability to deliver care and treatment to the poor, targeted training for healthpersonnel andre-equipped laboratory andX-ray hospital units would mitigate riskand strengthen effectiveness o f services delivery systems inboth IP facilities and inpublic hospitals (referral centers). The multidisciplinary "team approach" to treatment and effective supervision would facilitate the use o fWHO-sponsored guidelines S and treatment protocols and reduce some o fthe health systemrisks. TAP would also coordinate with other regional capacity building projects to buildimplementation capacity and training o fproviders. Extemal support by WHO and NGOs (intraining, M & E, volunteer services by HIV-positive healthpersonnel, etc.), and use o f efficient patient tracking systems developedwith WHO'Ssupport would further reduce the impact o f system weaknesses. TAP would also work closely with MAP and SWAP to identify and address systemic constraints to efficient service delivery. Overall RiskRating S Intensified supervision through the learning process. . Lowhegligible 6. Grant conditions and covenants 0 Project operational manual (including fiduciary guidelines); would be completed and reviewed with IDAbefore effectiveness. 0 Sub-grant agreements satisfactory to IDA would be signed between each MOH and the respective IPSas agreed duringnegotiations before Grant effectiveness; 0 Opening o f the Special Account(s) would be completedbefore disbursements start. D. APPRAISAL SUMMARY 1. Economicandfinancial analyses 68. Eculzomic analysis. The TAP would generate three direct benefits: improved health and productivity for recipients o f treatment; health system strengthening; and enhanced intemational knowledge on scaling up treatment. The economics o f HIV treatment is evolving rapidly. The annual drug price per patient has fallen from $10,000 in 1996 to $140 in 2003, and costs continue to drop. Price declines have also begun for key diagnostics and are expected to accelerate. In this dynamic environment, the cost-effectiveness o f treatment defies precise calculation but is steadily increasing. Ifa patient begins treatment today and sustains it through life, the average annual cost would be far lower than the current price. With the total cost of comprehensive treatment now approaching $500 per year, the present value o f the cost of treatment is already almost certainly less than the present value of the direct costs incurred by not treating. The direct costs o f an AIDS death includes the costs o f treating AIDS-related infections, lost output and income, funeral expenses, and death and survivor benefits. To this 18 must be added the indirect costs o f orphan care and support, crowding out o f other health services, proliferation o f counterfeit drugs, and loss o f social capital. This balance has already led a growing number o f private firms in Afiica to initiate comprehensive treatment for their employees, and it is widely agreed that the social benefits o f treatment significantly exceed the private benefits. Inaddition, strengthening health system infrastructure would help improve the delivery o f a range o f health services, which have suffered because o fbudget constraints and the impact o f AIDS. Finally, the knowledge generated by the TAP would help make future treatment more effective `and more affordable, with benefits accruing to a large number o f countries. In aggregate, this wide range o f benefits can be expected to generate economically substantialreturns. 69. Financial analysis. Over TAP'Sprojected three-year implementation period, financial resources from the project would be adequate. Further expansion of treatment will continue to be constrained by affordability, however, and further cost reduction and other means to make treatment more financially sustainable will be required. With limited funds for subsidizing treatment costs, further cost reductions offer the most effective means to expand access for the poor. 70. A number o f possibilities for reducing costs and increasing the potential for fiscal sustainability would be explored during project implementation. First, TAP would promote efficiency gains to fkrther reduce cost o f the ARV, 01 drugs, and diagnostic tests. The agreement IDA recently signed with the Clinton Foundation builds on volume discounts to realize a sharp reduction in prices from previous levels. Second, TAP would seek to increase contributions from a variety o f internal and external sources to defray the costs o f treatment as improved quality generates funding interest and increased demand for services. Among the possibilities, TAP would promote enhanced hnd-raising capabilities by implementing partners to sustain the community organizations, NGOs, and faith-based organizations involved in treatment. 71. A thirdoption involves co-financing with those with the means to contribute to their own treatment. Treatment under the TAP would not be denied to anyone on the basis o f ability to pay. Each o f the participating countries has some forms o f cost-sharing, which each considers inadequate. TAP would assist in testing more transparent and effective methods o f securing cofinancing with more affluent patients without preventing the poor from seeking or receiving treatment. All TAP-sponsored programs would be closely monitored to ensure that there i s equitable access to treatment and efficient safety nets for the poor. 2. Technical 72. TAP preparation has reviewed the basic framework for providing care and treatment to PLWHA, including: national policies and strategies; formal treatment guidelines and protocols; proposed norms for infrastructure, personnel, and pharmaceutical supplies; IP selection and accreditation criteria and procedures for service providers; and methods for monitoring patient compliance. These would be reviewed on a regular basis during implementation by technical committees in each country which would be assisted by WHO-hired experts working in the Secretariats o fthese committees. 19 73. Proposals from the IPShave been structured to ensure that the implementing partners would: (a) cover each of the five treatment elements; (b) address the broader health service delivery issues in partnership with strengthened referral services, training, drugs, and patient monitoring systems being developed by participating governments; and (c) work closely with MOH to support institutional capacity-building measures which would ensure sustainability o f the treatment programs at the end o f the TAP. Accompanying budgets have been structured to distinguish among: (a) direct patient care costs; (b) indirect patient care costs; and (c) management and general administration costs. IPShave plannedhumanresources to ensure that they have sufficient qualified personnel for the first 12months o f the project, and have the means to recruit and train additional personnel as needed. 74. Usingthese formats would provide a basis for monitoring the implementation of current proposals and criteria for evaluating future proposals, andprovide each country a solid empirical base for planningscale-up nationwide. 75. TAP implementation would rely heavily on the availability o f technical backstopping of: (a) local NGOs and associations by intemational NGO experienced insupporting local providers o f care and treatment; and (b) of country treatment programs by the regional multi-disciplinary advisory panel (RAP) and its sub-committee o f clinical experts (RCCC) andthe ITAC. 3. Fiduciary 76. Financial. The project's financial management arrangements vary by country in terms o f the institutional structure and implementation arrangement, in accordance with existing arrangements for health sector and MAP activities. Financial management capacity in these entities has been reviewed to ensure that it is in compliance with the minimum requirements to satisfy the fiduciary Operational PolicyBank Policy (OPBP 10.02). Specific time-bound actions have been recommended to each o f the implementing entities in each country that would help enhance capacity necessary to implement TAP. Details o f the specific areas o f weakness and associated risks as well as mitigating actions are articulated inAnnex 7. 77. This project poses significant challenges to countries and therefore poses significant risks to IDA. Project preparation built operational partnerships and clarified roles o f the MOH and IPS,negotiatedtechnical support byWHO and strengthened MOHimplementingpartners. Using simplified procurement and disbursement procedures with intensive supervision, provision i s made to reduce the risks highlighted inparagraph67. 78. Sub-grant agreements between MOH and the IPSwould provide an initial quarterly advance and regular replenishments. IDA has verified that the implementing partners have acceptable accounting policies, procedures and practices. To ensure proper financial accounting and auditing, IDA would require that an acceptable audit firm be recruited to audit the accounts of the IPSand identify areas o fweakness for further support. 79. Fundingto WHO andUNECA would be on basis o f agreements between IDA and each agency, to facilitate direct disbursement to these agencies as grant recipients for the benefit o fthe three countries. IDA would therefore have a direct relationship with the two UN agencies and would agree on their responsibilities, obligations and deliverables. This relationship i s built on the basis o f the Memorandum o f Understanding (MOU) negotiated between World Bank and the 20 UnitedNations Development Program (UNDP) as the representative body for the UnitedNations entities. A copy of the MOUis attached to Annex 7. 80. Procurement. Assessment of the government institutions responsible for procurement (including ARVs) has been carried out. The institutions identified are described inAnnex 8. In summary, all procurement institutions inthe three countries are already performing procurement management under IDA financing, following IDA guidelines. Only inBurkina Faso, services of a Financial Management Agent would be contracted to provide direct support to MOH inoverall financial andprocurement management. 81. Selection o f IPS was done during preparation through application o f technical and administrative criteria. The criteria include: (a) management o f existing treatment programs going beyond ART, and/or PMTCT-Plus programs; (b) inclusion o f innovations to reduce costs and enhance sustainability; (c) agreement to share implementation mechanisms, tools, service statistics for monitoring and evaluation, for comparison across countries, and for research by research organizations and scholars; (d) commitment to foster equity inpatient selection, using ethical and locally validated approaches to treatment complexities, as well as using efficient safety nets for poor patients. Other IPSmeeting these criteria will be identified within the first year. 82. Procurement of ARVs and related supplies. To ensure continuous supply o f ARVs in TAP countries, the following ARV procurement principles would apply: (a) Long-term contract agreements (or for the sub-grant duration) on the supply o f drugs would be signed between the IP and the MOH; (b) country drugprocurement agencies would use Limited International Bidding (LIB)andshoppingmethodsto procureARV fromWHO'Spre-qualified suppliersorthroughthe Clinton Foundation negotiated ARV prices; (c) the country drug procurement agency should guarantee a Safety Stock level (a suitable period per country requirement) through a monthly stock reporting system. The Project Operations Manual would include the safety stock monitoring procedure ineach TAP country. 83. Conflict of interest. N o government employee (of MOH or any government entity involved with TAP management) may be a member o f IP management in any capacity that can be regarded as conflict o f interest per IDA guidelines. N o member o f an IP may exert any oversight or selection authority over other IPS. 4. Social 84. TAP would support Government and IP activities to address persistent stigma and discrimination, within the community and between PLWHA and the health staff, empowering associations and NGOs particularly associations of women and PLWHA, to ensure care for the afflicted, to educate and sensitize communities and workers intheir workplace. TAP will target, and monitor the participation of, women inthe treatment programs supportedbythe project. The key indicators for monitoring the implementation o f the project have included gender sensitive indicators that will help track the participation o f women inthe treatment programs supported by the project. TAP will empower health professionals to provide proven medical treatment to PLWHA and, through extensive training, better working conditions and better patient /service provider relationships. 21 85. Increased availability of a continuum o f care and treatment through the TAP would provide other positive values: (a) encourage persons to be tested; (b) change the community's perception of PLWHA as patients with chronic illness rather than awaiting death; and (c) enhance household and community members support for patient compliance. Given evidence (particularly from the Noguchi Research Institute in Ghana) that herbal preparations for the treatment o f opportunistic infections appear to improve the quality o f life of some PLWHA, TAP would also seek to involve traditional practitioners where feasible. 5. Environment 86. TAP is a category BProject. An important environmental issue related the TAP concerns medical waste management. This issue has already been resolved by existing projects in each country and TAP activities would be covered through those safeguards. BurkinaFaso has within the MAP, completed a medical waste management plan (November 2002), which the TAP will use in selected treatment sites. Ghana has medical waste management guidelines approved by the Ghana Environment Protection Agency (EPA) under the Ghana Health I1Project. Training would be carried out for all health care personnel to implement the health care waste management guidelines. Therefore all activities and partners relevant to the TAP would also be subject to this policy and guidelines. For Mozambique, since all TAP activities would be either carried out by NGOs working inside public health facilities or the Ministry o f Health itself, the environmental assessments and safeguards applied under the Mozambique MAP would also cover TAP environmental safeguard requirements. 6. Safeguard policies NaturalHabitats (OPBP 4.04) rxl Pest Management (OP 4.09) [I [XI Cultural Property (OPN 11.03, beingrevised as OP 4.1 1) [I [XI Involuntary Resettlement (OP/BP 4.12) [I [XI Indigenous Peoples (OD 4.20, being revisedas OP 4.10) 11 [XI Forests (OP/BP 4.36) 11 [XI Safety ofDams (OP/BP 4.37) [I [XI Projects inDisputed Areas (OP/BP/GP 7.60). 11 [XI Projects on International Waterways (OP/BP/GP 7.50) [I [XI 7. Exceptions to Bank Policy N o exception * By supporting the proposedproject, IDA does not intendto prejudice the final determination o fthe parties' claims on the disputed areas. 22 Annex I-A: Country and Sector or Program Background Regional HIWAIDSTreatmentAcceleration Project BURKINAFASO 1. General (a) HIV/AIDS EpidemicandTreatmentNeeds Current situation. Estimations of the prevalence o f HIV in Burkina Faso have varied considerably over the years. Based on data from the limited number o f sentinel sites, overall prevalence was estimated at 7.1% in 1997 and 6.5% at the end o f 2001; prevalence rates among pregnant women at these sites decreased from 7.1% in 1997 to 4.4% in2002. Based on the EPP model, HIV prevalence among the populated aged 15-49 years was estimated at 4.2% at the end o f 2002. Preliminary data from the 2003 Demographic and Health Survey were recently released, which give an average adult HIV prevalence o f 1.9 % among those surveyed, but with significant regional variations (4.3 % in Ouagadougou, and 3.7 % in the southwest region borderingon Ivory Coast). Further analysis will be necessary to fully reconcile results from the EPP model and those of the Demographic Health Survey (DHS). Between 2002 and 2003, the cumulative number of AIDS cases reportedinBurkinaincreased from 19,540 to 20,446. Though still considered "generalized," these results indicate lower than expected levels o f infection among adults and potential benefits to be obtained by treating the epidemic at its current level. Large gender and geographic disparities remain. Treatment Needs. INSERM2(July 2003) estimates that 600,000 persons are currently infected and that approximately 70,000 couldbenefit from ART. The recent WHO 3x5 mission estimated that at least 30,000 people should be treated by 2005. Currently, an estimated 1,300 (or 2%) people are being treated with support from the national budget and from multilateral (MAP, Global Fund, African Development Bank (AFDB), bilateral (Brazil), and privatehon- governmental sources (the ESTHER Project, JCrCmi, MSF, CRF3, andTan Aliz). (b) Progressinthe implementationof the MAP The MAPproject in Burkina Faso (Projet d 'Appui du Programme de Lutte Contre le SIDA, PA- PMLS) was launched in 2002, following the close o f the Population and AIDS Project (1996- 2001). The project comprises four components, including: (i) support for the HIVIAIDS action plans of 22 Ministries, including the Ministry of Health as well as the National AIDS Council (SP-CNLS); (ii) support for decentralized HIVIAIDS programs in 13 pilot provinces (of 45 national), including support for Provincial AIDS Committees and micro-projects o f Village AIDS Committees; (iii) targeted interventions by large national and international NGOs for vulnerable groups (sex workers, miners, youth, orphans); (iv) support for coordination, monitoring, and evaluation. In February 2003 a new subcomponent was added to place 850 persons under ART at national and regional hospitals, with an intensive program o f research for 400 o f these patients. The $22 million credit is scheduled to close in 2006, but due to the Institut National de la Santt et de la Recherche Mtdicale FrenchRedCross 23 additional new activities and expansion o f several components, the project is disbursing ahead o f schedule and will be fully committed by late 2004. Preparation for a new project will begin in June 2004, to become effective by early 2005. Followingthe close o f the TAP in2007, activities will be integrated into this new project. The MAP'SProject Management Unit (PMU) will be located in the National AIDS Council in the follow-on project, to allow it to serve as the executing unit for support from various donors. (c) InstitutionalEnvironment:MOHandPartnerdpartnershipsinHIV/AIDS The Government o f Burkina has been very proactive in implementing a series o f national plans since the emergence of the first AIDS cases in 1986. There has been strong political commitment, an intensification o f the scope andrange o f interventions, and substantial growth in the financial resources being channeled for the national HIVIAIDS program. The HIVIAIDSIIST strategic plan (Cadre stratkgique de lutte contre le VIHISIDA et les IST 2001-05) focuses on: (i) strengthening preventive activities to reduce the transmission o f STI and HIV; (ii) strengthening epidemiologic surveillance; (iii) improving the quality o f care; and (iv) strengthening national andinternationalresponses andpromotingmultisectoralcoordination. The National AIDS Council with its Permanent Secretariat (SPKNLS-IST) established in October 2001 under the Office o f the Presidency, coordinates the multi-sectoral response program. The President o f the Republic heads the CNLS-IST and has providedpolitical support for its activities. The Minister o f Health i s the Vice-president. The CNLS-IST has also established corresponding structures at regional, provincial, and community levels. Organizationally, SPICNLS-IST comprises seven departments and employs more than 30 personnel; it coordinates activities among the respective partners in the areas o f prevention, treatment, community development, monitoring andevaluation. Responsibility for issues related to treatment is vested in the Ministry o f Health through the Ministry o f Health AIDS Committee (CMLSISantk), which is chaired by the Minister and includes the Directors o f all key departments involved in HIVIAIDS treatment. Daily responsibilities for planningand execution rest with the CMLSISantC Coordination Unit, which includes a Coordinator and several technical and support staff. Operationally, CMLSISantC Coordination Unit has organized treatment activities with the exception o f PMTCTFMTCT- Plus, which has been delegated to the Directorate for Family Health (DSF). More recently, the preparation o f proposals for the different rounds o f Global Fund financing has provided an opportunity for MOH authorities to update the strategic framework and strengthen their role in treatment. To oversee developments in the implementation of treatment programs and the quality o f care, M O H has recently instituted a national technical committee to provide guidance for scaling up treatment o fHIVIAIDS and STIs. Financing o f the overall HIVIAIDS response has been provided by numerous multilateral (WHO, UNICEF, UNFPA, UNAIDS, UNDP, WFP, World Bank, EU, etc.), bilateral (France, Belgium, Denmark, Netherlands, Canada, etc.), international non-governmental partners (MSF, Catholic Relief Services, Care, World Relief, AIDSETI, etc.), and a number o f local non- governmental partners, organized in several umbrella organizations. The Government's own contribution rose from only US$lO,OOO during the first phase to close to US$2.5 million during the most recent plan. IDA has played a pivotal role in supporting the government to intensify the fight against AIDS during the last eight years, first through the Population and AIDS Control 24 Project, and currently through the MAP (PA-PMLS) project, which currently finances about one- fourth o f the national AIDS program. (d) Optionsconsideredfor the institutionalset up and rejected Direct financing to NGO and CBOs networks to provide treatment. Given the critical role of the non-governmental organizations and the private associations in advocating, organizing, and carrying out care in both urban and rural settings, TAP originally assumed that these structures could assume full responsibility for scaling up treatment. Several constraints led to a reconsideration o f this assumption and the rejection o f the option, including: (i) the Government requires that N G O providing treatment be accredited not only as health facilities but also to provide ART, andthe majority o f eligible NGO are unlikely to receive such accreditationprior to project effectiveness; (ii) the lack o f managerial capacity to handle the financial resources envisaged by TAP; and (iii) the need to rely on public structures for certain key elements o f the program (including laboratory facilities, referral o f complicated cases, procurement and distribution o f ARV, etc.), and the need to strengthen partnerships between public facilities and associations o fpeople livingwith HIV//AIDS. Exclusive focus on public sector service delivery. Despite examples o f successhl partnership between the public and private sectors, relationships inBurkina are sometimes strained, and the roles o f the public and NGO sectors inART are not yet fully developed. While recognizing the essential role o f NGOs in providing psycho-social support and improving adherence, the authorities would have preferred to first focus on strengthening treatment at public sector facilities before integrating the private (especially the NGO/Association). In fact, the most recent Global Fund proposal constitutes the most comprehensive development o f the public sector approach. This approach was rejected because o f the valuable contributions to date o f the NGOs and associations (which the authorities recognize) and because it was determined that the public sector lacks the ability to offer all o f the treatment components envisioned by TAP inits own structures or with its own personnel. Inlight o f the limited number o f doctors inthe public sector, treatment can only be scaled up if there is a strong partnership between the public sector andNGOs, with multiple approaches to service delivery. Public/private sector partnership. Through the establishment o f the Associational and Community Support Program (PAMAC), a number o f partners (including UNDP, Denmark, and the Netherlands among others) are testing an approach allowing NGOs, associations, and CBOs to complement the public sector treatment efforts by strengthening VCT and home-based care. The success o f this program to date as well as that o f about a dozen NGO, which meet IDA'S criteria for providing services and which are accepted by the Government, offer a soundbasis for using TAP to buildon this public/private partnership andto pilot scaling-up. 2. BurkinaFaso InstitutionalFramework (e) Overallstructure Under the TAP, the roles o f existing institutions are maximized and no parallel structures are added. The CMLSISante (AIDS commission o f MOH) under the Minister o f Health will rely on existing institutions to carry out TAP implementation. The Coordination Unit of CMLS/Santt will receive all proposals from IF, perform technical reviews with the help o f the Treatment 25 Committee and Thematic Sub-committees and present to the CMLS/Santk for approval. TAP'S institutional arrangement is reflected in the following diagram, the text below explains the relationships and responsibilities. PRESIDENT of Burkina Faso National Council for Fight against HIWAIDSand STD (CNLS) ......................... jpAbst I I Fiduciary ............................................................................................. u National HMlS I""' ............. IPAlPMLS MAP Project I Family health .............. ther ministerial ommissions tares (CAMEG) I I NOTES FMA FinancialManagementAgent (contracted-in.to provide overall accounting,reporting, internalcontrol servicesand procurementmanagement) This will be supported by the project Dotted linesshow affiliations Institutionsin the shaded boxeswill play a direct role in TAP implementation o Oversightbody: The CMLS/SantC(coordinationunit) The existing CMLSISantk chaired by the Minister o f Health will be the oversight body o f the TAP. CMLS/Santk supervises the health sector component o fthe MAP,which is executed bythe Coordinator's Office with essential professional staff covering ART, surveillance, M T C T and laboratories. CMLS/ Santk has thematic sub-committees and a treatment committee. The project will strengthen CMLS/Santk, which will have overall responsibility to review TAP implementation progress, make strategic decisions and approve the annual work planof the TAP. The project will strengthen CMLS/Santk's (coordination unit) technical surveillance capacity by financing the services o f a fulltime M&E Specialist. A social development specialist will also be hiredto address treatment-related gender, ethics andsocial issues and provide guidance to IPSin these areas. TAP will also support essential office equipment and operational overhead. Details will be provided inthe Project Operational Manual/Guidelines. 26 o Technical Management: The Treatment Committee A National Technical Committee on HN/AIDS Treatment was established by the Minister o f Health on January 30, 2004 to provide technical support to the CMLS/SantC, particularly with respect to: (i)analysis and revision o f treatment guidelines and strategies; (ii)identification o f treatment problems and the search for solutions; and (iii) supervision o f the quality o f services provided. Its membership includes representation o f key stakeholders (the directors o f MOH, representatives of the principal treatment sites, SP/CNLS-IST, and WHO. The Committee will address issues related to diagnosis and treatment (STI, 01, and ARV) as well as the organization o f PMTCT and PMTCT-Plus. CMLS/SantC and DSF have delineated their complementary roles inthe implementation of expanded treatment. This committee will also review and approve Tp sub-grantproposals. o Other agencies CAMEG. The national essential drug procurement agency (CAMEG) has satisfactory capacity and capability for the necessary procurement of drugs including ARV. It has established management capacity and is already procuring ARV and related supplies financed under the MAPproject for the MOHandNGOs. Itwill bulk procure drugs (including ARV) andrelevant medical supplies under a Memorandumo f Understanding signed with PADS. PADS will provide drugs and laboratory supplies procurement plan to CAMEG on a six monthly basis. CAMEG will have comprehensive responsibility for procurement and distribution andwill produce stocks availability reports quarterly for all stakeholders. PAMAC. As an independent (autonomous) agency based within the National AIDS Council, PAMAC supports VCT andbasic capacity buildinginsubproject management for the NGO/CSO (Civil Society Organization). PAMAC is nominally under the SP-CNLS Community Department, but functions fairly independently o f it. A multi-donor Trust Fundmanagedby UNDP finances PAMAC activities. Disbursement from the TF is done based on a quarterly action plan. P A M A C finances NGOs for the establishment and operations o f V C T services throughout the country, andprovides technical assistance to NGOs involved incare and support o f persons infected and affected; as such, it already has a working relationship with nearly all the NGOs eligible for TAP. It does not currently receive MAP funds. PAMAC would be an option for: (a) technical support for VCT; (b) capacitybuildingo f IP and their member associations insub-grant proposal preparation and subproject implementation management; and (c) programmatic monitoring and evaluation o f sub-grants on behalf o f CMLS/SantC and the National AIDS Council. Technical and clinical M&E will be managed directly by CMLS/SantC's coordination unit. PAMAC will ensure that TAP funds are not used to supplement or replace ongoing activities currently financed by the UNDP TF. (f) ProjectCoordination As defined inthe arrete`(decree) establishing the CMLS/SantC, the CMLSISantC will continue to provide guidance, support, and supervision for the implementation o f the Ministry o f Health's program to combat HIVIAIDS. TAP will be the direct responsibility o f the CMLS, which i s chaired by the Minister o f Health. CMLS is also the coordinating body of the other sector programs (e.g. MAP'Shealth sector component). Day to day coordination o f TAP activities will 27 be the responsibility o f CMLSISantC (coordination unit) for scaling up medical care, while DSF will be responsible for scaling up PMTCT and introducing PMTCT+ in additional sites. This division o f labor reflects both previous experience and the anticipated volume o f additional work. CMLS/Santk has already gained experience in carrying out treatment related activities with financing from the MAPand other sources, while the DSF has beenimplementing the pilot programs for scaling up PMTCT in collaboration with UNICEF, JHPIEGO, and others. TAP will finance regular meetings o f the thematic commissions and the quarterly meetings o f the technical committee, which will provide periodic opportunities for coordinating interventions andanalyzing the results from the field. 3. MainImplementingPartners CMLS/Santk will implement the TAP country program, in collaboration with the relevant units o f MOH. CMLS/Santk will be the focal point for the partnerships linking the Ministry and the Implementing Partners. TAP'S strategy in Burkina is based on leveraging the energies and experience o f associations, their networks, and supporting NGOs at the community level to promote testing and treatment, provide support for positive living, and ensure improved compliance with treatment regimes. Associations and CBO operating under the coordination and supervision o fthe IPwill report through the CMLS/Santk to the SP/CNLS-IST and respondto all reasonable requests for technical and financial information. Progress reports will serve as monitoring and evaluation instruments as well as disbursement triggers for tranche releases. The following associations and related structures have indicated their interest in participating in the TAP: Sainte Camille, AIDSETI andCICDoc. (g) Ministry of Health(MOH) o Elementsof comprehensivetreatmentprogramsandactivities Burkina Faso has developed and published HIV/AIDS treatment guidelines for: (a) voluntary counseling and testing, (b) sexually transmitted infections, and (c) PMTCT; and (d) treatment guidelines for opportunistic infections and ART have been developed and will soon be published. The guidelines have been revised to incorporate new WHO recommendations on first and second line drug regimes and pediatric ART. The revisions are beingdiscussed with WHO under the "3 by 5" Initiative and will be subsequently approved by the Ministry's Technical Committee on HIV/AIDS Treatment. VCT. Burkina has opted for a two-pronged approach to organizing VCT under the overall coordination o f the Associational and Community Support Program (PAMAC): through the establishment o f fixed VCT centers and through the organization o f regular national campaigns. With the support of several partners (UNDP, Denmark, Netherlands, etc.), PAMAC provides: (i) technical and financial assistance to set up VCT services; (ii) procurement and logistical support to ensure adequate supplies o f needed materials; and (iii) supervision, monitoring and quality control o f the results. At the end o f 2003, P A M A C had worked with ten associations (which will participate inthe TAP) to ensure V C T services are available in 13 centers. Inaddition, PAMAC had organized (in collaboration with six national and international NGOs) a campaign in the eight principal cities o f Burkina to provide free testing. For 2004, 90 additional centers are planned for 19 localities; the number o f persons tested is projected to increase from 5,000 to 35,000. TAP would, through accredited centers, assume responsibility for treatment 28 management o f the identified HIV/AIDS patients. TAP resources would be used for VCT under current arrangements ifthe PAMAC external fundingdeclines. Community Care and Support for Positive-Living. In March 2004, the CNLS-IST, with assistance from P A M A C initiated a program to define the elements andmodalities for expanding community care and support to PLWHA through existing associations. Guidelines establishing an appropriate continuum for home-based care have been developed and costed and existing associations capable o f providing care have been identified. TAP funding would complement similar support as a continuum of STI/HIV/AIDS treatment by associations accredited by the Ministry for TAP activities. PMTCT / PMTCT Plus. Burkina Faso adopted a national approach for PMTCT in 2000 comprising VCT, prophylaxis (Niverapine or Azidothymidine (UT)), counseling on breastfeeding, monitoring o f the status o f the infant (up to 18 months), and VCT for the partner (ifrequested). PMTCT is currently limited to 23 health facilities in 20 health districts. The PMTCT Plus approach includes intensified neonatal and postnatal care, expanded care for infants (0-23 months, particularly with respect to breastfeeding andnutrition) andyoung children (24-59 months), and development o f services for seropositive infants. PMTCT Plus is currently limited to: the maternity wing of the national hospital (CHN de Yalgado) and three district hospitals (CMA) in Ouagadougou (Saint Camille and Pissy) and Bobo Dioulasso (Secteur 22). The number o f women being treated is limited and many important questions remain to be resolved, including low demand for ANC (especially in rural areas), weaknesses in service delivery (particularly for referral of complicated cases), and problems for infant feeding. The Directorate for Family Health (DSF) serves as the implementing agency for PMTCT and will supervise all PMTCT Plus activities in accordance with the Ministry's scale-up plan developed with the assistance o fUNICEF. This scale-up planhas provided the basis for TAP'Scontribution to the program. ART. While the Government has participated since 2001 inthe initiative to reduce the price of ARVs, ART has been ongoing in Burkina on a limited scale since 1998 through, inter alia the Centre Oasis (AAS), C H N Sanou Sourou/REV+, and the CTA4/0uagadougou. ART was officially launched in October 2003 with the support o f the ESTHER Program and is currently limited to 19 sites, virtually all in urban areas. Therapeutic and Eligibility Committees have been established in facilities carrying out treatment to provide guidance in the selection of candidates for treatment and the monitoring o f their treatment. Howgver, a national policy and strategic plan for HIV/AIDS treatment as well as national norms, guidelines and treatment protocols still need to be refined and published. A national training plan for treatment teams would thereafter be funded by the TAP with WHO technical support. The TAP would also assist the Ministry of Health in in-service training and supervision o f NGO's HIV/AIDS treatment programs. UnderTAP, MOH will provide technical support and supervision to these committees at the treatment sites to ensure the quality and standardization o f first and second line drug regimes used and the protocols followed by all health facilities within Burkina. Inaddition, TAP will fund the procurement o f drugs needed to treat additional patients enrolled in the sites operated by the implementingpartners. Financial and political commitment. As noted earlier, the President is chair of the National AIDS Council, and presides personally during the annual day-long meeting o f the full Council. Centre de Traitement Ambulatoire 29 The government has also made a strong commitment to expanding the number o f persons under treatment. This is evidenced not only bypublic statements from hi h-level officials insupport of 3x5 objectives, but also the government's decision to use H P C resources to purchase ARV B while awaiting arrival of support from Global Fund and other partners, and persistent efforts by the government to secure funding for HIV/AIDS programs from the World Bank, Global Fund, andother partners. Representatives from NGOs and associations o fperson living with AIDS sit on the National AIDS Council, andhave been keypartners indeveloping the TAP. o Human resourcedevelopmentfor TAP implementation According to Ministry figures, the number o f trained personnel is very limited: for the 3 tertiary and 9 regional levels, 58 physicians, 6 pharmacists and 48 other staff have been trained in treatment o f PLWHA; while at district levels and among NGO, the number i s somewhat less. The lack o f trained staff constitutes a major constraint to scaling up HIV/AIDS care and treatment inBurkina. Current MOH plans call for two types o f training: (i) treatment teams for concerned with STIs, OIs, and ARV, medical and paramedical staff from the district hospital (CMA) level, would be trained at training facilities in Ouagadougou and Bobo Dioulasso; and (ii) treatmentteamsinvolvedwithPMTCT,CMAstaffwouldbetrainedinOuagadougouand for Bobo Dioulasso while health center (CSPS6) staffwould be trained at regional level. Laboratory technicians would be trained centrally. Training modules have been prepared for these different types o f short-term training at central. Training for PMTCT covers 15 days while training for STIs, OIs/ARV, and laboratory techniques covers 5-6 days. TAP will support MOH inpreparing and implementing a human resource development plan outlining its strategy for increasing the quantity and improving the quality of staff, which must deal with the projected numbers o f patients resulting from scaling up VCT. o Adequacy of fiduciarymanagementper existingBankPrograms Fiduciary managementof TAP fbnds will be handledby the existing arrangements for disbursing funds through the Health District Support Project (PADS). The PADS reports to the Department o f Planning inthe Ministry o f Health, andis currently primarilysupported by Dutch and Swedish hnding, but the Ministry o f Health would like it to evolve into a common donor funding mechanism for the health sector. The PADS represents a continuation o f IDA's Health and Nutrition project, which was closed following IDA's transition to budget support for the health sector in 2002. Beginning in 2004, the M A P (PA-PMLS) project delegates responsibility to PADS for financial management o f all district level health activities financed by the MAP, and plans to delegate management of all health activities to PADS in 2005. Its current task is to perform fiduciary management of MOH's decentralization efforts to the regional and district levels, but the Ministry wants the project to evolve into a common financing mechanism for a variety o f donor programs in the health sector. Currently, the PADS manages a portfolio o f about US$ 12million with a modest professional team o f a director, 2 accountants, and some support staff. PADS has developed financial and procurement procedural manuals, and has experience with Bank financial and procurement reports/plans. Overall, the PADS will manage TAP finances. However, considering the current human capacity and not to incur quality compromise to their ongoing operations, TAP will finance the services o f a Financial Highly IndebtedPoorCountry CommunityHealthCenter-BurkinaFaso 30 Management Agent (FMA) or an accounting firm. PADS will contract-in 7 FMA staff for accounts management, reporting, fiduciary advisory services to all involved institutions, and to manage fiduciary supervision and capacity building o f the IPS.The FMA will work directly under the supervision of the Director PADS. The procurement will be carried out through three levels: (a) at the PADS level for common works, goods and services (either by PADS or delegated to a financial management agency); (b) CAMEG will procure all drugs (including ARV) and laboratory supplies, since it already procures such items under the MAP financing; and (c) IPSwill procure small quantitiesholumes of goods, drugs (that are not procured by CAMEG and are generally available in the local pharmacies for opportunistic infections) and services. Existing fiduciary manual for the MAP would need revision and minor updates to make it useful for the TAP and to ensure harmony with existing PADS procedures. A separate fiduciary manual will be developed for the Ips by the FMA. (h) ImplementingPartners Role of associations in building confidence and combating stigma. While stigma remains a major problem in Burkina, the associations o f PLWHA have made significant progress in reducing the effects o f stigma. These associations have demonstrated their importance for: (a) reducing the fear of stigma and discrimination which i s linked to low ART uptake; (b) mobilizing funding for treatment and nutrition support for members; (c) improving communication and advocacy to the community to inform them o f the availability of ART; (d) providing home-based care and treatment adherence support, and (e) contributing to community care and support and ensuring adherence. Technical andprogram management capacity. The implementing partners participating inTAP are already carrying out treatment activities inassociation with Government accredited treatment facilities. The accreditation process used by MOH in Burkina to ensure adequate treatment quality includes: physical criteria for laboratory and medical services, human resource norms, service delivery standards (and linkages with non clinical services), and logistics requirements. Eligibleassociations are currently inthe process of complying with the accreditation criteria and are expected to be ready by effectiveness. Each o f the eligible IPSis a legally established organization, which is audited annually. In addition, TAP will contribute resources for management o f the program. The Ministry has been workingwith several NGO and associations o f PLWHA to initiate treatment and prevention of mother to child transmission. AIDSETI, Sainte Camille andCICDoc are detailed inthe Supplement to this Annex (see attachments). Financial sustainability. The proposed interventions rely on a combination o f existing financing and additional TAP resources. Because the associations in Burkinaare essentially of national origin, the proportion o f TAP hnding will be somewhat higher than in the other TAP countries. Nevertheless, the I p s are expected to indicate their own resources (incash or inkind) as a pre-requisite for receiving TAP support. Financial sustainability in the long term will depend on the availability of resources from the Global Fund, the future MAP, and other sources, given Burkina's overall poverty. TAP will be integrated into the subsequent MAP operation, for which preparation is scheduled to begin inFY 2005. 