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The World Bank

Document o f

FOR OFFICIAL USE ONLY

Report No: 323 19-MG

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PROJECT APPRAISAL DOCUMENT ON A PROPOSED CREDIT

Public Disclosure Authorized

IN THE AMOUNT OF SDR 20.2 MILLION (USD30 MILLION EQUIVALENT)

TO THE REPUBLIC OF MADAGASCAR FOR A SECOND MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT June 13,2005

Public Disclosure Authorized

Human Development 1 1 1 Country Department 8 Africa Region

This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. I t s contents may not otherwise be disclosed without World Bank authorization.

CURRENCY EQUIVALENTS (Exchange Rate Effective February 23,2005) Currency Unit 1943.45 USD
Ariary = USDl = SDR1
=

F I S C A L YEAR January 1 - December 31

AiDB AGF AIDS African Development Bank

A B B R E V I A T I O N S AND A C R O N Y M S
M&E MIS MoH

Agence de gestion Financikre (Financial Management Agency)

Acauired Immuno Deficiencv Svndrome

Monitoring and Evaluation Management Information System Ministrv o f Health and Familv Plannine

CPAR CPFA CRESAN

I Country Procurement Assessment Report

Country Profile o f Financial Accountability IDA-financed Health Sector Support Project Comiti Rigional de Lutte contre le SIDA (Regional AIDS Com.) Commercial Sex Workers Demographic and Health Survey Fond dAppui a la Prevention (Fund for STI/HIV/AIDS

I OSE
PCN PID PLWHA PRSC PRSP

I Organisme de Suivi & Evaluation (Monitoring & Evaluation

Organization) %ham and Vulnerable Children Project Concept Note Project Information Document People Living W i t h HIVIAIDS Poverty Reduction Strategy Credit Poverty Reduction Strategy Paper

Organization)

ovc

crus csw
DHS FAP

Country Managermirector: Sector Manager: Task Team Leader:

V i c e President:

Nadine T. Poupart

Laura Frigenti

Gobind Nankani James B o n d

FOR OFFICIAL USE ONLY

MADAGASCAR Second MultisectoralSTI/HIV/AIDS Prevention project CONTENTS Page A

STRATEGIC CONTEXT AND RATIONALE

1.

Country and sector issues .................................................................................................... Strategic alignment with CAS. PRSP. and the health sector ............................................ Rationale for Bank involvement .......................................................................................
Eligibility for Repeater Status ...........................................................................................

.............................................................

8
8 10 11

2.

3.
4. B

11
14 14

2.

1.

PROJECT DESCRIPTION

3.
5.

Project development objective and key indicators ............................................................ Lessons learned and reflected in the project design .......................................................... Alternatives considered and reasons for rejection ............................................................ IMPLEMENTATION Project components ...........................................................................................................

Lending instrument ...........................................................................................................

...........................................................................................

14 15

4.

17
18

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19
19

1.

Partnership arrangements: Progress towards the Three Ones

2. 4.

.......................................

Institutional and ImplementationArrangements .............................................................. Monitoring and evaluation o f outcomes/results ................................................................ . . . Sustainability ..................................................................................................................... Critical risks and possible controversial aspects ............................................................... Loadcredit conditions and covenants ............................................................................... APPRAISAL SUMMARY Economic and financial analyses ......................................................................................

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21 22 22

3.

5.
6.

23
23

.............................................................................................

1.

23 24

2.

3.
4.

Technical ........................................................................................................................... Fiduciary ........................................................................................................................... Social ................................................................................................................................. Environment ...................................................................................................................... Safeguard policies ............................................................................................................. Policy Exceptions and Readiness......................................................................................

24
25

5.

27 27 27
1 - 1

6.
7.

/This document has a restricted distribution and m a y be used b y recipients only in the performance of their official duties.I t s contents m a y n o t be otherwise disclosed. without W o r l d B a n k authorization.

......................................................... 28 Annex 2: M a j o r Related Projects Financed by the Bank and/or other Agencies ................. 35 36 Annex 3: Results Framework and Monitoring ........................................................................ Annex 4: Detailed Project Description...................................................................................... 41 Annex 5: Project Costs ............................................................................................................... 45 Annex 6: Implementation Arrangements ................................................................................. 46 51 Annex 7: Financial Management and Disbursement Arrangements ..................................... 58 Annex 8: Procurement Arrangements ...................................................................................... 62 Annex 9: Safeguard Policy Issues .............................................................................................. Annex 10: Project Preparation and Supervision ..................................................................... 63 Annex 11: Documents in the Project F i l e ................................................................................. 65 67 Annex 12: Statement o f Loans and Credits .............................................................................. 69 Annex 13: Country at a Glance ................................................................................................. Additional Annex 14: Detailed Monitoring and Evaluation Arrangements ............. 71 Additional Annex 15: Supervision Plan.................................................................................... 75
Annex 1: Country and Sector o r Program Background Map: IBRD 34097

MADAGASCAR SECOND MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT PROJECT APPRAISAL DOCUMENT AFRICA AFTH3 Team Leader: Nadine T. Poupart Sectors: Other social services (65%); Health (35%) Themes: HIV/AIDS (P); Other communicable diseases (P); Participation and civic engagement (S); Gender (S); Other social protection and risk management (S) Environmental screening category: Partial Project ID: PO90615 Assessment Lending Instrument: Specific Investment Loan Safeguard screening category: Limited impact Project Financing Data [ ] Loan [ X I Credit [ 3 Grant [ ] Guarantee [ 3 Other: Date: June 13,2005 Country Director: James P. Bond Sector ManagerBIirector: Laura Frigenti
~~

For Loans/Credits/Others: Total Bank financing (USDm.): 30.00 Proposed terms: Financing Plan (USDm) Source Local BORROWERRECIPIENT 0.00 IDA GRANT FOR HIV/AIDS 24.70 24.70 Total:
Government of Madagascar PrCsidence de l a Republique Comite National de Lutte contre l e VIH/SIDA Nouvel Immeuble ARO Ampefilola 2eme Ctage Antananarivo 101 - Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 Secretariat ExCcutif du C N L S : secnls@dts.mg Responsible Agency: Unite de Gestion du Projet Nouvel Immeuble ARO Ampefiloha, Escalier B 2 Antananarivo 101 - Madagascar Tel: 261 20 22 382 86 Fax: 261 20 22 382 46 u,m(ii.wanadoo.mrr

Foreign 0.00 2.30 2.30

Total 0.00 30.00 30.00

Borrower:

4nnual kmulative

6.00 6.00

8.00 14.00

8.00 22.00

8.00 30.00

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

0.00 0.00

Expected effectiveness date: October 7, 2005 Expected closing date: December 3 1, 2009 Does the project depart from the CAS in content or other significant respects? [ ]Yes [XINO Re$ PAD A.3 Does the project require any exceptions from Bank policies? [ ]Yes [XINO Re$ PAD D. 7 Have these been approved by Bank management? [ ]Yes [XINO I s approval for any policy exception sought from the Board? [ ]Yes [XINO Does the project include any critical r i s k s rated substantial or high? [XIYes [ ] N o Re$ PAD C.5 Does the project meet the Regional criteria for readiness for implementation? [XlYes [ ] N o Re$ PAD D. 7 Project development objective. Re$ P A D B.2, Technical Annex 3 The MSPPIIs development objectives are the same as those o f the MSPP. Those objectives are to support the Government o f Madagascars efforts to promote a multi-sectoral response to the H I V / A I D S crisis and to contain the spread o f H I V / A I D S on i t s territory. T o do so, the project will intensify and build capacity to carry out the national response t o H I V / A I D S and sexually transmitted infections (STIs), a key risk factor for and contributor to the spread o f HIV/AIDS. In addition, the MSPPII will seek to improve the quality o f life o f persons living with H I V / A I D S through increased access to quality medical care and to non-medical support services. Given the current epidemiological situation, the project w i l l put an even stronger focus than the original project o n at-risk groups in high prevalence areas, while moderately expanding services t o other affected groups (e.g., orphans and other vulnerable children).

Project description. Re$ PAD B.3, Technical Annex 4 The proposed follow-on MSPPII will finance five components: 1) Harmonization, dono1 coordination, and strategies; 2) Support for health sector response; 3) Fund for STI/HIV/AIDS prevention and care-taking activities; 4) Monitoring and evaluation; and 5) Project managemenl and capacity building.
Component two is the only new component that was added to the project, in order to provide 2 stronger role to the health sector. Which safeguard policies are triggered, if any? Re$ P A D D.6, Technical Annex I O Environment: The proposed project has been classified as category B for environmental screening purposes, given the risks associated with the handling and disposal o f medical wastes. Safeguard policies: The only safeguard triggered i s the environmental assessment, because i Medical Waste Management Plan (MWMP) i s required. A full environmental assessment o f t e h health sector, which included HIV/AIDS, was also carried out as part o f the preparation o f t e h IDA-financed Second Health Sector Support Project (CRESANII). A MWMP was developecl for the MSPP. and has been imdemented since M a v 2004. The M o H has installed 200 small-

scale bumers to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that bumers are used at the sites supervised (district hospitals of Ankazobe, Antanifotsy and Faratsiho). The construction o f full incinerators at district level i s underway; some o f them should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out in Madagascar's different types of health facilities. The M o H has demonstrated the ability to plan for and prepare these activities, as well. Significant, non-standard conditions, if any, for: Re$ PAD C.7 Board presentation: None Loadcredit effectiveness: Recruitment o f auditors acceptable to IDA Covenants applicable to project implementation: 0 Submission o f the updated Project Implementation Manual, including updated administrative, accounting and financial Parts to IDA by August 3 1,2005 0 Submission o f the updated FAP procedures manual to IDA by September 30,2005 0 Finalization o f revised National M&E Plan and validation by all stakeholders by June 30,

2005

Completion o f a technical audit o f FAP sub-projects by October 3 1,2005

A. STRATEGIC CONTEXT AND RATIONALE

1. Country and sector issues
The proposed Second Multisectoral STYHIV/AIDS Prevention Project (MSPPII) i s a repeater o f the IDA-financed Madagascar Multisectoral STI/HIV/AIDS Prevention Project (MSPP) that i s supported by a USD20 m i l l i o n IDA credit, and i s expected to close late 2005. This section highlights the k e y country and sector issues since the start o f the original project in 2002.
Country Issues. Madagascar continues its recovery from a historical decline in per capita income until 2001. Since the 2002 political and economic crisis, the newly elected Government has embarked o n many courageous reforms, which are unique to Madagascar in the postindependence period. These reforms have helped growth to rebound, to 9.8 percent in 2003. The macro-economic environment in 2004 was difficult, however. The year was marked by exogenous shocks which included two cyclones, the sharp depreciation o f the exchange rate, and high inflation (27 percent). In spite o f these setbacks, the Government has continued to steadily implement i t s reform program, and growth i s s t i l l projected to be robust. Yet, Madagascar remains a poor country with a per capita income o f USD300 (2004), and l o w social indicators. Poverty i s mainly prevalent in rural areas with 77 percent o f the rural population being poor in 2001 compared t o 44 percent in urban areas.
Sector Issues. Until recently, Madagascar was considered an anomaly to HIV/AIDS epidemics in Sub-Saharan Africa: despite high sexually transmitted infections (STI) prevalence in approximately 20 at-risk zones countrywide, and risky sexual practices, H I V / A I D S prevalence among blood donors, S T I patients,' and sex workers had remained remarkably low.2 However, infection rates have inexorably progressed ( f i o m 0.01 percent in 1996 t o 0.15 percent in 1999 to 0.3 percent in 2001). HIV/AIDS prevalence rates m a y continue to grow unless Madagascar further strengthens i t s management efforts and targets the areas where HIV transmission i s most likely to occur.

HIV/AIDS. Characteristic o f l o w prevalence countries, Madagascar has lacked sufficient data to track the progression o f the epidemic with precision. However, several recent studies and the initiation o f a second generation surveillance system can n o w provide national and local authorities with current prevalence rates and behavioral data o n at-risk groups. The first nationally representative survey, conducted in 2003 , indicates that 0.95 percent o f pregnant women are i n f e ~ t e d . ~

The apparent paradox between high S T I rates (8% among pregnant women in 2003) and sexual promiscuity especially in some parts o f the country o n the one hand, and a l o w HIV H I V / A I D S prevalence rate o n the other hand, m a y be explained by (i) circumcision w h i c h i s generalized; (ii) limited transport infrastructure; and ( i ) w i il o herpes prevalence. The 2003 HIV-prevalence survey among pregnant women (Ministry o f Health) shows a H I V / A I D S prevalence rate o f 1.1%. However, this rate was not regionally weighted. I t was recently (January 2005) corrected to 0.95%. H I V i A I D S prevalence in the general adult population o f Madagascar i s most probably lower than among pregnant women.

' The proportion o f sex workers in the sample i s n o t known, and m a y have been l o w .

active syphilis in pregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions. In a 2000 study o f approximately 1,000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. Recent analysis o f a sample o f households surveyed for the Demographic and Health Survey (DHS) 2003-04 showed syphilis prevalence at 6.3 percent among adults aged 15-49.
Government Strategy. The Government, at the highest level, continues to be strongly committed to the fight against STI/HIV/AIDS. This commitment i s a critical element behind the achievements o f the MSPP. Over the past three years, the Government has taken the lead in mobilizing public opinion and organizing the Governments response to the epidemic. At the end o f 2002, the President o f Madagascar established the National A I D S Commission (Comite National de Lutte Contre le SIDA or CNLS) and appointed an Executive Secretariat to coordinate the implementation o f the H I V / A I D S program. A thematic group, made up o f representatives from the UN agencies and W o r l d Bank, was established under the auspices o f UNAIDS to advise the Government in developing and implementing its response to the epidemic. A National Strategic Plan for HIV/AIDS (2001-2006) and a Monitoring and Evaluation (M&E) Plan have been adopted.

Sexually Transmitted Infections (STI). S T I rates are extremely high in Madagascar. In 1998,

After a slow start and a mid-2003 re-structuring, the original project has rapidly increased its activities and has had a number o f successes. M o r e than 300 communal A I D S prevention committees, o f which more than 25 percent have produced local H I V / A I D S plans, have been established. Some 850 sub-proj ects have been carried out, promoting preventive interventions across a range o f target populations and sponsored by NGOs and community-based organizations (CBOs). About 400,000 S T I kits have been distributed through both public and private channels. A comprehensive communications strategy has been developed, and i s n o w being implemented.
The Governments strategy is evolving in several ways in response to a better understanding o f the epidemic and o f STI/HIV/AIDS management. First, the initial mass media campaigns for H I V / A I D S focused o n raising awareness and communicating basic messages about H I V / A I D S prevention to the population as a whole. With awareness now raised, the Governments new H I V / A I D S communication strategy complements the original media campaigns by focusing more o n interpersonal communication and actions that lead to behavior change and reduction o f stigma. The use o f local radios will be favored over print and television media, given radios relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement o f influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers associations). The cinemobile strategy has recently been revised t o become more interactive. Even in mass communication, interactivity through televised debates, hot lines, etc. will be introduced. Efforts to involve people living with H I V / A I D S (PLWHAs) in prevention efforts will also b e intensified. Second, under the local response (Fund for STI/HIV/AIDS prevention and care-taking activities) the MSPP supported general prevention efforts throughout Madagascar, with a loose focus o n most at-risk zones. The Government recently recognized the need t o strengthen i t s focus o n atrisk communes and prioritize interventions in these communes o n the most at-risk groups. This evolution is in line with evidence from other countries at the same stage o f the epidemic that

shows that halting the spread o f the infection among these groups significantly attenuates wider scale transmission. collaboration with several partners. Until now, the treatment o f about 29 A I D S patients has been supported by the Association Rive from the Rkunion. However, treatments are not standardized, and drugs are mostly non-combined drugs o f many different types. This increases the risks o f prescription errors, lack o f patient compliance to treatment, drug resistance, and complicates the drug procurement and distribution process. Furthermore, the cost o f treatment ranges from USD300 to USD6,000, which makes i t s use financially unsustainable if 3,000 new patients need ARV therapy each year, as projected. These factors do not allow rapid scaling-up o f ARV treatment in the Malagasy context. The World Bank looks forward to receiving the complete Governments ARV treatment guidelines that will address issues such as use o f standardized treatment regimens and Fixed Dose Combination, management o f medical supply cycle, compliance and adherence to treatment monitoring, capacity building program including for counseling. A medical and management expert committee should be set up to complete the guidelines. Fourth, the Government and its partners have taken steps to tackle high S T I prevalence under the MSPP by: (i) training both the public and private health providers in the syndromic approach nationwide; and (ii) developing S T I treatment kits for several sets o f symptoms, which have been sold at highly subsidized prices in public health facilities and in private facilities, through social marketing. Moreover, Population Services International (PSI) established a network o f franchised clinics run by generalists specially trained in providing reproductive health care to the youth, including the treatment o f STIs in several large urban centers (Antananarivo, Diego, Mahajanga, Tamatave). A syphilis elimination program targeting pregnant women and their spouses i s also being set up in hospitals and 350 peripheral health centers. There are a few areas o f strategy that remains to be finalized. The Government has just produced a draft revised strategy for condom distribution (with U S A I D and SantCnet support), and a draft strategy o n prevention o f mother-to-child transmission (MTCT). A committee has been set up to develop a strategy o n care for orphans and vulnerable children. Finally, a strategy o n blood transfusion will be prepared shortly in the context o f an African Development Bank (AfDB) project which will finance the control o f communicable diseases.