'Financial andprocurement professionals will be providedby a qualified FMA and the FMA will provide technical backstoppingwhen required. 31 (i) InternationalOrganizationRolesandResponsibilities Please refer to the main text o fthe PAD. 4. InstrumentsandDocuments (j) TAPOperationsHandbookoutline TAP will utilize the existing operations manuals that have been developed under the MAP project and by the PADS on fiduciary management. However, the existing manuals will need modest modifications to gear them for treatment related activities. The manuals will target two distinct audience, namely a) the Implementing Partners and b) government institutions. The manuals will cover the areas o fprogram management and monitoring, financial and procurement management, disbursement planning and process, reporting requirements and formats and roles andresponsibilities o fthe institutions/individualsinvolved. (k) BasicElementsof the MOH-IPRelationshipAgreement A sub-grant agreement, signed by the MOH and the IP outlines the roles, responsibilities, and obligations o f the different parties. The sub-grant agreement will stipulate, inter alia, the nature and costs o f the services to be provided by the IP; the qualifications o f staff to be provided; the relationships for managing the program (procurement, financial management, supervision and monitoring) by the IP, CMLS/SantC, and DSF, and the frequency and content o f the technical and management reports to be submitted to MOH. IP will provide annual plans detailing the costs o f the proposed HIV/AIDS treatment programs; these will be reviewed jointly by a committee comprising MOH, WHO and IDA. Disbursements through MOH to the consortium will be linked to agreed specific progress report indicators and related financial reports on utilization o f earlier funds received. (1) SpecialConsiderations:ARV logistics o Who will manageARV procurement? The Directorate (DGPML) incharge o f laboratory andpharmaceutical matters regulates all drugs (including ARV) and is responsible for ensuring the quality o f drugs imported and used in Burkina. To be imported, all drugs must be listed under the nomenclature o f the national list of previously approved drugs. The process for registering ARV in Burkina follows the same steps as for all other drugs, with the exceptionthat approval o f ARV has been accelerated by the use o f a temporary authorization. The Directorate intends to eliminate this accelerated approval once the national treatment guidelines are officially adopted and decisions are reached on the number andtypes o fARV to include on the national list. In addition, the DGPML plays an important role in controlling drug quality at the time of importation, duringdistribution to health facilities andprivate pharmacies at all levels, and at any time thereafter to ensure the permanent quality of the drugs in stock. Pre-market controls at CAMEG by the DGPML involve a review o f GPP produced the provider; post-market controls comprise physical and chemical tests produced by the National Public Health Laboratory on drug 32 samples collected. Additionally for ARV, the DGPML requires laboratory results on patients treated with these drugs to confirm their potency. The DGPML is also responsible for controlling the quality o f prescribing and dispensing practices for all drugs, including ARV. In public health facilities, the Ministry o f Health requires: (i)that both the health facility and the prescribing and dispensing personnel be approved and (ii) (preferably) these two types o f personnel be on the same site. However, that even at the district hospital level (CMA), the lack o f personnel means that it is difficult to meet these conditions, since only 25 pharmacists graduate each year and only 15 o f these are recruited for the MOH. MOH's rules also apply to associations involved in treatment. Since most NGO/Association clinics have prescribers (physicians), they do not often have pharmacists; in this case, the DGPML has agreed that any person with a BEPC8or a licensed nurse, who has completed 6 months o f pharmacy training under the tutelage o f a licensed pharmacist, will be allowed to dispense drugs. To dispense ARV, the same personnel will be required to take supplemental training inARV. o How will ARV bestored/distributedinthe country? Since 1994, CAMEG, an autonomous state pharmaceutical supply agency procures and distributes all drugs and medical supplies to public sector health facilities. It supplies the NGO and associations providing care and treatment o f HIV/AIDS, especially with regard to ARV. CAMEG operates through a convention signed with the Government, which includes performance indicators that are periodically evaluated by the DGPML. To insure the quality o f drugs, CAMEG has (i) adopted strict criteria for the pre-selection o f suppliers, (ii) organized intemational competitive tenders to establish a short list o f eligible suppliers, and (iii) signed three-year contracts (renewable annually) for those drugs for which they have offered the best price and conditions. This process is conducted annually to ensure that new suppliers are pre- qualified and that previously pre-qualified supplies widen the range o f their products. CAMEG carries out quality control evaluation o f drugs and medical supplies prior to shipping and after delivery inBurkina. Visits to CAMEG's drug central warehouse have confirmed that they meet intemational norms for cleanliness, temperature and humidity, and that air conditioning and refrigeration are adequate. CAMEG also maintains regional depots for supplying the regional and district hospitals. TAP would support current efforts to improve the availability o f quality drugs and particularly for ARV by strengthening the existing systems for all aspects o f the pharmaceutical sector, including: regulation, procurement, distribution and storage, andprescription and dispensing. (m) ProjectSupervisionPlan The project will require intensive supervision given its innovative approach, the large span of activities from the community to the national level, its blend o f public and non-public sector implementation agencies whose experience with HIV/AIDS programs varies considerably, and its multi-sectoral nature. The range o f activities in care and treatment is complex and will be implemented by many entities whose capacity will need strengthening in order to scale up * Nationaldiploma- Burkina 33 activities effectively. IDA'Ssupervision effort in the first year will focus on the following strategic areas: o NationalLevel Overall project supervision will be carried out under the authority o f the CMLS, which will be responsible for all aspects o f the TAP. As a practical matter, the Treatment Committee with support from CMLSISantC and the DSF will provide the supportive supervision and monitoring along with the regional and district health authorities as the program is rolled out. Hands-on technical supervision and support inthe participating treatment facilities will be organizedby the IP in cooperation with the previously identified referral sites. Periodic meetings o f the thematic commissions, quarterly meetings o f the Technical Committee, and annual consultative meetings will provide periodic venues for analyzing the results from the field. Additional technical support inthe country would be provided by WHO staff based in country offices, in Geneva, in WHO- AFRO. The TAP will also benefit from Bank supervision both through the Resident Mission and from Washington. o RegionalLevel Burkina's supervision organs andtechnicians will benefit from semi-annual meetings o f the RAP and RCCC coordinated by the World Bank, WHO and UNECA. The Technical Committee, as the quality assurance institution for Burkina will communicate quarterly reports to the RAP secretariat inAddis Ababa with copies to the World Bank, WHO (AFRO and Geneva) for review and preparation o f semi-annual regional learning meetings. WHO will back-up Burkina Faso's treatment program under the TAP on request and recommend extraordinary sessions o fRAP and RCCC upon requests o f individualTAP countries, IF or IP. WHO back-up support will focus on guidelines and treatment protocols, clinical monitoring systems and efficiency o f patient tracking systems set up as well as support trainingat referral hospitals. 34 Attachment to Country Annex 1-A Implementation Partners in Burkina Faso AlDSETl AIDS Empowerment and Treatment Intemational (AIDSETI), a non-profit organization created in December 1999, is an international network of 22 community-based associations of People Living with HIV/AIDS (PLWHA) focused on providing HN care and treatment in 14 o f the poorest countries o f Africa and the Caribbean. InBurkinaFaso, six associations are members o f the AIDSETI network: AAS, ALAVI, AMMIE9, Espoir-Vie, REVS+ and Vie Positive. An initial survey o f the six member associations from Burkina Faso indicates that at this time they provide care for about 4,000 HIV+ patients. O f these, 65 percent are inStages I11and IV o f the AIDS diseasewith 3,000 waiting for ARV; 74 percent are women, mostly mothers with children; 34joined a MTCT program. Already 125 children are HIV+orphans. As o fDecember 2003,330 patients were receiving ART, 30 o f them being directly financed by AIDSETI. All the six associations were already providing ARV drugs as of January 2003. The program is envisioned for three years, beginning 2004 with all activities begun in the first year and continuing throughout. SainteCamille Sainte Camille Medical Centre (CMSC) in Ouagadougouwas the first PMTCT site of Burkina Faso. Created inthe 60s, it was founded by Camillian Fathers. CMSC has a convention with the MinistryofHealth. The CMSC is specializedinmother andchildhealth, andoffers a largepanel o f services (pediatric day hospital, education and nutrition centre, maternity, laboratory, pharmacy, etc.) to women from the poorest urban areas. In2002, the CMSC was the first site to implement free PMTCT (with financial support from WHO, Italy, and UNICEF. In2003, the CMSC started to offer free PMTCT+, using ART offered by a private company from Burkina and technical assistance from ESTHER and Italy. Being a pilot site in PMTCT in Burkina, CMSC plays a critical role in the diffusion o f experience and training. Between May 02 and November 03, 5 320 women came to the CPN". The program is envisioned for three years, beginning 2004 with all activities beguninthe first year andcontinuingthroughout. CICDoc The CICDoc was created in 1999 by seven o f the most dynamic associations fighting against HIV/AIDS in Burkina (two of which, AAS and ALAVI, are also members of AIDSETI, and have submittedtheir proposals to TAP as part o f the AIDSETI network). CICDoc plays the role o f a coordination and concertation body for these associations and many practitioners already very active inthe fight against HN. In5 years, CICDoc developed preventionactivities, care & support activities, lobby, support to vulnerable children, psychosocial and financier support for PLWHN. CICDoc benefitedfrom the technical andor financial support o f manypartners, such as UNDP, USAID, Catwell, the German Cooperation (GTZ) and the Embassies o f Denmark, France, andthe Netherlands. With the CICDoc network, the CentreMkdical du Camp de Z'Unite' (CMCU) i s in charge of prescribing ARV to all of the associations part of the network at the national level. It is the CMCU, which welcomes the patients coming from all partners. Under the Network of teachers, doctors and nurses active inhealth (particularly children's health), education andpromotion of community level economic activities - Burkina loAntenatal consultation 35 TAP, the Ministryof Healthis likely to encourage CICDoc member associations to partnerwith additional district hospitals, to expand geographic coverage. Currently, 50 patients from 5 associations benefit from ART thanks to a grant of ARV from TAN ALIZ. Over the past year, 18.944 people participated to VCT and among them 2.021 were declared HIV positive. More than 1.500 patients are still waiting for ARV. The program is envisioned for three years, beginning 2004 with all activities begun inthe first year and continuing throughout. 36 Annex 1-B: Country and Sector or Program Background Regional HIVIAIDSTreatment Acceleration Project Ghana 1. General (n) HIV/AIDS EpidemicandTreatmentNeeds Current situation. The reported HIV prevalence rate in Ghana has increased from 2.3% (2000) to 3.6% (2003). However, there are wide regional variations (from 2.0 % inthe Northern Region to 8.0 % inthe EasternRegion). By the end o f 2003, a total of 378,000 people (of whom 26,000 are children aged 0-14) were living with HIV/AIDS. The cumulative number o f AIDS cases reported inGhana inSeptember 2003 was put at 72,200. Between January and September 2003, 7,850 new AIDS cases were identified. While these results suggest that the virus is on the increase nationwide preliminary data from the 2003 Demographic and Health Survey (DHS+) indicates lower than expected levels o f infection among adults. The relatively low rates and reassuring trends among the general population contrast sharply with HIV rates among high-risk groups, such as commercial sex workers, with 77 percent in Accra and 82 percent inKumasi. STI rates among sex workers, while lower than in eastern and southern Africa, are also relatively high: inAccra, 32.2 percent o f sex workers hadN.gonorrhea, 18.9 percent had C. Albicans, 11.2 percent had T. vaginalis, 10 percent had C. trachomatis and 9.8 percent had genital ulcers on examination. Thus, the infection gradient between sex workers and the general population i s amongst the highest in the world, highlighting a need for targeted action. Treatment Needs. Of the 352,000 Ghanaian adults estimated infected, the recent WHO 3x5 mission estimated that 62,000 could benefit from ART and established 29,000 as the target to be achieved by 2005. Currently, about 700 persons are receiving ARV through public financing at Korle Bu Teaching, Manya Krobo and Atua Hospitals. Information on the numbers o f people receiving ARV through the private sector i s very limited. (0) Progressinthe implementationofthe MAP The Ghana AIDS Commission i s considered to have contributed significantly in bringing HIVIAIDS to the forefront of the national agenda and in spearheading the multi-sectoral response at the national level. A mid-term review of the IDA-financed Ghana AIDS Response Fund (GARFUND) has just been completed. GARFUND'Saccomplishments were found to be quite significant. Over 2,700 line Ministries, CBOs, FBOs (Faith Based Organizations), and NGO have benefited from GARFUND support. GARFUND has also made progress inreaching out to the private sector. 1,400 orphans and vulnerable children are being supported. In addition, district AIDS plans are in the final stages o f preparation or have been completed showing a strong commitment at the 37 decentralized level to address HIV/AIDS issues. IDA considers management o f GAC to be an example of "best practice." Preliminary discussions have been held between the Government and IDA on a follow-up MAP operation, which could include treatment. MAP 2 has currently been included in the Country Assistance Strategy (CAS) for FY06 but could be moved to FY05. In addition to its own objectives, TAP would provide bridge funding for treatment, which could become available through MAP2, the Global Fund, andother funding sources. (p) InstitutionalEnvironment:MOHandPartnerdpartnershipsin HIV/AIDS Ghana's national response to the HIV/AIDS situation is organized through the Ghana AIDS Commission (GAC), established in September 2000 under the Office o f the President and charged with coordinating a multi-sectoral response program, with broad based, high-level representation o f all key sectors (15 Ministers of State are represented). The "Ghana HIV/AIDS Strategic Framework (2001-2005)" provides the basis for the Commission to coordinate the different interventions currently underway, while the "Health Sector HIV/AIDS Strategic Plan 2002-2006" provides the general principles and objectives for MOH. MOH has had overall responsibility for policies on gender and health issues. MOH's "Private Health Sector Policy'' was formally publishedin September 2003 and provides a framework for promoting partnership between the public and private providers and facilitating health-related interventions where the private sector has a comparative advantage. Collaboration among the MOH, the Global Fund Country Coordination Mechanism (CCM) andthe GAC has been significantly strengthened. The GAC has delegated issues concerning treatment and care o f PLWHA to the MOH's National AIDS/STI Control Program (NACP). The NACP i s a division within the Disease Control Unit o f the Public Health Directorate and will serve as the focal point for the TAP within the Ghana Health Service (GHS). To date, the NACP has overseen implementation o f a pilot treatment program intwo district-level hospitals (one public and the other faith-based), the results o fwhich are currently beingextended to two tertiary (teaching) hospitals inAccra and Kumasi. Financing o f the overall HIV/AIDS response and assistance in capacity enhancement has been provided b numerous multilateral (EU, UNAIDS, UNDP, WHO, World Bank, etc.), bilateral (DANIDA ,DflD, JICA, Netherlands, USAID, CIDA), and by local and international non- x governmental partners (Care, World Education, FHI, etc.) partners. All o f the partners work within the framework ofthe Health SWAP supported by donors includingthe World Bank. This approach is meant to improve resource allocation, minimize overlaps and build the capacity o f the MOH, especially inprogramming financial management and procurement. The flexibility o f the SWAP allows donors to earmark funds for specific interventions. To oversee the implementation o f the program and the quality of care and treatment, MOH has recently instituted a national advisory committee and a technical committee to provide guidance for NACP. The proposed committee would collaborate with other partners and receive technical support from WHO, UNICEF, and UNFPA. MOH has also established the Joint NACP/RCH Technical Committee, which includes those technical partners interested in M T C T and MTCT- Plus. Roles and responsibilities for implementation o f the Strategic Plan are clearly articulated among the Ministry, the GHS, andthe NACP. DanishInternationalDevelopment Agency 38 (9) Options consideredfor the institutionalset up andrejected Integration of TAP into the SWAP. Because TAP activities focus on treatment o f PLWHA and fall within the purview of the MOH, use o f the Health SWAP Pool Account was considered but deemedinappropriate for two reasons: (i) need to ensure that adequate amounts budgeted for the treatment are effectively disbursed and in a timely manner; and (ii) the need to carehlly track amounts for evaluation purposes. However, because o f established systems channels within the MOH and the ability to earmark funds for specific activities, it was proposed to the MOH and donors that TAP finding be channeled through the MOH systems and earmarked for HIV/AIDS, similar to the arrangement inplacefor the Global Fundactivities. Exclusivefocus on public sector service delivery. Since some governments have so far limited M A P treatment initiatives to public sector facilities to the exclusion o f non-governmental health institutions and services run through public-private partnerships, the option o f focusing only on the public sector was considered but rejectedbecause: (i) it was determined that the public sector rarely has the full capability to offer all of the treatment components envisioned by TAP in its own structures or with its own personnel; and (ii) the involvement o f a broad spectrum o f partners in different treatment components (including centers o f excellence, NGOs, associations o f PLWHA, faith-based organizations, regional and district hospitals, traditional healers, midwives and birth attendants, and the private sector) is an important element for accelerating treatment. Publidprivate sector partnership under MOH coordination through the NACP. The NACP is responsible for coordination o f the public/private sector partnership in STI/HIV/AIDS care and treatment within the MOH. This approach is consistent with the MOH policy for promoting public-private partnerships and extends the efforts by the GAC to develop a national HIV/AIDS Workplace Policy. This policy seeks to: (a) preventthe spread of HIV/AIDS among workers; (b) provide care, support and counseling for those infected and affected; and (c) protect PLWHA fiom discrimination inthe workplace. This policy andpartnership would be further strengthened by the TAP by extending comprehensive treatment to non-company PLWHA in each targeted community. This implementation approach was judged to be the most promising and was acceptable both to the Government andto IDA. (r) Institutionalsustainabilityandrisk Insufficient technical and program management capacity. Implementation o f the national scale-up plan with TAP, Global Fund, and other partner support will involve considerable additional responsibilities for MOH and especially for NACP. To increase the available technical capacity, MOH has created a national advisory committee and a technical working committee comprising the existing expertise within the ministry. TAP will provide additional staff for NACP and support for the operations o f these technical committees. In addition, to reduce administrative demands on NACP, it will rely on the procurement and financial management capabilities developed under the SWAP. Finally, in the areas o f accreditation, training and supervision, and patient monitoring, TAP will encourage NACP to decentralize and/or contract out responsibilities, where appropriate. 39 Drug availability. CMS data indicate that it regularly runs short o f about 40% o f the essential drugs needed for basic health care (andfor treatment o f 01s inparticular). This is due to: (i) the non-inclusion o f a number o f critically important drugs (e.g. anti fungal drugs) identified on the National Essential Drug list but not on the CMS list o f drugs in stock; and (ii) lack o f the communicationbetween the treatment sites and CMS on the one hand andbetween CMS andthe Procurement Unit/MOH on the other. MOH is currently taking measures to ensure that the two existing lists are merged and to improve the existing monthly and quarterly reporting. Treatment site activity reports relative to case load and use o f existing stocks would provide the basis for further supplies from CMS. Each HIV/AIDS accredited treatment center will purchase and collect its supplies directly from CMS and later from the RMS, thereby limiting seepage. A quarterly operational review of this system will be undertaken by the TWG with a view to makingneeded adjustments inrelation to modification o f dosage anddrugcombinations. These measures (along with the existing procurement arrangements with IDA/Netherlands'2) should provide for the availability o f drugs and eliminate the current CMS practice o f issuing certificates o f non-availability allowing clients to purchase items through an inadequately regulated private sector market and aggravating the difficulties the sick have of obtaining such drugs. TAP would address other constraints concerning specific logistical (storage spaces, particularly cold chain management) and organizational issues as well as relevant training for the efficient use o f these drugs. Inadequate financial and political commitment. In anticipation o f increased scale up challenges which even the TAP will not fully fund, the Government has established a line item o f US$1.5 million for HIV/AIDS-related procurement, particularly ARV inits FY04 budget and hopes to increase this figure on an annual basis. Following the UNGASS Declaration in 2001, government has directed that 15% o f Ghana's health budget will be committed to HIV/AIDS activities, but details on how this will be achieved are still being worked out. Given that the WHO 3x5 scoping mission identified that Ghana needs to be providing treatment to 29,000 peopleby the end o f 2005 out o fthe estimated 62,000 people needingtreatment, andthis number may have to continue to rise after 2005, it is necessary for the Government to continue to scale up the funds available from the national budget to provide treatment and cake for HIV/AIDS patients. Each o f the District Assemblies (DAs) has also been mandated to commit 1% o f the District Assemblies Common Fund for HIV/AIDS. Government has a treatment policy to subsidize cost13 of ARV, leave no infected person untreated, and rapidly expand treatment to four regions using a cost exemption policy to ensure equity. Duringthe first phase o f scaling up, Ghana has decided to create and maintain a separate ledger for HIV/AIDS services to better track expenditures. Inaddition, financial sustainability will come from the Global Fund, which has andwill continue to support largetreatment-related programs. 2. Ghana Institutional Framework (s) Overall structure l2InternationalDispensary Agency 13 5,000 cedis per patient for VCT services, and 50,000 cedis per monthper patient for a clinical management package, which includes and is explicitly defined as one month's supply o fARV, prophylaxis and treatment o fOIs, upto four (4) CD4count testsper year, andupto four (4) basic laboratory investigations per year (fullbloodcount, blood urea and electrolytes, liver function tests, and fasting blood sugar tests). Source: Ghana MOHLetter o f 10 September 2003, Ref.No. SD-I 10 SF.3 Vol. 1/36. 40 An Advisory Committee on Antiretroviral Therapy in Ghana (ACATG) was established on February 09, 2004 to streamline inflow o f ARV into Ghana and advise on future directions in ARV policy and implementation. Its membership includes representation o f key stakeholders (GHS, PLWHA, Pharmacy Council, Food and Drugs Board, GAC, MOH's Procurement and Supplies Division, and NACP). This committee is supported by a Technical Working Group on ARV Therapy (TWG), organized under the aegis o f the NACP and comprising members from the teaching hospitals, the medical school, private hospitals active in HIV/AIDS treatment, the medical research institute, MOH's procurement unit, and Family Health International (which has supported Ghanawith the pilot treatment program testing). The TWG will, inter alia: (i) provide support on matters related to treatment and care o f persons living with HIV/AIDS; (ii)take part inclinical sites visits and accreditationof all sites and service providers; (iii) technical provide backup and support to all sites earmarked for accreditation and all accredited sites; and (iv) provide relevant material based on both local and external clinical experiences and research for review and revision o fnational guidelines on treatment and care, when necessary. I Ghana NACP Organogram I IDirector Public Health I NACP Programme Other Disease Manager Programmes Surveillance (t) Relationshipto Ministryof Healthand other programs The ACATG will advise M O H on HIV/AIDS treatment, facilitate implementation o f the national policy to scale up HIV/AIDS treatment, and define modalities for streamlining the importation o f ARV into Ghana. Its senior membership will provide the Minister o fHealthwith a full range o f expertise and a venue for formulating and articulating policy on treatment. The TWG is a team o f clinical experts who will be responsible for setting treatment standards and ensuring quality within established HIV/AIDS treatment policy. This group will serve the MOH as an operational support group for effective treatment acceleration and will report to the MOH through its NACP and GHS Department. The TWG will refine treatment guidelines and 41 protocols for all elements o f Ghana's comprehensive treatment program (VCT, Positive living and nutrition support, OIs, STI, PMTCT-plus, ART, operational research and monitoring and evaluation). It will consult with treatment sites and district health administrations in setting criteria for home-based care activities as well as analyzing service statistics for guiding policy in areas o f standardized treatment, cost sharing, andtraining. (u) ProjectCoordination NACP has already gained experience in coordinating treatment projects through its association with Family Health International (FHI) in implementing the pilot scheme. Under the scale-up plan, NACP will serve as the secretariat to the National Advisory Committee and the Technical Working Committee, whose roles have been generally defined. Day to day coordination o f the program at the selected treatment facilities will be the responsibility o f the PEFPAIconsortium; monthly meetings o f the Technical Working Committee will provide a regular forum for analyzing the results from the field. TAP would finance coordination staff within the consortium andwithin NACP as well. TAP would also finance quarterly meetings o f the National Advisory Committee and an annual review o f the results o f the program. (v) Institutionalsupportinfrastructure To avoid the creation o f parallel systems for complementary health interventions, TAP will provide assistance to NACP and the Implementing Partners through the existing structures and mechanisms established by MOH. NACP will provide technical support to the oversight committees; will provide technical and financial support to the Implementing Partners; and assume responsibility for a number o f hnctions, including: accreditation o f treatment sites, in- service training o f health personnel on the newly developed treatment protocols and guidelines (VCTPMTCT, STI and 01treatment, and ART), and monitoring o f program performance and patient impact. NACP will rely on other institutions to carry out the actual TAP activities but will maintain the overall supervisory role for the Ghana TAP program. Infrastructure and equipment needs will be identified by the appropriate services within MOH and the Regional Health Administrations (Estates Management and Bio-medical engineering). AIDS-related drugs and equipment will be procured through the Procurement Unit (PU), in the Department o f Medical Services (DMS) under the MOH, and will be distributed through the Central Medical Stores (CMS) and their regional and district offices. Implementing Partners will be required to achieve the identified performance targets within their annual work programs. As part o f the continuous monitoring and information gathering, disbursement will be linked to financial and program reporting. Request for funds, together with program reports will be sent to the program coordinator (or NACP), for review and approval before being sent to the financial controller's office for processing o f payments. Pre-service training o f health personnel in the treatment protocols and guidelines established by the Technical Committee will be provided by the School of Public Health and Regional Teaching Hospitals, under the auspices o f the Chief Health Officer and the Regional HealthAdministration. 42 3. MainImplementingAgents The TAP country programwill be implemented byNACP incollaboration with the relevant units o f MOH/GHS. NACP will be the focal point for the partnership between PEFPAI, a private partnership representingthe efforts o fprivate companies to establish treatment programs for their employees. The TAP strategy in Ghana is based on leveragingprivate company health facilities and funding to provide care for all members (employees' families, and the general public, particularly the poor) o f the surrounding communities. Private company treatment sites operating under the coordination and supervision o f PEFPAIwill report to NACP and be ready to respond to inspection requirements by the TWG on HIV/AIDS quality assurance and perfonnance target matters. Monthly or quarterly progress reports would serve as monitoring and evaluation instruments. PEFPAIhave established working relationships with other existing organizations (CHAG14, CEDEP, associations o f PLWHA, etc.) and will enter into sub-contract agreements with them to indicate the perfonnance targets and standards applicable under the TAP. (w) Ministry ofHealth(MOH) o Elementsof comprehensivetreatmentprogramsand activities Ghana's HIV/AIDS treatment guidelines for: (a) voluntary counseling and testing, (b) opportunistic infections (c) sexually transmitted infections, and (d) anti-retroviral treatment were tested inthe pilot treatment initiative supported by FHI. Usinglessons drawn from the pilot, the MOH opened two new treatment urbansites at teaching hospitals inAccra andKumasi to serve as training sites for the program. The guidelines have recently been revised to incorporate new WHO recommendations on first and second line drug regimens and pediatric ART. The revisions were discussed with the WHO 3 by 5 scoping mission in March 2004 and have subsequentlybeen approvedbythe technical committee. VCT. National Guidelines for Development and Implementationof VCT inGhanapublished in November 2003 provide detailed guidelines on: (i) proper organization and operation o f a the VCT site; (ii) HIV test-related counseling, both pre- andpost for positive and negative results; (iii) testingproceduresforHN;and(iv) additionalqualityandreferralsteps. Ghana's actual planis to operate at least one VCT site ineach o fthe 110districts andthis is far behind schedule. Only 26 VCT centers have beentrained andaccredited to provide service. Under the TAP, VCT services provided by the designated sites will be enhanced byproviding additional staff to handle increased patient uptake o f VCT services at implementing partner sites infour regions and 12-15 districts. TAP will therefore promote the overall MOH policy while pushingit more rapidly to the district level. Community Care and Support (Home-based care). Guidelines on appropriate continuum for home-based care have been developed by NACP with the Technical Committee. TAP funding will allow training to be expanded to include to Community HealthOfficers. 14 The Christian Health Association of Ghana (CHAG) is a recognizedand accredited organization, based inGhana, which has extensive experience insetting up community based homecare programs and has worked previously with the GARFUND. 43 Treatmentof STI. Ghanadeveloped guidelines for the management o f STIs that were published inSeptember 2002. Recognizing STIs as a major avenue for increased HIV/AIDS transmission, Ghana has incorporated the treatment o f STI into its HIVIAIDS treatment program. Treatment guidelines would includes those for STIs and training modules for HIV/AIDS treatment would include STI and drugs supplies would also include medicines for STIs. Thus comprehensive treatment at all sites would target STIs to limit transmission rates. Treatmentof OIs. Ghana has developed guidelines for the management o f 01s and other HIV- related diseases that were published in September 2002. Training o f health personnel in the implementation of these guidelines has begun, and TAP funding will assist in rolling out this training to clinicians and medical assistants in the identified regions, as well as provide funding for procurement o f the necessary drugs needed to treat 01s at implementing sites. PMTCT and PMTCT-Plus. A national PMTCT program was launched inDecember 2001, and current treatment protocols and program guidelines are consistent with WHO recommendations, are adapted to conditions in Ghana, and provide an adequate framework for the TAP. A further component on PMTCT-Plus as well as a training module for it to have been approved by a technical committee. The on-going pilot program at two hospitals (Saint Martin's and Atua in Manya G o b o District in the Eastern Region) is being carried out by the Division for Reproductive and Child Health with substantial support roles from UNICEF, WHO, UNFPA, WFP (for nutritional aspects), and (untilrecently) by FHI. The pilot targets an area with one o f the highest HIV prevalence rates in Ghana. UNICEF and UNFPA support PMTCT activities to which the Global Fundi s allocating more resources. Under TAP, PMTCT services through the MOH will be provided free o f charge and the MOHwill undertake to train all relevant clinicians andhealthpersonnelon their acceptedPMTCT guidelines. ART. Guidelines for ART in Ghana were developed and published in September 2002. However, the MOH was not purchasing drugs at the time and did not indicate any national standard ART regimens to follow. With the MOH decision to procure all ART inGhana through the MOH Procurement Unit, these national standard regimens have now been developed. FHI, with funding from USAID has been involved in piloting comprehensive prevention, treatment, and care, including the initiation o f ART in Ghana. Under the TAP, the MOH will provide backstop medical support and referral services to the private implementing partners and ensure the quality and standardization of first and second line drug regimens used and the protocols followed by all health facilities within Ghana. Inaddition, the TAP will fundthe procurement o f drugs needed to treat additional patients enrolled in the sites operated by the implementing partners. o HumanResources An insufficient number o f trained personnel constitute a major constraint to scaling up HIV/AIDS care and treatment in Ghana. The policy is to train all prescribing staff at different technical levels, and to build up two regional training teams to launch a fast track decentralized training program. Government is contemplating other solutions, which include reclassification and additional recruitment for certain job categories (e.g., counselors and social workers), introduction o f HIV/AIDS into the pre-service training curriculum, and a major investment inin- service training for facility-based services and home-based care. 44 With important support from several partners, M O H and GHS are currently preparing a mechanism for the acceleration of training sessions. An ambitious training program covering training inthe use of treatment guidelines has begun and covers VCT, STIs, positive living and community psycho-social support, 01, ARV (for adult and pediatric patients) and PMTCT-plus. A draft periodic review planis envisaged for these guidelines andprotocols to facilitate regular adjustments inaccordancewith rapidly evolving informationinthe field (with respectto first and second line drugs). The training programs cover VCT guidelines and manuals (10 days), STI training (5 days), integrated 01and ARV training (10 days), an integrated VCT & PMTCT training (14 days), and a special training program for training TOTSfor counseling hasbegun. o Adequacyof fiduciary managementper existingBankPrograms Financialmanagement o f TAP funds will be handledthrough the existing Health Sector financial management systems, and within the framework o f the Health SWAP, as modified for the TAP flow o f funds. Further details are available in the financial management annex to the PAD. Procurement will carried out inaccordancewith the Public Procurement Act. Further details are available inthe procurement annex to the PAD. Retroactive Financing. The grant will include retroactive financing following the Bank's guidelines.Under this provision, the Government of Ghana will be eligible for reimbursemento f up to SDR 100,000 for expenses to make preparations for scaling up treatment under the TAP, which it has incurredafter May 13,2004. o AdequacyofEnvironmentalSafeguards For Ghana, as specified under the most recent Ghana Health I1PAD safeguard section, the Ghana Environment Protection Agency (EPA) has prepared national guidelines as the basis for segregation, packing, handling, storage, treatment, transportation, disposal and monitoring of health care waste. Subsequently, a policy document is being finalized by the Ministryo f Health for use by all relevant HIV/AIDS programs including, but not limitedto, the NationalHIV/AIDS Program, the Abidjan-Lagos Transport Corridor HIV/AIDS Project, the Ghana AIDS Response FUND (GARFUND), and all health care facilities (both public andprivate). Training would be carried out for all health care personnel to implement the health care waste management guidelines. Therefore all activities and partnersrelevant to the TAP would also be subject to this policy and guidelines. (x) ImplementingPartners o General Under TAP, the scaling up of service delivery through the private sector partners will be by a consortium comprising the Public Enterprise Foundation (PEF), PhannAccess Intemational (PAI), and their partners, Christian Health Association o f Ghana (CHAG) institutions. To date, PEF in collaboration with PA1 have spearheaded the initiative among private companies to organize prevention and VCT activities/services and to establish patient referral networks for laboratory services and treatment, including hospitalization; CHAG has been in the forefront of developing home-basedcare through grants from the GARFUND. 45 Stigma and utilization of services. Though GAC has identifiedmore than 2500 NGO working on HIV/AIDS, less than 10% o f the NGO surveyed indicated that PLWHA are primary beneficiaries o f their support. Such associations have demonstrated their importance for: (a) reducing the fear o f stigma and discrimination, which is linked to low ART uptake; (b) improving communication and advocacy to the community to inform them o f the availability o f ART; and (c) contributing to sustaining treatment and ensuring adherence. Resources to organize and strengthen associations o f PLWHA will be incorporated into the activities of the implementing partners to assist inreducing stigma. Technical andprogram management capacity. The implementing partners participating inTAP are already carrying out treatment activities within Government-accredited treatment facilities. There is a risk that the IPSwill be unable to handle the increased utilization o f treatment services due to lack o f capacity in laboratory and medical services, human resources, service delivery standards (and linkages with non clinical services), and logistics requirements. However, the accreditation process usedby the Ghana MOH includes verification of the availability o f these resources. Inaddition, TAP will contribute resources towards the management o f the program. Financial sustainability. The proposed intervention relies on private (for profit and not-for- profit) health service providers, which have been providing and/or have agreed to provide treatment for PLWHA. TAP will fund only a portion o f the program, which is already being financed by these providers and an additional amount for the PEFPAI consortium to ensure quality within the facilities andprovide linkages to the communities surrounding these facilities. The financial costs for utilization o f the treatment services will also be partially borne by the companies whose employees access treatment at the sites. Overall financial sustainability will depend on the availability o f additional resources from the Global Fund, future MAPprojects in Ghana, increased utilization o f the Health SWAP for HIV/AIDS treatment and the government budget line for health. o Relationshipbetweenthe ImplementingPartnersandMOH/NACP PEFand PA1haveproposed to expandservices to an additional twelve sites; they have identified the private companies served by them (along with the number o f employees served) as well as the appropriate public or private referral hospital, which would serve the referral needs o f these treatment sites. PEFPAI, on behalf o f the consortium, will sign a sub-contract (MOU) with the MOH-NACP that defines the roles and responsibilities o f the IPS,describes the services to be provided at the selected sites on behalf o f MOH, and indicates the criteria and process by which PEFPAI and the clinical facilities will provide financial and program reports to NACP and the Technical Committee, and subsequently receive disbursements o f additional funds if they meet the performance targets indicated in the MOU. MOH will strengthen those referral services, which have been identified as sites to receive referrals from the clinical facilities identified by the ImplementingPartners (as shown below). 46 TAP Selected Treatment Sites andReferral Centers Region Districtkeferral hospital MOHapproved IPtreatment sites Eastern 11Volta RiverAuthority Hospital (i) Hospital VR4 St. Joseph's Hospital, Koforidua (ii) Tuffour (iii) Joseph'sHospital St Western T a k a Government Hospital (i) JohnofGod(Sefwi-Asafo) St. (ii) (GhanaPorts) BOPP (iii) GoldFieldsClinic Takwa Ashanti Kumasi SouthHospital (i) Markus(Kumasi) St. Oboasi District Hospital (ii) (AGC) Oboasi (iii) Clinic(Teppa) Cocoa (i)OdomaClinic (ii) GAPOHA 47 GhanaHealthServices (GHS) publicHealthDept. AdmuuStration 1 InstitutionalArrangementsChart GhanaTAP - (z) InternationalOrganizationRolesandResponsibilities Please refer to main text o f the PAD. 4. Instrumentsand Documents (aa) TAP OperationsHandbookOutline A Public Procurement Act hasbeenpassedbyParliament and signedinto law bythe Presidentin December 2003. Adoption o f the Public Procurement Act and implementation o f the Public Procurement Institutions (Public Procurement Board, Secretariat, Entity Tender Committees and Tender Review Boards) is one o f the triggers for the Ghana PRSC I1 scheduled for Board Presentation inMay 2004. Furtherdetails are available inthe Procurement annex. While monitoring for VCTPMTCT is well developed, systems are currently inadequate for tracking patient progress and assessing impact. TAP is proposing to support current efforts while financing a feasibility study (and eventual procurement) o f a more comprehensive system. Inthe meantime, TAP will support ongoing patient management andmonitoring efforts as well as mechanisms to ensure treatment adherence mechanisms and the rapid identification o f ARV drugresistance. 48 A Memorandum o f Understanding (MOU), signed by the MOH and the PEFPAI consortium outlines the roles, responsibilities, and obligations o f the different parties. The MOU will stipulate, inter alia, the nature and costs o f the services to be provided by the consortium; the qualifications o f staff providing the services; the relationships for managing the program (procurement, financial management, supervision and monitoring) by the consortium and NACP; and the frequency and content of the technical and management reports to be submitted to MOWNACP. PEFPAIwill provide annual plans detailing the costs o fthe proposed HIV/AIDS treatment programs, and these will be reviewedjointly by a committee comprising NACPMOH, WHO and the World Bank. Disbursements through MOH to the consortium will be linked to agreed specific progress report indicators and related financial reports on utilization of earlier funds received. (bb) Special Considerations: ARV logistics o Who will manageARV procurement? Registration o f all drugs, including ARV is the responsibility of the Food and Drugs Board. No drugs, cosmetic medical devices, or chemical substances can be manufactured, imported, advertised, sold or distributed inthe country unless it has been registered inaccordance with this Board. For generic drugs, evidence must show that the patent has expired. For all drugs, registration is valid for 3 years and must be renewed thereafter. The boardpublishes a notice in the Gazette notifying the public o f current drugregistrations under these regulations. The Ghana Standards Board (GSB) is responsible for quality assurance, testing and surveillance of health sector goods and supplies in Ghana, including for HIV/AIDS drugs and related supplies. The GSB and the FDB do an efficient job, and provide fast track procedures for registering medical products with MA & GMP licenses from reputable Food and Drug Regulatory Agencies (FDRA). However improvements are needed in their surveillance function to ensure that required storage standards are respected. Drawing from its initial pilot project HIV/AIDS treatment, the Government has decided to procure drugs for all accredited HIV/AIDS treatment sites (public and private). This arrangement offers Ghana's population several advantages: (i)lower drug prices through economies of scale which individual private treatment centers were unable to achieve; (ii) lower treatment costs through Government subsidies to establish equivalent drugprices for all patients (public and private sector); and (iii)reduced misuse o f drugs. The Technical Working Group on Anti-Retroviral Treatment has already been established by the Ministry of Health to oversee the procurement o f HIV/AIDS drugs. Procurement inthe Ghana Health Service (GHS) headquarters i s the responsibility o f the Procurement and Supply Division (PSD), with a Procurement Unit (PU) and Procurement Committee, which provide technical support to other procuring BMC in the (GHS). A procurement manual was produced and disseminated to Central Medical Store (CMS), hospitals, and extensive in-service training was provided for concemed staff (latest version May 2003). IDA considers these procedures satisfactory. In addition, each BMC has established a Procurement Committee that ensure smooth implementation of its work plans, which they submit to the steering committee responsible for overall planning, review and approval o f contracts above thresholds, but the PU monitors and supervises all procurement activities in health. PU shall prepare and implement procurement plans, executes its plan and maintain an efficient record management system for all procurement activities including ARV. 49 o How will ARVs be stored/ distributedinthe country? All treatment centers would obtaindrugs either directly from CMS or at RegionalMedicalStores (RMS) and would be requiredto stock these instorage areas, which meet national standards with regard to temperature and humidity. The NACP has defined the criteria and procedures for evaluating and accrediting treatment facilities and is also responsible for ensuring that treatment facilities maintain these standards. The standards include the patient tracking system with: (i) a prescription log in two or three parts; (ii)a book for managing pharmaceutical stocks in the treatment sites. It also includes stock management software that will be usedby CMS, and linked to accredited health facilities, to monitor stock levels. (cc) Project Supervision Plan The project will require intensive supervision given its innovative approach, the large span o f activities from community to national level, its blend o f public andprivate sector implementation agencies whose experience with HIV/AIDS programs varies considerably, and its multi-sectoral nature. The range of activities in care and treatment is complex and will be implemented by many entities whose capacity will need strengthening inorder to scale up activities effectively. IDA'Ssupervision effort inthe first year will focus onthe following strategic areas: o Nationallevel Overall project supervision will be the responsibility o f the National Advisory Committee; as a practical matter, NACP and the Technical Working Committee will provide the supportive supervision and monitoring along with the regional and district health authorities as the program i s rolled out. The PEFPAIconsortium will organize hands-on technical supervision and support inthe participating treatment facilities. Monthlymeetingsofthe Technical WorkingCommittee, quarterly meetings of the National Advisory Committee, and annual consultative meetings will provide periodic venues for analyzing the results from the field. o Inter-country level Ghana's supervision organs and technicians will benefit from the semi-annual meetings o f the RAP and RCCC, coordinated by the World Bank and UNECA. The TWG as the quality assurance institution for Ghana will communicate quarterly reports to the RAP secretariat in Addis Ababa with copies to the World Bank, WHO (AFRO & Geneva) for review and preparation of the semi-annual regional learning meetings. WHO will back-stop Ghana's treatment program under the TAP on request and recommend extraordinary sessions o f RAP and RCCC when demanded by the individual TAP countries or IPS. WHO back-up support will focus on guidelines and treatment protocols, clinical monitoring systems and efficiency o f patient tracking systems set up as well as supporting the training at referral hospitals. o BankSupervision Bank supervision will be both through the Resident Mission and Washington. For country activities the MAP/Health SWAP TTL will be responsible for maintaining regular contact with the NACP, following TAP performance, provision o f no-objections, and regular reporting. As the TAP will deal with similar issues as encountered inthe MAP, Bank supervision can "piggy- 50 back" on MAP responsibilities with missions by health specialists, procurement and financial management specialists coinciding with TAP missions. An additional $50,000 annual supervision budget will be provided for country supervision. The Regional TAP TTL, responsible for both regional learning and coordination among the country programs, will be the back-up TTL for the country program, and the principal TTL for the entire TAP effort. The Regional TAP TTL will be provided with a separate budget that will allow country visits, and assistance to the country inthe learning aspects of the TAP. Frequency of missions. It is expected that there will be two supervision missions yearly, as well as participation by IDA at the semi-annual regional meetings. Supervision missions will be integrated into MAP and (when relevant) health sector supervisions. Supervision missions should include: Country TAP TTL Regional TAP TTL (as available) Health Specialist, complementing TTL skills Financial Management Specialist 0 Procurement Specialist 0 M&ESpecialist 0 Lawyer (as neededbasis) Regional meetings will include the participationo f Regional TAP TTL Country TAP TTL M&ESpecialist 0 Technical Specialist (ARV drugprocurement, gender, youth, nutrition, as needed) 51 Attachmentto CountryAnnex 1-B ImplementationPartners in Ghana PEF/PAI 1. Background The Private Enterprise Foundation (PEF) was founded in 1994 on the initiative o f four major business associations: the Association o f Ghana Industries (AGI), Ghana National Chamber of Commerce (GNCC), the Ghana Employers' Association (GEA) and the Federation o f Associations o f Ghanaian Exporters (FAGE). PEF is a non-profit, non-political, independent institution, which membership i s open to private businesses and trade associations. PEF's objective i s to manage workplace H N / A I D S and STI awareness and care programs. Over 270 small business leaders and 50 management staff o f seven large companies have benefited from the program. The PharmAccess International (PAI) i s an NGO based in Amsterdam, dedicated to providing HAART in a clinically justified way and at sustainable cost, and to provide technical support to public and private sector awareness, prevention and treatment programs. Since September 2001, PA1is co-implementing the Heineken HAART program in nine countries in Afiica, covering 7,000 employees, 6,000 spouses and 28,000 children. Subsequently PA1began to train staff in existing hospitals and clinics, and provide medical and organizational know-how to these facilities in order to support companies without medical amenities to finance and implement H N / A I D S treatment programs. PA1calls these upgraded facilities Affiliated Treatment Centers (ATC). ATC can be accessed by many companies and are characterized by their sustainability, transparency and quality or service. As a result o f the success and experience gained, more companies and institutions have now contracted PA1 to implement and guide their AIDS treatment program for employees and dependents. 2. Existing ProgramInformation PEFPAI have identified 12 sites as part o f their TAP-specific program o f activities (Eastern region: St. Joseph's, VRA, and Tuffour Memorial Hospital; Western region: Ghana Ports Hospital, St. John o f God Hospital, and Takwa Gold Fields Clinic; Ashanti region: St. Marcus Hospital, Cocoa Clinic - Teppa, and Oboasi (AGC) Hospital; Greater Accra region: Odoma Clinic and GAPOHA Hospital) and the list o f companies that they expect to access treatment at each site is listed in the IP Proposal. Current numbers o f patients accessing care at these clinics are unavailable because the facilities are not able as yet to provide ART to patients and so PEFPAIhavenot initiatedactivities althoughthey have experience with clinics in Accra. 3. AIDS-related staffing Currently, PEF has one office in Accra, with regional programs that use the offices o f existing members. Currently PA1 has sufficient fiduciary and administrative staff working on AIDS related activities. PA1 currently has one office situated in Accra, Ghana, with one (1) staff member dedicated to HIV/AIDS related activities, backed by an office in Amsterdam with 18 membersofstaff, including a financial controller. 52 4. Fiduciary Aspects Details are available inthe financial management and procurement annexes. 5. Adequacy of Environmental Safeguards Each o f the Implementing Partners has been informed o f the agreed-upon environmental safeguard guidelines on medical waste that must be followed by all medical facilities in Ghana and the implementing partners will be expected to follow these guidelines. In addition, the adequacy o f the medical waste management procedures at each site will be evaluated and upgraded, ifnecessary, duringthe accreditation process. 6. Monitoringand Evaluation Activities and Capacity A list o f clinical andnon-clinical indicators, identified from the National M&EPlanand agreed to by the Implementing Partners, will serve as the basis for monitoring and evaluating program performance. Progress against these indicators will be included as part o f the monthly and quarterly progressreports provided to NACP, andwill serve as the basis for achievement by the IPSo f their performance targets. PEF/PAI will providebackup support to the treatment centers incollecting andorganizingthis information for NACP. 7. ProposedProgramof activities Based on the treatment guidelines identified by NACP, all accredited treatment sites must provide the five (5) elements o f comprehensive care. NACP andthe Ips have identified at least 3 treatment sites in4 priority regions, and will begin with the sites in2 regions inthe first year of implementation and scale up to the other 2 regions inthe second year o f implementation. 8. TimeFrame The program is envisioned for three years, beginningmid-2004 with all activities begun in the first year and continuing for a three-year period untilthe identified Closing Date. 53 Annex 1-C: Country and Sector or Program Background Regional HlVlAlDSTreatment Acceleration Project MOZAMBlQUE 1. General (dd) HIV/AIDS Epidemic andTreatmentNeeds Current situation. Mozambique i s among the world's most affected countries interms o f HIV prevalence. Approximately 1.5 million Mozambicans are currently infected, and inthe age group 15-49 the prevalence o f infection is estimated at 13.6% (2002). The highest prevalence are found in the three central provinces: Manica (19%), Tete (14.2%), and Sofala (26.5%), along the transport corridors to Zimbabwe, Zambia, and Malawi. Estimates for Maputo and its environs exceed 17%. Higher rates are recorded in Gaza, which is home to migrant miners who work in South Africa. Current projections suggest that over the next three years the number o f people infected will rise to 1.8 million. The annual increase in new AIDS cases i s expected to rocket from 61,000 in 2000 to 170,000 by 2010, thereby putting additional burden on already overstretched health services. These trends would contribute to an estimated 27% drop in life expectancy by 2010 and substantially increase the number o f orphans to 900,000 by the end of this decade. Youth aged 15-24 are the most heavily affected and account for 60% o f new HIV infections. Half o f the nearly 1.5 million people already living with HIV/AIDS are between the ages o f 15 and 29. Girls and women in this age group are at especially high risk and are being infected at a ratio o ftwo to one over men. Treatment Needs. The number of people under ART (3228 in March 2004) i s extremely small compared to those estimated to be in immediate need o f ART. Less than one percent clinically eligible for treatment have access to anti-retroviral medication. As outlined in the Ministry o f Health's Strategic Plan to Combat STIs/HIV/AIDS ,2004-2008 (MISAU PEN), the Government plans to have approximately 8,000 patients on ARV by the end of 2004 and 132,000 by 2008. The Government's response to the HIV/AIDS epidemic is summarized in its National Strategic Planto Combat STIs andHIV/AIDS, 2000-2002 (National PEN), which seeks to slow the spread of HIV infections and to mitigate the effects o f the epidemic, though a multi-sectoral approach, focused mainly on prevention activities. Treatment and providing ARV therapy was not envisaged because of the high cost o f ARV at that time, and the complexity o f implementation. This National Strategic Planis now being revised andis due for completionbyJune 2004. Itwill be called the Plano Nacional de Combate ao S D A (PNCS) and will again be the guiding strategy for the implementation of the National response. It will encompass existing plans, including those o fthe line Ministries. The M I S A U PEN, which takes into account on one hand the escalating HIV epidemic, an overburdened health system, attrition o f health workers due to HIV/AIDS related mortality; and on the other hand reduction in prices o f antiretroviral drugs and increased funding, is estimated to require US$500 million over the next five years. The health sector planis being supported by a number o f bilateral donors, includingthe IDA HIV/AIDS Response Project (US$55.0 million) approved on March 10, 2003, and US$29.0 million in grants over two years from the Global 54 Fundto FightAIDS, TB, and Malaria (approved inJanuary 2003 but not yet effective). Despite this increased support, the government still faces funding shortfalls and has asked IDA for additional resources to accelerate ongoing NGOtreatment initiatives. The main focus o f the MISAUPENis the strengtheningo f the IntegratedHealth Network (HN) system. The IHNcombines prevention andtreatment provision ina comprehensive continuum o f care to reduce sexual and mother-to-child transmission, avoid transmission o f HIV in health facilities, and prolong the length and quality o f life o f PLWHA (including health workers) through treatment o f opportunistic infections and ART. Under this strategy, most o f HIV/AIDS treatment will be decentralized to day hospitals providing ambulatory care as the focal point o f integration and coordination o f the network, and o f HIV/AIDS care and treatment (including ARV). The health sector strategy will strengthen the health system through improvement o f infrastructure, humanresources, procurement and distribution, upgrading o f laboratory facilities andbloodbanks, nutrition, and logistics management. II centers I C Antenatal Cat (1-10 per Day Hosp) I Blood Bank I Tuberculosis I Maternity t Program Neviraoine Rx 1 Day Hospital(23 c in 2 yrs) -1-2 HAARTMDs, Med Asst Counseling nurses, aides Nutrition ' HAARTCare and DOT (ee) Progressinthe implementationof the MAP The MAP became effective inAugust 2003 and implementation ingeneral has been slower than expected. Implementation o f the MAPhealthcomponent, inparticular, has been slow, due inpart to the fact that the M I S A U PEN has only recently been finalized. The MAP will finance significant parts o f the health sector strategic plan especially for staff training, bio-safety issues, health waste management, research into traditional medicines, laboratory equipment, provision of test kits, condoms, medications for opportunistic infections, and other basic health-sector capacity aspects. Under the M I S A U PEN, ART will be extended to all eligible PLWHA. TAP support will supplement MAP and other donor funding to accelerate these ongoing treatment efforts and complement MAP efforts in providing accessible, equitable and affordable comprehensive prevention, treatment, care and support to PLWHA. The TAP provides an opportunity to test different approaches to scaling up, strengthening MOWNGO partnerships, 55 PLWHA involvement, andstrengthen health systems. The lessons leamed inthe TAP will enable Mozambique, using the M A P and other resources, to then scale up treatment initiatives supported byTAP to ensure continuity andsustain treatment efforts. (ff) InstitutionalEnvironment:MOHandPartnerdpartnershipsinHIV/AIDS The National Council to Combat HIV/AIDS (CNCS) was created in 2000 and is responsible for coordinating HIV/AIDS activities (including prevention, education, and care) among major partners (Government, civil society, donors, national and intemational NGO), as well as for mobilizingresources to fund the multi-sector response to the pandemic. It is headed by the Prime Minister and includes the Minister of Health as Vice President. An Executive Secretariat, which has the mandate to lead, catalyze, coordinate and monitor all activities insupport o f the National Strategy, but which does not implement programs, serves the CNCS. The Secretariat functions in close cooperation with the Ministry o f Health (MOH) and other ministries. It has a national office in Maputo with a provincial nucleus in each o f the ten provinces, and an eleventh in Maputo City. Each Ministry also has an HIV/AIDS focal point, and many Ministries have now elaborated HIV/AIDS plans. The CNCS is working closely with an umbrella organization o f NGOs, the Mozambique National AIDS Services Organization (MONASO), and with RENSIDA, a network o f 18 organizations o f PLWHA that focuses on orphans and vulnerable children and reducing stigma. International NGOs have grouped themselves into an association called NAIMA to assist the Government inits response to HIV/AIDS. Inthe MISAUPEN, MOHhas defined a management structure at national andprovincial levels. It has established a management team, technical groups, working groups within MOHas well as an inter-Ministerial working group to coordinate across interventions and sectors. A treatment committee has also been established. The government recognizes the importance of working withNGOs to implement its health sector strategic planandinthe area o ftreatment. While CNCS is responsible for overall coordination, MOH is responsible for implementing treatment and all health related aspects o f HIV/AIDS. There is close collaboration between CNCS andMOH since the Minister ofHealth is the Vice Presidento f CNCS. Donors and other partners inthe health sector are very well coordinated, meet every week, and engage on a regular two weekly basis with MOH through a SWAP forum. The bilateral funds will be channeled through the new general common fund for health (PROSAUDE), as is the intention for the Global Fund, as part o f the donor support for the M I S A U PEN. Other sources o f hnding for the MISAU PEN, e.g. MAP, Presidential Emergency Plan for AIDS Relief (PEPFAR), and some bilateralpartners, will not go through the common fund. (gg) Optionsconsideredfor the institutionalset up andrejected Integration of TAP into the MAP and as part of the Common Fund. Because o f the focused nature of the TAP, inclusion of various learning approaches, the need to synchronize activities with those o f the other TAP-supported countries, and the need to monitor carefully various aspects o f treatment activities for regional leaming, integration into the MAP was considered and rejected. Similarly, because of its focus on accelerating treatment of PLWHA and the regional 56 learning feature requiring cross-country comparisons, fimding under the TAP will go directly to the health sector, but outside o fthe existing common fundingmechanisms. Exclusive focus on public sector service delivery. The option o f focusing only on the public sector was considered but rejected because: (i) it was determined that the public sector would not have adequate capability to accelerate scaling up all treatment components envisioned in the MISAU PEN; (ii) up o f the magnitude envisioned will require rapid acceleration and scaling expansion o f ongoing demonstration initiatives by non-governmental partners; (iii)the involvement o f a broad spectrum o f partners in different treatment components (including NGOs, associations o f PLWHA, faith-based organizations, regional and district hospitals, traditional healers, midwives and birth attendants, and the private sector) will be an important element for ensuringthe full continuum o ftreatment and care. Partnership with non-governmental organizations through the CNCS. The option o f placing TAP inthe CNCS was considered but rejected, due to the fact that the CNCS is responsible for overall coordination, while MOH is responsible for implementing care and treatment interventions. The TAP approach is consistent with M I S A U PEN and MOH policy for promoting public-non-government partnerships to expand equitable access to comprehensive treatment to vulnerable groups. The collaboration o f MOH and experienced NGO was determined to be the most promising approach in achieving national treatment objectives, and consistent with TAP objectives to test approaches which mightbe replicated within Mozambique andelsewhere. (hh) Institutionalsustainability andrisks Basic issues with respect to institutional sustainability and risks relate to: (a) MOH continuing to strengthen andmaintain its treatment capabilities with respect to trained staff, adequate facilities, decentralization o f the health system, and reliability o f drug supplies; (b) effective partnerships and a collaborative environment for public andnon-public entities to respond to treatment needs; and (c) the readiness o f the Government to maintain high standards in carrying out its fiduciary functions, and to do so efficiently. 2. MozambiqueInstitutionalFramework (ii) OverallStructure The Minister o f Health has overall responsibility for the TAP. The Ministry's Advisory Council (Conselho Consultivo do Ministro- CCM) will assist him. Specifically, the Directorate o f Planning and Cooperation (DPC) and the Directorate o f Health (DNS) will have primary responsibility, coupled with intensive coordination with DAM,DEE, DSC, DRHandDF. 57 DPC NationalDirectorateo f I I MedicalServices National Directorate o f NationalDirectorate o f Plannin HumanResources + i 1 I DAM I &I Directorateo fClinicalProgram andHospitalAdministration I D i r e c t o ~ ~ ~ ~ ~ I f! ! o Oversightbody DPC will be responsible for coordinating the implementation o f TAP, drawing on the hll capabilities ofthe MOH. o TechnicalManagement:The TreatmentCommittee The M O H National Treatment Committee, headedby the Director of Medical Services (DAM), will provide regular technical guidance and review o f the TAP program. DNS will appoint a TAP Coordinator (Program Officer) financed from the TAP, who will be responsible for technical programming, as well as monitoring and evaluation, and operational coordination. S h e will prepare annual plans as part of the annual planning cycle o f the Ministry of Health. The DPC will be responsible for procurement and financial management. ImplementingPartners will deal principally with the Office of Coordination for Investment Projects (GACOPI) and the TAP Coordinator for operational matters, interface with the National Treatment Committee on technical matters, and Provincial medical officials at the facility level. DNS will be responsible for technical coordination and technical support to NGO, and technical monitoring and 58 evaluation. Under TAP, WHO will provide technical support to DNS on monitoring resistance and operations research. An operational manual will detail the organizational structure (see chart below) and procedures for the TAP, drawing on the following: The five treatment components are to be carried out by the Implementing Partners in MOH facilities. The TAP will build on expanding these existing activities. The Implementing Partners will be expected to reasonably respond to new treatment dynamics and implement their efforts consistent with the treatment protocols defined by MOH and the National Treatment Committee. With WHO assistance, technical review capacity will be put in place to recommend improvements in treatment and to provide the TAP Coordinator with quantitative and qualitative information on IP progress. o Other agencies Procurement Management. GACOPI i s a project implementation unit under DPC. It is fimded byseveral external agencies, includingthe IDAMAP.GACOPIprovides support to the MOHon management of external funds, which will include TAP. It will be responsible for the TAP procurement process and for providing reports to the TAP Coordinator. It will therefore work closely with C M A M (in the DNS) for drug and medical supply procurement. C M A M i s responsible for the planning and coordinating o f drugs and medical supplies. TAP drug procurement reports will become part o f the regular quarterly reports submitted to DNS and DPC, the Minister and the CCM. MEDIMOC will perform procurement processing tasks as directed and programmed by the MOH entities, namely C M A M and GACOPI. GACOPI duties will be similar to those it performs for the MAP, assuming its capabilities are strengthened, as agreed to and financed under the MAP. Financial Management. The financial management arrangements agreed for TAP are ingeneral based on the same framework being used for the Health Component o f the MAP. To avoid setting up any parallel systems, it is prudent to use the institutional structures that are already in place. In this regard, TAP'S financial management and disbursement will be managed by the Project Management Office (GACOPI), in the Ministry o f Health which has also supported the implementation of the closed Health Sector Recovery Project (Cr. 27880-MZ) and the Health Component of the on-going MAP project (Grant H0300-MZ). The project will disburse on basis of traditional approach, in which two methods o f disbursement will be used to access the grant proceeds, i.e. Direct Payment and use o f Statements o f Expenditures (SOEs). The flow o f funds includes funds for both the central level MOH activities as well as direct project support for the IPS(Pathfinder, Sant' Egidio andHealthAlliance International). All program proposals for TAP funds will pass through the MOH-DAM section for approval and harmonization which will ensure that all activities carried out by the IPSare in line with the MOH national policy and priorities for treatment of HIV-AIDS patients. Inthe event that there i s need for re-budgeting o f funds or any alterations to proposed activities by the IPS(or by sections of the MOH being supported via the TAP), then such revisions will require to be presented to the technical committee for approval. Disbursement and flow of funds from the Grant proceeds will be through the following two methods: I Direct Payment method - thismethodwill applyinrespect ofpayment to the IPS,if - the amounts involved exceed the minimum application value or size to be agreed at negotiations. The approved annual program proposals from the IPSand cash forecasts 59 will form basis for disbursementto the IPS,initially with an advance covering first 6- month period's cash needs. The methodwill also apply where payment may be made to a commercial bank for expenditures against IDA'SSpecial Commitment (SC) covering a commercial bank's Letter o f Credit (LC), issued infavor o f suppliers o f goods (ARV and other pharmaceuticals, medical supplies and equipment) whose value is above the minimumapplication size for direct payment byIDA (usually onbasis o fICB contracts). 2 Statements of Expenditure (SOEs) i.e. reimbursement claim - this method will be - used to reimburse MOH for payments o f eligible expenditures already pre-financed by the ministry (e.g. civil works carried out by force account, operating costs, payment against small contracts or purchase orders, etc). The limits for using SOEs will be discussed and agreed to. Under this method, supporting documentation for expenditures will be retained at GACOPI because these would be cumbersome and numerous for to attach to a Withdrawal Application, except for a summary sheet listing the different categories of eligible expenditures e.g. operating costs, etc being claimed. Special Account. Beside the Grant Account held by IDA, the project will have a Special Account to be opened by GACOPI in a commercial bank o f acceptable to IDA. GACOPI is familiar with the IDA procedures goveming the administration o f Special Accounts and will therefore be ready to initiate the process o f opening it after Grant effectiveness. The Special Account facility will be used to meet MOH cash needs only (not for IPS). The size o f the authorized amount for the Special Account will be discussed and agreed to, but not exceed 20% o f the Grant amount for Mozambique. Accounting, Reporting and Audit. All financial management operations for TAP will be managed by GACOPI and ensure that strict financial accountability is upheld for all parties involved in the TAP. Two additional senior accountants will be hired within GACOPI through financial support from TAP to ensure there is adequate capacity to properly manage the finances o f this project. Substantial support has already been given under MAP in enhancing capacity within. The IPSwill be required to submit their implementation and expenditure reports on a quarterly basis. GACOPI will consolidate the financial and physical progress reports and prepare Financial Monitoring Reports (FMRs) on quarterly basis. Annual financial statements will be prepared by GACOPI in readiness for audit, for the financial period ended each December 31. Annual review of IPS'technical and financial performance will be reviewed jointly by MOH/IDA/WHO, preferably each September/October. Approval o f subsequent year's annual program proposals from individual IP will be subject to satisfactory technical and financial performance as determined at the joint review. External auditing o f the project will be on an annual basis by independent and competent firm of auditors o f good standing and reputation. The current auditor for GACOPI is presently auditing all donors supported projects under GACOPI. It i s therefore proposed to adopt the same audit arrangement for TAP. The audited financial statements for TAP shall be submitted by GACOPI not later than six months after the end o f the accounting period to which they relate (every June 30). Although there exists an InternalAudit Unit inMOH, inaddition to the Internal Audit Service based inthe Ministry o f Planningand Finance, the frequency and focus o f their audit does not add value or complement the internal control environment in GACOPI. Recommendation for GACOPI to establish an internal audit function within its structure as a medium term goal has been givento MOH. 60 Monitoring and Evaluation. TAP will utilize the M&E system established bythe MOHthrough its National Treatment Committee members' participation, or through TAP advisory consultants execution. Data from TAP will flow both into the Mozambique national system, and will be provided for regional learning and development purposes. NGO will utilize and improve the patient tracking system. (jj) ProjectCoordination Preparation o f the National M I S A U PEN involved extensive consultation among all major partners, includingNGO, PLWHA, and the private sector. This broad collaboration strengthened the trust and working relations between the MOH and NGO active in the sector. With NGO treatment activities being carried out in public sector facilities, this cooperation becomes an operational necessity, especially for NGO accredited to carry out treatment services. TAP preparation highlighted the need for a more structured MOH-IP partnership through formal contractual accreditation arrangements with clearly defined activities and delegated responsibilities, coordination, common monitoring and evaluation indicators. Further, all partners recognize that the MOH is responsible for coordinating the technical treatment aspects in Mozambique. This coordination task will be done though the recently established MOH National Treatment Committee under the DAM. It comprises the main treatment units of the MOH and relevant support service units, and MOH leadership from those provinces where treatment is programmed for 2004-2008. CNCS and its secretariat will be kept informed o f program progress and will provide other stakeholders with such information. The MAP and TAP coordinators will meet regularly and share their respectivereports. The TAP Coordinator (Program Officer) will report to the head o f DNS. He/she will have multiple coordination and facilitation responsibilities, including serving as the principal TAP coordinator within the MOH, with the Implementing Partners, and work closely with GACOPI, with the donors, PLWHA (RENSIDA) and other relevant groups such as NAIMA. The TAP Coordinator will coordinate with CNCS, WHO and UNECA and facilitate TAP learning efforts. The TAP Coordinator will be well situated, through hisher position within DAM, to coordinate TAP technical implementation with MOH treatment efforts, as well as linkages with the MOH monitoring and evaluation system. TAP will be integrated into the system as a result o fthe MOH operational and support leadership being directly engaged with it, attending regional meetings, andsharingMozambique's results with others. (kk) InstitutionalStrengthening An analysis o f the MOH's capacity to implement the MISAU PEN with respect to the five treatment components identified a number o f areas requiring technical assistance and support during the implementation of TAP. These include: (a) support to the new national treatment technical committee and any working groups; (b) improving instruments and tools for clinical management and tracking of H N / A I D S patients; (c) strengthening the training program for HIV/AIDS care and treatment; and (d) strengthening procurement and distribution systems. The current situation and what is envisioned in terms o f MOH strengthening is described in more detail inthe following section on Main Implementing Agents. 