Third, the Government has produced partial anti-retroviral (ARV) treatment guidelines, in

2. Strategic alignment with CAS, PRSP, and the health sector

a) Strategic alignment with the CAS and PRSP

The Country Assistance Strategy (October 2003, p.17) recognizes that the Bank will continue to support the fight against H I V / A I D S through financing o f the second phase o f the MSPP. The MSPPII will directly support the PRSPs third pillar, to foster and promote systems for ensuring human and material security, by managing the H I V / A I D S epidemic through implementation o f the National Strategic Plan (NSP). Board discussions for the MSPP also highlighted the importance o f effective containment o f HIV/AIDS in Madagascars poverty reduction efforts. B o t h the MSPP and the M S P P I I support Millennium Development Goals 7 and 8, which aim to halt and reverse the spread o f H I V / A I D S and malaria and other diseases by 2015. Progress

10

towards these targets, in turn, will strengthen the human capital needed to achieve sustained reduction in poverty. Finally, the Secretariat o f the N e w Partnership for Africas Development has specifically requested the Banks support in fighting H I V / A I D S in Africa since the project directly supports i t s goals.
b)

Strategic alignment with the health sector

While the original projects design considered the Ministry o f Health and Family Planning (MoH) to be a clear project stakeholder, the Project Management Unit (UGP) and the M o H collaborated more than what was originally envisioned in the course o f MSPP implementation. Specifically, the UGP and the M o H were able to develop coherent and coordinated coverage o f HIV/AIDS-related interventions in the health sector, especially o n S T I treatment. The M S P P I I formalizes this collaboration through the creation o f a stand-alone health component. Moreover, as the H I V / A I D S epidemic rolls out and more HIV positive persons are being diagnosed, including within the framework o f the M T C T prevention, and treated, more resources need to be devoted to the M o H for diagnosis, ARV and opportunistic infection treatment as w e l l as nutritional support for A I D S patients. Finally, since the management o f medical waste and the implementation o f universal precautions i s lagging behind due to lack o f funds as w e l l as crowding o f multiple priorities in the health sector, the MSPPII will devote resources to scaling up these interventions.

3. Rationale for Bank involvement The rationale used to justify the Banks involvement in the MSPP remains valid for the MSPPII. While many donors support the Governments efforts t o expand the fight against HIV/AIDS, n o partner other than the W o r l d Bank is able to mobilize resources sufficient to finance implementation o f the key activities outlined in the NSP. The Banks financial support also provides the Government o f Madagascar (GoM) with: (i) credibility to leverage other the partners resources, and (ii) flexibility in the allocation o f resources, as the donor o f last resort.
In addition, the Bank contributes its cross-country experience in the design, implementation and evaluation o f Multi-Country A I D S Programs. Through its regional AIDS Campaign Team for Africa, the Bank i s well-positioned to provide the G o M with regional and international experiences and share lessons learned. Moreover, through involvement in various sectors in Madagascar and experience in support to decentralized, community-based projects (e.g., the social fund and community nutrition projects), IDA i s w e l l placed to continue to assist the Government in i t s national effort to fight H I V I A I D S in a truly multi-sectoral and communityoriented manner. The Banks technical input to the revision o f the N S P and the national M&E plan will be substantially increased under the MSPPII.

4. Eligibility for Repeater Status

a)

The MSPPII complies with general repeater requirements.

Project status report ratings. Since the projects original institutional arrangements were modified in early 2003, implementation problems have been mostly resolved, and project status report ratings have consistently been satisfactory. At the projects Mid-Term Review in

11

December 2004, the MSPP had: (i) disbursed USD12.2 m i l l i o n (54 percent o f the credit); (ii) committed an additional USD5.0 million; and (iii) planned to disburse the balance o f the credit by the end o f 2005.
Impact. Project impact has generally been consistent with original PAD expectations, exceeding expectations o n certain components while experiencing difficulties on others. In terms o f knowledge change, the proportion o f the population who knows o f H I V / A I D S has progressed significantly since 1997: 79 percent o f women know what H I V / A I D S i s today, up from 69 percent in 1997. In terms of the treatment o f STIs, a major driver o f H I V / A I D S transmission, STI treatment protocols are now consistently applied, and S T I treatment kits are widely available. These advances in the treatment o f STIs m a y have resulted in the lowering o f syphilis prevalence: at the time of the MSPP design, active syphilis in pregnant women was as high as 14.8 percent, and over 35 percent among sex workers in some regions, while the 2003/04 D H S survey indicates that syphilis prevalence i s n o w at 6.4 percent for women aged 15-49.

In terms o f behaviour change, however, the initial projects impact has been less apparent. Condom use remains extremely uneven despite the distribution o f about 32 m i l l i o n condoms over the last four years, and the promotion o f condom use in mass media campaigns and subproject activities. In the general population, only 4 percent o f men and 2.2 percent o f women used condoms the last time that they had sex. In high-risk groups, condom use varies considerably: use by women with non-regular sex partners varies between a high o f 7 1 percent in Mahajanga to a l o w o f 24 percent in Ilakaka. Condom use will need to be consistently higher in high-risk groups in order for HIV transmission to be effectively reduced.
Fiduciary, environmental, social and safeguard issues. There are n o unresolved fiduciary, environmental, social or safeguard problems. An environmental assessment o f the health sector, which included HIV/AIDS, was camed out as part o f the preparation o f the IDA-financed Second Health Sector Support Project (CRESANII). The assessment included preparation o f a medical waste management policy and plan, which has been discussed with all stakeholders to ensure full ownership. The plan includes specific actions which need to be camed out in terms o f medical waste disposal and management for the various types o f health facilities in Madagascar. In addition, specific training programs are recommended for each type o f health worker. The implementation of these waste management policies and actions started in M a y 2004. Fund availability from other agencies, supplemental funding or cost savings. The CNLS has undertaken a mapping exercise, comparing estimated financial requirements with available resources. I t has concluded that even with important contributions from the Global Fund (USD13.4 millions in 2004-06, with a possible addition o f U S D 6 m i l l i o n in 2007) and the expected contribution from the AfDB (USD11 m i l l i o n in 2005-07), there is a funding shortfall o f approximately U S D 3 1 m i l l i o n through 2007. There i s not yet any clarity o n the financial gap beyond that date. N o other partner agency i s currently able t o scale up its activities or to make up for this funding shortfall, and the shortfall will have the sharpest impact in areas where the MSPP has already invested significant resources. Based o n the fimding gap as w e l l as past and projected MSPP expenditures, i t seems clear that the M S P P I I goals cannot be achieved via a supplemental credit o r cost savings.

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b)

MSPPII complies with the MAP repeater requirements.

Strategy. In collaboration with UNAIDS, bilateral donors, NGOs and other c i v i l society entities, the G o M prepared a draft NSP to combat H I V / A I D S in 2000. The NSP was refined through an intensive participatory process at the regional and community levels, and was adopted in 2002. Budgeted action plans have been completed, and were used in the financial mappinggap analysis. The NSP is currently being updated to take lessons learned into account, and to integrate new initiatives (e.g., the Global Funds project). Coordination by the National AIDS CounciVlVational A I D S Secretariat. The CNLS and i t s Executive Secretary (SE) have been strengthened to carry out their coordinating role with the involvement o f c i v i l society and clear public accountability. After the 2002 political crisis, the Cellule de Coordination Nationale des Actions de Lutte Contre le VIHBIDA (CCN) was formally created to lead the development o f the NSP and to coordinate the multi-sectoral HIV/AIDS effort. I t has since been re-named the Comitb National de Lutte contre le SIDA (CNLS). The CNLS i s made up o f representatives o f the public and private sectors and c i v i l society organizations, and i s n o w placed under the direct authority o f the President o f the Republic. In late 2003, the SE was appointed to manage the MSPP, which substantially improved project performance. Management o fund for STmIV/AIDS prevention and care-taking activities. The Financial f Management Agency (AGF) established under the MSPP has ensured both the timely processing o f grant applications and the regular f l o w o f funds. Since assuming the grant management responsibility in March 2003, the AGF has processed more than 850 sub-projects valued at more than U S D 7 million. More than 75 percent o f approved sub-projects were for small grants o f U S D 10,000 or less. The parallel establishment o f a Facilitating Organization (OF) that helped CBOs to develop their sub-project applications reduced proposals revision rate from 60-70 percent o f all proposals to 30 percent. Explicit measures linked disbursements t o performance, although these tended to be more administrative in nature (i.e., submission o f the requisite reports) than technical. The MSPPII will build o n these strengths, while making improvements in the supervision and evaluation o f sub-projects. O f all approved sub-projects, less than 10 percent were supervised and/or evaluated, primarily due t o a shortage o f personnel. T o remedy to the lack o f oversight o f approved sub-projects, Regional Coordination Bureaus will take o n greater responsibility for sub-project supervision under the MSPPII, and OFs will be awarded contracts by region, instead o f nationally as under the MSPP. Contracting by region will place the OFs closer to the ground, increasing their ability to supervise sub-projects. Technical support for sub-projects and public sector activities. Technical support for subprojects i s provided by different actors, depending o n sub-project size. F o r example, CBOs and NGOs that apply for small sub-project funds receive assistance in developing their proposals from OFs, while proposals over USD100,OOO are reviewed by the technical sub-committee o f the UNAIDS Thematic Group. The MSPP also provided technical support for the development o f public sector strategies and pilot projects. There were significant difficulties in providing support to some ministries. Institutional issues related to the implementation o f pilot projects reduced some ministries interest in the development o f public sector strategies and pilot projects. Because the institutional issues are not likely t o b e resolved in the short- to mediumterm, the MSPPII will initially focus o n a limited number o f sectors that were able t o effectively

13

use MSPP technical support, and that play an especially important role in HIV/AIDS prevention or care-taking. These sectors have been identified primarily as health, education and security.
Monitoring and evaluation system. The MSPP financed a fully operational national M&E system. The M&E system was developed at two levels: (i) the national level, through at development o f an M&E plan guided by the SE and Institut National de la Statistique Malgache (INSTAT); and (ii) the project level, through the design and implementation o f a management at information system (MIS). Though significant strides in putting an M&E system into place were made under the MSPP, the composite parts o f the M I S need to be fully integrated (in a common sofhvare platform); second generation surveillance data needs to be better used in national programming and project decision-making; and project activities need to be evaluated.

B. PROJECT DESCRIPTION
1. Lending instrument
The lending instrument i s an investment credit with a medium-term focus (four years) to finance services, training, and goods in support o f implementation o f STI/HIV/AIDS interventions. The Country Financing Parameters, approved o n M a y 12, 2005, allow for up to 100 percent project financing, including taxes. The financing parameters also allow for recurrent cost financing where required, provided that the implications o f recurrent cost financing o n Madagascar's fiscal situation and debt sustainability are taken into consideration.

2. Project development objective and key indicators

The MSPPII's development objectives are the same as those o f the MSPP. Those objectives are to support the Government o f Madagascar's efforts to promote a multi-sectoral response to the H I V / A I D S crisis and to contain the spread o f HIV/AIDS o n i t s territory. To do so, the project will intensify and build capacity to carry out the national response to HIV/AIDS and STIs, a k e y risk factor for and contributor to the spread o f HIV/AIDS.
In addition, the MSPPII will seek to improve the quality o f l i f e o f persons living with H I V / A I D S through increased access to quality medical care and non-medical support services. Given the current epidemiological situation, the project will put an even stronger focus than the original project o n at-risk groups in high prevalence areas: while moderately expanding services to other affected groups (e.g., orphans and other vulnerable children).

The achievement of the development objectives will be measured by the following key indicators: Decrease by 20 percent in syphilis prevalence among commercial sex workers (data pending).
Madagascar has experimented with the "PLACE" method, which uses local ethnographic and contextual data rather than blood testing in order to identify sites where HIV prevention activities could b e particularly productive. A P L A C E pilot study was camed out in May, 2003 in seven towns judged at high-risk for sexual transmitted infections because o f their activities (e.g. mines, large cattle markets, tourism, ports.) Preparation o f a 2005 P L A C E study i s ongoing.

14

Increase in percentage o f people in high-risk groups (truck drivers, military, commercial sex workers) who can cite three methods o f HIV/AIDS prevention, from 52 percent to 85 percent o f truck drivers, from 48 percent to 85 percent o f military, and from 50 percent to 75 percent for commercial sex workers. Increase in percentage o f people in high-risk groups (truck drivers, military, commercial sex workers) who reject two major misconceptions about H I V / A I D S transmission, from 60 percent to 90 percent o f truck drivers, from 78 percent t o 90 percent o f military, and from 48 percent to 85 percent for commercial sex workers. Increase in proportion o f commercial sex workers reporting the use o f a condom in their last act o f sexual intercourse with a client from 76 to 90 percent. Decrease in percentage o f men and women aged 15-49 who report having sex with a non-regular partner in the last 12 months, from 16.8 percent to 9 percent for women and from 38.1 percent to 20 percent for men.

Some k e y performance indicators were changed since the MSPP to reflect an increased project emphasis o n high-risk areas and the behavior o f people likely to frequent those areas. In addition, the MSPP Mid-Term Review found that some key MSPP indicators were too ambitious, inappropriate or unavailable. A more complete l i s t o f the indicators that were validated with the U N A I D S thematic group in April 2005 (as part o f the revision o f the M&E Plan) i s presented in Annex 1.

3. Project components
component that was added t o the project in order to provide a stronger role for the health sector. Details o f the project components are described in Annex 2.

The proposed follow-on M S P P I I will finance five components. Component two i s the only new

15

Component and Sub-components

~

1. Harmonization, donor coordination, and strategies a) Harmonization and donor coordination b) Updating o f the national strategic plan c) Implementing the STI/HN/AIDS communications strategy and action plan d) Sector strategies and action plans 2. Support for health sector response a) Support for STI control. b) Support for care and treatment o f PLWHAs c) Other health sector response activities 3. Fund for S T m I V / A I D S prevention and care-taking activities (FAP) a) Sub-projects b) Fund management 4. Monitoring and evaluation a) Monitoring b) Epidemiological data collection c) Impact studies/Evaluation 5. Project management and capacity building

Indicative costs (USDM) 1.5 0.03 0.1 1.3

o/o o f Total

5y o

0.07 3.5 1.5 1.4 0.6 16.5 14.5 2.0 2.9 1.20 1.20 0.5 2.5

12%

55% 10%

8Y o

0.8 2.3
Total Financing Required
Parameters for Madagascar.

30.0

3y o 7y o 100% 100%

has the capacity to scale-up project activities, as the MSPPII credit amount o f U S D 3 0 M i s a reasonable progression from the MSPP credit amount o f USD20M. The two areas in which the budget has been significantly increased from the MSPP to the MSPPII are the financing o f the Fund for STI/HIV/AIDS prevention and care-taking activities (FAP), from U S D 13.9M to USD16.5M, and the support to the health sector component, which did not exist under the MSPP and will receive U S D 3 M under the MSPPII. N o significant problems are anticipated with the increase in volume o f these activities. There are two broader, capacity-related concerns, however. The first i s whether the UGP will have the capacity to successfully re-orient a larger volume o f finance towards high-impact activities in a much more limited geographic area (given the MSPPII's focus o n core-transmitter groups within high-risk communes). The project will need t o shift from supporting general knowledge-building activities to supporting knowledge and behavior change in Madagascar's high-risk areas. To manage this concern, the project has commissioned a demographic and epidemiological profile t o identify "hot" communes o n an empirically sound basis. I t also will undertake an ex ante cost-effectiveness analysis to assess which o f the eligible sub-project activities are likely to be the most effective in changing knowledge and behavior in high-risk 16

Capacity implications o the scaled-up activities. There i s little concern about whether the UGP f

areas. Finally, i t will provide support - potentially through the hiring o f a supra facilitating organization - t o facilitating organizations in how to best help CBOs t o develop and carry out high-impact activities in high-risk communes. The second concern i s whether the UGP - and the CNLS more broadly - will be able to implement an M&E System which i s more ambitious than under the MSPP. The MSPPII i s expected to generate more monitoring data than did the MSPP. I t will also aim to use the data in real-time project decision-making, which was not consistently done under the MSPP. To do so, data must be delivered to each level of CNLS or project management accurately and in a timely manner, and rapidly analyzed. The MSPPII will therefore place M&E specialists in the projects Regional Coordination Bureaus to guide implementation o f the M&E system at the sub-regional level and ensure good-quality data collection. The project will finance revisions to i t s M I S and data entry processes to speed data collection. Each year, the M S P P I I will also hire a consultant to collaborate with the C N L S to analyze the data generated each year and make programmatic recommendations based o n the data analysis. Data analysis and recommendations will be summarized in an annual report, Results and Strategic Re-Orientations.