61 3. MainImplementingAgents There are two categories o f treatment service delivery implementing agents, namely "Implementing Partners" (IPS)selected by Government, and those units in the MOH, which provide treatment services. As to IPS,at this juncture three organizations have met the basic eligibility criteria and have submitted proposals which meet minimum requirements for consideration o f TAP funding: Sant'Edigio, HA1 and Pathfinder International. The MOH has various departments and administrative units involved in the continuum o f care and treatment, either directly or indirectly. (11) MinistryofHealth(MOH) o Elementsof comprehensivetreatmentprogramsand activities ARTprograms and activities. The Ministry o f Health is engaged in the full range o f ART treatment activities described in the M I S A U PEN. It is recognized by the Government and external partners that there are critical gaps inthe capacity o f the public sector to perform these functions. The MAP will be financing priority elements, including: (i) provision o f test kits, condoms and medications; (ii) strengthening clinical laboratories; (5)strengtheningblood safety andbio-security; (iv) health sector staff sensitization; (v) health waste management; (vi) research into traditional medicines; and (vii) capacity building. Government policy is evolving. It began on the basis that all anti-retroviral drugs would be financed through the public system only for the prevention o f parent-to-child-transmission and as post-exposure prophylaxis for health workers who are occupationally exposed to HIV. With the expectation o f substantial donor financing, coupled with the reduction o f drug prices and growing experience with treatment protocols, this policy has been revised to expand treatment to all eligible PLWHA on a first come first served basis. Gender. GOM has identified gender inequality as a critical barrier to access and utilization o f care and treatment services. GOM confirmed its commitment to mainstream equity including gender equity incare and treatment health services. There was agreement to disaggregate data to monitor access and use o f services by women; train health workers on gender issues; conduct research to analyze gender power relations; work with other relevant ministries and sectors to address human and reproductive health rights and legal measures to protect against domestic violence. Improving the status o f women is a long-term goal. TAP has agreed to fund on contractual basis a full time gender focal person in MOH to assist with mainstreaming gender efforts. Nutrition. Nutrition is a key component for a successful treatment program. The Mission met with the World FoodProgram (WFP) to discuss nutritional support for people on ARV andother vulnerable groups such as orphans. TAP will benefit from the existing collaboration o f WFP and the selected IPSto supply nutritional support. Issues o f capacity to manage the distribution, local production and sustainability have been identified. Local production o f fortified foods should be encouraged and supported. Given the great demands on the health sector, distribution o f food would have to be contracted out. 62 Participation ofPL WHA. The number of associations o f PLWHAis increasing inMozambique. GOM is committed to involvingPLWHA inthe scalingup o fHAART-notjust as recipients o f treatment but also as agents o f change in the fight against stigma. Capacities of these CBOs and NGO remain inadequate to play an important role. TAP Lps currently work with PLWHA associations but will need to strengthen their capacities and catalyze the formation o f new PLWHAnetworks. o Humanresourcedevelopmentfor TAP implementation An insufficient number of trained and retainedpublic sector healthpersonnel constitute a major constraint in scaling up HIV/AIDS care and treatment in Mozambique. This covers the entire gamut o f health professionals, including doctors, nurses, midwives, counselors, laboratory technicians, and pharmacists. The MAP i s one o f the principal financing mechanisms with provisions for the training o f health workers in the management and care o f HIV infected persons. TAP will provide complimentary assistance to build technical and management capacity. The Minister o f Health has identified lack o f investments in training skilled provides andpoor infrastructure as major impediments to scalingup. (")Implementing Partners The principal program executors are to be international NGOs who have demonstrated experience in providing treatment. The MOH, CNCS, and international NGOs have worked together since the 1990s. There are regular informal and formal contacts at both management and policy levels, but more importantly day-to-day interaction at the facility-operational level. MOH has been working with three NGOs (HAI, MCdecins Sans Frontieres and Communita di Saint'Egidio) to initiate treatment and prevention o f mother to child transmission. HA1 and Sant'Egidio are detailed inthe Supplement to this Annex (see attachments). (nn) InternationalOrganizationRoles andResponsibilities Please refer to maintext ofthe PAD for additional information. 4. InstrumentsandDocuments (00) SpecialConsiderations:ARV logistics Government adopted a policy on ART, as set out in Ministerial Diploma No. 183-A/2001, in December 2001. With the approval o f the MOH Care and Treatment Plan by the Council o f Ministers inJuly o f 2003, Government policy now allows for the provision of ARV free through the public system. The original Diploma outlines the treatment protocols for PMTCT, ART o f children and adults, and treatment andprophylaxis o f opportunistic infections. o Who will manageARV procurement? Mozambique has adapted an ART (Antiretroviral Therapy) protocol, which provides for the distribution o f ARV (antiretroviral drugs) through the essential drug program. Registering new drugs in Mozambique follows a new law, requiring drugs and related medical suppliers be registered with the Pharmaceuticals Department (CMAM), in the MOH. The national medical 63 supplies agency (MEDIMOC) has to compete with other private suppliers inthe sector, although it receives priority for supplies to public health facilities. In view o f its historical relationship with the Government, MEDIMOC is exempt from taxes (including fees for registering new drugs), since it specializes inthe supply ofmedicines on the essential drugs list of the MOH. For other suppliers, registration i s required for each item and each brand. Two different suppliers may not register the same item. Each drug is registered for three years. The fees are not more thanUS$16 per item for the three years period. Although Mozambique does not have a national drug quality control laboratory, it does require suppliers to provide credible quality certification documentation for each drug. The National Essential Drug list was reviewed in 2000, and therefore does not include the new ARV that have been recently manufactured by pharmaceutical companies pre-qualified by WHO. The MOHhas usedthe WHO revised treatment guidelines to revise its STI/HIV/AIDS treatment protocols, adapting them to Mozambique's specific circumstances. Relevant drugs for STI/HIV/AIDS are to be distributed through the Essential Drug Program (EDP) and would require that ARV and related drugs go to facilities staffed by at least one health staff trained to prescribe ARV. As Mozambique has opted for a public health approach to scale-up STI/HIV/AIDS treatment, buildingtreatment teams within its resource-constrained health sector requires the selection o f a standard first line regimen and a limited number o f second-line regimens, as it has done. Training for health facility personnel managing STIIHIVIAIDS will be targeted at handling patient clinical care, side effects, coexistent conditions (e.g. co-infections, metabolic abnormalities, etc.), and patient adherence to treatment regimes. Personnel training will include surveillance of HIVIAIDS drug resistance methodology and a patient tracking file system. A s soon as a health facility expands the number o f PLWHA under ART, it will establish a routine HIV/AIDS drug resistance surveillance methodology to build a viable patient-tracking file. o Howwill ARV bestoredanddistributedinthe country? The Mozambican drug planning, procurement and distribution unit within the pharmacy department o f MOH (CMAM) contracts out the tendering process principally to MEDIMOC, but also to other private wholesale suppliers in Maputo. Once procured, supplies are stocked in CMAM's warehouse and are jointly managed with MEDIMOC when MEDIMOC has procured the supplies. Shipments are directed to regional warehouses in Maputo, Beira and Nampula. From there CMAM distributes them to the provincial depots and to central hospitals. MOH has three major supply and distribution chains for drugs, vaccines, consumables and non-medical equipment. These are (i) supplies for the Essential DrugProgram (EDP); (ii) Requisitions Drug (DR); and, (iii) immunization program(EPI). Medical equipment andrelated materials, other the consumables, and non-medical equipment are distributed through separate channels, but still managed by CMAM. This system distributes three types of kit through the EDP (kits A, B and C), packaged in accordance with the size and staffing o f the health facility concerned. CMAM's stock management system is computerized in Maputo, but there is as yet no linkage with Provincial services. Privatization of banks has facilitated the issuance of letters o f credit during the procurement process but delays in payment by the MOH still handicap CMAM's ability to sustain efficient management at a high level. CMAM recognizes the need for continuous training of health staff, which have to make prescriptions in light of constant changes in treatment regimes. TAP will provide a vehicle for testing appropriate ways o f reducing this problem. 64 (pp) Project Supervision Plan The project will require intensive supervision given its innovative approach, the large span of activities from the community to the national level, its blend o f public and non-public sector implementation agencies whose experience with HIV/AIDS programs varies considerably, and its multi-sectoral nature. The range o f activities in care and treatment is complex and will be implemented by many entities whose capacity will need strengthening in order to scale up activities effectively. IDA'Ssupervision effort in the first year will focus on the following strategic areas: o NationalSupervision The MOH will be responsible for the full range o f TAP activities, with the C C M the technical oversight body and GACOPI supervising the operational and fiduciary aspects o f the IPS,andthe MOHdepartments implementing the TAP. At the request o f the Government, technical treatment support will be provided by WHO, both in-country and from its regional office, and through consultancies. Regular regional meetings will provide opportunities to review progress, methodology, andoperational aspects with external experts, and make program improvements. o Bank Supervision Bank supervision will be both through the Resident Mission and Washington. For country activities the MAP/TTL will be responsible for maintaining regular contact with the MOH, CCM, and GACOPI, follow TAP performance, provisioned of no-objections, and regular reporting. As the TAP will deal with similar issues as encountered inthe MAP, Bank supervision can "piggy-back" on MAP responsibilities with missions by health specialists, procurement and financial management specialists coinciding with TAP missions. An additional $50,000 annual supervision budget will be provided for country supervision. The Regional TAP/TTL, responsible for both regional learning and coordination among the country programs, will be the back-up TTL for the country program, and the principal TTL for the entire TAP effort. The Regional TAP/TTL will be provided with a separate budget that will allow country visits, and assistance to the country inthe learning aspects o f the TAP. Frequency of mission. It is expected that there will be three supervision missions yearly, as well as participation by IDA at the semi-annual regional meetings. Supervision missions will be integratedinto MAP and (whenrelevant) health sector supervisions. 0 Supervisionmissions are to include the following: 0 Country TAP/TTL 0 RegionalTAP/TTL (as available) 0 Health Specialist, complementing TTL skills 0 FinancialManagement Specialist 0 Procurement Specialist 0 M&ESpecialist 0 Lawyer (as needed) 65 Regional meetings will include the participation of: 0 Regional TAP/TTL 0 Country TAP/TTL a M&ESpecialist 0 Technical Specialist (ARV drugprocurement, gender, youth, nutrition, as needed) 66 Attachment to CountryAnnex 1-C ImplementationPartners in Mozambique Comunita di Sant'Egidio The "Comunita di Sant'Egidio" (Sant'Egidio) was founded in Italy in 1968 and is formally recognized as an international non-governmental, non-profit organization (NGO). 1. ExistingProgramInformation The development of the program has been a collaborative effort of the Community o f Sant'Egidio, the Mozambique Ministry of Health, and the ItalianNational Health Institute. The program began in February 2001 with a 5-year agreement between the Ministry o f Health of Mozambique and the Community o f Sant'Egidio. Concrete activities are defined by means of yearly operational plans. The program has completed its first full year (2003) and focuses its activities on specific objectives such as a model for diagnosis andtreatment ofpeople livingwith HIV/AIDS. This program has been regularlymonitored with the aim o f extending it throughout the country. The program is integrated into the national policies. 2. HIV/AIDS TAP-SpecificProgramInformationincludingtarget group In 2003 Sant' Egidio provided VCT services for 7,141 clients; HIV-positive patients assisted numbered 4,054; and ART patients 1,400. (For 2004 the projected figures are 9,500, 5,415, and 2,594, respectively.) Based on 2003 data, annual non-ART client costs were roughly 400 Euros per client, and annual average cost per ART patient were roughly 68015Euros per client. Sant' Egidio concentrates its work in three high priority geographic areas in Mozambique, namely in the south(Maputo), central (Beira), andthe north (Nampula). 3. AIDS-relatedstaffing Over 50 local staff are currently employed inMozambique, includingexpatriate staff. 4. FiduciaryAspects Sant'Egidio will prepare annual financial reports, conforming to international standards required by IDA, and establish an internal control mechanism to monitor the management o f TAP funds, both for operational monitoring o f sub-activities and as well as to serve as a financial reporting tool. Emst & Young is assisting in designing a system to track program expenditures, and an extemal auditor will also be appointed. Full access to TAP project documentation will be available to the auditor to determine if (a) funds were used for agreed specified TAP purposes, (b) procurement was consistent with international practice, and (c) accounting documents were appropriate. $107,000 + health education (50%): $30,000 + localpersonnel (75%): $161,550 + share of costs not directly IsCosts attributable to those patients calculated as: Drugs and reagents (90%): $409,050 + foodstuffs (100%): associated with patients (38%): $231,000, equal to a total of: 938,600 dividedby the number ofpatients on treatment: 1,400 67 5. MonitoringandEvaluationActivities andCapacity Sant'Egidio will conduct applied research and expand its existing patient tracking and monitoringand evaluation system. 6. ProposedProgramunderthe TAP The five TAP treatment elements will be addressed through ten components. Includedis facility expansion in the three target areas with one reference center in each; and an access center for PMTCT; and community and home care; all will be fblly staffed with trained personnel. ' Associated centers will be attached to the program and provided with clinical supervision and coordination. 7. Scalingupthe program Sant'Egidio projects an approximate 50% increase in coverage each year, with VCT clients reaching 20,000; HN enrolled clients 11,400, and ART patients 6,122 by 2006. These increases inclient/patients will be insouth (Maputo), central (Beira), andnorth (Nampula) Mozambique, which are highprevalencetarget areas. 8. TimeFrame The program is envisioned for three years, beginning in2004, with all activities beguninthe first year and continuing throughout. Health Alliance International Health Alliance International (HAI) was founded in 1987 and i s formally recognized as an non- governmental, non-profit organization (NGO). 1. ExistingProgramInformation HA1is currently providing the principal technical assistance for the Mozambique National Plan to provide fiee ART throughout Mozambique. HA1 has assisted Mozambique MOH in designing, writing and revising the plan and is expected to play a key role inits implementation. HA1has expanded its support inthe area o fHIV/AIDS inthe past 3 years from initial prevention activities inhighly affected areas (corridors, urbancenter) to more rural underserved areas and to the introduction o f VCT, PMTCT and care and treatment. They have also have activities to increase involvement o f community leaders, including expansion o fhome-based care activities. 2. HIV/AIDS TAP-SpecificProgramInformationincludingtargetgroup Since 2002 HA1has supported family-centered health care and treatment for HIV positive adults and children in the Beira and Chimoio Day Hospitals. Both sites routinely enroll 200-300 new patients per month and by the end o f 2004 it is estimated that 7,000 patients will have enrolled in the two Day Hospitals and counseling center in the two cities (which also provide VCT, PMTCT, in-patient testing, etc.). Currently only 160 individuals are on ART to lack o f drugs and 68 laboratory capacity which is expected to increase after April 2004 via the National Care and Treatment Initiative. 3. AIDS-related staffing Currently HA1has four well-established and hlly operational offices inMozambique-two within M O H Provincial Health Departments (DPS) in Beira and Chimoio, a third in Chimoio and a fourth within the MOHinMaputo. HA1has over 50 field staffincluding 20 public health officers who have worked with the NationalHealth Service for an average of 10years. 4. Fiduciary Aspects HA1has financial control systems andreceives an annual A-133 audit that is inaccordance with international accounting standards and U S Government requirements. The annual budget o f HA1 has expanded from $150,000 to a current $3,500,000. HA1will establish an internal control mechanism to monitor the management of TAP fhds both for operational monitoring o f sub- activities and as well as to serve as a financial reporting tool. Full access to TAP project documentation will be available and will determine if a) funds were used for agreed specified TAP purposes, b) procurement was consistent with international practice and c) accounting documents were appropriate. 5. Monitoring and Evaluation Activities and Capacity HA1 currently has a full time national advisor who supports the head of monitoring and evaluation for the clinical medicine section o f the M O H and a full time Health Information Systems (HIS) specialist who manages the M&E o f HA1projects via the computerized tracking of indicators. The HA1proposal includes a monitoringand evaluation system designed allowing for rapid tracking o f progress in implementing planned activities as well as linking implementation with interimresults. 6. Proposed Programunder the TAP .Under TAP, HA1will deliver results related to expansion of care and treatment and training complemented by integrated health network operations research and national institutional capacity buildingto managethe expansion o fcare andtreatment. 7. Scaling up the program HA1expectsthat over the 3-year life of the project, that the four DayHospitals will initiateART for over 9,000 individuals, representing a roughly 50% increase in coverage yearly, from 160 patientdmonth currently. An additional 10,000 clients in care and 50% o f those testing positive at testing and counseling sites enrolled at the DayHospitals for comprehensive care andART. 8. TimeFrame The program is envisioned for three years, beginning 2004 with all activities begun in the first year and continuing throughout. 69 Pathfinder International Pathfinder International is a non-governmental organization with an international staff o f 392 people located in 17 field offices around the world. Its Headquarters are in Watertown, Massachusetts. In1997, Pathfinder initiated its reproductivehealthprogram inMozambique. 1. ExistingProgramInformation Pathfinder's goal in Mozambique is to build the capacity o f the public sector and NGO to increase the availability and use o f comprehensive reproductive health services and reduce the incidence o f STI and HIV/AIDS, especially among youth. In addition to Geraqgo Bizl6, Pathfinder's current work in Mozambique includes technical assistance on the adolescent HIV/AIDS component for the Kuhluvuka Project with the Foundation for the Community's Development, operations research on peer educators with the Inter-Agency Gender Working Group and participation on the NGO Network, which is a member o f the Mozambique Country Coordinating Mechanism for the Global Fund. 2. HIV/AIDS TAP-Specific ProgramInformationincludingtarget group Geraqzo Biz project has benefited more than 500,000 young people through the school- and community-based components since project inception, and more than 140,000 client visits have been provided through youth-friendly clinics. Pathfinder proposes to expand youth-friendly HIV/AIDS treatment and support activities in four o f the existing GeraqBo Biz clinics. In year one o f the project services will be expanded at the Adolescent Clinic at Maputo Central Hospital andat the Adolescent Clinic inXai-Xai (Gaza Province). 3. AIDS-related staffing To ensure that project objectives are met, Pathfinder proposes one full-time Project Manager who will be responsible for implementing and coordinating activities at a national level and overseeing four site supervisors, responsible for provincial implementation and coordination. An HIV/AIDS Technical Advisor will provide oversight o f training activities and provide technical assistance on key components to all Provincial Site Supervisors, as well as actively monitoring project implementation. Pathfinder's Senior Technical Advisor on HIV/AIDS in Mozambique will dedicate 30% of his time to provide technical guidance to the project. To complement the skills o f the in-country staff, Pathfinder will support the project with an outstanding, multi- disciplinary group of national and international technical resource professionals who have broad experience in ASRH, VCT, ART, gender issues, M&E, training, community mobilization, quality o f care and organizational development. Where necessary, international consultants, primarilyfrom Brazil, will complement in-house expertise andthe work o flocal consultants. 16 Geraqgo Biz is a project to builda foundation to addressyouths' lack o fknowledge, skills and access to appropriate youth-friendly services (YFS). Three Ministries (Health, Education and Youth and Sports) have coordinated activities, and work closely with selected NGO and youth networks to maximize reach and effectiveness. 70 4. FiduciaryAspects Pathfinder international has financial control systems. Pathfinder's experience managing and implementing technically, administratively and financially complex awards spans four decades and three continents. From a series o f successively larger central agreements to more than ten recent Mission-designed cooperative agreements and contracts, Pathfinder demonstrates its ability to implementandmanage projects of varying scope andcomplexity. 5. MonitoringandEvaluationActivitiesandCapacity Monitoring and evaluation o f expanded HIV/AIDS care and support activities will be integrated into the well-established Geraqilo Biz M&E system, which was recently computerized at the provincial level. For clinic and community-based activities, existing Geragilo Biz forms and processes will be adapted to include new services, such as VCT, PMTCT and clinical care. Peer educator and peer supervisor forms will be adapted to include CHBC services. Sources o f existing data used to monitor and evaluate the project include: Service statistics for each clinichealth center (monthly); Program activity reports for each community (quarterly); Program activity reports from each district/province, city directorate or NGO (quarterly); Program activity reports at Central level (quarterly). 6. ProposedProgramunderthe TAP Under TAP, Pathfinder will deliver results related to: Improvingthe diagnostic capacity o f MOH youth-friendly clinics and access to and utilization o f VCT; expanding access to youth-friendly STI/HIV/AIDS clinical care and treatment services, including diagnosis and treatment of opportunistic infections and administration and monitoring o f HAART; improving access to youth-friendly PMTCT-Plus services, including protection and treatment of the mother; improving the quality o f life for HN-infected individuals and families through expanded access and improved quality of palliative care, by improving access to community home-based care (CHBC). 7. Scalingupthe program Over the three-years of the project, Pathfinder will provide: V C T services to an estimated 5,500 youth; STL/HIV/AIDS clinical care to HAART and follow-up to 350 youth; PMTCT-Plus services to 1,400 young women and community home-based care services to 720 families. 8. TimeFrame The program i s envisioned for three years, beginning 2004 with all activities begun in the first year and continuingthroughout. 71 Annex 1 -D: Country and Sector or Program Background Regional HIWAIDS TreatmentAcceleration Project UNECA Why UNECAfor the Regional Coordination and Learning Component of the TAP? UNECA's Convening Power. ECA is a regional secretariat for the UnitedNations system and provides technical support in the areas o f socio-economic policy analysis and supports African governments in the implementation o f these policies. The UNECA manages the major regional development statutory bodies (e.g., Conference o f African Ministers o f Finance and Planning; the African Development Forum; and the African Learning Group on PRSPs; and other sector ministerial meetings). UNECA initiatives in Africa have gained worldwide recognition as the key arena for a wide-cross section o f stakeholders to engage in candid and very productive discussions on African socio-economic priorities. UNECA'swork on HIJVAIDS.UNECA houses the Commission onHIV/AIDS and Governance in Africa (CHGA), launched by the UN Secretary General, February 2003. Under the Chairmanship o f the Executive Secretary, K.Y. Amoako, CHGA represents the first occasion on which the continent most affected by HIV/AIDS will lead an effort to examine the epidemic in all its aspects and likely future implications. The TAP program offers CHGA a unique opportunity for addressing counter-acting factors inthe region's struggle to combat HIV/AIDS. UNECA's Role in Knowledge and Learning. UNECA interacts with national institutions and stakeholders in carrying out policy analytical work. As part o f this work, UNECA convenes learning events to share knowledge and experience among practitioners in key areas o f development. For example, UNECA organized the African Learning Group (LG) on PRSPs. The purpose o f this initiative is to promote and enhance African ownership o f poverty reduction strategies and to facilitate the articulation o f an African voice on the PRSP process. The LG provides a forum for the examination o f critical issues and challenges that African countries are encountering as they prepare their PRSPs, share best practices, formulate recommendations on action to foster mutual accountability for policy outcomes, and mitigate constraints such as the unpredictability o f aid flows. Moreover, the LG provides an opportunity for early identification o f implementation issues. Country studies and other analyses are prepared for these meetings, and the results are disseminated widely to stakeholders and partner institutions involved with PRSP issues. UNECA's Support to the TAP UNECA, incooperation with WHO and the World Bank, will support Component 3 o f the TAP (facilitating regional learning from TAP country experiences). For this purpose a small TAP coordinating unit will be established within the CHGA to organize regular TAP learning meetings, manage and disseminate quarterly reports from each TAP country (with WHO), and commission and manage research work on issues identified by the Regional Advisory Panel (RAP) o f the TAP. The CHGA will offer guidance and support to the TAP coordination unit, including support to the conduct o f agreed research activities. The lessons learnt from the TAP 72 will be fed directly into the work o f the CHGA as well as other fora inAfrica. The CHGA will draw on the staff resources of the relevant UNECA sub-programs in the commissioning and management o f the content o f the research. For example, inthe area o f gender, he/she will work with the UNECA Center for Gender andDevelopment. In-kind support: 0 UNECA technical staff support for report preparation, and commissioning/management o f research. 0 Administrative Support: CHGA Administrative Officer will provide the following services required to support the activities o f the TAP secretariat: travel authorizations, visa matters, budget management, and contracting. 0 Conference services: UNECA will offer its conference facilities and some conference staff free of charge to TAP for the RAPmeetings (this will not include interpreters). TheRole of the UNECA TAP Coordinating Unit A coordinating unit will serve as the secretariat for the RAP and regional liaison for TAP activities in collaboration with WHO (HQGeneva, Regional WHO/AFRO and WHO country offices) andthe country TAP Coordinatorswith regardto leaming activities. Under the guidance of the CHGA, the TAP secretariat will be responsible for the coordination o f UNECA's overall implementation o f the regional learning and facilitation activities o f component 3 o fthe TAP. Specifically, the secretariat will perform the following functions: On-going liaison with the RAP, WHO, the World Bank, and with country TAP Coordinators (including travel as needed). Set up a system for managing and disseminating TAP information from country quarterly reports received from country TAP Coordinators, and comments from RAP members. Undertake operational research to map the lessons leamt from the TAP initiative. Based on the information described above, provide biannual reports to all TAP countries members o f the RAP and the technical working groups. Inresponse to the RAP, and in consultation with WHO, country TAP coordinators, and the World Bank, commission and manage TAP related studies (see section 4 for a description o f studies anticipated at this time). Convene and host the bi-annual (weeklong) meetings o f the Regional Advisory Panel (RAP) and supporting technical committee -- Regional sub-committee o f Clinical Experts (RCCE) -- and other meetings as the need arises. Inconsultation with WHO, the World Bank, and the RAP, develop agenda andprepare documentation for discussion at the semi annual meetings o f the RAP and disseminate outcomes of these meetings agreed with RAP to countries and elsewhere - including through CHGA and other UNECA fora (the Afiican Development Forum (ADF), Conference o f Ministers o f Finance and Planning, andthe African Union/NEPAD). Work with the RCCEto delineate the actionable outcomes from the RAPmeetings. 73 Facilitation of TAPOperationalResearch andStudies As a regional learningprocess, the TAP would include operational research and studies designed to provide countries with practical tools and lessons leamt on scaling-up HIV/AIDS treatment in partnership with NGOs and the Private Sector. A core part o fthe work program o fthe TAP coordinating unitwill centre on: (i) devising non-clinical studies to map the evolution o f the program in order to capture important lessons learnt relating to scaling up treatment and care programs through partnerships with NGOs, private sector and governments. Through the TAP country coordinators and Implementing Partners the research will focus on: (i) documenting and analyzing the process involved in widening access to ART through NGOs and the private sector - including examining equity issues and human capacity needs; (ii) documenting the ways in which access to ART can best be regulated and decentralized through NGOs, to identify the optimum way inwhich decentralization can be managed; (iii)gain a comprehensive understanding of the roles of state institutions and infi-astructures, NGOs, private sector organizations, and community and local associations inthe provision o fART. (ii) commission non-clinical studies related to up scaling treatment in resource limited settings e.g: (i)comparative analysis o f country HIV/AIDS treatment policies, program- financing policies, cost sharing, and safety nets; (ii) Gender and vulnerable groups, particularly teenage boys and girls, young adults, widows, and the unemployed. Research is needed to identify innovative and promising approaches to address the complex gender dynamics and barriers; (iii) Nutritional requirements for PLWHA, and for patients under HAART. Preparation of Semi-Annual Meetings The launch meeting o f the TAP i s expected to be held inAddis Ababa in September 2004. This will be an occasionto, inter alia, affirm the objectives o fthe project, acknowledge the respective roles o f those involved, and address outstanding questions going forward which are appropriate for discussion in plenary. The second and subsequent RAP meetings will review quarterly country TAP reports, identify issues, agree operational research work to be commissioned, and review results of such studies. Agenda issues for discussion at the semi-annual leaming meetings will be developed inconsultation with the RAP, WHO, country TAP Coordinators, and the World Bank. The Secretariat will prepare documentation as requested for the meeting. The coordinating unit will manage invitations, travel and subsistence arrangements, and related logistics. Costs o f conference facilities and support o f conference services staff for logistics, security, protocol will be provided by UNECA as in-kind contributions. Other related direct costs such as air travel, accommodation, catering and hospitality, interpretation will be bome by the TAP Secretariat. Proceduresfor FinancialManagement, Recruitment and Procurement In discharging its administrative and financial duties, the UNECA adheres to the following official working documents o f the UnitedNations: 74 e Financial Regulations and Rules o fthe UnitedNations; e UnitedNationsProcurementManual; and e Administrative instructions issued inconnectionto the recruitment o fconsultants. All consultant recruitment will require anon-objection fromIDA. The grantwill includeretroactive financing following the Bank's guidelines.Underthis provision, UNECA will be eligible for reimbursemento fup to SDR 130,000 for expenseswhich it has incurred after April 1,2004. Financing Budgetto carry out UNECA fbnctions will be $2,000,000. 75 Annex 1-E: Countryand Sector or Program Background Regional HIVIAIDSTreatment Acceleration Project WHO Why involve WHO? WHO and UNAIDS have declared the lack o f HIV/AIDS treatment in resource constrained settings as a global emergency. WHO identifies the goal o f putting 3 million people on antiretroviral treatment by 2005 ("3 by 5" target) as an institutional priority and realigns expertise and activities across the Organization to achieve this target. Intensified support will be given to countries to scale up treatment programs to reach the "3 by 5" targets. WHO will, among other things, provide operational models for service delivery and integrated clinical guidelines for service delivery, develop methods for accreditation o f service delivery points, develop standardized training materials for community treatment supporters; simplify guidelines for HIV testing and counseling and referral, develop guidelines for better use o f "entry points'' (TB, acute medical clinics, PMTCT, STI, andharm reduction services for injecting drugusers) to identify those inneed o f ART, develop an AIDS Medicines and Diagnostics Facility (ADMF) to assist implementers at country level to overcome barriers inprocurement and distribution o f key commodities. WHO is developing a country support strategy for the "3 by 5". It includes identification o f a limited number o f high burden countries that account for large numbers o f people who require HIVIAIDS treatment. These countries will be provided with intensified support to scale up treatment programs. The strategy also includes adoption o f a country support process that will enable technical expertise across the Organization to be available with greater synergy to respondto the needs o fcountries for rapid scale up o f treatment programs. WHO considers the Treatment Acceleration Program (TAP) to be a vital component o f international efforts to close the HIV/AIDS treatment gap and supports its implementation. Burkina-Faso, Ghana, and Mozambique, the three countries identified for the TAP ("Participating Countries"), are also among the 34 focus countries for the "3 by 5" that have been identified by WHO for intensified support inscaling up treatment. Goals and Objectivesof the collaboration WHO will provide technical assistance to the Participating Countries and Implementing Partners (IPS)for the implementationand setting up of systems for the monitoring and evaluation ofthe treatment program supported by TAP. In addition, WHO will assist Participating Countries and their national partners, in particular the Implementing Partners (NGOs, Associations, private sector), to refine national treatment policies, adopt simplified treatment protocols and integrate lessons from TAP supported efforts into broader service delivery approaches. Specific support by WHO to TAP will include, based on the respective Participating Country's priorities and needs, the following: 76 - Updating and adapting policy strategy and standard guidelines for the 5 treatment components (VCT, PMTCT and PMTCT Plus, ART, Treatment o f 01s and Home-based patient care and family support) inrelation to therespectiveParticipating Country's needs. - Providing assistance in training programs for HIV/AIDS care and treatment for health professionals, paraprofessionals, and community treatment workers. The focus o f the latter i s to broaden service delivery approaches to integrate health and community care through standardizedtraining materials. - Assisting TAP in the development of a monitoring and evaluation framework, including confirmation o f the TAP project baseline data, development o f tools for monitoring HIV/AIDS treatment inthe above 5 components, piloting a set o f minimumnational core indicators to track theprogressmade, to the extent ofavailable resources, incollaboration with on-going initiatives. - Providing technical assistance in the surveillance and monitoring of ARV resistance, to the extent o f available resources. - Providing advice inthe use of instruments andtools for the clinical management of HIV/AIDS patients and their education and the development o f an ART package for clinical monitoring and Health InformationSystem consisting of: -- The client card andregister, The curricula and pedagogical methods for the training o f medical and paramedical personnel inARV delivery, -- National ART indicators for every level andstrengtheningofART system, includingdrug supply M&EART Plan(or sectionofbroader national plans). - Assisting inthe revisionandalignment, as appropriate, ofthe indicators ofperformance of TAP project and of the baseline data and a set o f minimum national core indicators to track the progressmade. - Assisting Participating Countries in setting up quality assurance systems for drug procurement and testing (country or through regional networks), to the extent o f available resources, in collaboration with on-going initiatives. - Providing advice in the development of national standards criteria and assessment tools for accrediting laboratories andtreatment sites. - Providingtechnical support to the new national treatment technical committee and any working groups. - Helping to support knowledge management through identifying lessons learned, sharing informationwith UNECA through the Regional sub-committee o f Clinical Experts (RCCE) and UNECA's Regional Multi-disciplinary Advisory Panel (RAP). - Providingtechnical support onthe creation of focused in-country operations research. 