4. Lessons learned and reflected in the project design

The MSPPII will draw o n a number o f lessons learned, from intemational experience and from the first MSPP. The intemational lessons emerge from the first generation o f Multi-Country A I D S Programs (MAPs). Some of these lessons have been compiled in the Implementing MultiCountry HIUAIDS Programs (MAPS) in Africa report, while others have been highlighted through continued operational research o n M A P s by the W o r l d Banks Development Research Group. The MSPP lessons were outlined in the Aide-Memoire for the MSPP Mid-Term Review Mission and in the Aide-Memoire for the MSPPII Pre-Appraisal Mission.

a)

International lessons learned

Focus on high-risk zones in low prevalence countries. The first generation o f M P projects A provided broad-based funding for H I V / A I D S prevention and care-taking activities. This model was well suited to countries with a high level o f HIV prevalence where generalized prevention strategies were needed, and/or to creating a facilitating environment for highly targeted H I V I A I D S interventions. I t i s n o w recognized that H I V / A I D S response in l o w prevalence countries may be highly targeted to high-risk zones to reduce the risk o f HIV transmission in the areas where that risk is greatest. T o take this lesson into account, the M S P P I I will change i t s coverage strategy to focus o n core-transmitter groups in the highest risk communes. An analysis o f existing epidemiological, behavioral and population-based data i s being financed under the MSPP to identify the high-risk communes. At least three-quarters o f the MSPPIIs FAP will be invested in these high-risk areas.

A comprehensive approach in the fight against HIV/AIDS. When the W o r l d Bank first published Confronting AIDS in 1999, the annual cost o f ARV therapy for one person (inclusive o f medical costs) was estimated to be about USD10,OOO for a first-line ARV regimen. This cost was considered to be too high for the vast majority o f developing countries to bear. Since 1999, however, the cost of ARV therapy has dropped considerably. Because the prices o f A R V s have

17

decreased substantially, and the regimens have become simpler to adhere to, i t i s now feasible for more countries, including Madagascar, to support a comprehensive approach that includes offering prevention, care and treatment to those infected. The MSPPII will therefore make financing available to the health sector through i t s second component, for purchase o f ARVs and drugs for opportunistic diseases. This financing w i l l compliment funding o f the purchase o f A R V s by the Global Fund.

b)

MSPP lessons learned

Stronger health sector involvement. The MSPP worked with sectors important to the prevention o f H I V / A I D S t o develop sector strategies and action plans for management o f the epidemic. Though the project did emphasize a relationship with the health sector, i t s Mid-Term Review found that the Ministry o f Healths collaboration was strong, particularly on the S T I kits, and highly complimentary to other MSPP activities. Given the strength o f this collaboration, there is n o w a need to expand MSPPII to support medical care o f PLWHAs. This support will be financed under a separate project component. Stronger M&E system and more effective use o data. The MSPP financed a series o f national f epidemiological and behavioral surveys, in f l or in part. However, these data are not il sufficiently used to reorient the strategy and actions. T o address these issues, the MSPPII will: (i) continue t o co-finance epidemiological and behavioral surveys; (ii) support collection o f data in MSPPII project areas through sub-contracted L o t Quality Assurance Sampling (LQAS) to finance annual analysis o f all survey and operational data, measure project-specific impact; (iii) and (iv) finance the development of an annual report, ResuZts and Strategic Re-Orientations, in close collaboration with CNLS staff, that will present the summary data analysis and recommendations for re-orientation o f the National H I V / A I D S Program based on the data analysis. The report and its recommendations will b e shared and discussed with development partners before implementation.

5. Alternatives considered and reasons for rejection

T w o alternatives to the MSPPII were considered and rejected, before determining that a repeater project was the best approach:

1. The alternative o f supplementinn the work done o n H I V I A I D S under the on-noing Second Health Sector Support Proiect was not felt to be the most effective solution, given the closing date o f the health project (already extended once to 2006) and the multisectoral nature o f the HIV/AIDS problem. However, based o n excellent previous
collaboration between the two projects, M S P P I I has developed an explicit health sector support component that involves the M o H in the project directly.

2. The alternative of including H I V I A I D S in the PRSC was rejected because o f the reduced amount o f PRSC2 financing made available for the k e y sectors o f education, health and nutrition, and because o f the need to earmark the use o f f i n d s for STI/HIV/AIDS.

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C. IMPLEMENTATION

1. Partnership arrangements: Progress towards the Three Ones

Madagascar i s making good progress towards the Three Ones approach t o management o f HIV/AIDS, which includes one national H I V / A I D S policy framework, one national coordinating authority, and one national M&E system. The country has one policy framework (2001-2006) and one national A I D S coordinating authority with reasonable technical capacity for coordination, M&E, resource mobilization, financial tracking and strategic information management. The CNLS has also developed a common M&E plan and a set o f performance indicators with U N A I D S support. The performance indicators were validated by the U N A I D S thematic group in April 2005, and the MSPPII will use these indicators in its logical framework (Annex 2).

To further support the Three Ones, the project will: (i) revise the national strategic framework to incorporate the results o f the recent studies, include the proposed interventions o f the various partners, and serve as a consensus-based management tool for the period 2007-2010; (ii) maintain the institutional arrangements which were carehlly established during MSPP, but will revise the projects operational manuals to reflect improved capabilities and streamline existing i iensure that the M I S h n d e d by MSPP serves the needs o f the national M&E procedures; and ( i ) strategy as w e l l as those o f all partners. The MSPPII will support revisions to the M I S system as needed.
coordination for H I V / A I D S interventions. The CNLS has begun to map out the availability and distribution o f funds according to the priorities o f the NSP. While there is currently n o intention of formally harmonizing o r pooling funds, the M S P P I I will seek to establish: (i) agreement o n the annual work plan and outputs; and (ii)detailed financing plan identifying specific activities a to be funded by specific agencies and the GoM. Individual partners financing will be earmarked in the annual work plan. However, it i s understood that the IDA contribution will be flexible, and used as funding o f last resort. Finally, the MSPPII will continue t o submit bi-annual program monitoring reports for review by the CNLS and i t s financing partners. Reporting formats (including summary reports o n activity outputs, financial statements, and procurement) will reinforce the Three Ones and will be agreed o n by CNLS and its partners. Adjustments t o the annual work plan will be j o i n t l y agreed upon at bi-annual reviews.

Under component 1, MSPPII will also provide funding to strengthen harmonization and donor

2. Institutional and implementation arrangements

The institutional arrangements for the National H I V / A I D S Program and the MSPPII are similar to those used under the MSPP. The responsibility for the oversight o f the National H N / A I D S Program rests with the C N L S at the central level; the Regional H I V / A I D S Prevention Committee (CRLS) at the regional level; and the Local H I V / A I D S Prevention Committee (CLLS) at the

A detailed description o f the differences between the MSPP and MSPPII institutional arrangements i s provided in Annex VI.

19

commune level. These committees are made up o f H I V / A I D S stakeholders, including representatives from Government, PLWHAs, NGOs, the private sector, and religious and CBOs.

At the central level, the CNLS was created by Government decree in October 2002. The mandate o f the CNLS i s to: (i) coordinate the national fight against H N / A I D S ; and (ii) guide the implementation o f the NSP. The CNLS i s made up o f an Executive Secretariat (SE) and a plenary committee. In addition to the day-to-day management o f national H I V / A I D S prevention activities, the S provides political and strategic support to the Govemments fight against E HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection o f rights. The SE also oversees implementation o f the MSPP, with the Executive Secretary serving as project director.
Implementation o f the national H I V / A I D S program i s coordinated at the regional level by the CRLS, which i s responsible for (i) supervising and coordinating H I V / A I D S interventions; (ii) guiding implementation o f the NSP; and (iii) liaising between the CNLS, the Local CLLS, and other STI/HIV/AIDS prevention actors in the region. At the commune level, the C L L S i s responsible for: (i)developing the local plan in the fight against HN/AIDS; ( i i) guidinglcoordinating implementation o f the plan; and (iii) mobilizing the local population in the fight against HIV/AIDS.
Project Implementation Arrangements. The UGP i s responsible for day-to-day management o f the project. Its responsibilities include: (i) development o f the annual work program and budget; (ii) management o f project activities, financial management, procurement, administration and logistics; (iii) oversight o f monitoring and evaluation (contracted to the Monitoring and Evaluation Organization or OSE); and (iv) periodic reporting to the W o r l d Bank. The UGP also serves as the Secretary o f the MSPP Council, which provides oversight o f the project as a whole. The Council reports directly to the President o f the Republic and is made up o f fifteen permanent members, including one representative from each o f the following: the Office o f the President o f the Republic; the Ministry o f Finance; the Ordre des Experts ComptabZes de Madagascar; the NGO sector; the private sector; beneficiaries associations; and key sectors such as health, education, security and youth.

The UGP is supported by the OSE and the Technical Review Organization (ORT). The OSE i s responsible for carrying out periodic project monitoring surveys and for supporting MSPP management to use data in project decision-making and strategic re-orientations. The ORT, under the auspices of the U N A I D S thematic group dargie, consists o f designated partners within the group who review for technical quality all proposals over USD25,OOO and a sub-set o f proposals over USDlO0,OOO submitted to the FAP.

At the regional level, the Regional Coordination Bureau (BCR) i s responsible for M S P P I I implementation. Each B C R covers one t o three administrative regions, and i s staffed by a Director and a Technical Coordinator. M&E Consultants will be assigned to each office to ensure high-quality regional data collection. Each region also has a Facilitating Organization (OF). The OF i s an NGO contracted by the project to assist: (i) communes in the development o f their local plans in the fight Against H I V / A I D S ; and ( i CBOs in the development and i) implementation o f the technical aspects o f their applications for Fund financing.

20

Lastly, a Financial Management Agency (AGF) i s responsible for: (i) evaluating the financial returning financially weak proposals to the CBOs viability o f CBO applications to the Fund; (ii) for revision; ( i ) i i forwarding suitable proposals to the OF for technical review; and (iv) making payments to the CBOs for approved sub-projects. The AGF i s also responsible for maintaining a database o f unit costs for the range o f activities eligible under the Fund.

3. Monitoring and evaluation o f outcomes/results

Though MSPP generally adhered to the arrangements described in the annex to the original PAD, two M&E specialists were insufficient to carry out the range o f responsibilities described. the Specific problems included: (i) coherent functioning o f the computerized M I S . The M I S i s in place and operational at the UGP and AGF but, while some parts o f the system w o r k individually, only one (sub-projects) i s fully automated and the parts do not function together as a whole; ( i the lack o f use o f monitoring data in national programming or project decisioni) making; and ( i ) lack o f impact evaluation(s) o f project activities. The MSPPII M&E i i the subcomponent will also ensure that the national M&E system used by all donors i s in place and operational.

a) Monitoring
The MSPPII Monitoring Plan contains five parts. First, a monitoring framework identifies the key performance indicators associated with MSPP project inputs (Annex 2). Second, outcomes (i.e., behaviors and knowledge) in the projects at-risk zones (as well as in a limited number o f control areas) will be measured using LQAS for recurrent behavioral surveillance. Third, k e y performance indicators as well as financial, input and operational data will be consolidated in the project MIS, which will be improved to form a single, coherent system. Fourth, sub-project quality will be monitored more closely by placing M&E staff in the BCRs, verify the accuracy o f monitoring data; monitor sub-project quality through periodic site visits; and share relevant data with regional partners. Fifth, monitoring data will be regularly released t o development partners and the public, primarily in the form o f quarterly, biannual and annual reports.

b) Epidemiological data collection and special studies

The MSPPII will continue to contribute to the financing o f a second generation surveillance system and other population-based surveys and large-scale studies. These include bi-annual behavioral surveys among high-risk groups (sex workers, sex workers clients, truck drivers, military and youth) and annual sentinel biological surveillance surveys o f clients at antenatal clinics (pregnant women, S T I patients, and commercial sex workers). The latter includes the cross-sectional HIV prevalence study (Enqugte Nationale de Sero-prevalence Auprks des Femmes Enceintes) first conducted in 2003; the 2008/09 Demographic and Health Survey; and the annual PLACES study o f high-risk sites and r i s k behaviors there. c) Impact studies The MSPPII will support one o r more (pending the availability o f funding) impact studies t o measure, for example, changes in H I V / A I D S prevalence and incidence, changes in A I D S related mortality, social norms, coping capacity in the community, and economic impact. These impact

21

studies will be launched only after technical review confirms that the study design has sufficient statistical power to test the study hypothesis. The study methodology w i l l be reviewed by the Global H I V / A I D S Monitoring and Evaluation Support Team.

d) Consolidated analysis to reorient the strategy

The project will also finance a consolidated annual report, ResuZts and Strategic Re-Orientations. The report will present: (i) analysis o f data generated and studies camed out in the course o f an the year, and (ii) recommendations on re-direction o f the National HN/AIDS Program or the MSPPII. The report will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based o n this analysis. The reports will then be disseminated to and discussed with the U N A I D S thematic group, with a view to regularly using monitoring and evaluation information in program decision-making.

4. Sustainability
Though perhaps less so in Madagascar than in neighboring countries, H I V / A I D S constitutes a pending natural disaster, to which response i s well beyond the Governments financial means. For the foreseeable fiture, there is general agreement within the international community that an effective and sufficient response to the epidemic i s largely dependent upon the continued financial support o f multilateral and bilateral donors. However, the project will try to build sustainability by measures such as advocating for budget lines for H I V / A I D S or assigning c i v i l servants f l time to the fight against the epidemic. il

5. Critical risks and possible controversial aspects

Risk
F o r equity reasons, the U G P m a y not b e able to focus the majority o f i t s resources o n highrisk areas, despite the pressing epidemiological case for doing so. Despite Governments efforts to mobilize public opinion, some religious organizations m a y continue to speak out against condom use a n d o r encourage stigmatization.

Risk Rating M

Risk-Mitigating Measures
The project will allocate 75 percent o f sub-project funds to identified hot, o r high-risk, communes. The Funds procedures manual will b e revised accordingly.

The MSPP has invested considerable resources in reaching both religious and traditional leaders. The M S P P I I will continue to do so, with a n emphasis o n continuing the dialogue with opposing groups. Within the project, communication regarding condoms will be less aggressive in mass media campaigns but intensified in communications with high-risk groups. In addition, the project will try to better leverage the Presidents commitment t o H I V / A I D S prevention to involve other national leaders in the promotion o f condoms and the reduction o f stigma.

22

The capacity o f the health care system to provide basic services for treatment o f S T I and HIV positive patients (opportunistic infections, M T C T , ARVs), and for voluntary counseling and testing i s too weak t o enable the project to meet its health sector-related objectives. National N G O s may not have the expertise to successfully assist CBOs in implementing more technically sophisticated o r socially challenging sub-projects, such as homebased care or support to orphans and vulnerable children or P L W H A s .

The project description allows the project to be flexible in i t s support to the health sector, intervene where it sees that it will have the greatest impact, and act in compliment t o the C R E S A N I I Project and health-related activities supported by the PRSCs. For example, i t may finance the training o f health staff.

At least twenty percent o f the regional OF contracts will be awarded to international NGOs with a proven
track record.

6. L o a d c r e d i t conditions and covenants (i)Conditions for effectiveness

0

Recruitment of auditors acceptable to IDA.

(ii)Covenants
0

0 0

Submission o f the updated Project Implementation Manual, including updated administrative, accounting and financial Parts (with new Chart o f accounts and Financial Monitoring Reports) to IDA by August 3 1,2005; Submission o f the updated FAP procedures manual to IDA by September 30,2005; Finalization o f revised National M&E Plan and validation by all stakeholders by June 30, 2005; and Completion o f a technical audit o f FAP sub-projects by October 31,2005.