77 - As required and to the extent o f available resources, providing advice or technical inputs to specific areas o f related work that may include scaling-up the involvement o f IPS,costing and equity o fARV delivery, quality o flife for patients. Implementation There will be three components o f WHO'S technical support to the Participating Countries and Implementing Partners in the implementation o f the Project namely: (i)planning, (ii) implementation andmonitoring and (iii) evaluation anddocumentation o f lessons learnt. I.Planning WHO will provide technical support to the Participating Countries and Implementing Partners (IPS) in their design of programs and development o f work-plans that are based on sound scientific evidence. Such plans must also incorporate monitoring and evaluation frameworks that are consistent with the broader national HIV/AIDS response and that will allow comparison o f results between countries. Specific activities to be undertaken by WHO will include: - Providing technical assistance to Ips, at country level, inorder to conduct a situation analysis, develop work plans and set up systems for monitoring and evaluation. - Providing technical assistance for human resources assessmentandplanning. - Providing input duringthe technical review meeting o f country work-plans. II.Implementation andmonitoring WHO will provide ongoing support to I p s inimplementing and monitoring treatment programs. Specific activities to be undertakenwill include: - Providing technical advisory services, in specific aspects of treatment programs, such as the components andstrategies outlined above inSection 2 above. - In addition, WHO will participate in TAP supervisory missions as part o f the overall monitoring o fthe program based on mutual agreements o f the scope and terms o fthese missions. III.Evaluation andDocumentation of lessonslearnt WHO will support the evaluation o fthe program and documentationo f lessons learnt by: - Assisting in ongoing collection and analysis o f health services data from implementation of TAP programs. - Supporting the RAP and RCCC under the leadership of UNECA, in the review of project specific outcomes through the facilitation and attendance oftechnical meetings andworkshops. - Assisting in the facilitation of the documentation and publication o f case studies under the leadership o fUNECA that capture experiences and lessons from TAP programs. 78 - Co-organizing workshops with UNECA to share experiences and lessons learnt among TAP countries andwith other countries. - Facilitating by providing advice on the final evaluation o f the Program including involvement inthe design, conduct and analysis ofthe final evaluation. Program management The Country Scale Up Team o f the HIV/AIDS Department at WHO Headquarters will provide overall direction and coordination o f WHO inputs to the TAP Program, including liaison with the World Bank, I T A C and other partners at global level. The Regional Program for HIV/AIDS o f the WHO Regional Office for Africa (AFRO) will, in coordination with WHO Headquarters, be responsible for ongoing monitoring and brokering technical support with the TAP coordination unit at UNECA. An AFRO regional technical officer will be recruited to provide technical support to the Participating Countries and Implementing Partners, identify consultants in response to identified country technical needs, and ensure harmonization and integration o f WHO-TAP activities and learning with other countries. The WHO Project Technical Officer, under the direction o f the WHO Representative, will provide ongoing technical support to ImplementingPartners and will facilitate linkages between TAP andbroader national treatment efforts. WHO will recruit technical officers (internationally recruitedP4 level) ineach o fthe three countries. These officers will link with the "3 by 5" teams that will be established inthe countries. This is a critical linkage to ensure country commitment to scaling up. The main focal point for TAP on behalf o f WHO will be the Country Scale Up "3 by 5" Team Director based at WHO'SHQ. Expected outcomesfrom the collaboration Through the provision of technical support to TAP countries, WHO will contribute to: - Filling the gaps at the normative level in HIV/AIDS treatment and ensuring the scaling up o f treatment to achieve its "3 by 5" targets - Strengthening partnerships with other stakeholders including World Bank,NGOs, communities through public/civil society/ private partnership in the scaling up o f HIV/AIDS treatment including "3 by 5" targets - Increasing the capacity o f partners and communities to be fully involved in HIV/AIDS treatment service delivery - Contributing to the monitoring o f HIV/AIDS treatment (VCT, PMTC, PMTCT plus, OIs, PLWHAs, ART) not only in data collection to track progress made, but also to generate information for decision makinginnational policy inHIVIAIDS treatment 79 Proceduresfor Financial Management, Recruitment and Procurement The ST/AI/285 o f 1 March 1982 approved by the General Assembly stipulates that program support cost should be charged as administrative and operational costs for all projects and programs funded by bilateral and multilateral sources (such as the World Bank). Inthis regard, it i s generally accepted that multilateral organizations will be charged a program support cost (i.e. overhead) amount of 13% o f the total cost o f the project concerned. In discharging its administrative and financial duties, WHO will adhere to the official working documents o f the United Nations: FinancialRegulations andFinancial Rules o fthe WHO; Staff rules and regulations o f the WHO, including those applicable to consultants; Administrative instructions issued inconnection to the recruitment o f consultants; and WHO Manual andprocurementrules, regulations andprocedures. Because WHO has declared ART scale up as a global emergency, therefore program support costs i s charged at 6% rather than the usual 13%. Financing Budget to carry out WHO functions will be $4,000,000, allocated by WHO offices (countries, region). Retroactive Financing. The grant will include retroactive financing following the Bank's guidelines. Under this provision, WHO will be eligible for reimbursement o f up to 270,000 SDR for expenseswhich it has incurred after April 1,2004. 80 Annex 2: Major Related Projects Financed by IDA andlor other Agencies RegionaI HIV/AIDS Treatment Acceleration Project 1. BurkinaFaso Latest Supervision Sector Issue Project (PSR) Ratings (Bank-financed projects only) Implementation Development Bank-financed Progress (IP) Objective (DO) HIV/AIDSDisaster ResponseProject (Cr. 3557-BUR) S S I Multilateral agencies UNAIDS Preventioflreatment o fparastatal workers UNFPA Treatment of MST UNICEF MTCT WFP Foodaid for PLWHA WHO Blood transfusion; ARVMTCT; surveillance GFATM Expansion of PMTCT from 3 to 11health districts and increase access to ARV by treating 3,600 patients over next 4 years Bilateralagencies Belgium PNLS support; district-level preventiodtreatment; treatmendtraining(Centre Muraz; St. Camille) Canada District-level preventiodtreatment Denmark PNLSsupport; financing ofassociations, parastatal sector France PNLS support; financing of associations; blood transfusion; district-level preventiodtreatment Holland PNLS support; financingo fassociations NGOand Private Sector AIDSETI Continuum of care for PLWHA InternationalHIV Support to associations, cooperatives, mutuals Alliance MSF Continuum o f care for PLWHA Projet Esther Hospital-based care for PLWHA 81 2. Ghana Latest Supervision Sector Issue Project (PSR) Ratings (Bank-financed projects only) Bank -Financed Implementation Development Progress (IP) Objective (DO) MAP AIDS ResponseProject - GARFUND(Cr. 3458-GH) S S SWAP SecondHealth Sector Program Support (Cr. S S 3731/HO19) Multilateral agencies GFATM Expand DRI, increase VCT and PMTCT coverage for vulnerable groups, establish comprehensive care for PLWHAand increaseprovisiono fHBC UNAIDS District ResponseInitiative (DRI) support; GAC part o f M&EReference Group 3ilateral Agencies IFID GAC support through GBP20 million SIPAA project for capacity building(used for GARFUND beneficiaries); financed IEC" materials for MOE target groups and development o fmanuals for mainstreaming HIV/AIDSinto basic and secondary school curriculums (not disseminated yet) JSAID GAC support for strategic framework, sentinel surveillance, M&Esystem, and strengthening o f GARFUNDNGObeneficiaries; NACP support for ART pilots at 2 sites; BCC/demandgeneration, at-risk group behavior change; private sector programming; condompromotion and distribution; training on STI management, counselors and nurses for ART, volunteers for HBC; 2 VCT services inEastemregion and Accra, more to be established this year NGOand Private Sector PrivateEnterprise Continuum o f care for employee PLWHAand Foundation workplace prevention activities FHI US AID-fundedpilot program for comprehensive community-based ART program inEastemregion and at Korle-Bu hospital ~ "Information, Education, and Communication 82 3. Mozambique Latest Supervision Sector Issue Project (PSR) Ratings (Bank-financed projects only) Bank -Financed Implementation Development Progress (Tp) Objective PO) IMAP HIV/AIDSResponseProject (Cr. H030/Q340) U S Multilateralagencies GFATM Training o f health care workers, condom promotionldistribution, support to PLWA and orphans, increase access to home care based services, increase access to VCT (50 centers to be established over 5 years), ARV and 01treatment (56 day clinics planned byyear 5 to treat 56,000 HIV+patients for 01,ARV provided in22 clinics for 20,000 patients), STI syndromic treatment, scale upPMTCT to cover 20.000 newborns with nevirapine UNAIDS Program support andnational coordinationwith CNCS UNDP Program support, CNCS staff support and support to MinistryofEducation UNFPA Program support and condom supplies UNICEF CNCS staff support, adolescent awareness, health- friendlyhealth services, home-basedcare, orphan care WHO Surveillance support, assistanceincombating HIV, STIs and treatment o f 01 Bilateral agencies Belgium Support for infrastructure CIDA (Canada) Programsupport, health sector support through the Common Fund(CF) DanishCooperation Programsupport, health sector support DFID Program support to CNCS for CF activities to NGOand public sector; condom supply and distribution through PSI; support to ActionAID SteppingStonesproject; support of MANASO; participationinMOHCF; final year of GBP25 million fund for central medical procurement including ARV EU CNCS Programsupport and condommarketing; health sector support French Cooperation Programsupport, health sector support Finnida Programsupport to CNCS and civil society through CF Germany Programsupport, health sector support Ireland Program support through the CF IrishCooperation Programsupport to CNCS for CF activities to NGOand public sector 83 Italy Programsupport,uspecializedlab equipment Japan(JICA) Program support, healthsector support Norway Programsupport, healthsector support through CF Netherlands Programsupport, health sector support SIDA(Sweden) Programsupport, health sector support through CF Swiss Cooperation Programsupport to CNCS and NGO through CF Spain and Portugal Programsupport USAID and U S CNCS program support, NGO-based targeting highrisk Government PEPFAR groups and hot spot regions, M&Edesign, prevention and advocacy; support to PSI for condom social marketing, VCT, and PMTCT; support 3-year Maputo Corridor HIV/AIDS Program untilSept. 2004; PEPFAR support to World Relief, World Vision, PSI and HAIfor prevention, OVC care and support, PMTCT, VCT, home-basedcare, and future ARV provision NGO and Private Sector CARE Prevention activities, local capacity buildingand advocacy inVilanculos FamilyHealth Support inZambezia for PMTCT hternational HA1 USAID-fundingPMTCT inManicaand Sofala John Snow Support for logistics and distribution o f ARV (future) htemational Medecins San Prevention and advocacy Frontieres Pathfinder Youth friendly services htemational Sant'Egidio Preventionand advocacy activities, continuum o f care for PLWHA, home-based care and ARV provision to patients World Vision Preventionadvocacy, PMTCT, VCT, and later ARV htemational provision (through institutional, USAID, and PEPFAR IPDORatings: HS (Highly Satisfactory), S (Satisfactory), U(Unsatisfactory), HU(HighlyUnsatisfactory) 84 88 ru 0 a 8 cd 41 0 0 .3 b id a s a o E 0 E u c 0 63 E ."0 b co z c1 0 id m id c .-0m 1"1" 3 .B u cs 8c a e, 5e, 8e,E: Lo 0 e, B? '2 e, Lo a m c mLo- & 0 Y f Lom a m c cu .I 0 .- u6c50 m .if 41 'p 0 .3 41 0 5e, 0 c .3 c % .$! % .. 3 .. I 3 3ag 0 g 5a l2 c) a3 .ecdh ,a A P I a cd e h c, L a 0 a m 1 :I b + w a s HB ... :" 0 0 0 0 0 ... 8 g O O W m r - m s s g . . . c r a m v, ... P 4 m $ C - m - m E E 3 0 3 3 A " N " N U Key TAP Performance based Indicators - 1. Numbero fpersons utilizing VCT a. Proportion female b. Number ofyouth under 25 (intotal and o fwhich female) 2. Number ofpersons receiving 01prophylaxis/treatment a. Proportion female b. Number o f youth under 25 (intotal ando fwhich female) 3. Numbero fmother-baby pairs underPMTCT care a. Number ofmother-baby pairs on ARV treatment 4. Number ofpersons being treated with ARVs a. Proportion female b. Number o fyouth under 25 (total, number female, andalso shownby age group) 5. Case fatality o fpeople on ARVs 6. Numberofpersons receivinghome based care a. Proportion female b. Number o fyouth under 25 (intotal ando fwhich female) 7. Number o f facilities upgraded to provide comprehensive prevention, diagnosis, treatment andcare services a. Numbero ftreatment teams trained and operational (number o f teams per site?) 8. Numberof facilities providingtreatment and care in: a. rural b. poor urban c. peri-urban areas 9. Number o fpeople eligible for treatment who cannot afford it & are exempt from user fees (Ghana only) 10. Numbero fTAP regional publications reflecting lessons learned andbest practices disseminated among TAP andother countries to facilitate learning 11.Numberofongoing operationalresearch activities 91 Annex 4: Detailed Project Description Regional HIWAIDSTreatmentAcceleration Project The proposed IDA Grant o f US$ 60 million would finance a three-year Regional HIV/AIDS Treatment Acceleration Program (TAP) to: (a) expand existing treatment programs; (b) monitor results and facilitate the effective exchange o f experience among selected countries; and (c) replicate the most promising practices as rapidly as possible, either through existing programs or through new programs. Burkina Faso, Ghana, and Mozambique have formally agreed to participate as pilot countries inthe proposed program. TAP'S overall objective is to strengthen each country's capacity to scale-up and implement comprehensive treatment programs providing a range o f quality services that are effective, affordable and equitable for persons living with HIV/AIDS (PLWHA). This objective would be achieved through the implementationo f three components. At the country level, TAP would: (i) strengthen the capacity o f Ministries o f Health to expand treatment through support for reviewing evolving treatment issues and for improving the infrastructure and logistical support; and (ii)scale up the ongoing treatment programs through contracts with already existing treatment and care programs byNGO and private sector service providers. At the regional level, TAP would facilitate: (iii) in-country technical and clinical support through WHO to intensively monitor and evaluate country-level program experience and regional coordination and learning through UNECA to rapidly exchange and disseminate the lessons and implementation tools to other African countries involved intreatment. Component 1: Testing approaches for scaling-up HIPYAIDS care and treatment service delivey at the county level (Total: US$ 38.82 million: Burkina: US$ 13.48 million; Ghana: US$9.86 million; and Mozambique: US$15.48 million) The TAP would: (a) scale up already existing care and treatment programs by NGO and private sector programs to ensure the delivery o f the full continuum o f care; and (b) increase significantly the number o f patients at each stage o f care and treatment. The component also supports provision for ARVs andrelateddrugs and supplies. Treatment programs in each country would be managed by NGOs and associations and/or by private sector entities with proven experience in providing HIV treatment, working in partnership with the public sector. These sub-grants ensure the full continuum o f care and treatment to PLWHAs; and increase significantly the number o f patients receiving care and treatment at each stage inthe progressiono f the disease. Specifically, TAP will improve the quality o f treatment and increase the number o f persons being treated through: (a) the further development o f treatment and care services provided by associations o f persons living with HIV/AIDS in Burkina Faso; (b) the extension of treatment programs offered by the associations o f private sector companies in Ghana to include not only their employees and dependents but also members o f the surrounding communities as well as government workers in that area; and (c) the geographical expansion o f existing treatment and care services provided by large international NGOs in Mozambique beyond their currently 92 covered regions. Thus far, the following implementing partners have prepared proposals for review and approval by the respective Ministries o fHealthinconsultation with IDA: Burkina Faso: AIDSETI (with 5 associations o f PLWHA), CICDoc (with 4 other associations o f PLWHA), and St Camille Ghana: PEF andPharmAccess inassociation with intemational and Ghanaianprivate companies Mozambique: Sant'Egidio, HealthAlliance International, andPathfinder International This initial group o f implementing partners has met the criteria defined in the TAP Project Concept Note. Ineach country, additional NGOs may be identified in coordination with MOH, andtheir programs wouldbe considered, ina second (and final) round o f consultations to review andapprove proposals immediatelyafter project effectiveness. Submitted proposals are required to: (a) indicate the estimated number o f PLWHA who will benefit from the intervention; and (b) estimate the amount and indicate the nature o f the planned expenditures as either direct patient care costs, indirect patient care costs or program management costs. Each o f the proposals should describe how the implementing partner intends to implement each o f the five essential elements for care and treatment and estimate the amounts and sources o f funding available and indicate where the TAP can provide additional support. The five elements o f treatment and care encompass: In particular, the TAP would finance improvements in all five elements o f treatment: Voluntary Counseling and Testing (VCT); Home-Based Care (HBC); Prevention o f Opportunistic Infections (01); Anti-Retroviral Treatment(ART); andPrevention o fMother to Child Transmission (MTCT and MTCT-Plus). VCT. VCT will bebased on baseline blood tests, includingwhere feasible a CD4 count, creation of a patient medical file; and organization of psychosocial support either by the provider and/or an association o f people living with HIV/AIDS or another referral institution providing such services. The patient is classified into stages 1,2,3,4 o f HIV disease, using either their CD4 count, or a syndromic classification based on observed symptoms o f the disease. Based on the classification, the patient will follow the treatment protocols appropriate to the stage o f the disease, as agreed upon by WHO and the Government. Existingopportunistic infections or other illnesses will be treated, and special attention will be given to treating sexually transmitted diseases, tuberculosis, anddepression. DoctorsPhysicians will be actively involved in the implementation and supervision o f this element, but the TAP will also focus on utilizing trained nurses/technicians for clinical support and on counselors for the psychosocial support to increase outreach. Services for serious opportunistic infections will initially be provided through hospitals and clinics, but they should quickly become readily available in outreach facilities in all urban and rural communities, with referral becoming increasingly the exception, rather than the rule. It may even be possible to train traditional healers to assist inthe process o f referring patients to V C T and supporting them on their return to the community. TAP would expand and improve the quality o f services at each o f the entry points for HIV- infected people: VCT centers, antenatal care sites, STI and TB clinics, and hospital in-patient services. TAP would: (a) rehabilitate and expand the number of VCT and ante-natal sites (including limited civil works and basic equipment); (b) promote the demand for VCT services through organization o f local information and education campaigns and community meetings 93 under the auspices o f the beneficiaries o f the MAP; and (c) improve the quality o f testing and counseling services by providing adequate training to all staff andby ensuring the availability o f laboratory equipment and supplies. Where possible, the TAP will augment the support already being provided under the MAPSinthese areas. Home-based patient care and family support. The various components o f this will be coordinated though a single site (e.g.the Day Hospital inMozambique) and comprise outpatient care (laboratory services, treatment o f OIs, etc.), hospice care (with psycho-social support, nutritional counseling, healthy living, survival skills, etc.), and linkages to existing community andhome-based support programs. TAP will finance the training o f additional community counselors, operational costs associated with home visits to provide medical and psychosocial support, and nutritional education and supplementation where appropriate. Experience has demonstrated that the involvement o f PLWHAs as counselors, nurses and technicians improves the effectiveness o f these front line services by providing an environment where the patient is understood and faces no stigma from the caretakers. TAP would support efforts to build the capacity o f PLWHA associations as first line providers o f services intheir communities bothinthe early stages o f the disease (interms o f prevention and peer support), and later when such associations will mobilize latent capacities to provide treatment services, increase treatment adherence through regular monitoring visits, and may also reduce the costs o f having overly skilled health professionalsperforming these services instead o f a local trained community counselor. Where the implementing partner does not have the required skills to provide these services, it will sub-contract and/or coordinate its efforts with the services o f agencies currently providing such services (e.g., WFP inBurkina Faso, and CHAG inGhana) under other programs and allow them to integrate the TAP home-based care and support activities into their regular programs. This will complement other available support for home-based care being provided under MAP grant beneficiaries. Treatment of opportunistic infections. Prophylaxis starts when the patient reaches stage I11o f the disease, as indicated by a CD4 count o f less than 200 or active opportunistic infections. Treatment o f these opportunistic infections (which occur despite prophylaxis or for which prophylaxis i s not available) as well as o f sexually transmitted diseases, tuberculosis, and depression are an integral part o f this component. Treatment will not rely solely on referral to secondaryltertiary health facilities, but will be expanded to community health centers and associations where nurses can manage the majority o f cases under the supervision o f a doctor. TAP will strengthen the organization o f appropriate ambulatory care (including making available resources for regular testing based on the evolution o f the illness and for treatment o f opportunistic infections) and the referral o f complicated cases. In addition, the feasibility o f training and involving traditional healers inthe referral system for 01prophylaxis and treatment will be explored and tested as part o f this initiative. The exact steps for this have yet to be determined. Because the treatment o f complex opportunistic infections will require heavy involvement o f doctors/physicians and secondary or tertiary health facilities, TAP will emphasize the establishment o f formal relationships between these facilities and the associations and community health centers within their catchment's areas. Scale-up plans for areas served by the 94 implementing partners have identified referral facilities to be rehabilitated and expanded, inventoried equipment needs to upgrade their diagnostic capabilities, and formulated training plans to adequately train staff (see Component 1). TAP will contribute to these scale-up plans, finance the organization o f appropriate ambulatory care (including resources for regular testing based on the evolution o f the illness and for treatment o f opportunistic infections), and provide financial resources to subsidize the costs o f hospitalization and post-hospitalization o f patients, as needed. ART. According to the WHO treatment protocol for resource limited settings, anti-retroviral treatment should be initiated when the C D 4 count falls to or below 200, or when the patient shows symptoms o f AIDS-defining opportunistic infections. Unlike in the developed world, most o f the patients starting triple ART under the TAP will be treatment-naNe (they will have had no previous exposure to treatment), and their virus will not be resistant to any o f the ARVs. Therefore first line treatments will typically use the lowest cost and simplest forms o f treatment, a single pill inthe morning andinthe evening. TAP-financed implementingpartners will strictly adhere to the current WHO protocol, andrigorous patient monitoringwill be instituted to provide alternatives to patients who are intolerant to any o f the components o f the first line treatment, or who already have resistant viruses, or who develop resistant viruses during the course o f treatment. In addition to the periodic testing and counseling, TAP would finance the procurement and distribution o f a range o f appropriate diagnostic materials, pharmaceutical supplies, and the pertinent patient monitoring and quality assurance measures required for implementing partners to maintain the necessary care and provision o f services. Some o f this support may already be available under the existing MAPSand TAP will complement this support. Implementing partners will control the budget for procuring drugs and other diagnostic materials but will place orders through the existing national drug agency, unless exceptional circumstances exist requiring direct procurement by the IPS(e.g. incase o f stock outs). Where user fees are applicable (as i s the case in Ghana and Burkina Faso), the MOH will identify standard national user fees to be charged by the IPSand the criteria used to determine treatment availability for priority patients (e.g. mothers and pregnant women) who cannot pay the user fees. Once ART starts, adherence is fostered by combating depression, and by adherence support, either inthe form of Directly Observed Treatment Systems (DOTS), and/or other forms o f patient support from family members, fiends, and other PLWHAs under treatment. PMTCT and PMTCT-Plus. Prevention o fmother to child transmission (PMTCT) o fHIV/AIDS involves training o f birth attendants in simple practices which reduce M T C T at birth, the administration o f ARVs (most commonly a single dose ofNevirapine) at birthto the mother and the new born baby where possible, and the prevention o f transmission o f the virus through breastfeeding, either by training mothers to take precautions in the breastfeeding process itself, and/or by providing ART to the mother. TAP would finance the training o fbirthattendants as well as the purchase anddistribution o fthe needed drugs to prevent mother to child transmission (In some cases purchase may not be necessary, as the manufacturer o f the primarydrugis providingit freely to IDA countries for five years). TAP would also promote the components o f PMTCT-Plus, which include: (a) family- centered care linked to the local community; (b) continuity o f care drawing on a multi- disciplinary team of providers, and long term retention o f patients; (c) psychosocial support, 95 treatment o f STIs and depression; and (d) interventions to integrate treatment adherence with other available community andNGOprograms such as family planning and reproductivehealth. Component 2: Strengthening institutional capacity for expanding HIV/AIDS care and treatment (Total: US$ 16.51 million - Burkina Faso: US$ 4.63 million; Ghana: US$ 5.72 million; and Mozambique: US$6.16 million) To ensure effective public oversight o f the treatment scale-up process, TAP will: (i) strengthen the capacity o fthe National Treatment Committee, established ineach country by the Ministry o f Health, to provide technical guidance and quality control; (ii) coordinate program expansion through improved planning o f infrastructure, human resource development, and drug procurement; and (iii) monitor the quality o f care and disseminate the results o f treatment to identifythe lessons learned and areas requiring improvement. Strengthening the capacity of the National Treatment Committee. Each o f the participating countries has established a National Treatment Committee. Among other responsibilities, these committees will: (a) refine the national treatment policy and adapt WHO-recommended treatment protocols to their national (epidemiological) situations; (b) assess and accredit institutions (private, public, and NGO-operated) seeking to provide HIV/AIDS treatment and care services; (c) review and approve progress reports (and future proposals) submitted by the Implementing Partners (IPS); and (d) supervise the delivery o f treatment services through identified patient tracking andmonitoring tools. TAP will provide resources both for the National Treatment Committee and for the technical sub-committees and working groups (which vary by country) and for the coordinating secretariat (CMLS/S in Burkina Faso, NACP in Ghana, and DAM in Mozambique). On receipt o f the annual plans proposed by the national treatment committees (and all sub-committees or working groups as appropriate), TAP would finance selected activities related to treatment policy, accreditation and approval o f providers, and patient monitoring. Additionally, the project will finance necessary office equipment, technical assistance and training (especially for patient . meetings and workshops, and supervision). TAP will also finance activities related to the tracking and monitoring), small-scale operations research, and operational funds (for supplies, financial management, auditing, andprogram monitoring and evaluation. Coordination of program expansion. Given the need to rapidly expand care and treatment, M O H will need to coordinate the implementation o f the treatment scale-up initiatives, both in terms o fpolicy formulation and development of physical infrastructure, training needs, and drug requirements. The TAP will find policy analysis and development, as required (e.g. on issues concerning gender, eligibility, exemptions, etc.). While Mozambique has prepared a detailed scale-up plan, Burkina Faso and Ghana's plans are more general and the TAP would finance infrastructure and humanresource development plan to increase the geographic coverage by the implementing partners. TAP would finance limited civil works, extensive diagnostic and laboratory material and equipment, technical assistance and training, and operating funds, particularly for supplies andmaintenance. To ensure coordination o f expanded diagnostic and hospitalization services, the development o f staff skills, and the availability o f quality and affordable drugs and reagents, procurement responsibilities will be shared between the government and the implementing partners. In each 96 participating country, the TAP will use existing MOH structures with experience in managing World Bank funds (either through health projects or through the MAPS)to procure limited civil works and extensive diagnostic and laboratory material and equipment, and to finance technical assistance, training and operations, including supplies and maintenance. Government (through MOH) would have overall responsibility for implementing the budget for infrastructure development since such investment would occur in public facilities; implementing partners would control the budget for drugs and consumables and will procure pharmaceutical supplies anddrugs through the existingpublic sector agencies. Monitoring the quality and disseminating the results of treatment. While patient tracking methods inthe participating countries have beenjudged to be adequate for the current number o f PLWHAs under treatment, there is agreement that systems for monitoring compliance, identifying potential resistance, and integrating the results into operational research and learning will require improvement. Given the anticipated increases innumbers of patients, the countries will carry out feasibility studies to determine the most appropriate measures for scaling up (through LAN and/or web-based systems) patient tracking among dispersed treatment sites; the project has allocated resources to finance this study and the implementation o f the subsequent recommendations. From the perspective o f treatment, the MOH and its implementing partners will need to regularly review procedures for: (a) identifying and referring patients at entry; (b) managing care during the early phases o f the disease; and (c) organizing the clinical monitoring and staging o f ART at the appropriate time, including drug resistance monitoring. TAP would finance costs related to this supervision o f treatment. It is anticipated that WHO will provide significant technical support inthe areas o fpatient tracking and small-scale operations research. From the perspective o f program management, MOH will be responsible for managing the overall implementation o f TAP, including planning and budgeting, and regular consultation and annual reviews with the various partners providing financial and technical resources for expanding treatment. TAP will use existing fiduciary mechanisms put inplace under the MAP (inthe MOH) for fiduciary management, including external auditing. Implementingpartners are also expected to include provisions in their proposals for institutional support (comprising advocacy, operational manuals, periodic meetings, annual evaluations, etc.) and project management (comprising training, financial accounting and auditing, and operational costs). In addition, MOH and the IPSin each country will need to: (a) meet regularly to review and evaluate progress and to address implementation difficulties; and (b) periodically revise treatment guidelines and protocols, with the assistance o f WHO. Regionally, TAP will finance participants from the countries inthe quarterly RAP meetings andperiodic RCCC meetings. Component 3: Facilitating regional learningfrom the TAP country experiences (Total: US$ 6.00 million - WHO: US$4million and UNECA: US$2million) To support in-country learning, TAP will finance WHO, through its headquarters and regional offices, to provide assistance in: (i) refining. and making operational treatment guidelines and protocols; (ii) developing national standards, criteria and assessment tools for accrediting laboratories and treatment sites; and (iii)setting up quality assurance systems for drug procurement and testing. WHO would also provide additional technical assistance in: (i) developing curricula and pedagogical methods for the training o f medical and paramedical staff; (ii)strengthening program monitoring and evaluation; and (iii)establishing methods for managingpatient compliance and evaluating treatment outcomes and potential drugresistance. 97 To support cross country learning, the TAP would establish a regional multi-disciplinary advisory panel (RAP) to promote the rapid incorporation o f lessons from the TAP into MAPS and GFATM and other donor funded programs. The RAP will meet semi-annually (or more often ifnecessary) inAddis Ababa, andthe participants would include, inter alia, representatives from each TAP country (4-6 per country); World Bank; WHO-Geneva and WHO-AFRO; UNICEF; and all implementing partners. UNECA would establish a unit to serve as the secretariat for the RAP and to coordinate and follow up on recommended improvements and treatment scale-up lessons emergingfrom TAP countries. UNECA, in cooperation with WHO and the World Bank, will facilitate regular consultation and learning among TAP countries. As the regional secretariat for the United Nations system and a source o f analysis, learning, and support for African implementation o f socio-economic policies, and as the host o f the Commission on HIV/AIDS and Governance in Africa (CHGA), UNECA would provide: (i) support on HIV/AIDS issues; (ii) to important regional development access statutory bodies (e.g. Conference o f African Ministers o f Finance and Planning, the African Development Forum, and the African Learning Group on PRSPs); and (iii) organization and hosting o f regularmulti-country expert meetings, including preparation o f documents andreports andadministrative support andconference services. To carry out these responsibilities, a small TAP coordinating unit will be established within the CHGA to serve as the secretariat for the RAP and regional liaison for TAP activities in collaboration with WHO (HQ Geneva, Regional WHO/AFRO and WHO country offices) and the country TAP Coordinatorswith regardto learning activities. The unitwill beresponsible for: (i)managing and disseminating quarterly reports from each TAP country; (ii) convening and hosting the regular TAP learning meetings; and (iii) managing (in consultation with WHO, country TAP coordinators, and the World Bank) operational research on issues identified by the Regional Advisory Panel (RAP) of the TAP. The CHGA will offer guidance and support to the TAP coordination unit, particularly on the conduct o f agreed research activities, and it will draw on the staff resources o f the relevant UNECA sub-programs (e.g., the Center for Gender and Development) inorganizing andmanagingthe research program. Lessons learned from the TAP will be incorporateddirectly into the work o fthe CHGA andother fora as well inAfrica. The RAP will establish a regional clinical coordination sub-committee (RCCC) to work with the International Treatment Coalition (ITAC) and WHO to maintain regular review o f treatment regimens and protocols as lessons from country treatment programs are gathered and shared at the regional level. The RCCC will comprise African clinical experts recognized for their work in HIV/AIDS treatment, to enable African countries to share experiences, to review clinical results, and to recommend policy reforms inparticipating countries. WHO will serve as the rapporteur o f the RCCC. Costs o f conference facilities and support o f conference services staff for logistics, security, and protocol will be provided by UNECA as in-kind contributions. Other related direct costs such as air travel, accommodation, catering andhospitality, interpretation will beborne by the TAP. TAP would also finance the costs o fbothWHO andthe TAP coordination unit. IDA would conclude an agreement with WHO and UNECA for these services. Inaccordance with the Operations Committee decision, the Board would be requested to approve this arrangement as an exception to policy and as an extension to the IDA 13 grants framework, in 98 view of the public good nature o f the activities. This arrangement takes into account major institutional constraints that would make the disbursements o f funds by one country or organization on behalf o f other TAP participating countries cumbersome and inefficient. 99 * c! 1 0 9 " : 9 , 9 0 9 N N N + 0 0 - m 2 0 3 0 I I 2 c ! " : N 3 2 I I 2 O N ' c ! " ?N I I c? b ? ? 