D. APPRAISAL SUMMARY
1. Economic and financial analyses

Detailed economic analysis o n H I V / A I D S has been carried out under the Multi-Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR, paragraphs 76-78). The analysis demonstrates the impact o f the epidemic on economic development and poverty as well as the cost-benefit o f f H I V / A I D S interventions. The fiscal impact of the project i s expected to be modest. Counterpart funds are not required and will therefore not impose a financial burden on the GoM. C i v i l works will be minimal and will be primarily restricted to the renovation o f voluntary counseling and testing (VCT) facilities in existing health centers. The recurrent cost o f maintenance for infrastructure built under the project i s thus expected to be negligible. Finally, the MPPPII will finance expansion, staffing and operating costs o f the BCRs. This will involve some supplemental costs relative to the original project. As detailed in the "sustainability" section above, however, the international community i s expected to finance the response to the H I V / A I D S epidemic for the foreseeable
23

future. The slight additional costs o f new BCRs should therefore not create any additional fiscal burden o n the G o M .

2. Technical

The design o f the MSPPII i s based on the MSPP. The MSPP, in turn, relied o n existing knowledge and experience gained in Madagascar and in other African and Asian countries. The preparation team relied heavily on the U N A I D S Thematic Group in Madagascar for the projects technical content. The design follows the MAP principles and the NSP, which reflects a consensus among all stakeholders. In addition for MSPPII, UNICEF provided technical support for communication and o n orphans and vulnerable children (OVC) activities. The design o f the new health component i s based o n IDAS experience with the health sector in Madagascar through successive health support projects, and from international experience in the financing o f care and treatment for PLWHAs. The M&E component has been strengthened through the
collaboration o f the World Bank and U S A I D . The M&E sub-committee o f the U N A I D S Thematic Group will continue to advise the CNLS and UGP during implementation. The UGP will also continue to rely heavily on i t s partners for technical support o n the Fund implementation. For example, before approval by the AGF, all sub-project proposals to the FAP above USD25,OOO will be reviewed by designated partners o f the U N A I D S Thematic Group with comparative advantage in the type o f activity proposed (Annex I V provides details). The UGP can at all times apply for technical support from the partners to the U N A I D S Thematic Group and/or f r o m the U N A I D S Secretariat. Annual technical audits will be undertaken by independent consultants.

3. Fiduciary
Procurement. The third Country Procurement Assessment Review (CPAR) for Madagascar was conducted in November 2002. I t was followed by a workshop in June 2003 that validated ajoint

CPAR/ Country Profile o f Financial Accountability (CPFA) action plan to ensure rapid implementation o f procurement reforms. K e y elements o f the intended procurement reforms are: (i) revision o f the draft procurement code to ensure transparency, simplify procedures, and comply with international standards; (ii) establishment o f effective procurement institutions to ensure that the new regulations will be adequately applied, provide sufficient oversight and control, and improve efficiency through adequate delegation o f responsibilities; and (iii) implementation o f adequate training and capacity building to ensure the sustainability o f the procurement reforms.

Government, which causes unnecessary delays. In addition, insufficient programming and procurement planning contribute to delays in project implementation resulting in slow disbursement. T o mitigate risks o f delays for the proposed project, proper prerequisites for the

A new procurement code was enacted in July 2004. Since the texts for regulatory application are s t i l l under preparation, however, the existing Procurement Code o f 1998 will continue to be applied. The World Bank ascertained that deficient features identified in the 1995 CPAR have been properly addressed. IDA standard bidding documents are widely used. An area o f concern, however, i s the cumbersome and overly bureaucratic approval process for contract signing by the

24

use o f Bank standard bidding documents, including evaluation reports for national competitive bidding procedures, have been agreed upon with Government during negotiations. The Project Implementation Manual will be updated.

A procurement capacity assessment o f the UGP, including training needs and arrangements, was conducted as part o f project preparation. O n the basis o f the initial assessment, an action plan was drafted to address areas where the UGP needs to be strengthened. The action plan includes: (i) specific section o n procurement in the Project Implementation Manual to be updated by a August 3 1, 2005; (ii) improvement o f organization o f the filing o f procurement-related the documents, including within the regional offices; (iii) procurement training sessions for project staff; and (v) the financing o f independent procurement and technical audits to be carried out o n
a regular basis.
Financial management (FM). In accordance with Bank policy and procedures, the financial management arrangements o f the UGP responsible for the implementation o f the MSPPII have been reviewed to determine whether they are acceptable to the Bank. This review is an update, since the FM system o f this entity has already been assessed in the context o f the MSSP. The conclusion o f this review rated the project FM system "globally satisfactory". However, the following measures need to be taken to ensure adequate recording o f project transactions and timely production o f financial reports required for managing and monitoring M S P P I I activities: i)review o f the project Chart o f accounts to reflect components and activities to be financed under M S P P I I credit; i ) i determination o f the format and contents o f the financial and physical progress reports t o be agreed by August 3 1,2005; and i i recruitment, o n a competitive basis, o f i) an accounting assistant to better handle the high volume o f transactions and activity, and ensure appropriate segregation o f duties. All these recommendations should be implemented by early July 2005.

The project financial statements will be audited annually by independent and qualified auditors acceptable t o IDA, in accordance with International Standards o f Auditing. The auditors should be recruited prior to effectiveness. The audit report will be submitted to IDA not later than six months after the end of each fiscal year. The content and format o f the new financial management reports (FMRs) will be agreed before effectiveness. N o significant problems have been encountered in terms o f audit covenants: the MSPP and all other Bank-financed projects in Madagascar have consistently submitted their audit reports in due time.

4. Social 4.1
Summarize key social issues relevant to the project objectives, and specify the project's social development outcomes.

Madagascar i s still at an early stage in the epidemic and i s therefore in the fortunate position to be able t o curb its spread. The project i s designed to reach the most at-risk groups, which include sex workers and their clients, migratory workers, youth, etc. It will empower these groups to undertake H I V / A I D S activities, reduce transmission and ultimately avoid the severe socio-economic impact of H I V / A I D S that i s seen in countries with high prevalence rates. Recent

25

studies o n sexual and socio-cultural behavior will be used to fine-tune proj ect-financed activities for STI/HIV/AIDS prevention and treatment.

4.2

Participatory Approach: H o w are key stakeholders participating in the project?

stakeholders. Different focus group discussions were conducted at the central level and local levels. In addition, several regional meetings were carried out with the participation o f local development actors and potential beneficiaries to develop regional and sectoral H I V / A I D S strategies. Technical assistance was provided to assist the government in empowering the communities and NGOs to actively participate in designing and implementing the national H I V / A I D S program through the PRSP process. During the pre-appraisal mission (March 2005), the proposed repeater project was discussed with the Partners Forum. The project design reflects input from i t s members.

The original project was developed on the basis o f the government's NSP and in close consultation with key government, NGO and elected representatives as well as international

Finally, representatives o f FIFAFI, Madagascar's only association o f PLWHAs, are members o f the MSPP Council, the CNLS, and the Country Coordinating Mechanism (CCM). Four P L W H A s are currently working in the CNLS and the UGP.

H o w does the project involve consultations or collaboration with NGOs or other 4.3 civil society organizations?
T o date, 850 sub-projects requested by N G O s and CBOs have benefited f r o m funding from the Fund. A consortium o f three international NGOs was also hired to provide technical support to the NGOs or CBOs that submitted sub-project proposals under USD25,OOO. With the increase in volume o f component 3 (the FAP), NGOs and CBOs will continue to be eligible to request subproject funding. Those NGOs with specialized capacity and experience in the fight against communes in the development o f their local H I V / A I D S will be contracted as OF t o assist: (i) plans in the fight against HIV/AIDS; and (ii) CBOs or N G O s in the development and implementation o f the technical aspects o f their applications for Fund financing. There will be 22 OF contracts, one for each region o f Madagascar. Up to 80 percent o f the contracts m a y be w o n by national NGOs.

W h a t institutional arrangements have been provided to ensure that the project 4.4 achieves i t s social development outcomes?

At the central level, the CNLS oversees the national, multi-sectoral H I V / A I D S prevention efforts. The mandate o f the CNLS includes attention to social development objectives and the involvement o f P L W H A s in the National H I V / A I D S Program and MSPP in particular. At the regional and local levels, the project facilitates achievement o f social development outcomes through i t s Fund, which seeks t o empower local communities by allowing them to apply for funds for and implement their o w n STI/HIV/AIDS activities. On the supply side, as above, the MSPPII provides the opportunity for national NGOs to develop their ability to facilitate STI/HN/AIDS prevention and care-taking activities by acting as OFs.

26

4.5 How will the project monitor performance in terms of social development outcomes?
The MSPP i s a social development project. I t s M&E arrangements are described in brief in the "Monitoring and Evaluation o f Outcomes and Results" section, M&E indicators are listed in Annex 2, and in detail in Additional Annex 14 on Detailed Monitoring and Evaluation Arrangements.
5. Environment

The proposed project has been classified as category B )) for environmental screening purposes, given the risks associated with the handling and disposal o f medical wastes. 6. Safeguard policies

The only safeguard triggered i s the environmental assessment, because a medical waste management plan (MWMP) i s required. A full environmental assessment o f the health sector, which included HIV/AIDS, was also carried out as part o f the preparation o f the IDA-financed Second Health Sector Support Project (CRESANII).

A MWMP was developed for the MSPP, and has been implemented since M a y 2004. Since that date, the MoH has installed 200 small-scale burners to bum medical wastes in all 200 health centers rehabilitated under CRESANII. Recent supervision found that burners are used at the sites supervised (district hospitals o f Ankazobe, Antanifotsy and Faratsiho). The construction o f full incinerators at district level i s underway; some o f them should be functional by June 2005. The Plan also specifies the medical waste disposal and management actions that are to be carried out in Madagascar's different types o f health facilities. The M o H has demonstrated the ability to plan for and prepare these activities.
Safeguard Policies Triggered b y the Project Environmental Assessment (OP/BP/GP 4.01) Natural Habitats (OPBP 4.04) Pest Management (OP 4.09) Cultural Property (OPN 1 1.03, being revised as OP 4.1 1) Involuntary Resettlement (OP/BP 4.12) Indigenous Peoples (OD 4.20, being revised as OP 4.10) Forests (OP/BP 4.36) Safety o f Dams (OP/BP 4.37) Projects in Disputed Areas (OP/BP/GP 7.60)* Projects on International Waterways (OP/BP/GP 7.50)

Yes

[x 1

No

[I [I [I [I 11 [I [I [I [I

[ XI [XI [ XI [ XI [ XI [ XI [ XI [ XI

[I

[I

7. Policy Exceptions and Readiness

The proposed project does not require any exceptions from Bank policies o n repeater projects.
* By supporting theproposedproject, the Bank does not intend to prejudice the f i n a l determination o the parties' claims on the f disputed areas

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Annex 1: Country and Sector o r Program Background M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

1. Current Dimensions o f the HIV/AIDS Epidemic in Madagascar

HIV was first diagnosed in Madagascar in 1984. In 1998, 37 A I D S cases and 233 HIV positive cases were reported to the World Health Organization (WHO). While sparse study results indicated that HIV had more than doubled in three years, from 0.07 percent (1996) to 0.15 percent (1999), i t i s only in 2003 that the first national representative survey showed that HIV prevalence was 0.95 percent.6 Based o n the HIV rate differential between pregnant women and the general population observed in other country studies, HIV prevalence in the general adult population o f Madagascar i s probably lower than among pregnant women. The estimated number o f reported deaths due to A I D S in 2003 was 24, and the number o f people known t o be living with A I D S was 68.7 Current estimates suggest that there are at least 35,000 HIV positive people in Madagascar. Studies conducted in 2001 estimated that 96 percent o f H N infections were acquired through sexual transmission.
2. Risk and Vulnerability Factors
Extremely high STZ rates. Rates o f sexually transmitted infections (STI) are extremely high in

Madagascar. Because ulcerative genital disease, such as herpes genitalis and syphilis, increases the r i s k o f HIV transmission by 50 to 300 times (male to female), control o f STIs through condom use with irregular partners and the availability o f prompt and affordable STI treatment is particularly critical in the fight against H I V / A I D S in Madagascar.

Syphilis and gonorrhea rates, in particular, are among the highest in the world. In 1998, active syphilis in pregnant women was as high as 14.8 percent, and was over 35 percent among sex workers in some regions. In a M a y 2000 study o f approximately 1,000 sex workers in Antananarivo and Tamatave, 82 percent had at least one STI. The first nationally representative survey carried out in 2003 found that active syphilis was 8 percent among pregnant women.* Recent analysis o f a sample of 2003104 D H S showed syphilis prevalence at 6.3 percent among adults aged 15-49. The 2003/04 D H S confirmed most o f the findings of the national survey o f pregnant women, and provided more insight into the variations in s y p h i l i s prevalence: (i) highlands (Antananarivo the and Fianarantsoa) are less affected than the coastal areas; (ii) while the capital city has a very l o w prevalence rate, the other cities have a slightly lower prevalence than the rural areas which are the most affected; and (iii) there i s a clear inverse relationship between syphilis prevalence and welfare (the poorest being 5.9 times more l i k e l y to be positive than the richest), and syphilis prevalence and education (those with n o education are 3.5 and 5.7. times more likely to be infected than those who have had some primary and secondary education, respectively).
The previous national prevalence figure o f 1.1% was subsequently corrected t o take into account the proper weighting o f the different provinces. Project data. The analysis o n the r a w data however ignored the different weight attached t o the sample groups. F o r example, young rural women were n o t weighted in relation with their representation in the actual population.
6

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High-risk sexual behavior and misconceptions. The median age at f i r s t sex in women has

remained constant at around 17.5 years over the past years.' Fifty one percent o f women and 61 percent o f men k n o w that condom protect against HIV. But this proportion i s lower among the youngest: only 44 percent of young girls who knew about H I V / A I D S and were sexually active, know that condoms protect against HIV (DHS 2003/04). Sixty percent o f women and 73 percent o f men knew that limiting the number o f sexual partners could protect against HIV. This knowledge has dramatically increased, especially among women, compared t o D H S 1997 (38 percent o f women). Nevertheless, when i t comes to the behavior, 17 percent o f women and 38.1 percent o f men said they had high-risk sexual behavior during the past 12 months. There i s a great variation o f behavior depending o n social, demographic and geographical characteristics: m e n in general and single women tend to have more high-risk sexual behavior. In Antsiranana and Toliara, multiple sexual partners are more common. Risky behavior i s particularly high among the youngest (43 percent among the 15-19 year old girls, and 89.2 percent among the 15-19 year old boys). The use o f condom also remains very l o w (5.4 percent for girls, 12.2 percent for boys). Moreover, there are s t i l l about 25 percent o f men and women who have had an S T I and w h o did not look for treatment or counseling. lo

Misconceptions regarding STI/HIV/AIDS are consistently reported, including among youth (1519 years o f age). This includes the belief that H l V / A I D S can be transmitted by insect bites, and by sharing dishes with someone with AIDS, as w e l l as that a person looking healthy cannot be HIV positive. Cultural bamers and misconceptions about transmission m a y help to explain why condom use remains very low. A large proportion o f those interviewed stated that they know what a condom i s but would not propose the use o f one during occasional sex. Condoms are also source o f misconceptions such as causing uterine cancer and leading t o infertility and people often consider that condoms are less important than fidelity. Qualitative research shows that talking about sex remains taboo. The influence o f parents seems to remain very high in Madagascar (53 percent o f interviewees stated that they are mostly influenced in their behavior by their parents), but most parents are reluctant to discuss sexuality with their children. On the other hand, virginity i s considered less important n o w throughout most o f the country and there i s a strong link between material or financial compensation and sex. This link has led, in some instances, to an easy transition to commercial sex. Despite the strength o f religion as reflected in the level o f churchgoers, the clergy seem to have little influence o n sexual behavior' .

3. Strategic Axes
Communication. The project will support a reorientation o f communication activities f r o m topdown mass communication (which will be reduced) t o grassroots communication using participatory methods (which will be intensified). Even in mass communication, i t will be important to introduce interactivity though televised debates, hot lines, etc. Efforts t o involve
D H S 2003. Nevertheless there i s a general opinion that DHS overestimated the median age w h i c h could b e closer to 13. lo H S 2003 D 11 Synthesis Report : Society, culture and H I V - A I D S in Madagascar. M e i Zegers. April, 2003.

29

P L W H A s in prevention efforts will also be intensified. The use o f radio will be favored over print and television media, given radios relatively higher cost-effectiveness. Stronger grassroots communication will require the involvement o f influential informal networks (e.g. video-clubs or community gathering places) and local leaders (e.g. community leaders, health agents, teachers or teachers associations). The project will support training and capacity building o f these different groups.
Local response. The MSPPII will continue to finance the Fund created under MSPP to support

the local response, and the Fund will continue to be managed by an independent AGF. During the MSPP, nearly 850 sub-projects run by local NGOs and CBOs have contributed to the implementation o f prevention programs across the country. Under the MSPPII, CBOs will take over o f the local response to HIV/AIDS from the NGOs, under the leadership o f the CLLS. The local response will include: (i) condom distribution in identified high-risk communes; (ii) H I V / A I D S peer education and training o f community counselors, with a special emphasis o n communication for behavior change; (iii) home delivery o f treatment and non-medical caretaking services t o P L W H A s (activities could include psycho-social and nutritional support); (iv) orphans and vulnerable children activities; (v) awareness-raising in high-risk groups and areas to increase the demand for H I V / A I D S services; (vi) reinforced communication to reduce stigma and discrimination towards PLWHAs, including greater focus o n elimination o f misperceptions about PLWHAs; and (vii) H I V / A I D S in workplace programs both in the public and the private sector. Technical coordinators at the regional level, assisted by OFs, will supervise the preparation o f the local plans to fight against HIV/AIDS and the implementation o f the plans by CBOs (in the form o f local response activities). There will be up to twelve regional coordinators in Regional Coordination Offices, and twenty-two OF contracts, one for each o f Madagascars regions. The OF will be local or international NGOs. Twenty percent o f the regional contracts will be awarded to international NGOs. Several steps will be taken to enhance the effectiveness o f local response activities. The terms o f reference o f the AGF and the OF will be revised in order to enhance the coordination between them. As a result, the AGF (whose number o f regional offices i s l i k e l y t o grow in the future) will start keeping a database o f unit costs and will adapt the latter to the regional contexts, as needed. The menu o f standard sub-projects will also be revised and tailored t o C B O capacities. In addition, a second menu will be elaborated to address the needs in the lower r i s k areas. Finally, the Funds procedures manual will be modified in order to improve C B O selection criteria, and encourage a sub-program approach (long-term) versus a sub-project approach (short-term) at the commune level.

Sexually transmitted infections (STIs). A broad national S T I control program was launched in 2003. The strategy i s based o n the syndromic approach,12 w h i c h promotes the subsidized sale o f two standardized S T I treatment kits through the public and private sectors (the latter through

STIs are classified by syndrome. Each syndrome i s made up o f a combination o f symptoms and clinical signs identified upon lower abdominal pain for women; (iii) vaginal examination. The four main symptoms are (i) urethral discharge for men; (ii) discharge for women; and (iv) genital ulcers for both men and women.

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social marketing in pharmacies and pharmaceutical wholesalers; see B o x 1.l).13 The high prevalence o f STIs, combined with the high percentage o f the poor who cannot afford to pay for STI treatment, provides the argument for subsidizing STI treatment a n d o r making treatment available at no cost to the very poor (indigentsy. In addition, P S I has established a network o f franchised clinics run by general practitioners (GPs) in several towns (Antananarivo, Diego, Mahajanga, Tamatave). The GPs are specially trained in providing S T I treatment and other health care to youth. A recent Government decree allows GPs to provide their S T I patients with S T I treatment k i t s directly. Finally, as syphilis treatment for pregnant women has been shown to be highly cost-effe~tive,~ syphilis campaign for pregnant women will start in regional and a district hospitals as w e l l as in about 350 rural health centers. Box 1.1: STI Treatment Kits
W h i l e HIV prevalence in Madagascar i s still l o w compared with other Sub-Saharan African countries, rates o f chlamydia, gonorrhea and syphilis are high. Studies in Tanzania and Uganda have demonstrated that improved S T I treatment can reduce HIV transmission by up t o 4 0 percent in countries or areas where, like Madagascar, HIV prevalence i s l o w and S T I prevalence i s high. Because S T I treatment n o t only prevents but lowers the r i s k o f HIV infection, such treatment has strong, positive spillover effects w h i c h justify focused public attention and subsidy. Since the public sector alone cannot fill the need for the S T I treatment nationwide, Population Services International (PSI) has set up a program t o distribute subsidized pre-packaged S T I k i t s in the public and private sectors, with assistance f r o m U S A I D and the W o r l d Bank-financed C R E S A N I I and M S P P project. S T I kit distribution i s coupled with promotional and educational activities, and training for health professionals.
I

The pre-packaged therapy contains antibiotics t o treat the STI; sufficient condoms for the duration o f treatment; partner referral cards; and educational and informational leaflets. In the last two years, 360,000 CURA 7 kits (to treat infections with genital discharge symptoms) and 78,000 Genicure k i t s (to treat ulcerative infections) have been sold. The luts have proven t o b e the preferred treatment option for STIs, with CURA 7 kits selling at 135 percent o f projected volume f o r the period and Genicure luts selling at 205 percent o f projected volume.
f (Source: Preventing H I V through Social Marketing o Pre-Packaged Sexually transmitted Illness treatment kits, 2004, as cited in Performance o f the Madagascar health sector: Current situation, constraints and p o l i c y recommendations, under preparation by the W o r l d BanWAFTH3).

Condom promotion. Awareness o f the importance o f condoms in protecting individuals from HIV has increased considerably since 1997. The 2003/04 D H S shows a 30 point increase in the percentage o f women who k n o w that condom use can protect against the virus (from 27.2 percent in 1997 to 50.8 percent in 2003). Increased awareness o f the importance o f condoms has not been matched by increased condom use, however. Condom use in the general population i s l o w (2.2 percent o f women and 4 percent o f men used a condom the last time that they had sex). Although i t i s consistently higher among populations with non-regular sex partners, condom use in this population varies widely by region: condom use by women with non-regular sex partners varies between a high o f 71 percent in Mahajanga t o a l o w o f 24 percent in Ilakaka, a Wild West type mining area.
l3 Cura-7, a kit combining ciprofloxacin and doxycyclin for genital discharge and Genicure combining ciprofloxacin and penicillin. Both kits are fitted with ad hoc information, simple instructions for using the drugs, illustrations showing several pictures o f the respective syndromes including genital diseases that are not cored by the kits as w e l l as waming cards for the sexual partner(s). For detailed information see box STI kits. l4I s antenatal syphilis screening s t i l l cost effective in sub-Saharan Africa. Sex Transm Infect. 2003 Oct; 79(5):375-81. TerrisPrestholt F. et al.

31

Social marketing has facilitated condom access: over 32 million units were distributed from 2000 to 2004 through more than 25,000 retail points nationwide, at the cost o f almost USD0.20 each. Nonetheless, gaps in condom access persist in the general and in high-risk areas. T o address these gaps, a new brand o f luxury condom will be launched, with a projected distribution o f five m i l l i o n the next few years, and 15 m i l l i o n basic quality condoms will be distributed for free in high-risk areas.
Voluntary counseling and testing (VCT), prevention o mother-to-child transmission (MTCT), f and safe blood transfusion. The country currently has 49 V C T centers for a population o f 17

million, mostly located in the province o f Antananarivo (22 VCT). The other provinces respectively have 3 to 8 V C T centers (8 in Toliara, 7 in Antsiranana, 5 in Fianantsoa, 4 in Toamasina, 3 in Majunga province). Nevertheless free testing is the rule in only three provinces (Fianarantsoa, Toamasina, Mahajunga). In the province o f Antananarivo, only 11 out o f 22 V C T centers provide free testing. Compared to 6 to 7 in Antsiranana, and 6 to 8 in Toliara). U N I C E F finances HIV screening for pregnant women and the prevention o f M T C T in 11 Hospitals and 14 health centers. With the support o f U N I C E F and the Global Fund (USD13.4 million), the Government i s planning to significantly expand the number o f V C T centers over the next few years. The MSPPII will complement these efforts where necessary. Currently, given the overall l o w prevalence and the fear o f stigmatization, few people actually use these services. I t i s expected that the utilization rate o f the V C T services will be boosted once ARV and adequate lab testing for ARV follow-up will be made available as planned by the M o H and coordinated by the CNLS, and as communication campaigns help to reduce stigmatization. Properly tested blood transfusions are available o n demand, using family relatives as donors in all hospitals practicing surgery. Outside Antananarivo and a few other cities, blood banks are not yet functional. The A D B i s launching a U S D l 1 m i l l i o n project t o strengthen the safety o f blood transfusion and implementation o f universal precautions countrywide. Finally, the M o H i s currently organizing a circuit t o collect medical waste in peripheral health centers and is building Montfort incinerators at the district hospital level to properly to manage medical waste. Again, the project will complement these efforts where necessary.
Anti-retroviral treatment. Currently, treatment o f A I D S cases i s fully supported by the Association Rive from the Reunion. The association i s providing technical and laboratory

assistance, as w e l l as generic and brand name ARV drugs. However, the ARVs are prescribed according to French treatment protocols, which are not adapted to a developing country environment. Moreover, drugs that will be ordered shortly are mostly not fixed-dose combinations o f ARV. This choice increases the r i s k o f prescription errors, poor adherence to treatment (too many pills to take, mono o r bi-therapy, increase in drug resistance) and drug management risk (drug forecasting, expiration date, stock out). All these factors are likely to hamper health services quality and prevent from a rapid scaling up o f antiretroviral therapy all over the country o f Madagascar. Moreover, while the current cost o f treatment under these protocols remains affordable due to the very limited number o f patients served, i t will be beyond
(i) OMS, 2003; (ii) MSF two pills t o save lives, fixed-dose combinations o f ARVs, February, 2004.

l5 Sources:

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Madagascars financial means to treat AIDS patients under these protocols as the number o f patients seeking treatment increases.16 Treatment guidelines. In 2004, the M o H developed PLWHA treatment guidelines, including treatment protocols for opportunistic infections at the different levels o f the health system (primary health care centers, district hospitals, referral centers). However, these protocols did not take into account the limited laboratory infrastructure o f the health facilities (testing equipment, laboratory monitoring). The M o H recently developed draft treatment guidelines that are closer to WHO recommendations. The draft guidelines were partially approved by the Partners Forum which requested that these also address issues such as the use o f standardized first and second line regimen^,'^ the use o f Fixed Dose Combinations o f ARVs, when to start ARV therapy and when to change regimen, clinical and laboratory monitoring, drug resistance monitoring, management o f the medicine supply cycle, lab analysis and ihfrastructure management (taking into account the existing capacity in health facilities), capacity building program including counseling and treatment adherence, and strategy for setting up o f the ARV prescribing sites. These guidelines are expected to follow international recommendations for countries with limited resource^.'^ Monitoring and evaluation o ARV treatment would be carried out by the treating doctor who f would track: (i) treatment tolerance and toxicity; (ii) clinical and immunologic response to treatment; and ( i ) i itreatment adherence. This last point could be promoted by the use o f Fixed Dose Combinations but will also require strong education campaigns carried out by treating doctors, counselors, health workers, and voluntary organizations working close to patients home. Patient follows-up should also be put into place to evaluate the treatment efficiency, and monitor toxicity and emergence o f drug resistance. Medical and management expert committee. In January 2003, the GoM established a technical committee on drug management, which includes laboratory analysis experts, representatives o f the National Referral Laboratory, and some health partners. A national coordinator for drug procurement planning and distribution was recently appointed. A sub-committee including experts from technical and financial partners has been asked to finalize the guidelines taking into account international recommendations as soon as possible. However, there i s no formal

l6I t i s expected that approximately 3,000 n e w patients w i l l need ARV therapy each year, w h i c h will quickly increase the financial burden o f providing such treatment. In 2003, the WHO recommends for the first line regimens: d4T/3TC/NVP o r ZDV/3TC/NVP o r d4TI3TCIEFV o r ZDV/3TC/EFZ. EFV should n o t b e given to pregnant women and ZDV requires haematologic monitoring. 2e line regimen: TDF o r ABC+ddI+LPV/r o r SQV/r o r NFV if n o cold-chain available. In Annex D o f the WHO document, 2003, there i s a l i s t o f F i x e d Dose combination o f A R V s that are available and pre-qualified by the WHO. The l i s t o f WHO pre-qualified manufacturers i s continuously updated and i s available at : ~~~W.Who.iiit,:edicines. l9 WHO 2003. Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health if approach. WHO recommendations for initiating antiretroviral treatment therapy are the following ones: (i) CD4 testing available, offer ARV t o patients with either WHO stage I V disease irrespective o f CD4 cell count, o r WHO stage I11 disease and C D 4 cell count b e l o w 350/mm3, o r WHO stage 1 or I1 disease with CD4 cell count below 200/mm3;(ii) C D 4 testing unavailable, offer treatment t o patients with WHO stage I V o r I11 disease, irrespective if of total lymphocyte count, o r WHO stage I1with a total lymphocyte count below 1200/mm3.

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committee o f national medical and management experts in charge o f the development o f the national treatment guidelines. Consequently, the G o M will need to establish a national committee consisting o f medical experts o n the one hand, and drug and laboratory monitoring management o n the other hand. The medical sub-committee would consist o f two or three referring physicians specialized in H I V / A I D S treatment, and who have an expertise in public health in developing countries. This committee w o u l d act as a medical reference for prescribing physicians all over the country, especially regarding more complex clinical cases, and could provide counseling to the CNLS and the M o H o n national medical issues linked with diagnosis, treatment and follow up o f AIDS patients. The sub-committee for drug and laboratory monitoring management should include experts with strong knowledge of the national health system capacity to better address logistical bottlenecks. This committee should work in close collaboration with the medical expert sub-committee. The project will strengthen the capacities o f this sub-committee through technical support provided by organisms with background in developing countries with a similar epidemiologic and socioeconomic profile or through periodic clinical training seminars that follow international recommendations for resource-limited settings.

Orphans and vulnerable children (OVC). According to the latest U N I C E F estimates,20 100,000 orphans live in Madagascar, and 30,000 o f them are A I D S orphans. About 2,400 orphans are estimated to be orphans o f both parents. In an effort to avoid further discrimination and stigmatization vis-&vis A I D S orphans, the implementation and respect o f all O V C r i g h t s will need to be assured throughout the country.
In order to develop appropriate programming for orphans OVC, a needs assessment o f Malagasy orphans and other vulnerable children will be undertaken. The needs assessment will: (i) identify different categories o f OVC; ( i compile an inventory o f formal and informal services that i) ii currently address these childrens needs; ( i )develop profiles o f the types o f families most likely to become foster or adoptive families at present; and (iv) analyze the challenges particular to O V C care in community settings. The needs assessment will be used t o identify the policies and programs that are most urgently needed for O V C children. In terms o f program options, the extended family model should be preferred to programs involving the creation o f childrens homes or the identification o f non-family-related foster parents. The extended family model has consistently been shown to be the most effective and cost-effective intervention in terms o f childrens welfare.

I addition, a network o f technical assistance for all national O V C support programs and services n should be established (the creation o f a National Steering Committee for O V C i s currently underway). Finally, existing norms and guidelines regulating public and private institutions for orphans and abandoned children will be revised, and minimum standards o f services concerning early childhood care and development are likely to be developed.

2o

UNICEF Children on The Brink 2004 : 26

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Annex 2: Major Related Projects Financed by the Bank and/or other Agencies

MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project

The Multisectoral STI/ HIV/AIDS Project (World Bank, USD20 million credit). This project was approved in November 2001, and is expected to close around December 2005, i.e. a year ahead o f time. Its development objective is to support the Government o f Madagascars efforts to promote a multi-sectoral response to the HIV/AIDS crisis and contain the spread o f H I V / A I D S o n its territory. T o do so, the project builds capacity and scales up the national response to H I V / A I D S and STIs, a key r i s k factor and contributor to the spread o f H I V / A I D S . The project has financed, inter alia, sector strategies and pilot projects, including communication campaigns, P the implementation o f the local response, and M&E activities. I t i s rated satisfactory o n both I and DO ratings. The Second Health Sector Support Project (World Bank, USD40 million credit). The project was approved in November 1999, and a supplemental credit (USD22 Million) i s under preparation. Health services are provided at approximately 2,500 health facilities nationwide (public sector and NGOs). Approximately 60 percent o f the population i s estimated t o l i v e within a five-kilometer radius o f a public facility. An emerging but limited private health sector operates essentially in urban and suburban centers. Quality o f services i s below standard and the supply o f basic medicines and supplies has been poor. The project objective i s to contribute to the improvement o f the health status o f the population through more accessible and better quality health services. The project i s rated satisfactory o n both I and DO ratings. P Intensification of the fight against HIV/AIDS: (Global Fund, USD13.4 million grant). The goal o f this project (November 04 - October 06) i s to maintain a l o w level o f HIV infection in 20 high-risk districts by: (i) increasing access to V C T services in 20 high-risk areas; (ii) improving access to prevention opportunities o f transmission from mother to child in healthcare facilities; (i) i i reinforcing existing prevention measures by the application o f universal precaution measures, reinforcing transfusion safety and free access to condoms in public healthcare facilities; (iv) assuring proper care o f persons suffering f r o m H N through the establishment o f a technical platform in three regions, the supply o f tests for biological examinations, and the social and community care; and (v) improving the care o f orphans o f AIDS, reinforcing the capacity o f associations o f persons living with HIV, and host families and by assuring the care o f basic needs o f the orphans. Project to Support the Control of Communicable Diseases (STI/HIV/AIDS/Tuberculosis (African Development Fund, OPEP, UNAIDS, USDll million). The project i s under preparation and i s expected to be approved shortly. I t will be implemented over a five-year period. The specific objective i s to ensure safe blood transfusion and improve the populations access to preventive and curative care with respect t o communicable diseases, notably the HIV/AIDS, S T I and tuberculosis. The project includes: (i) establishment o f an operational improving the populations access to services for the prevention, blood transfusion network; (ii) diagnosis and treatment o f communicable diseases (STI/HIV/AIDS, tuberculosis and hepatitis); (iii) national capacity building for epidemiological surveillance; and (iv) capacity building for the management o f the project.