0 0 2 I I 'c! m 'c!? q i O N 'c! m T09 9 0 - -- I I Annex 6: ImplementationArrangements Regional HIV/AIDSTreatment Acceleration Project 1. Overview While the situation will differ from country-to-country, certain features for each o f the national programs are common: The Ministry o f Health has the responsibility for overseeing all treatment programs and, in collaboration with the National AIDS Council and National AIDS secretariat, will define the institutional framework within which TAP activities are carried out; Activities o f the Ministryo f Health, financed under the TAP, will be consistent with the national health program and integrated into existing structures within the Ministry o f Health. N o new public sector implementing organizations will be created, although additional funding to support the TAP is envisioned for these purposes, and may include a designed small TAP project unit; M A P procurement and fiduciary arrangements will be applied, wherever possible and appropriate, so as not to complicate or delay TAP activities. This includes audit requirements. The flow o f funds will be through the appropriate public sector entity, which has the capacity to assure satisfactory fiduciary management o f TAP resources; Implementing Partners (IPS) will receive funds under terms set forth in a contract between the IP and the Government's designated lead entity, which will likely be the head o f the small TAP project unit, anchored inthe Ministry o f Health. 2. Institutional Framework Each TAP country has established an advisory National Treatment Committee to oversee expansion o f treatment programs, monitor TAP implementation TAP, and rapidly disseminate useful information among TAP (and other) countries in the region. The National Treatment Committee will report to the Minister o f Health and will draw on expertise from WHO and UNECA, as well as existing HIVIAIDS technical partners. The composition, tasks, and responsibilities o f this committee are detailed inthe ministerial decrees establishing them. (qq) BurkinaFaso Burkina's national response to the HIVIAIDS situation is organized through the National Secretariat for Combating HIVIAIDS and STIs (SPICNLS-IST), established in October 2001 under the Office o f the Presidency and charged with coordinating a multi-sectoral response program with high-level representation o f all Government Ministries. The President o f the Republic heads the CNLS-IST and has provided political support for its activities. The CNLS- IST has also established corresponding structures at regional, provincial, and community levels. Organizationally, SPICNLS-IST comprises seven departments and employs more than 30 staff; it coordinates activities among the respective partners in the areas o f prevention, treatment, community development, monitoring and evaluation. Responsibility for issues related to treatment is vested in the Ministry o f Health through the Ministry of Health AIDS Committee (CMLSISantC); operationally, CMLSISantC has organized 101 treatment activities with the exception o f PMTCTFMTCT-Plus, which has been delegated to the Directorate for Family Health (DSF). A National Technical Committee on HIV/AIDS Treatment was established by the Minister o fHealth on January 30,2004 to provide technical support to the CMLSISantC, particularly with respect to: (i) analysis and revision o f treatment guidelines and strategies; (ii)identification o f treatment problems and the search for solutions; and (iii) supervision o f the quality o f services provided. Its membership includes representatives o f key stakeholders (the directors o f MOH, representatives o f the principal treatment sites, SP/CNLS- IST, and WHO). When fully operational, the committee will address issues related to diagnosis andtreatment (ISTs, OIs, andARV) as well as the organization o fPMTCT andPMTCT-Plus. (rr) Ghana Ghana's national response to the HIV/AIDS situation is organized through the Ghana AIDS Commission (GAC), established in September 2000 under the Office of the President and charged with coordinating a multi-sectoral response program high-level representation o f some 15 ministries. The GAC has delegated issues concerning treatment and care o f PLWHA to the MOH's National AIDS Control Program (NACP). The NACP is a division within the Disease Control Unit o f the Public HealthDirectorate andwill serve as the focal point for the TAP within the Ghana Health Service (GHS). An Advisory Committee on Antiretroviral Therapy in Ghana (ACATG) was established on February 09, 2004 to streamline inflow o f ARVs into Ghana and advise on future directions in ARV policy and implementation. Its membership includes representation o f key stakeholders (GHS, PLWHA, Pharmacy Council, Food and Drugs Board, GAC, MOH's Procurement and Supplies Division, and NACP). This committee is supported by a Technical Working Group on ARV Therapy (TWG), organized under the aegis of the NACP and comprising members from the teaching hospitals, the medical school, private hospitals active in HIV/AIDS treatment, the medical research institute, MOH's procurement unit, and FamilyHealth International (whichhas supported Ghana with the pilot treatment program testing). The TWG will, inter alia: (i) provide support on matters related to treatment and care o f persons living with HIV/AIDS; (ii) take part inclinical sites visits and accreditation of all sites and service providers; (iii) technical provide backup and support to all sites earmarked for accreditation and all accredited sites; and (iv) provide relevant material based on both local and external clinical experiences and research for review andrevision o fnational guidelines on treatment and care, when necessary. (ss) Mozambique Created in 2000, the National Council to Combat HIV/AIDS (CNCS) i s responsible for coordinating HIV/AIDS activities covering prevention, education, and care among major partners (Government, civil society, donors, national and international NGOs), as well as for mobilizing resources to fund the multi-sector response to the pandemic. It is headed by the Prime Minister and includes the Minister o f Health as Vice President. CNCS does not implement programs, but functions in close cooperation with the Ministry o f Health (MOH) and other ministries through their focal points for the implementation o f the HIV/AIDS plans. CNCS is representednationally as well as ineach o f the ten provinces and inMaputo City. Assisted by the Ministry's Advisory Council (Conselho Consultivo do Ministro or CCM), the Minister ofHealthhas overall responsibility for the TAP. Within the Ministry,the Directorate o f 102 Planning and Cooperation (DPC) and the Directorate o f Health (DNS) will have primary responsibility inclose collaboration with DEE, DSC, DRHandDF. DPC will be responsible for coordinating the implementation o f TAP, drawing on the full capabilities o f the MOH. The M O H National Treatment Committee, headed by the Director o f Medical Services (DAM), will provide regular technical guidance and review o fthe TAP program. 3. TAP Implementation,administration,and monitoring Ineach o f the three countries eligibility/selection of the initial IP has been made for the first phase o f the TAP. Additional IP may be added in future, but would be approved in accordance withthe guidelines established bythe National Treatment Committee andmust receive IDAnon- objection. The National Treatment Committee will review and approve future IP grant requests, review regular reports, and monitor and evaluate the performance o f the IP. Overviews o f the implementation arrangements may be found on the following pages. (tt) Burkina Faso CMLS/SantC supervises the Health-Sector MAP component, has a Coordinator's Office with essential professional staff covering ART, Surveillance, MTCT and Laboratories. CNLS/ Santt has established a treatment committee and thematic sub-committees. CMLS/ Santt will review the TAP implementation progress and make strategic decisions and approve annual work plano f the TAP IP. Additional staff, including a fulltime M&E Specialist and a social development specialist will be hired to provide guidance to IPS. Day to day coordination o f TAP activities will be the responsibility o f CMLS/Santk (coordination unit) for scaling up medical care, while DSF will be responsible for scaling up PMTCT and introducing PMTCT-Plus in additional sites. This division o f labor reflects both previous experience and the anticipated volume o f future work. CMLS/SantC has already gained experience in carrying out treatment related activities with financing from the MAP and other sources, while the DSF has been implementing the pilot programs for scaling up PMTCT in collaborationwith UNICEF, JHPIEGO, and others. Sub-grant agreement, signed by MOH and the IPS outlines the roles, responsibilities, and obligations o f the different parties. The sub-grant agreements will stipulate, inter alia, the nature and costs o f the services to be provided by the IPS;the qualifications o f staff to be provided; the relationships for managing the program (procurement, financial management, supervision and monitoring) by the IPS,CMLS/SantC, and DSF, and the frequency and content o f the technical and management reports to be submitted to MOH. IPSwill provide annual plans detailing the costs o f the proposed HIV/AIDS treatment programs; these will be reviewed jointly by a committee comprising MOH, WHO and IDA. Disbursements through MOH to the consortium will be linked to agreed specific progress report indicators and related financial reports on utilization o f earlier fimds received. (uu) Ghana NACP has already gained experience in coordinating treatment projects through its association with FHIinimplementingthe pilots. Underthe scale-up plan, NACP will serve as the secretariat to the National Advisory Committee and the Technical Working Committee, whose roles have 103 been generally defined. Day to day coordination o f the program at the selected treatment facilities will be the responsibility o f the PEFPAI consortium; monthly meetings o f the Technical Working Committee will provide a regular forum for analyzing the results from the field. To avoid the creation o f parallel systems for complementary health interventions, TAP will provide assistance to NACP and the Implementing Partners through the existing structures and mechanisms established by MOH. NACP will provide technical support to the oversight committees; will provide technical and financial support to the Implementing Partners; and assume responsibility for a number o f functions, including: accreditation o f treatment sites, in- service training o f health personnel on the newly developed treatment protocols and guidelines (VCTPMTCT, STI and 01treatment, and ART), and monitoring o f programperformance and patient impact. NACP will rely on other institutions to carry out the actual TAP activities but will maintain the overall supervisory role for the Ghana TAP program. Infrastructure and equipment needs will be identified by the appropriate services within MOH and the Regional Health Administrations (Estates Management and Bio-medical engineering). AIDS-related drugs and equipment will be procured through the Procurement Unit (PU), in the Department o f Medical Services (DMS) under the MOH, and will be distributed through the Central Medical Stores (CMS) and their regional anddistrict offices. (w) Mozambique DNS will appoint a TAP Coordinator (Program Officer) financed from the TAP, who will be responsible for technical programming, as well as monitoring and evaluation, and operational coordination. She will prepare annual plans as part of the annual planning cycle o f the Ministry o f Health. The TAP Coordinator will be the contact point for the CNCS, and also for regional development and learningefforts with WHO andUNECA. Implementing Partners will deal principally with the Office of Coordination o f Investment Projects (GACOPI) and the TAP Coordinator for operational matters, interface with the National Treatment Committee on technical matters, andProvincial medical officials at the facility level. 4. Procurementand fiduciaryarrangements (ww) BurkinaFaso Procurement and fiduciary management o f TAP funds will be handled by the existing arrangements established under the Health District Support Project (PADS). Supported by IDA since 1992 in its efforts to strengthen MOH's fiduciary capacity, PADS'S task is to perform fiduciary management o f MOH's decentralization efforts to the regional and district levels. Currently, the PADS manages a portfolio o f about US$12million with a modest professional team o f a director, 2 accountants, and some support staff. PADS has developed financial and procurement procedural manuals with the help o f IDA and other donors and produces regular financial and procurement reports/plans. It has a computerized financial and procurement system per Bank requirements. 104 Overall, PADS will manage TAP finances. However, considering the current human capacity andnot to incur quality compromise to their ongoingoperations, TAP will finance the services o f a Financial Management Agent (FMA) or an accounting firm. PADS will contract-in FMA for accounts management, reporting, fiduciary advisory services to all involved institutions, and to manage fiduciary supervision and capacity buildingo f the IP. FMA will work directly under the supervision of the Director PADS. Procurement will be carried out through three levels: (a) at the PADS level for common works, goods and services; (b) CAMEG will procure all drugs (including ARVs) and laboratory supplies. It already procures such items under the MAP financing; and (c) IPSwill procure small quantities/volumes o f goods, drug (that are not procured by CAMEG and are generally available inthe localpharmacies for opportunistic infections) and services. (xx) Ghana Procurement in the Ghana Health Service (GHS) headquarters is the responsibility o f the Procurement and Supply Division (PSD), with a Procurement Unit (PU) and Procurement Committee, which provide technical support to other procuring BMCs in the (GHS). A procurement manual was produced and disseminated to Central Medical Store (CMS), hospitals, and extensive in-service training was provided for concerned staff (latest version May 2003). IDA considers these procedures satisfactory. While procurement in MOH is essentially decentralized, PUmonitors and supervises all procurement activities inhealth area, with overall planning, review and approval o f contracts above certain thresholds submitted to the steering committee. Each accredited Budget Management Center is thus responsible for its own procurement, but procurement o f large value and strategic items (e.g. essential drugs, vaccines and ARVs) is centralized. The PU shall prepare and implement procurement plans and shall maintain an efficient record management system for all procurement activities including ARVs. MOH has hired two procurement agents to assist in the procurement o f ARVs and other HTV/AIDS health sector equipment, drugs, test kits and reagents. The procurement procedures in MOH are now institutionalized, and with the exception o f procurement from earmarked funds from a few donors, all procurement inthe sector, irrespective o f the source o f fbnding is subject to either prior or post review by the Development Partners. As part of the FMR, MOH will submit 6-monthly reports to IDA not more than three calendar months after the end o f every semester. The FMR should include the status o f (i)implementation o fthe procurement plan, and (ii) contract management and expenditures on contracts. The financial management responsibility under the TAP will be vested inthe finance division o f the Ministry o f Health (MOH). The accounting system o f the Ministry is documented in an accounting procedures manual, the Accounting, Treasury and Financial Reporting Rules and Instructions (ATF Rules). The finance division is headed by a professionally qualified accountant, the financial controller (FC), and is assisted by a team o f qualified and partly qualified accounting staff. All the staff have worked on previous Bank projects and are familiar with the World Bank's Disbursementprocedures. The treatment program will be in line with the guidelines laid out by the MOH and hospitals within the M O H system providing treatment for HIV/AIDS patient, under TAP, will receive hnds through the MOH system (same as under the health SWAP). It is however recognized that 105 there will be some hospitals outside the MOH system that will also provide treatment to HIV/AIDS patients. In such situations the modalities to be followed will be similar to how Christian Health Association o f Ghana (CHAG) hospitals presently receive funds from the MOH. Although the same M O H systems will be used, the funding for the TAP will not be part o f the "donor pooled funds", but rather maintained in a separate special account on similar lines to the Global Funds. Since funding for TAP activities i s provided through a separate special account (SA), managedby the FC office within MOH (on behalfo fNACP as the main executing agency), the request and release o f funds can be made as and when funds are needed. Under the GhanaHealth SWAP, private sector auditors have been engaged to undertake the audit o f the Ministry's financial statements. Since the TOR are for the audit o f the Ministry's operations, the TAP activities will automatically be covered, but to ensure that the institutions and hospitals outside the MOH systems are covered in the audit, the TAP program will be mentioned inthe scope of the audit, and a statement included inthe audited financial statements on the activities o f TAP and whether participating IPShave executed the program in accordance with the agreed project documentation. There will therefore be no separate audit report for the TAPproject. (yy) Mozambique The DPC through GACOPI will be responsible for procurement and financial management. GACOPI provides support to MOH for management o f external funds, includingthe MAP and will be responsible for TAP procurement and reporting to the TAP Coordinator. GACOPI's duties will be similar to those performed for the MAP, assuming its capabilities are strengthened, as agreed to and financed under the MAP. It will work closely with C M A M (in the DNS) for planning the procurement drugs and medical supplies, while MEDIMOC will carry out procurement as directed and programmed by the MOH entities. TAP drug procurement reports will become part of the regular quarterly reports submitted to DNS and DPC, the Minister and the CCM. Based on already existing fiduciary arrangements, TAP'S financial management and disbursement will be managedby GACOPI, which has also supported the implementation o f the closed Health Sector Recovery Project and the Health Component o f the on-going MAP project. The project will operate a Special Account to be opened by GACOPI in a commercial bank acceptable to IDA. GACOPI i s familiar with the rules governing the administration o f Special Accounts and will therefore be ready to operate it after Grant effectiveness. The size of the authorized amount for the Special Account will be discussed and agreed at negotiations. All accounting work for TAP project expenditures will be managed by GACOPI. Capacity building for GACOPI will be supported under TAP for any gaps identified. A substantial capacity support has already been given under MAP. However, it is likely that TAP will stretch the present capacity, hence the need to consider financing the gaps under TAP. Reporting (FMRs) by GACOPI will be on quarterly basis. Annual audit of TAP financial statements will be by an independent and competent firm o f auditors of good standing and reputation. Audit reports will be due to IDAnot later than six months after each year-end. 106 5. Monitoring and evaluation (zz) Burkina Faso TAP will finance regular meetings o fthe thematic commissions andthe quarterly meetings o fthe technical committee, which will provide periodic opportunities for coordinating interventions andanalyzing the results from the field. (aaa) Ghana A list of clinical and non-clinical indicators, identified from the National M&E Planand agreed to by the Implementing Partners, will serve as the basis for monitoring and evaluating program performance. Progress against these indicators will be included as part of the monthly and quarterly progress reports provided to NACP, and will serve as the basis for achievement by the IPSo f their performance targets. PEFRAIwill provide backup support to the treatment centers incollecting andorganizingthis informationforNACP. (bbb)Mozambique DNS will be responsible for technical coordination andtechnical support to NGOs, andtechnical monitoring and evaluation. Under TAP, WHO will provide technical support to DNS on monitoring resistance and operations research. TAP will utilize the M&E system established by the MOH through its National Treatment Committee members' participation, or through TAP advisory consultants execution. Data from TAP will flow both into the Mozambique national system, and will be provided for regional learning and development purposes. NGOs will utilize andimprove the patient tracking system 6. RegionalLearning and Coordination (ccc) WHO WHO will be looked to for: (i) in-country support for the refinement o f protocols and training o f medical and paramedical staff; (ii)technical assistance to monitor patients and treatment outcomes; and (iii)information exchange on treatment topics. A Memorandum o f Understanding or Management Contract will be entered into with WHO Headquarters to outline the basic objectives o f the programs and how it will be implemented. For each country the WHO Representative, working in conjunction with WHO/AFRO, will develop a plan o f action on a yearly basis. The WHO representative will manage and administer the funds (a modest administrative fee will be covered by TAP), providing reports on their use through WHO Headquarters, which will consolidate the information andreport to IDA. WHO will provide technical support on all quality assurance issues pertaining to treatment. These include: 0 Assisting in finalizing and updating policies and standard guidelines for HIV/AIDS treatment and care pertaining to VCT, PMTCT, PMTCT-Plus, ART, 01s and care and support for PLHWA (WHO recognizes the availability o fnational policies and guidelines as key factor for scaling up interventions); 107 0 Assisting in broadening service delivery approaches to integrate health and community care through standardized training materials for community treatment supporters; 0 Assisting in the development o f monitoring and evaluation framework including the development o f tools for tracking HIV/AIDS treatment adherence, including drug resistance, and piloting a list o f minimum set o f national indicators to track the progress; 0 Providing inputs inthe regional multi-disciplinary advisory panel (RAP) and in the sub- committee o f clinical experts (RCCC) to ensure incorporation o f data and information in the review o f clinical results, and to promote operational research to feed recommendations for policy reform; 0 Supporting access to, and efficient distribution o f low cost medicines and diagnostics through provision o f technical and operational support for procurement, regulation, and to ensure that the quality o fmedicines anddiagnostics are strengthened; 0 Facilitating learning between facilitating partners dialogue through regional forum to exchange experiences and ensuring the documentation o f cross-country cooperation. (ddd)UNECA In support of cross-country learning under the TAP, UNECA will perform the following functions: (i) organize and host semi-annual learning meetings involving technical experts; (ii) manage and disseminate information based on quarterly country reports; and (iii) conduct non- clinical research activities relevant to the enhancing the results o f the TAP, on issues such as gender and yulnerable groups; youth; and nutrition. UNECA will establish a small coordinating unit in Addis-Ababa (UNECA Headquarters) in order to carry out its functions. UNECA administrative procedures will be following in the management ofthese resources with annual reporting, and auditing reports provided to the World Bank. Established in 1958, the Economic Commission for Africa (ECA) is one o f five regional commissions under the administrative direction o f United Nations (UN)headquarters. It reports to the UNEconomic and Social Council (ECOSOC). ECOSOC sub-bodies implement programs inaccordance with UNAdministrative Rules and Procedures. Compliance with UNprocedures satisfies requirements o f the Association, and this would include where a UN entity is itself a grant beneficiary. With respect to UNECA, it has specified in writing it follows the UN Financial Regulations and Rules, as well as the UN Procurement Manual. Subsequent discussions with relevant UNECA fiduciary personnel, including the UNECA Director o f Finance, confirmed UNECA's adherence to UN rules and practices. These arrangements are consistent with IDA'Sframework regarding financial management due diligence in connection with UN agencies. There are no special circumstances at this time to warrant more extensive fiduciary capacity assessment. The Association will reserve the right to request data, information, reports and meetings with regard to any specific financial, auditing and procurement matter, ifcircumstances should so require. UNECA intends to undertake certain activities inthe near term inorder to assure rapidtakeoff o f the TAP learning component. It has already provided senior staff advice and participation on TAP pre-appraisal and appraisal missions and will continue this process with, inter alia, consultancies and country-level workshops. It also intends to initiate recruitment for the TAP 108 coordinating unit in Addis and provide essential equipment for the unit's functioning. These expenditures are eligible for the UNECA under the TAP grant, and estimated to require retroactive financing o f $200,000 (equivalent to 10%o fthe grant.) 7. Bank supervision Bank supervision will be both through the Resident Mission and Washington. For country activities the MAP/TTL will be responsible for maintaining regular contact with the appropriate national structures, follow TAP performance, provide non-objections, and regular reporting. As the TAP will deal with similar issues as encountered inthe MAP, Bank supervision can "piggy- back" on MAP responsibilities with missions by health specialists, procurement and financial management specialists coinciding with TAP missions. An additional $50,000 annual supervision budget will be provided for country supervision. The Regional TAP/TTL, responsible for both regional learning and coordination among the country programs, will be the back-up TTL for the country program, and the principal TTL for the entire TAP effort. The Regional TAP/TTL will be provided with a separate budget that will allow country visits, and assistance to the country in the learning aspects o f the TAP. It is expected that there will be two supervision missions yearly, as well as participation by IDA at the semi-annual regional meetings. Supervision missions will be integrated into MAP and (when relevant) health sector supervisions. Supervision missions are to include the following: Country TAP/TTL; Regional TAP/TTL (as available); Health Specialist, complementing TTL skills; Financial Management Specialist; Procurement Specialist; M&E Specialist; and Lawyer (as needed). Regional meetings will include the participation of: Regional TAP/TTL; Country TAP/TTL; M&E Specialist; Technical Specialist (ARV drugprocurement, gender, youth, nutrition, as needed) 109 Annex 7: Financial Managementand DisbursementArrangements Regional HIV/AIDS Treatment Acceleration Project This Annex reflects the general aspects o f Financial and Disbursement Management Arrangements applicable to all three TAP countries. Country specific assessment and arrangements are included inthe Attachments to this Annex. 1. Summaryofthe FinancialManagementArrangements The project's financial management arrangement varies in the three TAP countries in terms o f the institutional structure and implementation arrangements. However, inprinciple, the financial management arrangements for TAP will follow the existing system in the lead implementing entity responsible (MOH) for the TAP program. Assessment o f the financial management capacity in these entities has been reviewed and updated to ensure that it is in compliance with the minimumrequirements to satisfy the fiduciary Operation Policy/Bank Policy (OP/BP 10.02). Specific time bound actions have been recommended to each o f the implementing entities in each country that will help enhance capacity necessary to implement TAP. Details o f the specific areas o f weakness and associated risks as well as mitigating actions are articulated in the Attachments to this Annex. Inview ofthe challenges this projectposes to boththe recipient countries and IDA, the need for close supervision at each country level will be critical. It will also be imperative to learn from implementation experience and adjust the financial management and disbursement arrangements to meet the needs o f the project. Flexibility on the part o f all involved parties i s therefore strongly emphasized. Table-1 below illustrates summary o f the implementation arrangement adopted for TAP in each country. Table 1-Summary ofimplementationarrangements Burkina Faso Unitofthe MAP at the Disaster o f a Financial Management step to get the project effective national level. ResponseProject Agency to be selected (MAP) competitively Ghana Ministry o fHealth Second Health MinistryofHealth-HQ Retention o f a Financial Sector Program InNACP-underthe Financial Accountant inNACP. Support Project Mozambique NationalAIDS Council IResponseProject IMinistryo fHealth's external IController Opening a Special Account the SWAP HIV-AIDS I1beside GACOPI will disburse -ExecutiveSecretariat funds management unit advances to IPSintranches (CNCS) and GACOPI (MAP) (GACOP) for both the initially for 6 months and for the M O H ministry's activities and as a quarterly thereafter on component channel for funds to the performance basis evaluated ImplementingEntities (IPS) jointly by MOHiIDANVHO 110 Fundingto United Nation (UN) agencies - Fundingto the World Health Organization and the United Nations Economic Commission for Africa will be on basis o f specific tripartite agreements between the agencies, recipient countries and IDA. The relationship between the UN entities and IDA under this project i s built on the foundation set forth in the Memorandum o f Understanding (MOU) negotiated between the World Bank and United Nations Development Program (UNDP) as the representative body for the United Nations entities that receive grants directly from IDNIBRD for specified tasks. The substance o f the agreement formalized in the MOU is that compliance with the UN's Financial Regulations and Rules will satisfy the IDA'S Financial Management requirements. In particular, there are two important fiduciary worth noting: 1- Audit Exemption: There will be no requirement for a separate audit for the purposes o f IDA financed operation, and instead, reliance shall be placed on the overall audit opinion issued by the UN's own Board o f Auditors on the WHO and UNECA financial statements. However, where circumstances so necessitate, IDA will have the right to request an audit o f the operation. To this end, IDA shall monitor centrally the biennial audited financial statements o fthe UNagencies. 2 - As a corollary, IDA will recognize the WHO and UNECA respective `External Auditor' or UN's own `Board o f Auditors' to be independent auditor and the adherence o f U N ' s own `auditing standards' as satisfactory and acceptable for this purpose. The two UNAgencies shall report to IDA on basis o f FMRs. However, inview o f the adequate financial management systems and capacity in the UN Agencies, reporting on a six-month interval would be reasonable and acceptable to IDA. 2. Disbursementand Flow of FundsArrangements The disbursement arrangements in the respective countries will in principle adopt the current channels under the ongoing IDA supported operations in the three countries. There will be separate Development Grant Agreement (DGA) for each country, with a specific amount o f each grant inthe Grant Account held by IDA. Ineach case, grant proceeds will be drawn on basis o f Withdrawal Applications (WA) to be submitted to IDA by the implementing entity for TAP in each o f the three countries. Each o f the three countries will open a Special Account with a reputable commercial bank acceptable to IDA, into which the initial deposit will be deposited when the grant becomes effective. Details o f the disbursement arrangements vary between the recipient countries and are clearly specified inthe country attachments. Inview o f the nature of the project, and there being no previous exposure and experience in implementation o f this type o f sub-regional program, all parties involved must be willing to learn in the process and apply prudent flexibility where this would facilitate project implantation and achievement o f the desired results. Financial reporting will also vary from country to country in view o f the different disbursement arrangements and accounting systems being used in the implementation o f TAP. However, reporting o f financial expenditures by the IPSand MOH in each country will be based on agreed Financial Monitoring Reports (FMRs) even where report based disbursement (FMR) approach is not adopted for TAP in a country. Details of the accounting systems, reporting arrangements and audit are all indicated inthe attachments for each country. 111 Table2 Allocationsof Grant Proceeds (in US$ million) - Unallocated 1.6 1.5 2.0 0.425 0.185 5.1 Total 18.1 15.0 20.9 4.0 2.0 54.0 3. Audit The main objective o f an audit by an extemal auditor o f TAP will be to obtain an independent opinion on the operation and transactions under TAP on an annual basis, as well as report on the annual financial statements, prepared by the implementing entity in each o f the three countries. The external auditor will be expected to ascertain that the financial statements are in agreement with the books of accounts used in the project; that there is no material misstatement in the financial statements, which give a true and fair view o f the financial status o f the project, and that project funds have been properly used for intended purposes. In all the three countries, it is anticipated that the auditing arrangement inplace for ongoing operations will be applied for TAP as well, unless there is any justified reason to deviate. Existing Terms o f Reference (TORS)for the external auditor may be modified to include audit o f TAP, or new separate TOR will be prepared, where a separate audit is preferred. Specific arrangements have been detailed in the country attachments. Each country shall submit audited project financial statements not later than six months following the end o f the financial year under review, in compliance with the financial covenant inthe respective Development Grant Agreements (DGAs). Inall the three countries, the recommendation is to use internal audit units inthe Health Sector Program in Ghana, and in MOH in Mozambique and Burkina Faso be used to provide internal audit reviews of operations under TAP. Where appropriate, the implementing entity may also consider establishing an internal audit outfit that would complement the internal control environment. 112 Ministries o f Health in the three countries have also been advised to consider the medium to long-term benefit of creating Audit Committees to have oversight responsibility over audit matters. (eee) Burkina Faso o Summaryof assessments Financial management assessments o f the government and IPSwas carried out to establish the overall project financial management requirements per institutional arrangement o f the project andto ensure efficiency inbringingthe TAP resources closer to the beneficiaries as efficiently as possible. Assessment o f the government entities included: PADS, PAMAC, PA-PMLS,Dutch HIV/AIDS financing (through a Financial Management Agent -Deloitte and Touche), and NGO Implementing Partners including CICDOC, Saint Camille and ALAVI. The objectives o f the assessments were to (i)determine whether the key implementing entities have in place an adequate financial management system as required under Bank guidelines and (ii) recommend to financial management arrangements for the mitigation o f the fiduciary risk components identified during the assessment. Table 1 suggests an action planto lay the foundation work for the project's financial management. Table3 FinancialManagementactionplan - Finalmanual including IDA comments and acquisition of the required software to the benefit of FMA August 15, 2o04 GOB/PmS,,IDA Recruitment of the external auditor for PADS and local N G n c August 15, 2o04 GOB/PADS I *...-VI I Installation o fthe computerized financial management I I system to the benefit of FMA (budgets available from technical proposals, the two special accounts opened, August 15, 2o04 GOB / adequateparameters set up for the computerized system) Assessment of the readiness for effectiveness of the FM 7 system and clearance of TAP for the related FM September 1, FMSI IDA. conditions 2004 113 I establishment o f a FMA prior to the TAP effectiveness based on the action plan inTable 1. The FMAwill be housedat PADS office andwill operate underthe directives ofthe PADS Director. The PADS financial management staff will thus benefit from the FMA related experience. The selection of the FMA for the TAP is a condition o f effectiveness. Financial Management Manuals. Two manuals will be developed. One will be for the local NGOs (Implementing Partners) and the other for the beneficiary government entities and the FMA. The existing one used by PADS for financial management at regional and district levels will be also an adequate arrangement for the TAP. These manuals represent a condition o f effectiveness. Accounting System to be maintained by the PADSFMA: The accounting system o f the project will be based on a Financial and Accounting ProceduresManual. Proper books o f accounts will be kept on a double entry accounting principle using the cash based system. Written job descriptions with defined duties, responsibilities, lines o f supervision and approval limitswill be established and described in the FM Manual. Definition o f responsibilities should ensure segregation of duties for proper accountability. Through a computerized accounting system is in place, P A D S F M A will put inplace adequate mechanism to ensure that proper books o f accounts are kept. This is achieved through a well defined filing system that allows authorized users easy access to accounting and supporting documents on a permanent basis. Financial Management Information System. PADS'S accounting. system is already computerized, meeting IDA requirements. The same software will be customized for the TAP by the PADSFMA. The chart o f accounts (expenses categories and activities) of the TAP, the Financial Monitoring Reports (FMR) andthe annual financial statements must be customized in the accounting software prior to effectiveness inorder to ease their production. The TAP will put in place an Integrated Management Information System. The system will integrate the Budgeting, Operating and Accounting Systems to facilitate monitoring and reporting. System generated formats for periodic reports will be developed and agreed with P A D S F M A that will prepare quarterly Financial Monitoring Reports (FMR) based on an activities annual plan to be developed every year. The format o f the FMRwill be discussed and agreed before effectiveness. The quarterly reports will cover financial management, procurement, and physical progress monitoring, and will take into consideration all activities financed under the TAP regardless all the local NGOs selected and other entities involved in the TAP implementation. The major problem is foreseen about the timeless in collecting the information related to the procurement andthe physical progress monitoring activities; CAMEG, PAMAC, CMLS andDEPMS should provide this information. The physical progress reports included inFMR set will be based on the output and outcome indicators. Consolidated quarterly FMRs will be produced to include: 0 Sources andUses o f Funds byproject Categories and Components; 0 OutputMonitoringReport; 0 Procurement MonitoringReports. IncompliancewithInternationalAccounting Standards (US) andWorldBankrequirements, the project will produce Annual Financial Statements, which will include: e A Statement o fCash ReceiptsandPayments; 0 A Statement o f Sources andUses o fFunds; 0 Notes to the financial statements including accounting policies underlying the preparationo f financial statements. 115 External Audit arrangements. PADS will appoint a qualified independent auditor. The selected auditor will be acceptable by IDA interms o f independence, qualifications and experience. The audit will be based on terms o freference agreed with IDA. The external audit work will include only the Grant funds managed by PADSFMA and by the local NGOs. Where possible efforts will be made to include other donors' funds. In addition to the audit report, the auditor will prepare a Management Letter where internal control weaknesses and recommendations for improvements, are highlighted. However, incompliance with the World Bank new Audit Policy, the current External Auditors will be encouraged to issue a single audit opinion on project income and expenditures, special accounts and statement o f expenditure. The audit reports along with Management Letters will be sent to IDA and all other financing partners not later than six months after the end o f each period. The selection o f the auditor for the TAP will be a condition o f effectiveness. o Supervision Financial Management Supervision will be done by the project Financial Management Specialist over the project life to ensure the implementation o f strong financial management systems. Regular Statement Of Expenditure (SOE) reviews will be undertaken where necessary, in compliance with World Bank requirements. The Project Status Report (PSR) will include a financial management rating. o Disbursementsarrangements Flow of Funds and Banking Arrangements. The following Bank accounts will be maintained for the TAP funds: 0 Special Account A: This will serve as the main TAP account to finance the local NGOs activities. 