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Annex 3: Results Framework and Monitoring

MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project

Results Framework

T S U D D Othe Govemment o ~~ ,f Madagascars efforts to romote a multi-sectoral esponse to the HIVIAIDS :risis, and to contain the :pread of HN/AIDS on i t s emtory

commercial sex workers

communication strategy i s effective or needs modification. Determine if targeting strategy (both high-risk groups and communes) needs to be changed.

Percentage of respondents who can both correctly 2. identify ways of preventing the sexual transmission of HIV and reject major misconceptions about H N transmission and prevention (by age group and gender) 3. Percentage of people in high-risk groups (commercial sex workers, truck drivers, military), who can cite three methods of HN/AIDS prevention . 4. Percent of youth 15-24 exposed to STI/HIV/AIDS communication activities/products in the previous 6 months (by source o f information)
dtitude Indicator Percentage of population aged 15-49 who do not 5. express discriminatory attitudes towards PLWHA (by age and gender) lehavior Indicators 6. Percentage of youth aged 15-24 reporting the use o f a condom in their last act of sexual intercourse with a non-regular partner in the last 12 months

Provide data for impact evaluation studies.

Percentage o f men and women aged 15-49 who 7. report having sex with anon regular partner

8. Percentage of men and women aged 15-49 reporting the use of a condom in their last act of sexual intercourse with a non-regular sexual partner in the last 12 months
Percentage o f commercial sex workers reporting 9. the use o f a condom in their last act o f sexual intercourse with a client 10. Percentage of truck drivers and military reporting the use of a condom in their last act o f sexual intercourse with a non-regular sexual partner in the last 12 months

36

Component One:

Intermediate Results One per Component

Component One:
1.1. The National Strategic Plan for HIV/AIDS i s revised and disseminated by the end o f 2006 1.2. Annual reporting allows identification o f donor contributions to the program in a coherent manner 1.3. The national communication plan is updated according to recommendations o f the midterm evaluation

Component One:
3ighlights donor duplication o f :fforts and identify gaps. Racks coherence between strategies md activities.

1, Coordination among donors and 3artners on contribution to the iational HIVIAIDS strategy

Component Two:
2. Strengthened the capacity of the health sector to effectively provide :are and support to PLWHA.

Component Two :

Component Two:
Tracks availability o f condoms and STI kits to determine adequacy o f nesponse Ensure adequacy o f treatment

2.1 Number o f STI treatment kits distributed to M O H per year and sold in public and private sectors per year 2.2. Number o f condoms distributed and sold through the public sector and N G O programs per year 2.3. ARV Treatment Guidelines are adequate and implemented Component Three: 3.1. Seventy five percent o f the FAP resources are allocated to hot places 3.2. Number o f CLLS implementing and monitoring their PLLS on a monthly basis 3.3. Number o f interpersonal communication activities camed out per year in hot spots 3.4. Number o f beneficiaries reached b y group 3.5. Number o f CBOs receiving capacity building in STVHIV/AIDS by OFs

Component Three:
3. Sub-projects promote behavior change and implement support and care activities mainly in at-risk areas.

Component Three:
Flags problems with increased commune-level activities. Tracks targeting o f most at-risk zones

Component Four:

Component Four:

Component Four:

4. The MSPPII monitoring and evaluation system provides data that i s used to orient programming and funding decisions.
Component Five:

4.1. Annual operational plan reflects recommendations o f Consolidated Annual Report

Provides data to MSPPII management for decision making.

Component Five:

Component Five:

5. Capacity o f regional coordinating staff to manage MSPPII activities i s increased.

5.1. Capacity building plan is produced and implemented annually

Highlights project staff weaknesses so as to improve skills at the regional level.

37

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Annex 4: Detailed Project Description

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

PROJECT COMPONENT 1: Harmonization, donor coordination, and strategies (USD1.5 million equivalent). Under MSPP, eight different sectoral strategies were developed, but the process has been difficult and the results tentative at best. This was generally due to the l o w priority given by the sectors which did not see much benefit in developing sector plans, given the limited resources provided to implement pilot activities. This component will be revised to include donor coordination, the updating o f the national strategy, and a more selective support to sectors. This component will emphasize four activities: Harmonization and donor coordination: This activity will support practical mechanisms o f coordination among donors to ensure better impact and cost-efficiency o f H I V / A I D S interventions. Although Madagascar has achieved two o f Three One principles (one national authority for HIVIAIDS, and one strategic framework) donor coordination needs to be intensified, particularly o n the M&E system. Updating o f the NSP. The current plan covers the period through the end o f 2006, and will need to b e updated and re-validated thereafter, based o n recent knowledge about the disease and the evaluation o f past activities. Implementing the STI/HIV/AIDS communications strategy and action plan. Though knowledge o f HIV and information o n prevention i s n o w relatively ~ i d e s p r e a d ,actual ~~ sexual practices remain risky,25 and stigma strong. The project will maintain mass media campaigns, but will place more emphasis o n activities that facilitate dialogue and action o n prevention and stigma reduction at the grassroots level. This sub-component will finance mass communication activities initiated by the UGP and communication materials and toolkits for NGOs and CBOs that will implement grassroots communication sub-proj ects under the Fund. If needed, the existing communications strategy (October 2004) m a y be updated based o n the evaluation o f communication activities. Support for the development of sector strategies and action plans. This sub-component will finance an assessment o f impact effectiveness o f the support received by k e y line ministries and public sector agencies f i o m the MSPP. I t will also finance sector strategies and/or action plans for a limited number o f sectors (two to three) which focus o n high-risk groups (e.g. education for the youth, security for the solders, prisoners, police personnel etc.), and which has been found to be most effective. If implementation o f the public sector response progresses satisfactorily, the number o r sectors m a y b e expanded during the course o f the project. T o address the limitations found in the public sector response under the MSPP, the project will try to institutionalize the relationships with the sectors (e.g. periodic

24 The DHS 2003-04 showed that knowledge o f HIViAIDS satisfactorily progressed since 1997 from 69% to 79% for women and it i s at 88% for men in 2003. 25 The 2004 pilot PLACE survey among r i s k groups in certain hot spot areas showed that condom use by women with nonregular partners varies between highs o f 71% (Mahajanga) and lows o f 24% (Ilakaka).

41

working groups, participation o f these groups in strategic decisions such as the revision o f the NSP etc.)

PROJECT COMPONENT 2: Support for health sector response (USD3.5 million equivalent). Under the MSPP, the M o H was involved in the implementation o f a major S T I program, and o f the medical waste management plan. The involvement o f the health sector in the fight against STI/HIV/AIDS will be strengthened under the MSPPII, which will complement general funding t o the sector provided by CRESANII (USD40 m i l l i o n for the original credit and U S D 2 2 m i l l i o n for a supplemental credit that will be submitted to the Board in early FY06).26 This component will finance a range o f activities, including the revision o f the health strategy for the prevention o f HIVIAIDS. The UGP and the M o H m a y decide together to sub-contract some o f these activities to NGOs and the private sector.
a) Support for STI control. MSPP made a significant effort to control STIs by financing (a) training based on the syndromic approach, and (b) the sale o f two STI treatment kits at subsidized prices in both the public and in private sectors.27 MSPPII will expand these activities in high-risks places or groups, particularly for pregnant women by supporting a program o f syphilis elimination.

b) Support for care and treatment of PLWHAs. Based o n the preliminary experience o f the

IDA-financed Regional Treatment Acceleration Program, and o n the interim review o f the M P Program in Africa, MSPPII will help the M o H establish a range o f complementary serA vices such as: (a) expansion o f the V C T centers in a l l 111 district hospitals and in health centers in high-risk areas28. These V C T will be staffed by one nurse or laboratory technician and one counselor; (b) psycho-social, nutritional, and other support for persons infected and affected by HIVIAIDS; and (c) treatment o f P L W H A s (ARVs, C D 4 count), prevention o f M T C T , and treatment o f opportunistic infections (diagnosis tools and pharmaceutical products). This financing will compliment financing by the Global Fund.

c) Other health sector response activities. MSPPII will provide complementary funding for other activities as needed, such as laboratories (mainly supported by the Global Fund) or blood transfusion (mainly supported by the AfDB), training o f health staff, and medical waste management.

PROJECT COMPONENT 3: Fund for STI/HIV/AIDS prevention and care-taking activities (USD16.5 million equivalent). Under MSPP, some 850 NGO, CBO, and associationsponsored sub-proj ects have contributed to a range o f preventive interventions. These local response activities will be scaled up with a stronger focus o n places where the population i s at greatest r i s k o f being infected or o f transmitting the infection. Seventy five percent o f the Fund
The objective o f this project i s to contribute to the improvement o f the health status o f the population through more accessible and better quality health services. 27 More than 400,000 STI kits for genital discharge were sold in 2004 at approximately USDO.5 through social marketing in the private sector and at USD0.35 in the public sector. STI kits for genital ulcer are being commercialized through social marketing and w i l l soon be available in the public sector at the same price. However, this activity has not been evaluated. 28 Along with the reconstructionirehabilitation o f 300 health centers, a comprehensive needs assessment was recently performed at district (first-referral) level providing the needed information to prioritize the creation o f VCT centers and the strengthening o f lab facilities.
26

42

resources will b e allocated to these places, which will be identified using the PLACE methodology (already piloted) and the LQAS. This component will finance the following activities: condom distribution through social marketing a) Sub-projects. Sub-projects will include: (i) and promotional distribution; (ii) grassroots communication activities that s h i f t the focus from general knowledge about the epidemic to behavioral communication for change; (iii) home-base care and other support for PLWHAs and associations o f PLWHAs; (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for H I V / A I D S services; (vi) training o f peer educators and community-based counselors; (vii) activities that aim at reducing stigma and discrimination against PLWHAs; and (viii) workplace H I V / A I D S plans for the public sector. b) Fund Management. This component will finance fund management by the AGF, the OFs and the ORT. The AGF reviews sub-project proposals for the strength o f financial management arrangements, and transfers funds from the project to organizations who have received approval for the sub-project proposal. The OFs will i)support the CLLS in incorporating STI/HIV/AIDS activities into their Communal Development Plans in the highest r i s k areas; and (ii) strengthen C B O capacity to develop and implement sub-projects. This sub-component will also finance the updating o f the l i s t o f the standardized activities eligible under the Fund and developed under the MSPP. Under the MSPP, the l i s t o f the standardized activities was used to increase the effectiveness o f Fund-financed activities and to avoid over-programming o f geographic areas and/or target populations. The updating will refine this instrument and its mode demploi so that it can be used as effectively as possible in the MSPPIIs high-risk communes.
Operation ofthe fund. A s under the original project, the management o f the Fund will be contracted out by the UGP to an AGF using a performance-based contract. The AGF will have processing requests for financing; representatives in each province and will be responsible for (i) ( i approving requests under U S D 100,000 using selection criteria; ( i ) i) i i submitting requests above USD100,OOO to the Conseil for approval; (iv) notifying applicants o f financing decisions; (v) disbursing approved financing; and (vi) providing necessary data and information to auditors for annual technical and financial reports, and to UGP on a regular basis. The AGF will receive training on HIV/AIDS.

Proposals under USD100,OOO will be automatically approved by the regional office o f the AGF according to agreed upon criteria, as outlined in the procedures manual. Proposals over USD100,OOO will be submitted by the regional office o f the AGF to the Conseil for approval after technical review by the technical sub-committee o f the U N A I D S Thematic group. In all cases, the regional office o f the AGF i s responsible for contracting the implementation o f the approved project and disbursing approved financing. All proposals over USD25,OOO and a subset o f proposals over U S D 10,000 will b e submitted for technical review to designated partners o f the U N A I D S Thematic Group.

A beneficiary contribution will be requested in-kind or in-cash for sub-project costing more than USD10,OOO. This contribution will amount to 3 percent o f sub-project cost (for proposals costing

43

between USD10,OOO and USD25,000), 5 percent (for proposal costing between USD25,OOOO to USD100,000), and 10 percent for proposals costing between more than USDlO0,OOOO).

PROJECT COMPONENT 4: Monitoring and evaluation system (USD3.0 million equivalent). In accordance with the Three Ones principle, the M S P P I I project will support the national M&E plan to which all H I V / A I D S partners in the country adhere. This component provides support to a single M&E system, and has four objectives: (i) ensure that the national M&E system i s operational; (ii) develop a functional monitoring system (including MIS) to measure and manage the performance o f the MSPPII project; ( i ) i itrack the evolving status o f the HIV/AIDS epidemic in Madagascar; and (iv) learn h o w government policy can slow the epidemic and mitigate i t s consequences, drawing from the Malagasy experience. The M&E component will have three parts: monitoring; epidemiological studies; impact studies and consolidated annual report. M o r e details on this component are provided in Additional Annex Monitoring: The project will support implementation o f a five-part monitoring plan. The monitoring plan i s designed to generate and/or collect k e y performance indicators, financial, input and operational data for the project; consolidate this data in a fully functional MIS; and use the data collected in project decision-making. L Q A S will be used for quality data collection o f a sub-set o f k e y performance indicators. Epidemiological surveys: The component will continue t o finance a series o f second generation surveillance surveys and other population based surveys. These include biannual behavioral surveys among high-risk groups (sex workers, truck drivers, military and youth); annual sentinel surveillance surveys o f clients at antenatal clinics (pregnant women, S T I patients, and commercial sex workers). The latter includes the crosssectional HIV-prevalence study (Enqugte Nationale de Sero-prevalence Aupr2.s des Femmes Enceintes) first conducted in 2003; the 2008/09 DHS; and the annual PLACES study o f high-risk sites and risk behaviors. Impact studies and consolidated annual report: The M S P P I I will support one or more impact studies. The project will also develop a consolidated annual report, in close collaboration with the CNLS. The report will provide a summary analysis o f data collected in the course o f the year and recommendations o n re-orientation o f the national H I V / A I D S program, based o n the data analysis. The study methodology will be reviewed by the Global HIV/AIDS Monitoring and Evaluation Support Team. COMPONENT 5: Project management and capacity building (USD2.5 million). MSPPII will support the institutional arrangements and operational modalities established under MSPP, at the central level (CNLS, M S P P I I Council, and UGP), and the new structures established at the regional level (BCR), following the creation o f regions mid-2004.29 This component will finance part o f each levels staff, equipment and operating costs, vehicles, periodic technical assistance, and some training based o n annual capacity building plans.

29

U n d e r MSPPI, UGP h a d an office in each o f the six provinces. U n d e r the MSPPII, this arrangement will b e replaced b y an office in each o f the 22 regons.

44

A n n e x 5: Project Costs

MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project

Table 5.1: Project Costs by Component Project Costs By Component or Activity Component 1: Harmonization, donor coordination and strategies Component 2: Support for health sector response Component 3: Fund for STI/HIV/AIDS prevention and care-taking activities Component 4: Monitoring and evaluation Component 5 : Project management and capacity building Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs Interest during Construction Front-end Fee Total Financing Required Local USM 1.45 2.50 Foreign USM 0.05 1.oo
Total

16.50 2.25 2.00 24.7 0.7 0.1 25.5 25.5

0.00 0.65 0.50 2.2 0,1 2.2 4.5 4.5

16.50 2.50

30.0

3.1 0 0

'Identifiable taxes and duties are USDO, and the total project cost, including taxes, i s USD30 million. Therefore, the share o f project cost including taxes i s 100 percent.

T a b l e 5.2: Disbursement Schedule (in USD million)

I D A FY Annual Cumulative

2006 6 6

2007 8 14

2008 8 22

30

2009 8

45

Annex 6: Implementation Arrangements M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

1.

Institutional and implementationarrangements

The institutional arrangements for the National H I V / A I D S Program and the MSPPII remain similar to those used under the MSPP, and are charted in Figure 6.1. Generally speaking, the institutional arrangements for the National H I V / A I D S Program and the M S P P I I Project are complimentary. This i s consistent with the Three Ones approach to management o f the H I V / A I D S epidemic, in which a common approach to management o f the epidemic i s seen as the most coherent, cost-effective means o f containing the virus. Figure 6.1 : National HIV/AIDS Program and MSPPII Project InstitutionalArrangements

MSPPII Operational Arrangements

Council

I I I

I
I

National HIV/AIDS Propram Arrangements

.........................

......... I ........................................

However, there will be four significant institutional changes between the MSPP and the MSPPII. First, the National3 Coordinating Committee (Comitk de Coordination Nationale, CCN) was a temporary committee mandated to guide definition o f national H I V / A I D S priorities in the leadup to the MSPP, and was described as such in the MSPP project appraisal document. The committee was formalized as the National HIV/AIDS Prevention Committee (Cumitk National de Lutte contre le VIH/SIDA, CNLS) during the MSPP and i s n o w consistently referred to as the CNLS. Second, the UGP was moved under the under the direction o f the Executive Secretary o f

46

the CNLS in December 2003. This has allowed an improvement in coordination and a more steady response o f actions. Third, Madagascar i s in the process o f decentralizing and has recently created 22 regions, between the province and district levels. T o accommodate regionalization, the MSPPII will increase the number o f Provincial H I V / A I D S Prevention Committees (Comitks Provinciaux de Lutte contre le VIH/SIDA, CPLS) from six to up to twelve; the name o f these committees will be changed to the Regional HIV/AIDS Prevention Committee (Comitks Rkgionaux de Lutte contre le VIH/SIDA, CRLS); and the CRLS will be expected to cover a set o f regions rather than provinces. Fourth, the project adds contracting o f a monitoring and evaluation organization (Organisation de Suivi et Evaluation, OSE). The OSE i s responsible for carrying out periodic project monitoring surveys and for working with the CNLS and MSPP management to use data in project decision-making and strategic re-orientations.

a) Institutional arrangements for the national H I V / A I D S program

The institutional arrangements for the National H I V / A I D S Program include the C N L S at the central level; the CRLS at the regional level; and the Local H I V / A I D S Prevention Committee (CLLS) at the commune level.

Central level. The CNLS was created by Government decree in October 2002. The mandate o f coordinate the national fight against H I V / A I D S and ( i guide the i) the CNLS i s t o (i) implementation o f the National Strategic Plan.
The CNLS i s made up o f an Executive Secretariat (SE) and a plenary committee. The SE has day-to-day management o f national H I V / A I D S prevention activities and provides political and strategic support to the Governments fight against HIV/AIDS, advances partnerships and mobilizes resources both nationally and internationally, and promotes the protection o f rights. The SE also oversees implementation o f the MSPP, with the CNLS Executive Secretary serving as project director. The plenary committee i s responsible for overseeing implementation o f the NSP. I t i s made up o f eighty stakeholders, including representatives f r o m Government, PLWHAs, NGOs, the private sector, and religious and CBOs. The Partners Forum (Forum des Partenaires) enhances the dialogue between the C N L S and the major bilateral and multilateral donors and NGOs. Coordinated by the Executive Secretary o f the CNLS, Partners Forum provides the CNLS a venue to monthly inform a l l major donors o n i t s current and future activities. Donors participating in such periodic reunions have the opportunity to offer their feed-back to the C N L S and express their possible concerns over existing issues identified within the scope o f the project implementation. The Country Coordinating Mechanism (CCM) was recently added at the Global Funds request. The mandate o f the C C M i s to submit, monitor, and evaluate activities o n AIDS, Tuberculosis and Malaria to be financed by the Global Fund. The CCM is coordinated by the CNLS, and includes representatives o f major donors, Government, NGOs, CBOs, Academia, the private sector, and PLWHAs. The C C M meets o n a monthly basis and has become very active. The CNLS also houses a U N A I D S Thematic Group, which i s made up o f representatives o f U N agencies and the W o r l d Bank. The group meets o n a monthly basis t o provide support and

47

advice to the Government on HIViAIDS. The group has prepared an Inter-Agency Program to support the Governments NSP, in which each UN agency outlines their support to the NSP.

Regional level. Implementation o f the national HIV/AIDS program i s coordinated at the regional level by the CRLS. Up to twelve CRLS will be formed during the M S P P I I implementation period.30 The CRLS i s responsible for (i) supervising and coordinating H I V / A I D S interventions; ( iguiding implementation o f the NSP; and ( i ) i) i iliaising between the CNLS, the CLLS, and other STI/HIV/AIDS prevention actors in the region. As with the CNLS, CRLS members include representatives from a range o f public, private and non-governmental organizations implicated in the fight against H I V / A I D S . Local level. At the commune level, a C L L S i s responsible for: (i) developing the local plan in the fight against HIV/AIDS; (ii) guidingcoordinating implementation o f the plan; and (iii) mobilizing the local population in the fight against HIV/AID.S. Again, as with the CNLS, the C L L S i s made up o f representatives from a range o f public, private and NGOs implicated in the fight against H I V / A I D S .
b) Project implementation arrangements

The implementation arrangements for the M S P P I I include the UGP, the Technical Review Organization (ORT), the Monitoring and Evaluation Organization (OSE), and the M S P P I I Council at the central level, as w e l l as the Regional Coordination Bureau (BCR), the Facilitating Organization (OF) and the Financial Management Agency (AGF) at the regional level. Given the Government long-term commitment to the fight against HIV/AIDS, the option o f eliminating the UPG and merging i t s functions under a Multi-Sectoral Response Unit o f the CNLS will be explored during project implementation.
Central level. The UGP is responsible for day-to-day management o f the project. I t s responsibilities include: (i) development o f the annual work program and budget; (ii) management o f project activities, financial management, procurement, administration and logistics; ( i ) i ioversight o f monitoring and evaluation (contracted to the OSE); and (iv) periodic reporting to the W o r l d Bank, and integration o f data into project decision-making. The U G P also serves as the Secretary o f the MSPP Council.

An MSPP Council provides oversight o f the project as a whole. Its responsibilities are to: (i) approve the UGPs annual work program and budget; (ii) approve requests to the Fund over USD100,000; (iii) ensure that the project-financed activities achieve the project development objective; (iv) approve annual technical and financial audits; (v) adopt and approve the procedures manual o f the Fund and the Project Implementation Manual, and approve modifications to them; (vi) evaluate the perfonnance o f the UGP based o n performance indicators, in consultation with IDA; and (vii) approve the recruitment o f the AGF. The Council also includes an audit committee, whose role i s to facilitate the work o f external project auditors, review auditors findings, and ensure the implementation o f such recommendations.

30 Prior to the recent creation o f Madagascars regions, responsibility for coordination and oversight o f HIV/AIDS prevention efforts at the sub-national level f e l l t o the Comitb Provincial de Lutte contre le VIHSIDA (CPLS).

48

The Council reports directly to the President o f the Republic. It i s made up o f fifteen permanent members, including one representative from each o f the following: the Office o f the President o f the Republic; the Ministry o f Finance; the Ordre des Experts Comptables de Madagascar; the NGO sector; the private sector; beneficiaries associations; and key sectors such as education, security and youth.
The UGP i s also supported by the ORT, under the auspices o f the UNAIDS Thematic Group. The ORT, made up o f designated partners, undertakes a technical review o f a l l proposals over USD25,OOO and a sub-set o f proposals over USD100,OOO submitted to the FAP to ensure quality and provide recommendations for improvement, as necessary.
Regional level. In addition to its responsibilities within the CNLS, the B C R i s responsible for ensuring M S P P I I implementation at the regional level. Each B C R covers one to three administrative regions, and i s staffed by a Director and a Technical Coordinator. The Director (i) coordinates project implementation by component; (ii) liaises with development partners across sectors in order to ensure effective project implementation and maximum complimentarity with other STI/HIV/AIDS activities in the region; and (iii) supervises the w o r k o f the OF and AGF in h i s or her region(s). The Technical Coordinator i s responsible for supervising the development o f local plans in the fight against HIV/AIDS, with the assistance o f the OF, and the technical quality o f the work performed by the OFs. The Technical Coordinator also plays an active role in implementation o f quality activities under the projects other components.

Each region also has an OF. The OF i s an NGO contracted by the project t o assist: (i) communes in the development o f their local plans in the fight Against HIV/AIDS; and (ii) CBOs in the development and implementation o f the technical aspects o f their applications for Fund financing. Particular emphasis will be placed o n the use o f key messages focusing o n all three means o f preventing HIV transmission - abstinence, fidelity and condom use - and not a sub-set of those messages. There will be 22 contracts available under the MSPPII, one for each o f Madagascars 22 regions. An OF m a y hold a single contract to cover one region, or m a y hold several contracts. In order to ensure the continued transfer o f technical expertise t o national NGOs and CBOs, 20 percent o f regional contracts will be awarded to international N G O s for at least the first two years o f the project. evaluating the financial viability o f C B O applications to Finally, an AGF i s responsible for: (i) the Fund; (ii) returning weak proposals to CBOs for revision; ( i ) i iforwarding suitable proposals to the OF for technical review; and (iv) making payments to CBOs for approved sub-projects. The AGF i s also responsible for maintaining a database o f unit costs for the range o f activities eligible under the Fund. A single AGF i s engaged by the project; i t i s expected t o have eight regional offices.
c) Implementation arrangements for monitoring & evaluation

The UGP i s responsible for monitoring project performance and contracting out the impact evaluation studies. The M&E Unit i s currently staffed by two M&E specialists; a third staff member (or long t e r m consultant) will be hired t o perform spatial analyses o f data using a Geographic Information System. Funds are budgeted to contract consultant services

49

internationally and nationally to provide the necessary support to the teams approach to M&E and i t s instruments. Additional M&E staff will be contracted and placed in eight regional MSPPII offices to perform periodic spot checks o f subprojects and to monitor the data collected and compiled at the local level. These staff will report to the UGP M&E team and will be technically qualified to provide continuous M&E presence in the field to supplement the intermittent site visits by the UGP M&E staff.

50

Annex 7: Financial Management and Disbursement Arrangements

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

Country issues
Several diagnostic works carried over the last t w o years31 confirmed the weak capacity o f the country public financial management system. To increase the quality and success o f MSPPII, it i s more efficient to entrust the implementation o f this project to the UGP which had already a strong experience in managing World Bank funds.

peer reviews, continuing education requirements, quality control mechanisms to harmonize methodology. To improve the capacity and the competitiveness o f the local auditing firms, the obligation for local auditors to enter into partnership following measures have been taken: (i) with international accounting f i r m s while auditing Bank/IDA financed projects in order to improve the quality o f audit reports and ensure practical training and real transfer o f methodology in the areas o f organization and execution o f audit assignments; (ii) effective participation o f the international accounting firm while carrying out audit works in the field and submission o f audit report jointly signed by the local and international audit firms.

The CPFA (Country Profile o f Financial Accountability) carried out in September 1998 established also the weak capacity o f the accounting profession in Madagascar: a number o f accounting firms were operating below the international standards due to the lack o f regulatory framework, proper auditing standards, clearly defined guidelines and procedures for systematic

Risks
Implementing Enti@ Stafflng Funds Flow. Rsk o f delays in the payment o f NGOs, CBOs and other partners (associations, communes) working at the regional.

Table 7.1: I s Analysis ; k Risk Mitigation Measures Risk rating

Low Low Moderate

NIA

Establishment o f a bank account in the name o f each regional AGF, with an initial deposit covering three months o f expenditures (Special Account 90day advance procedure). Maintain good liquidity level both at central and regional levels by: (i) close monitoring o f cash a forecast prepared on a quarterly basis; (ii) regular submission (at least on a monthly basis) o f withdrawal application to replenish regional bank accounts and project special accounts.

Accounting Policies and Procedures

Low

NIA

Country Financial Accountability Assessment (CFAA), Country Procurement Assessment Report (CPAR), HIPC-Assessment and Action Plan, IMF Technical Assistance Report, European Union Financial Audit and Public Expenditure Review.
31

51

I n terna1 Audit External Audit: The CPFA (Country Profile o f Financial Accountability) carried out in September 1998 established the weak capacity o f the accounting profession in Madagascar. The C F A A conducted in 2003 confirmed that the country public financial management poses a major fiduciary risk. Monitoring and Reporting Information Systems

Low Substantial

NIA Local auditors who intend to audit the financial statements o f Bank financed projects should enter into partnership with international auditing firm to strengthen their capacity.
Effective participation o f the auditing firm in the fieldwork. international

Reinforcement o f the accounting profession after the completion o f the ROSC mission.

NIA

NIA

Implementingentities
The UGP i s responsible for coordinating project implementation, and managing procurement, financial management, disbursement, project monitoring, reporting and evaluation. I t will assure the record-keeping o f transactions under the components 1, 2, 4 and 5 as well as the consolidation o f project accounts and the production o f quarterly Financial Monitoring Reports (FMRs) in compliance with international accounting standards and IDA requirements. Implementation o f project activities under the component 3 will be sub-contracted to existing structures such as NGOs, CBOs and other associations whereas the financial management o f funds financing these activities will be contracted to the existing AGF. Procedures and modalities for selection and contracting o f these executing agencies are described in details in the operation manuals. The AGF will keep an accounting system satisfactory to IDA and will prepare i t s o w n financial statements as w e l l as other financial and technical reports as required by the UGP. Each o f the AGFs regional offices has an accountant responsible for regional accounts as well as the electronic transmission o f regional accounts t o the central level, using the existing computerized accounting and financial management system.

Strengths and weaknesses

The U G P has strong experience in managing W o r l d Bank funds for being in charge o f the implementation o f MSPP. The accounting/budgeting system is adequate and the internal control procedures appropriate. I t has also qualified and trained accounting staff who are very knowledgeable about Bank procedures. However, to further strengthen the project financial management system, some measures need to be taken. The following table provides relevant measures to address main deficiencies identified in the UGP financial management system.

52

Significant Weaknesses Chart o f accounts n o t reflecting yet the new components and activities t o b e executed under M S P P I I project Accounting manual of procedures not being updated to include the new chart o f accounts and the models o f financial and physical progress reports required for managing and monitoring M S P P I I activities

Table 7.2: Measures to address deficiencies o f financial management svstem

Resolutions Review o f the chart o f accounts to reflect new components/activities eligible under MSPPII credit to satisfy reporting requirements

Update o f the accounting manual o f procedures to facilitate adequate record keeping o f M S P P I I transactions, and satisfy reporting requirements Recruitment o f a qualified and skilled accounting assistant in conformity with the Bank procedures Recruitment o f an accounting firm acceptable t o IDA to carry out the audit o f M S P P I I accounts

Inadequate number o f accountant commensurate with the volume o f tasks t o be coped with. Auditors in charge o f the review o f M S P P I I accounts have not been recruited yet

Funds Flow
T h e flow o f f u n d s from IDA i s presented as f o l l o w s :

World Bank (Credit)

l-7
(Special Account A)

I
I

(Special A c c o u n t B)
I

Central AGF

(Special sub-account)

Regional AGF

Grants to recipients (NGOs, CBOs, other associations) f o r p r o v i s i o n o f goods and services

I
I

Suppliers o f goods and services

I
53

Staffing
The UGPs accounting staff i s qualified. However due to the volume o f project transactions and activities and t o ensure appropriate segregation o f duties in financial management area, the Bank recommended t o recruit an accounting assistant in conformity with the Bank procedures. The recruitment o f this second accountant has been completed prior to negotiations.

Accounting policies and procedures

The accounting system in place is in compliance with generally accounting standards and IDA requirements and capable o f producing timely financial information required for managing and monitoring project activities. The project accounting manual o f procedures needs to be updated to include the new Chart o f accounts as well as the models o f financial and physical progress reports to be produced.

Internal audit
T o ensure consistent application o f the procedures and efficient use o f f i n d s by executing agencies, the accounting firm Delta Audit Deloitte and Touche in collaboration with the U G P M&E staff will continue to play the role o f internal auditors. All issues identified during internal audit should be addressed quickly to improve the project performance.

External audit
The project financial statements will be audited annually by an international private accounting firm acceptable t o IDA, in accordance with International Standards o f Auditing and the new Guidelines describing Audit Policy and Practices for W o r l d Bank-financed Activities. The auditors will provide a single opinion o n the annual financial statements, stating whether the financial statements fairly present the financial transactions and balances associated with the implementation o f the project, and if the expenditures financed by the credit were appropriate. The auditors will be also required to carry out a comprehensive review o f the internal control procedures and provide a management report outlining any recommendations for their improvement. The audit report will be submitted to IDA not later than six months after the end o f each fiscal year. The auditors should be recruited prior to effectiveness.