0 Special Account B: This will be used to finance the districts, the regional hospitals, the MOH central directorates and the operating expenditures o f PADS, PAMAC, CMLS, DSF and DEP. These accounts will be maintained in a commercial bank acceptable to the World Bank. Disbursement o f IDA Funds to PADS: Disbursements o f Grant funds to PADS will be done based on Financial Monitoring Reports (FMRs) that integrate financial reporting, procurement and contract management with physical implementation progress. An advance will be made into the Special Accounts at the inception o f the TAP. The advance will be meant to cover project expenditures for 6 months as indicated in the initial six-month cash flow forecast. After every subsequent quarter, P A D S F M A will submit FMRs that include a cash flow forecast for the following 6-month period. The cash request at the reporting date will be the amount required for the forecast period as shown in the approved FMRs less the balance in the Special Accounts at the end o fthe quarter. Subsequent disbursements o fthe IDA funds will be made inrespect of this request. The option of disbursing the finds through direct payments from IDA on contracts above a pre-determined threshold will also be available. Withdrawal applications for such payments will be accompanied by relevant supporting documents such as copies of the contract, contractors' invoices and appropriate certifications. 116 Transitional Arrangements for disbursement: Inthe intervening period after Credit effectiveness but before the project adopts report-based disbursements, the Grant will be disbursed using transaction-based disbursement. An advance into the Special Account will be made at the inception o f the project, and subsequent replenishments will be made on the basis o f withdrawal applications and Statements o f Expenditure (SOE's). In the initial period, the authorized allocation o f the Special Account will be limited to an amount that can be increased once a certain threshold o f total project expenditures has been exceeded. During intervening period, FMRs that are required under FMR-based disbursements will be prepared by the project and submitted to the IDA for review. They will be used to assess progress towards meeting the requirements o f FMR-based methods o f disbursement. At the time o f conversion, the project will prepare a reconciliation o f project expenditures, disbursements received, and Special Accounts movements up to the proposed date o f the conversion. Other details for the conversion will be worked out closer to the time of conversion between the project team andIDA. Petty Cash a?CMLS/San?k.Inorder to finance the miscellaneous expenditures, apetty cash fund will be established with Government funds andreplenishment will beprovided bythe TAP Grant funds based on receipts collected byFMAPADS. (fff) Ghana o CountryRisk The main country risks as identified during the preparation o f the Ghana Health SWAP I1have not changed as indicated by the Country Financial Accountability Assessment (CFAA) update conducted in 2004. The country and control risk mitigation factors put in place for the Ghana Health SWAP I1are therefore applicable to the TAP project as well. Due to the specific TAP requirements, which will involve the use o f some agencies outside the MOH system, additional control risks and mitigating factors are expected. The summary risk analysis i s limited to these additional control risk identified the mitigating factors put inplace to address them. Table5 SummaryOfAdditionalControlRisks - MitigatingAction i) inreleasingoffundstonon-MOH Delays Increase monitoring and set service standards for time to implementing partners (IPS); effect transfers. ii)Delaysinaccountingforfundsreceivedfrom Also introduce simplified funds flow arrangements. MOHby implementingpartners; M Provide training for accounting staff o f IPS. iii)Poorrecordkeepingbyimplementing partners; Simplify the accounting record and documents to be keptat the lower levels. Increase training o fstaff at all levels InternalAudit (IA) unit within M O H is still in This will be addressedthrough the use o f external the processeso f being strengthened, and may auditors who will provide additional checks o f IP records on Deriodic basis. 117 Risk Rate Mitigating Action MOH. External Audit Likely project audit reports will be submitted TOR will be expandedto include activities being carried late. out byIPs outside the Ministry. MOHwill engage services to review accounting records andperfonnance of IPSas additional checks to mitigate the absence o f internal audit within IPS. Reporting and Monitoring Delays inthe submission ofmonitoring and Joint monitoringteams o f GOG and Bank to review evaluationreports. TAP activities will be fielded as part o fthe SWAP monitoringteams to carry out quarterly fieldvisits to independently monitor financial performance o f BMCs and IPSundertaking TAP activities. Overall Control Risk M o ImplementationArrangements The detailed implementation arrangements for the TAP activities are detailed out inthe country annex for Ghana (Annex 1). o FinancialManagement arrangements The financial management responsibility under the TAP will be vested in the finance division of the Ministry o f Health (MOH). The accounting system o f the Ministry is documented in an accounting procedures manual, the "Accounting, Treasury and Financial Reporting Rules and Instructions" (ATF Rules). The finance division is headed by a professionally qualified accountant, the financial controller (FC), who is assisted by a team o f qualified and partly qualified accounting staff. All staff have worked on previous Bankprojects and are familiar with the World Bank's disbursement procedures. The treatment program will be in line with the guidelines laid out by the MOH and hospitals within the MOH system providing treatment for HIV/AIDS patients, and under the TAP, funds will be received through the MOH system (same as under the health SWAP). It is however recognized that some hospitals will be outside the MOH system providing treatment to HIV/AIDS patients. In such situations the modalities to be followed will be similar to how Christian Health Association o f Ghana (CHAG) hospitals presently receive funds from the MOH. This is elaborated inthe flow o f funds below. Although the same MOH systems will be used, the fimding for the TAP will not be part o f the "donor pooled funds", but rather maintained ina separatespecial account onsimilar lines to the GlobalFunds. Retroactive Financing. The grant will include retroactive financing following the Bank's guidelines. Under this provision, the Government o f Ghana will be eligible for reimbursement of up to SDR 100,000 for expenses to make preparations for scaling up treatment under the TAP, whichit has incurredafter May 13,2004. 118 o Flow of Funds Health Institutions within MOH Institutions within MOH, which will receive TAP funds, include the National AIDS Control Program (NACP) and the regional hospitals of Eastern, Western, Central, and Ashanti Regions. The regional hospitals are already qualified as budget management centers (BMCs) within the framework established by the Ghana SWAP. Though not a B M C by this definition, NACP will be considered as one for the purposes of TAP and will receive funds from MOH/HQ for its planned activities. Since funding for TAP activities is provided through a separate special account (SA), managed by the FC office within M O H (on behalf o fNACP as the main executing agency), TAP will not be part o f the donor Pooled Funds, andthe request and release o f funds can be made as andwhen funds are needed. The participating M O H institutions will not necessarily have to wait for funding to be released in line with funds for their other health activities. As a result, based on the approved budgets for the TAP, NACP and the regional hospitals will prepare their quarterly cash flow needs for carrying out the planned treatment and treatment-related activities. MOWHQ will then transfer funds, incedis, directly to the respective institutions. NACP, the regional hospitals, and any other BMCs, which may eventually receive funds under the TAP program, will include reportingon expenditure o f the TAP program when they submit their financial returns in line with the MOH reporting procedures. B M C financial reports are expected to include: Revenue and Expenditure Budget Status Report, Bank Reconciliation Statement, bank statements, Schedule of Below The Line Items for each source and will include TAP program expenditure reports. The regional hospital BMCs will submit their financial reports on monthly basis to their respective RHA. NACP will submit monthly financial reports to the Financial Controller's Office at the MOH. Currently, MOH sends additional funds to the BMCs on a quarterly basis based on the original cash budgets submitted andinline with the POW. This will be expanded to cover disbursement for TAP activities. Institutions OutsideMOH Institutions outside MOH, which will receive TAP funds, include the mission hospitals, non- governmental organizations (NGOs), and private self-hnding institutions. These institutions comprise: 0 The mission hospitals are already considered as quasi-public since MOH has traditionally provided themwith financial subsidies; 0 The NGOs will include the Public Enterprise Foundation, PharmAccess, the Christian Health Association o f Ghana, and eventually others who have formed a consortium to provide the complementary elements o f the continuum o f care required by TAP. 0 The private clinics and hospitals set up or contracted by the various companies to treat their employees (and their employees dependents), which have agreed to 119 treat members of the surrounding communities at the fixed rates and to be associatedwith the mission or regional hospitals for referral purposes. While their administrative status may vary these institutions share the commitment to provide services to all STI/HIV/AIDS patients according to the norms and guidelines established by NACP andMOH. Mission hospitals. Inconformity with current practice, MOH and the mission hospitals will sign anannual performance agreement (PA) describing the services to be delivered and estimatingthe costs to be financed by the TAP. The agreement will include information on: 0 Thenumber o fpatients to benefit from the treatment; 0 The average cost o f treatment; 0 The reports that will be required to be submitted and their frequency. On the basis o f the PA, MOH will advance finds to the hospital for the purchase of: drugs, medical supplies, and any other such input as may be stipulated inthe PA. The "hospital" will carry out the planned activities (including the treatment o f patients), and submit, on a monthly or quarterly basis, statements o f expenditures to the MOH-HQ for reimbursement. Incases where the Hospital prefers to pre-finance its treatment activities, TAP will reimburse approved actual expenditures. Where the mission hospital prefers to request an advance payment, it must submit a cash flow statement for its quarterly funds needs to the MOH-HQ. The MOH-HQ on receipt o f request will transfer the required funds to the hospital. No firther request shall be made until earlier transfers have been accounted for. Non-Governmental Organizations. NGOs and consortiums o f NGOs wishing to participate in TAP must submit a proposal to M O H detailing the planned activities, related costs and sources of financing for implementing the proposed treatment activities. The proposal will cover a year's activities andwill include: 0 The estimated number o f patients to benefit from the program, the resulting annual work plan, and the relatedprocurement plan ifrequired; 0 The cash flow projection covering six months o fplanned activities; 0 Information on: (i) the NGOs or other organizations which may be required to carry out activities under the proposals; and (ii)the activities they will be required to perform; 0 The content and frequency o f financial reports that will be prepared under the proposal (to be agreed with MOH); and, 0 The monitoring andreportingrelationships o f the NGOs. The proposal must be co-signed by all o f the participating NGOs and be sent to NACP for review to ensure: (i) conformity with the overall treatment scale-up strategy andthe objectives of TAP; and (ii) coherence between the work plan, the procurement plan, and the projected cash flow requirements. 120 On the basis o f the agreed proposal, MOH will sign an Agreement with the NGO, which is similar to the performance agreement between M O H and the Mission hospitals. The agreement will define: 0 The respective roles and corresponding budgets o f the collaboratingNGOs for the carrying out the activities described inthe proposal; 0 The geographical scope and chronological timeframe for implementing the activities; 0 The rights and obligations o f the NGOs and MOH for the adequate allocation of resources, the appropriate quality o f implementation, and the timely submission o f agreed reports. Upon approval of the agreement, the NGO will request an advance payment by submitting a cash flow statement for its six-months funds needs to the MOH-HQ. The MOH-HQ on receipt of request will transfer the required funds to the account o f the lead NGO. The NGO will carry out the planned activities, and submit, on a monthly or quarterly basis, statements o f expenditures to the MOH-HQ for reimbursement. N o further request shall be made until earlier transfers have been accounted for. Private clinics and hospitals. The mechanisms for the participation ofprivate clinics are being developed and it is not clear at this stagewhat the modalities will be. Since these selected private clinics andhospitals will access Bank funds, a financial management assessmentwill have to be carried out prior to contract signingto ensure that the risks to Bank funds are mitigated andthat they meet IDA'SFMrequirements. After the assessment o f these clinics andhospitals, those certifiedwill then receive funds from the MOH for their TAP activities. The flow o f funds will follow the same mechanism as outlined for the mission hospitals above. o AuditingArrangements Under the GhanaHealth SWAP, private sector auditors have been engaged to undertake the audit of the Ministry's financial statements. Since the TOR are for the audit of the Ministry's operations, the TAP activities will automatically be covered, but to ensure that the institutions and hospitals outside the MOH systems are covered in the audit, the TAP program will be mentioned inthe scope o f the audit, and a statement included inthe audited financial statements on the activities of TAP and whether participating IPShave executed the program in accordance with the agreed project documentation. There will therefore be no separate audit report for the TAP project. o ReportingandMonitoring IDA reporting requirements expects projects to prepare quarterly financial monitoring reports (FMRs) in the areas o f finance, procurements including contract details andproject progress as follows: 0 The Quarterly Financial Reports would consist o f Sources o f Funds and their Uses o f Funds, Statement o f Uses o f Funds by Project Components and Activities, Special Account Reconciliation statement and a six months Project Cash Forecast, where needed; 0 Quarterly Project Progress Report would consist o f a report on Output Monitoring on Contract Management and on Unit of Outputbyproject activity; 121 0 Quarterly Procurement Management Report would consist o f procurement process monitoring for goods and works and that for consultants' services, and contract Expenditure reports for goods, works and consultants' services. 0 Since the implementation o f the TAP includes institutionshospitals outside the Ministry of Health there will be the need for additional reports (including FMRs and M&E) to be prepared to ensure that all the activities are captured in the MOH's reporting. These reports will be agreed upon prior to negotiations. o DisbursementArrangements The proceeds o f the Grant would be disbursed over a 3-year period. A period o f four months after closing date would be allowed to make disbursements for expenditures incurred until the closing date o f the Credit. SpecialAccount (SA). To facilitate disbursements, the MOHwill open a US$ Special Account at commercial banks, under terms and conditions satisfactory to the IDA. The project will use the Report Based Disbursement system to access funds from the grant. Upon Grant effectiveness, a s u m of US$ 3.0 million, representing twenty (20) percent o f the Grant amount for Ghana, would be deposited by the IDA into this account. Further deposits would be made into the account against withdrawal applications supported by appropriate financial reports as agreed. (ggg) Mozambique o Overview Financial management arrangements for TAP, inprincipleadopts the framework put inplace by the Ministry o f Health (MOH or M I S A U inPortuguese) for management o f the projects that are donor supported (external resources). The Ministry's Office o f International Cooperation (GACOPI) is the unit responsible o f managing funds from external resources that are used to support health interventions. GACOPI has been providing the implementation support in fiduciary and civil works management to the IDA-fundedHealth Sector Recovery Project (Cr. 2788-MZ) since 1996. Presently, GACOPI is providing the same service to the Health Component o f the MAP in the Mozambique. The Director of Planning and Cooperation (DPC) in MOH has oversight responsibility of GACOPI as part of its function of planning and cooperation affairs with donors supporting MOH. The primary objective o f establishing GACOPI was to have an independent outfit for managing donor funded projects outside the mainstream MOH's finance department (for which DAG is responsible), which manages the government-funded operations o fMOH. Inview o f this, functions o f GACOPI are managedby a technical assistance [non-civil servants] team, headed by coordinator who is supported by a secretariat. GACOPI's financial management capacity assessment done under MAP in 2002 has been reviewed and actions recommended have substantially been taken. Based on this, it is evident that GACOPI has the capacity to provide fiduciary service to TAP with additional support under MAP and complemented by TAP. Specific support areas are indicated in the action plan agreed with GACOPI comprising o f the key functional divisions as illustrated in diagram below. 122 GACOPIfunctional structure I MOH (Oversight Responsibilifyfor GACOPI) , .................... CACOPI Cordinator Head of GACOPI Operations ......................................................................................... Secretariat INTERNALAUDIT FUNCTION 1 Administration (Proposed) LI_-.- ................................................................ ~ ! I i I PROCUREMENTMANAGEMENT CIVIL WORKS II Contructiin and RehabilitationWorks L__ ___I___._ The various sections within the financial management unit o f GACOPI are well positioned to ensure that internal controls are adequately provided. A Financial Controller heads the financial management unit while Accountants head the sections, supported by a contingent o f accounting staff. For GACOPI to take up the added responsibility o f managing the finances o f TAP, it will be necessary to strengthen the unit's capacity with additional staff. The specific type and numbers o f accounting staff have not been specified. However it's anticipated that the additional staff will not exceed 1 accountant and 2-3 accounting support staff. The additional staff will be competitively selected on contractual terms by the Coordinator o f GACOPI in liaison with the Director o f Planning and Cooperation, and these costs will be absorbed under TAP. All marginal operational expenses related to TAP (overhead) due to GACOPI will be absorbed by TAP on terms similar to the health component o f MAP under GACOPI and other donor-supported projects inMOH. o Flow of Funds andDisbursementArrangements An IDA Development Grant Agreement (DGA) for an amount of US$21 million will be signed with the Governmento fMozambique. After Grant effectiveness, grantproceeds will be available for withdrawal from the Grant Account, to be maintained inWashington, D.C. and administered by IDA. Withdrawal ofGrant proceeds will beinaccordance with the disbursement categories to be indicated in Schedule 1 to the Grant Agreement using the traditional disbursement approach (transaction-based). Withdrawal Applications (Form 1903) will be prepared and submitted to IDA by GACOPI for components 1and 2. Disbursement of grant proceeds under Component 1 will basically flow through a Special Account, to beopened andmanagedbyGACOPI soon after Grant effectiveness. The authorized amount for the Special Account will be based on 4 months estimated expenditures o f operating costs and other small value expenditures eligible under the project. This amount together with the initial deposit amount will be discussed and agreed at negotiations. MOH will be able to use Statements o f Expenditures (SOEs) for specified type o f expenditures, in view o f GACOPI financial management capacity meeting the minimum fiduciary requirement under OPPB 10.02. GACOPI will also avail itself use o f direct 123 disbursement especially in the payment to suppliers through Special Commitment Direct Method- Disbursement of funds under the supporting Letters of Credit issued by sub-grants to IPSbased on an annual program and GACOPI's commercial bank in favor of the budget approved by MOH, will be disbursed periodically (quarterly) through this method fiom supplier's bank. the grant account with IDA. The withdrawal application amounts to be disbursed through this Disbursement o f grant proceeds to the IPS method will be above the minimum application will be based on approved annual program size for direct payment. Under this method, proposals, which will be an annual slice o f GACOPI will submit Withdrawal Application the overall individual IP's proposal for the (Form 1903) for the amount required by the IPS sub-grant under TAP. Funds to support the based on an approved annual plan of act. IPS in the implementation of first year's Activities. Amount required by the IPSfor the annual program proposal will be disbursed initial period (2 quarters' advance) to IDA. The inthe form of an advance, covering aperiod funds will be disbursed directly to the IPSbank o f 6 months. The IPS will however, be account based on details indicated in the Withdrawal Application. The IPSwill subsequently required to account for expenditures along submit their expenditures reports to GACOPI, with their implementationreport to MOH on preferably on a monthly basis. GACOPI will then a quarterly basis. This will allow the IPS consolidate each individual IP's expenses into one remain liquid in the transition period comprehensive expenditure report for each quarter between one quarter and the next, inview of andsubmit a WithdrawalApplicationfor sumto be the sensitivity and risk attributed to use o f directlydisbursedto the IP's bankaccount. ARVs in treatment of HIV-AIDS patients. Consideration was given to the possibility o f using report based disbursement approach, i.e. Financial Monitoring Reports (FMRs) for the project. However, this approachwas determined as inappropriate at this stage in view o f the capacity gap within GACOPI and general lack of exposure inuse o f FMRs inMOH and the country ingeneral, given the sensitivityof the project and direct link to potential risk o f losing human life among the patients put on ARV treatment. Based on the primary goal o f prolonging life among the HIV-AIDS population inMozambique, by scaling up treatment with ARVs, an efficient andreliable flow of hnds mechanism is one of the critical factors upon which or the success o f the project will depend. The traditional disbursement approach, which allows the IPSto receive advanced amounts of funds for a 6- months period (as opposed to usual 3 months provided for in the Disbursement policy/practice) i s considered most appropriate for the project. An exception to policy will be sought from LOA to facilitate usage the proposed mechanism. To this end, the IPSwill therefore receive grant proceeds covering the first year's initial six months. The amount will bebased on the first year's approved annual program proposal. Disbursement o f the advance to IPSwill be processed by GACOPIthrough a Withdrawal Application for direct payment. The amount to be disbursedwill inthat regardbeabovethe minimumapplication size, to bediscussedandagreedatnegotiations. 124 The flow o f funds mechanismandinformation flow is illustratedbelow: Supplier's Banks DirectPayment pecialCommitment World Bank Grant Account Washington DC Withdrawal ImplementingPartners Government CommercialBank (IPS)Bank A/C Mozambique CommercialBank GACOPI (Maputo) MOH(Maputo) MonthlyBankStatements QuarterlyReports (FMW I---*', .....`\,`.,. I#>,.:, I/ ...... ..\\ Quarterly 1 Reports ..\ ` ` (FMRs) . . *> World Bank LocalCurrency ProjectA/C CommercialBank " (Maputo) GACOPI-MOH-will prepare withdrawal application and submit to IDA for direct payment to implementing partners (IPS)based on a six month slice o f the Annual Work Plan and cash forecast for 6 months. GACOPI-MOH-will prepare and submit IDA withdrawal application for the initial deposit to the special account and subsequently submit replenishment applications at least every month. GACOPI-MOH-will as necessary, prepare and submit to IDA special commitment to back letters of credit issued by its banker for contracts o f amounts exceeding direct payment threshold (or minimum application size) in favor of suppliers' banks for goods procured. Implementing Partners will submit their financial and implementation progress report to GACOPIon quarterlybasis for review. Theywill prepare and submit annual work program/plan andbudget to GACOPIfor review byjoint World Bank TTL/WHO/MOH review and approval. GACOPI's Commercial Bankers will provide monthly bank statements to GACOPI on the special account (in US$) and project account (in local currency). GACOPI-MOH will prepare bank reconciliation and prepare its quarterly FMRs for submission to IDNTTL. To include reports submitted by the IPSon implementation programand expenditures. The World Bank TTL, jointly with MOH supervise the project every six months and provide guidanceto GACOPI/MOH every so often as needed. The World Bank TTL and Task team, will jointly with MOWWHO review implementation performance o f IPSand review/approve annual 125 work plans and budget not later than October 31st in the last quarter o f government's financial year (Jan to Dec). o FinancialPlanning,BudgetingandAccounting The financial management and accounting system already in use at GACOPI for the accounting o f the health component o fMAPhas memory capacity to accommodate accounting requirements o f TAP. The Government of Mozambique financial year (January through December) will be followed under TAP as well. The planning process includes input from the IDA and MOH to agree on the annual resources to be used under the project based on the annual proposals from IPSand MOH. In this regard, GACOPI in consultation with the Department o f Planning and Cooperation will assist the relevant technical units of MOH involved in the project to develop annual plans and budgets for TAP. This shall include all the major expenditure blocks and line items ineach block, inline with the disbursement categories set up inthe DGA. Budget coding procedure used by GACOPI will be used for program resource allocation under TAP for both Components 1and 2, which are beingmanaged by GACOPI. Ingeneral, GACOPI has a reasonably well-managed and documented intemal control system. However, the internal audit function is lacking and the service being provided by the Internal Audit Unit inMOH and also Internal Audit Service in the Ministry o f Planning and Finance does not focus on intemal controls, neither is it regular. This has therefore not added any value to GACOPI's internal control environment. In the medium to long-term existence of GACOPI, it might be worthwhile investing in the establishment o f an intemal audit function within GACOPI. The accounting o f project expenditures will be clearly set up to provide a mechanism for tracking expenditures under the two components distinctively. GACOPIwill also ensure accounting information for each of the `IP' is maintained separately in the general ledger in the Financial Management Information System (FMIS). The `IPS' will be have an obligation to submit their periodic expenditure reports to MOH (specifically the TAP Coordinator). M O H will review the reports and advise GACOPI to extract the financial information and incorporate the same into the FMIS in which the expenditure coding i s synchronized with the plan and budget. Details o f the financial planning, budgeting, and accounting procedures will be provided in the Mozambique TAP Project Operational and Procedures Manual. o FinancialReporting The project will be monitored by both MOH and IDA on a continuous basis through various instruments. With regard to this, Financial Monitoring Reports (FMRs) will be prepared and submitted to IDA periodically (quarterly) by GACOPI. In principle, FMRs will present the project's financial status matched to the physical progress o f the project and state o f implementation o f the procurement plan at end o f each quarter. Since the project will not use report based (FMR) disbursement approach, the FMRs will generally be used for monitoring purposes only. The FMR formats will be agreed between IDA and GACOPI before Grant effectiveness. GACOPI i s already familiar with FMRs from its experience in managing the health component of the ongoing Mozambique HIV-AIDS Response project (MAP). 126 Technically, the final quarter's FMR inan accounting period (financial year) used to prepare the annual financial statements, subject to usual year-end adjustments that will need to be incorporated. GACOPI will ensure the annual financial statements are prepared and approved by the management in MOH within three months following the end of the financial year under review. GACOPI will subsequently manage the audit process with support o f the Audit Committee (to be established by MOH andMPF). o Audit Audit of the project will be conducted annually by an independent and competent auditing firm. Presently, an auditing firm has been hired to audit the various programs and projects being managed under GACOPI. In view o f this, TAP will be audited under the same arrangements, provided the auditor meets the stated requirements. Specific Terms o f Reference (TOR) for the auditor in respect o f TAP that are satisfactory to IDA will be developed by GACOPI. Auditor shall express an opinion on the project financial statements, which shall comprising o f Project Account, Statement of Expenditures and a statement on the operation of the Special Account. To fulfill the financial covenants onauditinthe DGA, the Government ofMozambique shall submit the audited financial statements not later thansix months after the end o fthe financial year under review. o Assessment of FinancialManagementCapacity of the IPS All the three IPSinMozambique, i.e. Sant'Egidio ,Health Alliance International and Pathfinder were assessedfor their financial management capacity to manage IDA funds and account for the same in a satisfactory manner. With the exception of Pathfinder, the other two IPSare already collaborating with the MOH and are operating inhealth facilities o f the ministry where they are providing treatment. The Finance and Accounting systems in all the IPS reviewed provide assurance that they meet the minimumrequirement and have the capacity and ability to account for the IDA fimds separately from other sources o f funding, and provide reliable and timely accountability for the IDA funds as required (quarterly). Staffing in each case is a constraining factor, which will be mitigatedby recruiting o f additional staff. The financial cost o f this action i s reflected inthe individual IP's proposal and financingplan. 127 o Financial Management Risks Generally, this is a potentially highrisk project consideringthat it i s supporting an innovation that has not been tried before inany o fthe IDA supported programs inAfrica. From a financial management perspective, the risks attributedto this operation and mitigating arrangements are shown inthe Table below. - Risk State or Rate Delayeddisbursement of funds and flow o f fundsto IPS and reporting of expenditures will be quarterly, H upon which additional funds will be released. IPSwillhavearevolving fundto ensurethey remain liquid MOHdelay inreview of expenditure reports Cashreleaseon quarterly basis to be linked to from IPSand cash forecast H IPSfailure to account for advancedamounts and link expendituresto implementation M and remedial action o f close monitoringbe progress satisfactorily Delay or poor performance o f GACOPIin processing payments to IPS M Financial Management services be invoked Late submission of audited annual financial Close follow up and early remedial action statements L taken 128 Annex 8: ProcurementArrangements Regional HIWAIDSTreatmentAcceleration Project General Procurement for the TAP 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 M a y 2004, and the provisions stipulated inthe Grant Agreement. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, estimated costs, prior review requirements, and time frame are agreed between the Recipient and the Bank project team inthe Procurement Plan. The ProcurementPlanwill be updated at least annually or as required to reflect the actual project implementationneeds and improvements in institutional capacity. To the extent practicable Bank's standard bidding documents for goods and Standard Requests for Proposals for consultants as well as all standard evaluation forms would be used throughout project implementation. Advertising A General Procurement Notice (GPN) is mandatory and would be published for each TAP countries before Board presentation in the Development Gateway online, UN Development Business online and in a national newspaper as provided under the Guidelines. In addition, a Specific Procurement Notice (SPN) for ICB for goods andworks i s required and Expressions o f Interest (EOI) for consulting services with an estimated value inexcess o fUS$200,000. Summary of Institutional Responsibility Procurement management in the three TAP countries will use the existing procurement capacities supported under the MAP projects as well as under the Health sector projects where suitable. The following table shows the responsible institution for procurement in each country. TAP will support operational overheads including additional staff and other relevant expenditures. 129 Institution Institutionresponsible responsiblefor for overall procurementunder procurementunder Comments - the MAP theTAP ___ Burkina Fas ProjectManagement MinistryofHealth D PADS supportedby a FMA will Unitofthe MAPat through the Projet organize a n d or do the the national level d'appui aux districts procurement of goods, works, (PA-CMLS). sanitaires (PADS) and consultants' services and supported by a FMA. for the district healthcenters. D Drugsandrelatedsupplies will be procuredby the Central Medical Store (CAMEG). The I p s will do their own procurement for goods and services not procured centrally byPADS or CAMEG. Thiswill be done accordingto their manual o f procedures to be developed by the FMA and approved by the Bank. Ghana Ghana AIDS MinistryofHealth TAP will use MOH's Commission through its NACP procurement capacity underthe Secretariat. Health sector SWAP initiative that has satisfactory procurement management capacity. Drugs andMedicalsupplies will beprocuredby MOH. The Ipswill enter into sub- contract agreement with MOH. The IPSwill do their own procurement for goods and services for those not procured centrally. This will be done accordingto their manual of procedures approved by the Bank. 130 _. . - --- Institution Institutionresponsibfe responsible for for overall procurement under procurementunder - the MAP .- - ._the TAP - __.- - Mozambique GACOPI (Office o f GACOPI(Office o f GACOPIprovides support to Coordination of Coordination of the MOHon management of Investment Project) Investment Project) external funds including TAP. (MOH) (MOW 0 DrugsandMedical supplies willbe procuredby CMAM. 0 The IPSwill enter into sub- contract agreement with MOH. The IPSwill do their own procurement for goods and services for those not procured centrally. This will be done accordingto their manual of procedures approved by the Bank. Assessment of the agency's capacity to implement procurement Burkina Faso 0 Procurement of civil works, goods and selection of consultants will be carried out bya financial managementagency (FMA) underthe direction ofPADS.The existing manuals will be updated and used inthe TAP project. The Operations Manual will include, inaddition to the procurement procedures, the SBDs to be usedfor eachprocurement method, as well as model contracts for works andgoods procured. 0 Three NGOs have been assessedas IPS.The overall IPprocurement capacity i s weak. They will use a ProceduresManual and the necessarytraining will be provided by the FMA. Ghana The implementingagencies underthe TAP arethe Ministry o f Health. All public sector procurement under the proposedTAP will be inaccordance with the Public Procurement Act. Progressmade since SWAP inthe health sector started in 1999 includes (a) establishment o f a procurement unit inMOHwith competent staff and technical assistance; (b) development and launching o procurementprocedures manual for the health sector; (c) training (including BMS staff); (d) preparationof annual plans and procurement monitoring reports; (e) carrying out annual independent ex-post procurement review. The risk i s the weakness inthe distribution systemby the Central Medical Store (CMS) to insure the continuous distribution o f ARVs. The TAP will support CMS inthe logistics and stocks distribution capacity. TAP will also use IPSand other capable NGOs andprivate sector entities for ARV storage and distribution activities. Most o fthe procurement staff inMOHhave attendedBank procurement courses. The key staff inNACP andthe FDBhave attended the specialized Bank course on the procurement of ARVs and Health Sector goods. The Private Enterprise Foundation (PEF) inassociation with PharmaAccess International (PAI) will coordinate the publidprivate sector response inproviding treatment, care and support to HIV/AIDSpatients. 131 Assessmentofthe agency's capacityto implementprocurement Mozambique 0 TAP Implementationwill betheresponsibility ofthe MinistryofHealth, specifically the DirectorateofPlanning andCooperation(DPC) andthe National Directorate ofHealth (DNS), which haveprimary responsibility for the provision ofhealth services. The MOHNationalTreatment Committee, headedby the Director o fMedical Services (DAM),will provide regular technical guidanceand review of the TAPprogram. MOHwill appoint aTAP Coordinator (Program Officer) financedfrom the TAP, who will beresponsible for technical, programming, as well as monitoring andevaluation, andoperationalcoordination. GACOPIthe DPC implementing arm, -- underthe technical direction andpurview of CMAM, whenprocurement concernsdrugs andmedical supplies --,will be responsiblefor procurementandfinancial management. 0 IPSwill dealprincipally with GACOPIandthe TAP Coordinator for operational matters. The procurementcapacityassessmentneeds to be confirmed. 4. ProcurementCategories andMethods Procurement of ARVs and related supplies o GeneralApproaches To ensure continuous supply o f ARVs in TAP countries, the following ARVs procurement principles will apply: (a) long-term contract agreements (or for the sub-grant duration) on the supply o f drugs (especially ARVs) would be signed between the Clinton Foundation and the Government; (b) in order to assume security o f supplies, at least two parallel contracts are recommended to be signed with different qualified ARVs suppliers. Each supplier can deliver the drugs inturn (monthly, quarterly or a suitable period for a TAP country). It i s not necessary that the ARVs cost each supplier be the same. The contract with multiple suppliers must ensure a safety stock o f ARVs to be maintained at all time, depending on the shelf life o f ARVs and other related drugs; (c) country drug procurement agencies will use Limited Intemational Bidding (LIB)andShoppingmethodsto procureARVs from ClintonFoundationnegotiatedsuppliers and WHO'Spre-qualified suppliers. The country drugprocurement agency should guarantee a safety stock level and a daily or weekly safety stock monitoring. TAP resources can be used for such capacity building. The key challenge in the TAP procurement and supply chain manapement i s to ensure a continuous supply o f ARVs (and related products) to avoid discontinuity o f ARVs supplies for the HIVpatients targeted under the proiect. ARVs must be maintained infull supply for the patients intreatment. o ClintonFoundation The Bank has entered into a partnership with the Clinton Foundation to make it possible for developing countries to purchase high quality AIDS medicines at low prices. The drug agreements, which now include first-line treatment regimes only, could save from US$l50 to US$400per patient per year (depending on the country), allowing more people to be treated. The diagnostic agreements will result in savings o f up to 80 percent, depending on the country and the particular test. 132 Over the last eight months, the Clinton Foundation has worked with drug and laboratory testing manufacturers to execute agreementsthat will result inaffordable HIV/AIDS care and treatment for participating countries. So far, the Foundation has entered into agreement with four formulators, two producers of active pharmaceutical ingredients, and five leading medical technology companies. The Foundationhas also signed partnership agreements with countries in Africa (Mozambique, Rwanda, South Africa, and Tanzania) and it is working to include more countries. Inthe context ofthis project, the ClintonFoundation will work with BurkinaFaso and Ghanato assess governments' ability to efficiently conduct procurement through their national medical stores, manage the entire supply chain including proper storage and distribution facilities, and adhere to the principles of the agreement. If these countries lack such capacity, they may ever choose to outsource their procurement to UNICEF or another organization that can operateunder the Clinton Foundation Agreements. TAP countries will be required to provide guarantees o f payment, sign multiyear contracts with suppliers, and ensure the security o f drug and reagent distribution. To help ensure the quality of drugs, the Bank will work closely with the World Health Organization (WHO) and the Clinton Foundation to strengthen the capacity o f regional and national quality control laboratories. The following table shows the responsible institution for procurement o fARVs ineach country. Prc urementofARVs andRelated 1DDlies ~ BurkinaFaso Ghana Mozambique Under the res onsibility of MOHat the central level Planning, procurementand the CAMEG ps already responsible for procurement distribution o f ARVs is done by assessedby IDA and found of large value goodddrugs the C M A M lgwhichcontracts satisfactory. including essential drugs, out the tenderingprocess An agreement will be signed vaccines and ARVs. Ithas a principally to MEDIMOC, and and the PADS will provide procurement unit with jointly manages all warehouses CAMEG with the quantity competent staff and inthe country (inMaputo, Beira and the nature o fproducts to technical assistance andNampula). be procured. The MOHhas hired Drugs are distributedfrom these CAMEG's capacity to UNICEF as procurement warehouses inessential drug manage higher quantities agents for the procurement packages, including ARVs and and distribution of ARVs to o f HIVIAIDSconsumables reagents. IPwillbesupportedbythe andreagents and C M A M will work closely with TAP. International Dispensary GACOPI"and will contract out Itwill be the responsibility Association (IDA) as the tendering process principally o fPADS and CAMEG to procurementagents for the to MEDIMOC. GACOPI will ensure that the procurement procuremento f ARVs. make the payments to suppliers o f ARVs are insync with the Selectionof the products as directedbythe planning cycle o f the was based onthe WHO list CMAM/MEDIMOC. This ImplementingPartners. o f prequalified products. arrangement i s currently worhng favorably under MAP Project and other donors-funded tlroiects. 18The Drug Central Medical Store. *' l9The Mozambican drug planning, procurement and distribution unit within the pharmacy department of MOH. Office of Coordination o fInvestmentProject. 133 Procurement Methods of ARVs and related medical supplies: Under TAP, the default method o f procurement for ARVs will be Limited International Biddin (LIB)from the WHO prequalified suppliers and the Clinton Foundation negotiated suppliers For contracts less than $ 250,000, shopping procedures may be used, inviting quotations from a minimum o f three prequalified suppliers. Inthe cases of products with single manufacturer, direct contracting will be used and MOHwill negotiate aprice with the manufacturer. o ProcurementPlan During the negotiations, the draft procurement plan for eaeh country was discussed with the respective delegation. The final version o f the procurement plan will be reviewed and approved bythe BankbyJune 15,2004. o Procurementof Works (All three countries) Works procuredunder TAP, would include support rehabilitation o f some health facilities across the country. N o I C B works contracts are expected under the project Works estimated to cost between USD 500,000 and USD 50,000 equivalent per contract shall be procured using N C B procedures satisfactory to IDA in accordance with the Bank's Procurement Guidelines. Very small contracts estimated to cost less than USD 50,000 equivalent may be procured by way o f soliciting quotations through written invitations from not less than three qualified contractors. RegistratiodClassification o f contractors maybe usedto identify contractors for such very small contracts. o Procurementof Goods (ExcludingARVs andrelateddrugs) (All three countries) Goods procured under this project would include office equipment, computers, vehicles, motorcycles, laboratory equipment, laboratory consumables, medical kits, reagents, drugs, office suppliesand fbmiture.The procurement will be done usingBank's SBD for all ICB andNational SBD satisfactory to the Bank. To the extent possible, goods that could be procured from one supplier would be grouped into contract packages, and packages estimated to cost the equivalent o f USD 250,000 or more would be procured under I C B procedures (ifappropriate). Procurement of goods packages estimated to cost more than USD 50,000 but less thanU S D 250,000 would be procured using N C B procedures. Goods packages estimated to cost less than U S D 50,000 would be procured by shopping on the basis of comparison o f quotations from at least three qualified suppliers. Requests for such quotations will include a clear description and quantity o f the goods, as well as requirements for delivery time andpoint o f delivery. o SelectionofConsultants(All three countries) The consultant services are related to training, workshop and studies with government agencies, with firms and individuals. Consulting firms for all assignments estimated to cost the equivalent o f USD 100,000 or more will be selected though Quality and Cost Based Selection (QCBS) methodology. For assignments costing less than USD 100,000, QCBS, Least-Cost Selection '' Initiallyfor Mozambique only, who have signed a partnership agreement with Clinton Foundation. The two other countries will be able to include CF negotiatedsuppliers inthe LIB list after they have signed the agreement with CF. 134 (LCS) or Consultants' Qualifications (CQS) procedures may be used provided the assignment meets the requirements of paragraph 3.6 in the case of LCS and paragraph 3.7 in the case of CQS. Assignments estimated to cost the equivalent of U S D 200,000 or more would be advertised for Expressions of Interest (EOI) in Development Business (UNDB), in DgMarket online and inat least one newspaper of wide national circulation. Inaddition, EO1for specialized assignments m a y be advertised in an international newspaper or magazine. In the case of assignments estimated to cost less than U S D 200,000 but more than U S D 100,000 the assignment will be advertised nationally. The shortlist of firms for assignments estimated to cost less than U S D 100,000 may be made up entirely of national consultants ifat least three qualified firms are available at competitive costs. However, foreign consultants who wish to participate shouldnot be excluded from consideration. Consultant services estimated to cost less than the equivalent o f U S D 50,000 may be contracted by comparing the qualifications of consultants. In case of assignments requiring individual consultants, the selection will follow the procedures stipulated in Section V of the Consultants Guidelines. Implementation Partners (IP) Burkina Faso (3) Ghana (2) Mozambique (3) 0 CICDOC Private Enterprise Foundation HealthAlliance 0 AIDSETI PharmaAccess Intemational International 0 Centre MCdicale Saint- (PEFPAI) Pathfinder Intemational Camille. Sant'Egidio. Other IPS:Others may be identified during the life o f the TAP but they will have to fulfill the criteria in accordance with the Procedures Manual. The Procedures Manual, acceptable to IDA, will give the details o fthe selection, contracting, supervision and Management ofthe IPS. Sub-Grant Agreement: A Sub-Grant Agreement will be signed between the Ministry o f Health and the IPS.The Sub-Grant will be reviewed by IDA for no-objection before signature and approval. Conflict of interest: No govemment (MOH, or any government entity involved with TAP management) may be the member of the IP management in any capacity that can be regarded as conflict of interest per IDA guidelines. No member of an IP m a y exert any oversight or selection authority over other IPS. 135 Training and Workshops All training and workshops under the Project will be conducted on the basis ofprograms, which should be approved by the Bank on a quarterly basis, and which shall, inter alia, identify: (a) the training and workshops envisaged; (b) the personnel to be trained; (c) the institutions which will conduct the training; (d) the duration of the proposedtraining and (e) an estimate o f the cost. BurkinaFaso TableA: ProjectCostsby ProcurementArrangements - (US$ millionequiva1ent)l ProcurementMethod ExpenditureCategory ICB LIB NCB Other' N.B.F. Total Cost 1. Works (0.00) (0.00) (0.00) (0.3 1) (0.00) (0.3 1) 2. Goods, Drugs (5.71) (1.80) (0.00) (0.08) (0.00) (7.59) 3, ConsultantServices, (0.00) (0.00) (0.00) (1.73) (0.00) (1.73) Training 4. Sub-Grants (0.00) (0.00) (0.00) (8.06) (0.00) (8.06) 5. OperatingCosts (0.00) (0.00) (0.00) (0.41) (0.00) (0.41) Total IDA (5.71) (1.80) (0.00) (10.51) (0.00) (18.10) 'Includes goods to be procuredthrough shopping procedures and consulting services, ARVs and related drugs by LIB and shopping (< $200,000). Ghana TableA: ProjectCostsby ProcurementArrangements - (US$ millionequivalent) ProcurementMethod ExpenditureCategory . ICB LIB NCB Other N.B.F. Total Cost 1.Works 0.00 0.00 0.00 0.16 0.00 0.16 (0.00) (0.00) (0.00) (0.14) (0.00) (0.14) 2. Goods, Drugs 3.81 1.08 0.00 0.05 0.00 4.94 (3.60) (1.05) (0.00) (0.04) (0.00) (4.69) 3. ConsultantServices, 0.00 0.00 0.00 2.35 0.00 2.35 Training (0.00) (0.00) (0.00) (2.13) (0.00) (2.13) 4. Sub-Grants 0.00 0.00 0.00 7.35 0.00 7.35 (0.00) (0.00) (0.00) (7.35) (0.00) (7.35) 5. OperatingCosts 0.00 0.00 0.00 0.78 0.00 0.78 (0.00) (0.00) (0.00) (0.70) (0.00) (0.70) Total 3.81 1.08 0.00 10.69 0.00 15.58 (Total IDA) (3.60) (1.05) (0.00) (10.36) (0.00) (15.01) ''Allcostsgoodsto include contingencies. Includes beprocured through shopping procedures and consulting services, ARV andrelated products by LIBandshopping (<$250,000). 136 Mozambique- TableA: ProjectCosts by ProcurementArrangements (US$ millionequivalent) ProcurementMethod Expenditure Category ICB LIB NCB Other N.B.F. Total Cost 1.Works 0.00 0.00 0.00 1.49 0.00 1.49 (0.00) (0.00) (0.00) (1.28) (0.00) (1.28) 2. Goods, drugs 4.45 1.14 0.00 0.3 1 0.00 5.90 (4.45) (1.14) 0.00 (0.26) 0.00 (5.85) 3. ConsultantServices 0.00 0.00 0.00 2.33 0.00 2.33 (0.00) (0.00) (0.00) (2.00) (0.00) (2.00) 4. Sub-Grants 0.00 0.00 0.00 11.18 0.00 11.18 (0.00) (0.00) (0.00) (11.18) (0.00) (11.18) 5. OperatingCosts 0.00 0.00 0.00 0.74 0.00 0.57 (0.00) (0.00) (0.00) (0.59) (0.00) (0.59) Total 4.45 1.14 00.00 16.05 0.00 21.64 Total IDA (4.45) (1.14) (0.00) (15.31) (0.00) (20.90) (hhh)IDA Prior Review All works contracts estimated to cost USD 500,000 or more and goods contracts estimated to cost USD 250,000 or more will be subject to the Bank's prior review in accordance with the procedures inAppendix Io f the Procurement Guidelines. Any amendments to existing contracts raising their values to levels equivalent or above the prior review thresholds are subject to IDA review. All contracts awarded on basis o f direct contracting will require prior review and clearance o f IDA. All single source selection will be subject to IDAprior review. Consultancy contracts with firms with estimated value o f USD 100,000 or more, and consultancy contracts with individuals estimated value o f USD 50,000 or more will be subject to prior review by the IDA inaccordance with the procedures in Appendix Io f the Consultants Guidelines. All out o f country training/workshops will be subject to IDA review. (iii) PublicationofResultsandDebriefing Publication o f results o f the bidding process will be required for all ICBs, NCBs, L I B s and Direct Contracting. Publication should take place as soon as the no objection i s received, except for Direct Contracting and NCB, which may be done quarterly and in a simplified format. For selection o f consultants disclosure o f results is also required. All consultants competing for the assignment should be informed o f the result o f the technical evaluation (number of points that each firm received) before the opening o f the financial proposals, and at the end o f the selection process the results should be published. The publication o f results in selection of consultants applies to all methods, however for QCBS and Single Source Selection (SSS) the publication may be done quarterly and ina simplified format. MOH and implementing agencies shall debrief losing bidders/consultants on the reasons why they were not awarded the contract, if the losing bidders/consultants request for explanation. 137 (Jj) Fraud, Coercion and Corruption All procuring entities as well as bidders/Suppliers/Contractorsshall observe the highest standard of ethics during the procurement and execution o f contracts financed under the project in accordance with paragraphs 1.15 & 1.16 o f the Procurement Guidelines and paragraphs 1.25 & 1.26 o f the Consultants Guidelines. Table B: Thresholds for Procurement Methods and Prior Review22 (All three countries) ContractValue Contracts Subject to Threshold(US$) Prior Review Expenditure Basedon estimateinthe ProcurementMethod (US$ millions) procurementplan Estimated Works 500,000 ICB Not Expected <500,000 NCB PostReview ><250,000 50,000 Shopping Post Review 2. Goods ICB All <250,000 NCB Post Review <50,000 Shopping Post Review Drugs, ARVs >250,000 LIB All <250,000 Shopping PostReview 3. Consulting > 100,000 QCBS All Services: Firms < 100,000 QCBSILCSICQS Post Review 4. Consulting > 50,000 IndividualConsultant All Services: Individuals < 50,000 IndividualConsultant PostReview Frequency of procurement supervision missions: Once every four (4) months (including special procurement supervision for post-review/audits). Actions Burkina Faso Ghana Mozambique Completion Completion Completion Publicationof GPN PADS 06/30104 MOH 06/30/04 GACOPI 06/30/04 Publicationof SPN for PADS 06/30/04 FMA. Publicationof SPNfor MOH 06/30/04 ProjectCoordinator NegotiateAgreements Govemment 08/30/04 Govemment 08/30/04 with Clinton Foundationfor ARVs Select FMA PADS 10/30/04 Select Project MOH 07/30104 Coordinator. 22 Thresholds generallydiffer by country andproject. Consult OD 11.04 "Review o fProcurementDocumentation" and contact the Regional Procurement Adviser for guidance. 138 Annex 9: Economicand FinancialAnalysis Regional HlVlAlDSTreatment Acceleration Project Economic analysis. The TAP would generate three direct benefits: improved health and productivity for recipients o f treatment; health system strengthening; and enhanced international knowledge on scaling up treatment. The economics o f HIV treatment is evolving rapidly. The annual drug price per patient has fallen from $10,000 in 1996 to $140 in 2003, and costs continue to drop. Price declines have also begun for key diagnostics and are expected to accelerate. In this dynamic environment, the cost-effectiveness of treatment defies precise calculation but is steadily increasing. Ifa patient begins treatment today and sustains it through life, the average annual cost would be far lower than the current price. With the total cost o f comprehensive treatment now approaching $500 per year, the present value o f the cost o f treatment i s already almost certainly less than the present value o fthe direct costs incurred bynot treating. The direct costs o f an AIDS death includes the costs o f treating AIDS-related infections, lost output and income, funeral expenses, and death and survivor benefits. To this must be added the indirect costs o f orphan care and support, crowding out o f other health services, proliferation o f counterfeit drugs, and loss o f social capital. This balance has already led a growing number o f private firms in Africa to initiate comprehensive treatment for their employees, and it is widely agreed that the social benefits o f treatment significantly exceed the private benefits. In addition, strengthening health system infrastructure would help improve the delivery o f a range o f health services, which have sufferedbecause o f budget constraints and the impact o f AIDS. Finally, the knowledge generated by the TAP would help make future treatment more effective and more affordable, with benefits accruing to a large number o f countries. In aggregate, this wide range o f benefits can be expected to generate economically substantial returns. Financial analysis. Over TAP'Sprojected three-year implementation period, financial resources from the project would be adequate. Further expansion o f treatment will continue to be constrained by affordability, however, and further cost reduction and other means to make treatment more financially sustainable will be required. With limited funds for subsidizing treatment costs, further cost reductions offer the most effective means to expand access for the poor. A number o f possibilities for reducing costs and increasing the potential for fiscal sustainability would be explored duringproject implementation. First, TAP would promote efficiency gains to further reduce cost o f the ARV, 01drugs, and diagnostic tests. The agreement IDA recently signed with the Clinton Foundation builds on volume discounts to realize a sharp reduction in prices from previous levels. Second, TAP would seek to increase contributions from a variety o f internal and external sources to defray the costs o f treatment as improved quality generates funding interest and increased demand for services. Among the possibilities, TAP would promote enhanced fund-raising capabilities by implementing partners to sustain the community organizations, NGOs, and faith-based organizations involved intreatment. A third optioninvolves co-financing with those withthe means to contribute to their own treatment. Treatment under the TAP would not be denied to anyone on the basis o f ability to pay. Each o fthe participating countries has some forms o f cost-sharing, which each considers inadequate. TAP would assist intesting more transparent and effective methods o f securing 139 cofinancing with more affluent patients without preventingthe poor from seeking or receiving treatment. All TAP-sponsored programs would be closely monitoredto ensure that there i s equitable access to treatment and efficient safety nets for the poor. 140 Annex IO: Safeguard Policy Issues Regional HlVlAlDSTreatment Acceleration Project Environmental Safeguards The most important environmental issue for the TAP relates to medical waste management and as indicated by the paragraphs below, this issue has already been resolved by existing projects in each country and TAP activities will be covered through those safeguards. For Mozambique, since all TAP activities will be either carried out by NGOs working inside public health facilities or the Ministry o f Health itself, the environmental assessments and safeguards applied under the Mozambique MAPwould also cover TAP environmental safeguard requirements. For Burkina Faso, it was determined under the Burkina Faso MAP project that the concerns about medical waste management would be addressed by incorporating criteria about waste management into the selection o f sub-projects for communities and work program agreements for the ministries. A medical waste action plan was prepared following approval o f the MAP project, and the MOHplans to request financing for implementing inthis year's funding re uest, for which a budget line has been reserved. Also, the Global Vaccination Initiative (GAVI ) has 9 developed an action plan for vaccine disposal/safety. Since the activities under the TAP will be carried out by non-governmental implementing partners accredited under the MOH, they will be covered under these same action plans. For Ghana, as specified under the most recent Ghana Health I1PAD safeguard section, the Ghana Environment Protection Agency (EPA) has prepared national guidelines as the basis for segregation, packing, handling, storage, treatment, transportation, disposal and monitoring o f health care waste. Subsequently, a policy document and technical guidelines are being finalized by the Ministryo f Health for use by all relevant HIV/AIDS programs including, but not limited to, the National HIVIAIDS Program, the Abidjan-Lagos Transport Corridor HIV/AIDS Project, the Ghana AIDS Response FUND (GARFUND), and all health care facilities (both public and private). Training would be carried out for all health care personnel to implement the health care waste management guidelines. Therefore all activities and partners relevant to the TAP would also be subject to this policy and guidelines. 23Global Alliance for Vaccines and Immunizations 141 Annex 11:Project Preparation and Supervision Regional HIV/AIDS Treatment Acceleration Project Planned Actual Concept Paper review 04/28/04 InitialPID to PIC 05/05/04 InitialISDS to PIC n.a. Appraisal 04112/04 Negotiations 05/10/04 Board/RVP approval 06117/04 Planned date of effectiveness 09115/04 Planned date of mid-term review 03/13/06 Planned closing date 09/30/07 Key institutions responsible for preparation of the project: Burkina Faso: Ministryof Health (CMLS-Santk, PADS, DRF), CNLS, DEPMS, WHO, UNICEF, AIDSETI, St. Camille, CICDoc, CAMEG. Ghana: Ministry of Health(NACP, GHS, CMS), PEFPAI, GAC, WHO. Mozambique: Ministryof Health(DPC, DNS, GACOPI, DAM,MEDIMOC), CNCS, Sant'Egidio, Pathfinder International, HealthAlliance International, WHO, UNECA. Bank staff and consultantswho worked on the project included: Name Title Unit Keith E.Hansen Manager AFRHV Michael N.Azefor Sr. Public Health Specialist, co-Team Leader AFTH3 Elizabeth Laura Lule Adviser, co-Team Leader HDNHE Aguiratou Savadogo-Tinto Procurement Specialist AFTPC Alison P. Rosenberg Lead Partnership Specialist AFTPX Anne Anglio Sr. ProgramAssistant AFTH3 Anne Marie Bodo Consultant AFTS3 Caroline Forkin Consultant AFTS4 Caroline Vagneron Consultant AFRVP Cassandrade Souza Operations Analyst AFRHV Debrework Zewdie Director HNDGA DidemAyvalikli Operations Officer AFRHV Eileen Murray Sr. Operations Officer AFTH2 Evelyn Awittor Operations Officer AFTH2 Frederick Yankey Sr. Financial Mgt. Specialist AFTFM Hans Binswanger Sr. Adviser AFRVP Joan M.MacNeil Sr. HIVIAIDS Specialist HDNGA Joao Tinga Financial Management Specialist AFTFM JohnNyaga Sr. Financial Management Specialist AFRHV Therese Cruz ProgramAssistant AFRHV John StephenOsika Consultant AFTTR Jonathan C.Brown Operations Adviser AFTOS KevinBillinghurst M&ESpecialist HDNGA 142 Name Title Unit Kofi Awanvo Sr. Procurement Specialist AFTPC MamadouYaro Financial Management Specialist AFTFM Manuel J. P. Sumbana Procurement Analyst AFTPC NadeemMohammad Sr. Operations Officer AFRHV Peter Bachrach Consultant Patrick Lumumba Osewe Sr. HIV/AIDS Specialist WBIHD Richard M.Seifman Consultant AFRHV Sheila Braka-Musiime Counsel LEGPI Catherine Moyer Junior Professional Associate LEGAF Slaheddine Ben-Halima Sr. Procurement Specialist AFTPC SusanA. Stout LeadM&E Specialist HDNGA Timothy Johnston Sr. Human Development Specialist AFTH2 Bankfunds expended to date onproject preparation: Bankresources: US$407,82524 Trust funds: none Total: US$407,825 Estimated Approval and Supervision costs: Remaining costs to approval: US$37,030 (+ CTF US$128,000) Estimated annual supervision cost: US$325,000 The project will require intensive supervision given its innovative approach, the large span o f activities from the community to the national level, its blend o f public, private and civil society implementation agencies whose experience with HIV/AIDS programs varies considerably, and its multi-sectoral nature. The range o f activities in care and treatment i s complex and will be implemented by many entities whose capacity will need strengthening in order to scale up activities effectively. IDA'S supervision effort in the first year will focus on the following strategic areas: National Level Overall project supervision will be carried out under the government institutions responsible for supervision in each country. These institutions are identified and conclusions are described in Annex 1and 6. At the request of the TAP countries, technical support will be provided by WHO, both in-country and from its regional office and through consultancies. Regular regional meetings organized by UNECA will provide opportunities to review progress, methodology, and operational aspects with external experts, andmake program improvements. Treatment Committees ineach country with support from project coordination units (MOH), will provide the supportive supervision and monitoring along with the regional and district health authorities as the program is rolled out with special focus on procurement o f ARVs, its logistics and medical services. Hands-on technical supervision and support inthe participating treatment facilities will be organized by the IPSin cooperation with the previously identified referral sites. Periodic meetings o f the thematic committees, quarterly meetings o f the Treatment Committees, 24Bankresources were providedbythe Africa Regionandthe GlobalHIV/AIDSProgram. 143 and annual stakeholders consultative meetings will provide periodic venues for analyzing the results from the field. Financial management, procurement, monitoring and evaluation, and implementation channels represent the core fiduciary responsibilities that need to be continuously assessed and enhanced duringsupervision. The principle that program monitoring and evaluation ispart o fthe fiduciary framework o f the TAP approach is new for the three countries and for IDA; it will require special attention during implementation and accelerated M&E support from IDA'S Global HIV/AIDS Monitoring and Evaluation Team (GAMET). Regional Level The three countries' supervision organs and technicians will benefit from semi-annual meetings o f the RAP andRCCC coordinated by the World Bank and UNECA. The Treatment Committees of the three countries, will communicate quarterly reports to the RAP secretariat (in Addis Ababa) with copies to the World Bank, WHO (AFRO & Geneva) for review and preparation o f semi-annual regional learning meetings. The lessons learned on scaling up that will come out o f regional learning meetings will be shared with other donors and implementing partners around the world including Global Fund. WHO will back-up each country's treatment program under the TAP on request and recommend extra-ordinary sessions o fRAP and RCCC upon requests o f individual TAP countries, IFs or IPS. WHO back-up support will focus on guidelines and treatment protocols, clinical monitoring systems and efficiency o fpatient tracking systems set up as well as support training at referral hospitals. Bank Supervision Bank supervision will be both through the Country Offices and Washington. For country activities the MAP/TTL will be responsible for maintaining regular contact with the individual country project implementation units, follow TAP performance, and provide regular reporting. As the TAP will deal with similar issues as encountered in the MAP, IDA supervision can "piggy-back" on MAP responsibilities with missions by health specialists, procurement and financial management specialists coinciding with TAP missions. An additional $75,000 annual supervision budgetwill be providedfor each country MAPTTL. The Regional TAPITTL, who will have an additional supervision budget o f $100,000, responsible for both regional learning and coordination among the country programs, will be the back-up TTL for the country program, and the principal TTL for the entire TAP effort. The Regional TAP/TTL will be provided with a separate budget that will allow country visits, assistance to the countries in the learning aspects o f the TAP and coordination among stakeholders and with WHO, UNECA. A C T Africa and the Global HIV/AIDS Program will also assist inthe supervision effort to ensure region-wide andworldwide learning. Mission Frequency. It is expected that there will be three supervision missions yearly, as well as participation by IDA at the semi-annual regional meetings. Supervision missions will be integrated into MAP and (whenrelevant) health sector supervisions. 144 Supervision missions are to include the following: 0 Country TAP/TTL 0 Regional TAP/TTL (as available) 0 Health Specialist, complementing T T L skills 0 Financial Management Specialist 0 Procurement Specialist 0 M&ESpecialist 0 Lawyer (as needed) Regionalmeetings will include the participation of: 0 Regional TAP/TTL 0 Country TAP/TTL 0 M&ESpecialist 0 Technical Specialist (ARV drugprocurement, gender, youth, nutrition, as needed) Benin BJ:HIV/AIDSMULTISECTOR S S BurkinaFaso HIV/AIDSDisasterResponse S S Burundi Multisect.HIV/AIDSCon&.& Orphans S S Cameroon CAM:Multi-sectoralHIV/AIDSProject S S Cane Verde CV HIV/AIDS S S 145 Annex 12: Documents in the Project File RegionalHIV/AIDS TreatmentAcceleration Project (a) BurkinaFaso "Dkveloppement des prestations de PTMEplus duCentre Mkdical St. Camille de Ouagadougou, BurkinaFaso D, Centre Mtdical St. Camille de Ouagadougou. << Prtsentation de la Structure de Coordination D,04/15/04. G Programme Global de Lutte contre le SIDA - Liste des PVVIHinscrites a laprise en charge de la SEMUS du 9/2000 au 30/06/2003, Association Solidaritk et Entraide Mutuelle au Sahel (SEMUS). <,The Global Fundto Fight AIDS, Tuberculosis andMalaria (CG/FG-STP) ,Mars 2004. (b) Ghana "Appointment on to the Technical Working Group on Antiretroviral Therapy, National AIDSET1 ControlProgramme", GhanaHealthService, March 3,2004. "Care and Supportfor PersonsLiving with HIV/AIDS -Introductiono fAntiretroviral Therapy, Ministryo fHealth, dated September 10, 2003. "Guidelines for Management of Opportunistic Infections and Other RelatedHIVDiseases", DiseaseControl Unit,Ministryo fHealth, September 2002. 146 "Health Care Waste Management Policy", MinistryofHealth, Ghana. "HIV/AIDS StrategicPlan (2004-20lo)", USAID/Ghana, July 2003. Memorandum, "Formation of NationalWorking Committee on Antiretroviral Therapy", to the Director General of GhanaHealthServices, datedFebruary26,2004. "The Joint Review ofGhana's NationalHN/AIDS Response", Draft Executive Summary, GhanaAIDS Commission, 8 April, 2004. (c) Mozambique Constataqaese recomendaqaesdes workshops sobre os resultadosdos estudos "Despesa Ptiblica e aPrestaqiiode Serviqosna Sahde emMoqambique", fevereiro de 2004. HealthCare Waste Management Plan. ImplementingPartnersProject Proposals andBudgets for Sant'Egidio, HealthAlliance International and Pathfinder International. MinisterialDiplomaNr. 183-A/2001 on Treatment ofPatientswith HIV/AIDS Infection. M O HProcurementPlan. National Strategyto Combat HIV/AIDSand STDs, 2000-2003. `Strategic Plan for Scaling-up HIV/AIDSCare andTreatment inMozambique, The Republic of Mozambique, 2004-2008 ( MISAUPEN). Strategic Plan for the Health Sector (PESS), 2001-2005. <"pared wth its income-group average lfdataare missing the diamondwll be inmmplete 150 PRfCESand GOVERNMENTFlNAMCE f482 1992 20M Dornestlcprkw 1%dnw) Consumerprices 3s -5 9 40 ImplicitGDPdeflatai 9 0 -18 48 Oovemmentfm%nce (W of GDP, !nclu&s cun'eM grants) Current revenue 132 140 Current budgetbalanee 14 2 1 2.5 Overallsurplusidekd -I7 -110 -11.5 TRADE 1982 1992 2001 EWSCtw~hOnsI Tot31&~~o:ortS(fob) 238 221 Cotton 524 128 141 Livestock products 33 42 ' 53 ManMachres m Total imports (a0 516 510 877 Food 90 73 a2 5fa Fueland energy 53 Y3 laB Capital goads 131 165 186 0 Exportpncendex{fggt;=fOL?t 48 105 Importpnceindex (fgYci=fO@ M 126 Tems of trade(f895=104 88 83 BALANCE Q~PAYYENTS 1982 1992 2001 2w2 I (US$ mrllrom) Currentaccountbdanceto GDP (y9) Exportsof goodsand servlces 175 302 251 288 Q Importsof goods and Sewices 3% 724 658 734 Resourcebalance -3% -422 407 446 .b Net inwme -10 -12 d -2 Netcurrent transfers 248 78 82 -10 Current accountbalance -281 -186 -333 Finanangibms (net) 2Bc1 247 325 Changesinnet reserwes 0 -61 5 Memo. &serves includinggoldWSS rmli,onsi Conwsion rate / E C .iccohUSSI 328 6 326 6 7x30 697.0 EXTERNALDEBTand RESOURCEFLOWS 1982 1992 2001 2w2 (USSrmlgonsf Compositionof 200%debt (US$milL) Tot31debt outstandinganddisbursed 352 1040 1,490 IBRD 0 0 0 G 6 4 IDA 95 364 636 F 3 Totaldebt service 20 33 55 IBRD 0 0 0 IDA 2 5 12 Compostionaf net msourm flows OfRaal grants 97 204 207 Offiual crediton 45 128 113 Privatecreditom 21 a 0 Foreigndirect inwslment 2 3 26 Portfolioequity 0 0 0 C: 117 World Bank program Commitments 92 117 204 A. IBRD E Bilateral - Disbursements 12 50 71 B IDA - D .Other muhilabrnl F Private ~ Prmcipalrepayinenls 2 2 7 C IMF ~ 0 Short-term ~ Netflows 11 48 65 Interest payments 1 3 5 Nettransfers 10 45 60 TheWorld Bank Gmup http/bwwworldbank orcy'datai &2W03 151 Ghana at a glance Sub- POVERTYand SOCIAL Saharan Low" Ghana Ahlca incmc 2002 Population.mid-year@#ions) 20 1 688 2,495 GNIpercapita ~AtlasmMod.US$) 270 450 430 GNI (Afiesnaaaod. US$lvEaOnsl 5A 306 1,072 AvaraQOannualgmwth, 1896-02 Populabon 2 1 24 1 9 Laborforce j%) 24 2 5 2 3 GNI Gross par primary Moat recent ostlmate(MoBt war amiiablo. 1XlE-02) capita nmllment ~ovetty(% Urpopukition~ ~ ~ o ~ ~ n ~ ~ o ~ ~ ~ UrbanpopulationPA o ~ ~ ~ ~ ~ p o 37 p ~ ~33 ~ ~~30 Life expectancyat birth(@orsl 55 46 59 Infantmortality (per f,oOaAve brrths) 55 I05 81 Childmalnifiritton(% aS &Wen undci Si 25 Amea to impwedwater suum Accws b a nimprovedwalersource(% ofpopulafionl 73 5.3 76 Illiteracy@ arfwulalioo rga fst) 26 37 37 Gmssprimaryenrollment (% dscbofagepopuSr8on) 80 85 95 #am -Lowincanre v p M e 84 92 103 Female 76 80 87 KEY ECONOMICRATIOSand LONG-TERMTRENDS 1482 1992 2ooi 2002 Economicrayus` GDP(USSbr!koiW 40 64 5 3 6 0 GlossdomesbcinvestmenEDP 3 4 12a 24 0 22 7 Exp~rtsof goodsand sewiceu'GDP 3 3 172 52 2 51 0 Trade GrossdomeshcsaungdGDP 5 7 1 3 5.3 6 5 Gmss natimal savingsGDP 3 5 3 6 182 166 Currentaccount balanceXjDP 4 8 -9 2 -7 3 -8 I InterestpaymentsiGDP 0 7 13 1 3 2 1 TotaldebVGDP 36 8 70 3 1275 Totaldebt rervimkxports 155 28 2 129 Preerentmlueof debtiGDP 744 I Presentvalueof debtiexports 1604 lndehtRjness 1982-92 1992-02 2001 20m 2002~06 (aw8gea m & groWIi1 GDP 47 4 2 4 0 4 5 5 0 GDPper mpita 1 1 2 0 I 9 26 3 6 Expo& of goodsandsewices 6 8 9 6 0 3 4 2 2 4 STRUCTUREaf thc ECONOMY 1982 1942 2001 2002 146 d GW) Growthof investmentand EDP(9) mnculture 67 3 44 8 35 9 247 Industry 6 2 174 25 2 25 9 Manufacturing 3 6 9 3 9 2 8 4 S e " 3 364 37 a 35 Y 40 3 Pnvateconsumption 89 a 86 6 78 7 79 1 Generalgaw"ent cunsumpbon 6 5 28 a 12 1 156 144 Importsofgoodsandserwces 3 0 7n5 61 1 1982-92 1892-02 24x34 I Growtbof axportsandImports(K) fawags anmatgrawthi I Agncultum 2 1 3 9 3 7 Industry 7 1 3 7 4 0 ManuFacturing 7 3 1 2 7 6 Sewices 7 3 4 8 4 3 Pnvile consumption 4 7 1 2 I 4 Generalgavm"nt mnsumpbon 4 5 4 5 15 0 -1o.a Gross domesbcinestmenl 7 1 1 9 -1 1 10.1 Importsofgoodsand serums 74 94 20 6.6 Nnte 2002data are preliminaryeshmates Thistablevvlils producedfram the DevelopmentEmnomicscentraldatabase *The diamondsshowfourkey indicatorsin the muntrylin told) ampardMthI&income-groupaverage lfdata are missing the diamondwll be inmmplste 152 PRICESand GOVERHUENT FlNkWCE 1982 1992 2001 Dommtlcprices fU cbn& Consumerprices 22 3 100 33 0 15.9 ImplicitGOPdeflstor 279 112 346 20.2 Gowmmentftflanco c6of GQP inchcludescurram'grants) Current revenue 60 185 20 7 22.3 Cunent budgetbalanm -3 2 4 2 2 9 3.0 mraiisurpiushjcncit -6 1 -5 4 -4.5 TRADE 1982 1992 2001 2#2 iussmmt?s) Total exp3rk (fob) 986 2 380 2.681 Coma 302 503 535 Timber 114 215 265 ManufactLlres T O Mimporls (a0 1,589 3,781 4.093 Foud 38 Fueland energy 162 257 275 capita1goods 277 Exportpriceindex [fgQ5=100, 85 78 81 Importpnceindex (fW5=1PO) 103 99 95 T e n s of trade (fQQ6=fP0! 83 79 85 W N CE of PAYMENTS 1982 $992 2001 (US'Sr;lllimt?s) E&mtsof goodsand serwms 711 1.105 2 433 2,607 0 Importsof goods and wmices ai3 1,BJs 3 428 3.662 Resouroeb d m m -103 -740 -885 -1.055 .6 f 4 d in"? a -106 -178 -185 N dcurrent transfen -1 255 187 750 -10 C U Kamountbalanm ~ -192 -592 -3S6 492 .(E Finanangitems(net) 191 467 465 5% Changesin net reserves 1 124 -19 M@mw Reserws includinggold lUSS mdAons) 431 679 Conwrsion rate (DEC. ioCol!llSW 21 4 437 1 7,lM 8 7.932.7 EXTERNALDEBT andRSSOWRCE FLOWS 1982 1992 2001 (us$mlons) Total debtoutstanding and disbursed 1484 4,508 6 159 IBRD 131 97 6 *' IDA 125 1,631 3 172 G 5 S ToQl debtservice 111 319 316 IB W 16 21 4 IDA 1 14 59 Composition of net resoure flws Uffiaalgrants 30 218 305 Oflaal creditors 53 309 2653 Privatecrediton 14 45 154 Foreigndired indment 16 23 a9 P@MQllO equity 0 0 0 D5d5 c p @ 4 World Bank program Commitments 0 375 433 E Eilawrai ~ Disbursements 24 170 193 Principalrepyments R 15 37 Netflows 16 156 156 Interestpayments 9 20 25 Nettmnsfers 7 136 130 TheWorldBankGroup http.i&mworldbank orgdatal Si20i03 153 Mozambiaue at a dance 8120433 Sub- POVERTY and SOCIAL Saharan I Mozambique Afrlca 184 588 2,486 Lifeexwtancy 200 450 430 3 7 306 1,572 A.rera@eannual gravrth. 199b-02 Populaboni%) 2 1 2 4 1 8 Laborform (5%) 2 1 2 5 2 3 Gms I pnmary Most recent sstimate (k+estyear amilable, 1936-02) capita enrollment 69 34 33 41 46 126 105 26 57 58 76 I 54 37 92 86 1oj 92 79 80 KEY ECONOllC RATIOSand LONO-TERM TRENDS 1982 1992 2C@l 2002 Economicratios' GDP(USBbii'rons) 3 6 1 9 3 4 3 6 Grossdomestlcinwstmentr;DP 6 0 15 6 26 5 23 7 Expo& of goads and serricegGDP 8 3 139 21 8 233 I Trade Gross domesbcsawngsGDP -11 9 -17 2 12 8 8 9 -I Gross nationalswingdGDP 5 4 3 6 Currentncmunt balanceGDP -13 7 -13 0 4 6 7 ' Interestpqments'GDP 0 0 2 3 0 2 0 8 Domestic ---I tnvssb-nsnt Total debtiGDP 3 5 216 S 1295 128 I wilnngs Totaldebt serrice'exports 0 2 I 9 7 7 6 8 4 Present mlue of debtrGDP 26 7 Present mlueof debtiexports 78 9 Indebkdiiess 198242 1992-02 2001 2002 2002-06 {we*spranrunt grwfl?] I GDP 2 4 s.l 130 8 3 GDP per capita I 1 6 7 106 6 1 EXPO& of goods and services I S 153 50 1 12 3 STRUCTUREofthe ECONOMY {% d G W I kenculture 338 320 267 268 ea Industry 326 I 6 3 276 277 ca lvlanuhduring 7 6 153 154 4: -li) servia5s 336 513 457 455 I Pn.raleconsumption 977 1046 764 801 ~3 Generalgovemmeiltcnnsumptroi? 141 126 10s 110 Impartsofgoods and s m w s 262 467 354 382 "DI -FDP 1982-92 1992-02 2801 2902 {awsye an"! qrowth? Growthof axpartsandimpolla(%I 1 Agriculture 3 1 6 7 126 T " I L Industry -37 173 201 151 Manufacturing 188 232 6 2 SeWllXS 8 6 3 1 8 1 0 3 Pnmk consumption 0.2 4.3 -2.1 10.8 Generalgovernment cunsuinptrun D.O 5.4 17.9 14.7 Gross domesbcinvestment 5.6 12.0 -10.0 3.9 lmportsofgoods andserums -1.9 4.3 -14.9 16.6 Note 2002data are preliminary eatimak This table was produmdfrom the DevclopnientEconomicscentralddbttlse The diamondss h m four key indicatorsin the muntrycin told) cumparedvnth its income-groupaberage Ifdata are missing the diamondwill be inmmplab 154 ~ ~ ~ PRICESand GOVERNMENT FINANCE 1982 1992 2001 DomaSNcprims (% C b R W ! WI Consumerprices 137 45 1 9 0 168 'O ImplicitGDPdeflabr I 7 6 446 106 10.6 Govurnmwr finsncs IO [% of GDP rnchrdescurrentgranfsi n Culrent revenue 192 20 3 19 2 18.0 Culrentbudgetbalance 3 2 4 4 3 7 2.2 Overallsurpluddeficd -5D -10 0 -16.5 -I 5.8 TRADE 1982 1992 ZOO$ ((ISS ml&o'oras) Total exprts (fob! 223 139 703 Gashews 45 i a 31 I Prawn 39 65 81 1@8 Manufacbms 14 13 13 low TUbl Imporb [Ufi 715 1063 1,263 Food 72 93 rJrN Fueland energy 41 43 CaplBl good5 398 525 Exportprice indexflgQ5=1001 El 90 a i Importpncsindex (?9G5=10q 110 93 82 T e n s of trade (~QQ6=fO@l 81 97 106 W N C E of PAYMENTS 1982 1992 2001 2002 (US3milBans) Currentaccaiint balanceto GDP4%) - Exportsd yoodsand serwes 333 304 1,008 1.187 Importsof goads and setvices 860 1518 1.837 02 Rejouroj halanru -5% -5% -570 -650 Net iiimmb -20 -183 -254 -1W Netcurrenttransfers 0 0 Current amount balm= -497 -352 -1.6M Finwoiiyitems t.iir9.l 356 392 1607 Changes in net r e s e m 141 4 0 .3 -192 Menio: Raerws includinggold iUSS!WlirOflS) Conversionrate ( E C ,kc3lUSS) 37 8 2,5665 20,703.6 23,678.0 EXTERNALDEBTand RESOURCE FLOWS $982 1992 2004 2002 (US$mlstomi Compositionof 2002 debt(USImill.) Tobl debtoutslandingand disbursed 125 5,130 4.450 4,610 IBRD 0 0 0 0 IDA 0 417 771 985 G 271 Tobl debtsewice 1 83 89 103 IBRD 0 n 0 0 IUA 0 3 5 r Compostionof not rrsourceIluws Offioal grants 101 726 656 Offiaal creditom 63 171 93 229 Privatecreditors 0 -3 -30 -37 Foreigndirect investment 0 25 4.50 Portloll0equity 0 0 0 E 1,028 V h i d Bank program Commitmenk 0 289 229 180 A IERO E Eilitsrsl Disbursetneiits 0 106 52 149 E IDA -- D Other multilsteral -- ~ F Privsts Principalrrplymenk 0 0 3 2 C-IMF 0 . Shon-Lem Net flows 0 106 49 147 Inkrest paynents 0 3 4 5 NettransJsrs 0 103 44 142 TheWutldBank Group httprhWworldhank orgrdataf BiZDiQJ 155 MAP SECTION