Reporting and monitoring.

T o monitor project implementation, the UGP will produce the following reports that should be prepared in compliance with international accounting standards:
Annualfinancial statements comprising:

a) Summary o f sources and uses o f funds (by components/project activitiedcredit category and showing all sources o f finds); b) Project Balance Sheet;

54

QuarterZy FMRs: The F M R s includes financial reports, physical progress reports and procurement reports to facilitate project monitoring. The FMRs should be submitted to IDA within 45 days o f the end o f the reporting period (quarter). The form and content o f F M R s has been determined as part o f project appraisal and will be agreed at negotiations. Models of these reports will be presented in the project accounting manual o f procedures.

Information systems
The UGP and AGF are using an integrated financial management system capable o f recording and producing in a timely manner all financial reports required for managing and monitoring project activities.

Impact o f procurement arrangements

Procurement arrangements do not present substantial risk.

Action plan
The present action plan agreed with the borrower describes main actions to be taken to strengthen the M S P P I I financial management system.

Table 7.3: Action plan for strengtheningMSP: 1 financial manag ment system 1
1

Actions Update o f the project Chart o f accounts to reflect new components and activities to be financed under MSPPII;
Submission o f the content o f FMRs to be agreed at negotiations. Recruitment of auditors in charge o f the audit o f MSPPII accounts: 0 Agreement on Terms o f reference 0 Submission o f the technical and financial proposal to the VPM; 0 Negotiations Submission o f contract to IDA for non objection Award of the contract to the auditors. Production of the first FMRs and submit them to the Bank.

Date due by 06/15/05

Responsible UGP/AGF

0613 1/05

UGPIAGF UGP

06/ 15/05 07130105

08/06/05 081lolo5 08/20/05 07106105

55

Disbursement from IDA credit

For the implementation o f MSPPII the following bank accounts will be opened in local commercial banks under conditions satisfactory to IDA:
0

Special Account A: Denominated in USD, disbursements from the IDA credit will be deposited o n this account to finance MSPPII activities under expenditure categories 1 (Goods and Works), 2 (Consultant Services, Training and Workshops), and 4 (Operating Costs) in accordance with the disbursement percentages indicated in the D C A . Special Account B: Denominated in USD, disbursements from the IDA credit will be deposited on this account to finance MSPPII activities under expenditure category 3 (Grants to Sub-Projects) in accordance with the disbursement percentages indicated in the D C A .

Funds deposited in these accounts will be used to ensure timely payments o f (i) suppliers o f goods and services, and (ii) contractors (NGOs, CBOs, other organizations) in conformity with the terms o f the contract signed by the parties concerned. The project implementation and accounting manuals describe in details all procedural aspects regarding financial management (payments, replenishment, reporting, internal control) and reference to the procedures outlined in these manuals will be indicated in the D C A .

Disbursement arrangements Method o Disbursement. The project would follow the transaction-based disbursements f procedures (traditional mode) outlined in the Bank's Disbursement Handbook. The use o f reportbased disbursements could be possible thereafter if requested by the borrower and if the following criteria are met: (i) FM rating has been maintained at satisfactory level; and (ii) the the submission o f at least three quarterly satisfactory FMRs that could be relied upon for purposes o f disbursement. Detailed disbursement procedures will be described in the project accounting manual o f procedures. Minimum o Application Size. The minimum application size for direct payments, to be f withdrawn directly from the Credit Account, and special commitments i s 20 percent o f the amount advanced to the related special account.
Use o Statements o Expenses (SOEs). Withdrawals are to be made o n the basis o f SOEs for f f the following cases: 0 Contracts for equipments and goods in an amount inferior to USD150,OOO; 0 Contracts for works in an amount inferior to USD200,OOO; 0 Contracts for consulting services, training by f i r m s o f less than USD100,000; 0 Contracts for consulting services, training by individual o f less than USDl00,OOO; 0 All incremental operating expenses; and 0 Miscellaneous training expenditures (ie., those not subject to contract)

Special Accounts. To ensure that funds will b e available when needed, two special accounts in USD will be established in a local commercial bank under conditions satisfactory to IDA. The special account A, in the amount o f U S D l .O million, will be opened in the name o f the UGP,

56

whereas the special account B in the amount o f USD1.25 m i l l i o n will be in the name o f AGF. The amounts have been estimated to cover about four months o f expenditures and would be withdrawn from the credit account after effectiveness.

The special accounts would be replenished on the basis o f documentary evidence o f payments required by IDA, made from the special accounts, eligible for financing under IDA Credit. All SOEs supporting documentation will be kept by the executing agencies and made available for review by bank supervision missions and external auditors.
Allocation o f C r e d i t Proceeds

Amountin

Financing

4. OPERATING COSTS UNALLOCATED

Total Project Costs

2.1 3.1

100% foreign

30.0

57

Annex 8: Procurement Arrangements

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

A. General
Procurement for the proposed project would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated M a y 2004; and "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers'' dated M a y 2004, and the provisions stipulated in the Legal Agreement. The various items under different expenditure categories are described in general below. For each contract to b e financed by the Credit, the different procurement methods or consultant selection methods, the need for prequalification, estimated costs, prior review requirements, and time frame are agreed between the Borrower and the Bank in the Procurement Plan. The Procurement Plan will be updated at least annually or as required to reflect the actual project implementation needs and improvements in institutional capacity.

Procurement o f Works: Works procured under this project would include: the rehabilitation o f V C T centers and incinerator construction. The procurement will be done using the Bank's Standard Bidding Documents (SBD) for all International Competitive Bidding (ICB) and National S B D agreed with or satisfactory to the Bank. Since n o major works are expected for this Project, for contract estimated to cost less than USD200,OOO equivalent per contract, c i v i l work procurement m a y be carried out through National Competitive Bidding (NCB) and contracts for small works, estimated to cost less than USD50,000, will b e procured through quotations procedures. Nevertheless, for minor works to be procured under sub-projects, specific procedures details can be found in the Manual o f Procedures for the FAP (Annex 7). Procurement o f Goods: Goods procured under this project would include: print media furniture, reproduction o f movies, f m i t u r e for STI control, medical treatment for PLWHA, equipment for VCT centers, vehicles, office equipment, and I T and software. The procurement will be done using the Bank's S D for all I C B and National S B D agreed with or satisfactory to B the Bank. T o the extent practicable, contracts shall be grouped into bid packages estimated to cost the equivalent o f USDl50,OOO or more and w o u l d b e procured through I C B procedures. For contract estimated to cost less than U S D 150,000 equivalent per contract, procurement o f goods may be carried out through N C B procedures and purchase o f small furniture estimated to cost less than USD30,OOO will be conducted through prudent shopping procedures. Vehicles, ARV and medical treatment m a y be procured f r o m U agencies. S T I kits m a y be procured from N SALAMA, Madagascar Central Purchasing Agency for Essential Medicines and Medical Material. SALAMA procurement procedures have been assessed by the Bank and found t o be acceptable. Procurement o f non-consulting services: distribution o f kits for CBOs, and TV and radio broadcast. The project will contract NGOs and TV and radio using Direct Contracting methods. Selection o f Consultants: technical assistance, training and workshops, operationalization o f cinemobiles, films production, financial management agency (AGF), data collection and surveys, financial and technical audits, and capacity building. Short lists o f consultants for services

58

estimated to cost less than USD100,OOO equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines if a minimum o f three qualified ones are available. Wherever applicable, public training institutions such as INSPC and INSTAT, and NGOs may be hired for capacity building and surveys. Firms will be recruited o n the basis o f the Quality and Cost Based Selection (QCBS) method, using the Banks Standard Request for Proposals. Selection based o n consultants qualifications (CQ) can be used for the recruitment o f training institutions and for assignments that meet criteria set out in para. 3.7 o f the Consultant Guidelines. Single source selection can be used to contract firms for assignment that meet criteria set out in para. 3.9 to 3.13 o f the Consultant Guidelines and for contract which amount do not exceed USD100,OOO. Operating Costs: The project will finance project management unit and regional office management salaries, incremental costs, CNLS salaries, and capacity building for project staff. All staff selection within this category shall be done according Section V o f Consultant Guidelines. Others: The Manual o f Procedures o f the FAP will govern sub-project financing in high-risk and rion high-risk communes. The procurement procedures and SBDs to be used for each procurement method, as w e l l as model contracts for works and goods procured, are presented in the Project Implementation Manual

B. Assessment of the agencys capacity to implement procurement

Procurement activities will be carried out by the UGP which includes a Procurement Officer and a Procurement Assistant. An assessment o f the capacity o f the UGP to implement procurement actions for the project has been carried out by Sylvain Rambeloson (Sr. Procurement Specialist) in April 2005. The assessment reviewed the organizational structure for implementing the project and the interaction between the projects Procurement Officer and the Ministrys relevant central unit for administration and finance. The k e y issues and risks concerning procurement for implementation o f the project have been identified and include the phasing o f activities to be undertaken and possible emerging o f emergency cases. The corrective measures which have been agreed are the close follow-up o f the agreed procurement plan and activity scheduling. A procurement action plan will be fine-tuned quarterly and the main procurement plan will be up-dated accordingly.

The overall project risk for procurement i s Average.

C. Procurement Plan

The Borrower, at appraisal, developed a procurement plan for project implementation which provides the basis for the procurement methods. This plan has been agreed between the Borrower and the Project Team o n M a y 23, 2005 and i s available at UGP. I t will also be available in the projects database and in the Banks external website. The Procurement Plan will

59

be updated in agreement with the Project Team annually or as required to reflect the actual
project implementation needs and improvements in institutional capacity.

D. Frequency o f Procurement Supervision

In addition t o the prior review supervision to be carried out from Bank offices, the capacity assessment o f the Implementing Agency has recommended annual supervision missions to visit the field to carry out post review o f procurement actions.

E. Details o f the Procurement Arrangements Involving International Competition

1. Goods, Works, and Non Consulting Services

(a) L i s t o f contract packages to be procured following I C B and direct contracting:

13

6 Domestic Preference by Bank (Prior / Post) (yes/no)

Prior

Estimated Procurement PRef. Contract Method N o . (Description) Q

cost

Expected BidOpening

Comments

I.3.3.1 Billboard production t.1.1

144,000 Direct contracting 1,400,000 ICB

N o No

Oct 07

installation Social marketing o f STI treatment

l u t s (purchase

N o No

Prior

Feb 06

0.35KUSD per year for four years

L2.1 L3.1
gL

distribution) Medical treatment for PLWHA

Incinerator

Direct 990,100 contracting

250,000 Direct Contracting

N o No
N o No

Progressive and w/UN agencies

IAPSO

Construction 5.1.3.1 Vehicles

5.3.2.1

175,000 contracting

Direct

N o No

(b) I C B contracts estimated to cost above USD200,OOO for works and USD150,OOO for goods per contract and all direct contracting will be subject to prior review by the Bank.

60

2. Consulting Services
(a) L i s t o f consulting assignments with short-list o f international f i r m s .
1
2

1 3 Estimate d cost

14
Selection Method

15
Review by Bank (Prior I

5
Expected Proposals Submission Date T o be determined
Dec 05

7
Comments

Ref. No.

Description o f Assignment

1.32

3.1.1

Production o f radio programming (programs, spots and flashes) Agence de Gestion Financiere

h e contract

3.1.2 4.1.2

4.1.3.1 4.2.1 4.3.2.1 5.4.1 5.4.2

Organization o f 1,084,0001 QCBS facilitation LQAS baseline, mid588,000 CQS/QCBS point and final surveys, analysis and dissemination Technical audit 92,000 IC ImDact studies (TBD) I 500.000 I OCBS HIV/AIDS Epidemiological I C Situation report Financial Audit 104,600 LCS 105,000 CQS CNLS capacity building and workshop on M&E data use
____

663,000

QCBS

1
I

Prior

Prior Prior

Sept 05

w i t h phases :client satisfaction) The actual 4GF will 3perate to Jun 36 Annual

Feb 06

Prior Prior Prior Prior Prior

JulO5 Oct 05 T o be Year 1 will be determined covered by Dec 05 Feb 06

I
I

(b) Consultancy services estimated to cost above USD100,000 per contract and single source selection o f consultants (firms) and for individual consultants assignments estimated t o cost above USD50,OOO will be subject to prior review by the Bank.
(c) Short lists composed entirely o f national consultants: Short lists o f consultants for services estimated to cost less than USD100,OOO equivalent per contract may be composed entirely o f national consultants in accordance with the provisions o f paragraph 2.7 o f the Consultant Guidelines.

61

Annex 9 : Safeguard Policy Issues

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project The project i s rated as category B. The Borrower has demonstrated the capacity to properly develop and implement a medical waste management plan (MWMP). The MWMP i s the only safeguard-related study required for this project.

training program for the staff o f all hospital, health centers and community-based programs, including traditional midwifes and practitioners, who m a y be involved in H I V / A I D S testing and treatment. ensuring Under the MSPP, three different agencies were responsible for, respectively: (i) development and implementation o f the MWMP; (ii) implementing the plan; and (iii) supervising implementation o f the plan at the provincial and district levels.

A MWMP was developed for the MSPP, approved and has been implemented since M a y 2004. I t was disclosed under the MSPPII prior to project appraisal, in-country and in the Infoshop. The existing MWMP includes proper disposal o f hazardous bio-medical waste and a bio-safety

Ensuring development and implementation o the plan. The UGP has been responsible for f ensuring development and implementation o f the MWMP. The UGP has satisfactorily hlfilled this role, supervising implementation o f the MWMP according to the agreed-upon calendar and undertaking additional activities in support o f implementation o f the plan (national kick-off ceremony, annual evaluations o f the plan). Implementing theplan. The M o H has been responsible for implementation o f the MWMP, and has demonstrated capacity to properly implement the plan. Since M a y 2004, the M o H has installed 200 small-scale bumers to bum medical wastes. in all 200 health centers rehabilitated under the CRESANII Project. Recent supervision found that burners are being used at the C H D of Ankazobe, Antanifotsy and Faratsiho. The construction o f full incinerators at district level is underway, and some o f them should be functional by June 2005. The Plan also includes specific medical waste disposal and management actions, t o be carried out in Madagascars different types o f health facilities. The M o H has demonstrated the ability to plan for and prepare these activities, as well. Supervising implementation o theplan: The Office for the Environment o f the Ministry o f the f Environment (MINENV) has been responsible for supervising its implementation at the provincial and district level. I t has performed this role satisfactorily.

62

Annex 10: Project Preparation and Supervision

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project Planned Actual 0 1112/05 0210 1/05 03/07/05 03114/05 06/02/2004

P C N review Initial P I D to PIC Initial ISDS to PIC Appraisal Negotiations B o a r d R V P approval Planned date o f effectiveness Planned date o f mid-term review

0 1/ 12/05 02/01/05 03/07/05 05/06/05 05123I 5 O 07/07/07 10118/05 07/07/07

K e y institutions responsible for preparation o f the project: - in Government : CNLS, MSPP UGP, Ministry o f Health - Donor partners included: UNICEF, and U S A I D B a n k staff and consultants who worked o n the project included: Name Nadine Poupart Jean-Pierre Manshande Hope Neighbor Mead Over Joseph Valadez Nancy Lemay Michele Tarsilla Anne-Claire Haye Peter Bachrach Etienne Poirot Diane Coury Farellia Venance Tahina Manuella Varasso Gervais Rakotoarimanana Sylvain Rambeloson Hisham A. Abdo Kahin Sameena Dost Michael Fowler Maryanne Sharp Astania Kamau Andrianina N o r 0 Rafamatanantsoa Joan MacNeil John M a y Patricio Marauez
~

Title Sr. Economist, TTL Sr. Health Specialist ET Consultant Lead Health Economist Sr. Monitoring and Evaluation Specialist Monitoring Consultant Consultant Consultant Orphans and vulnerable children Orphans and vulnerable children Communication Communication Sr. Financial Management Specialist Sr. Procurement SpeciaIist ET Consultant Counsel Sr. Finance Officer Operations Officer Team Assistant Team Assistant Sr. H I V I A I D S Specialist & Peer Reviewer Sr. Population Specialist & Peer Reviewer Lead Health Specialist & Peer Reviewer

Unit

____

AFTH3 AFTH3 AFTH3 DECRG HDNGA USAID AFTH3 AFTH3 AFTH3 UNICEF UNICEF UNICEF UNICEF AFTFM AFTPC LEGAF LEGAF LOAG2 AFTH3 AFTH3 AFTH3 HDNGA AFTH2 ECSHD

63

Bank funds expended to date on project preparation:

1. Bank resources: USD95,OOO 2. Trust funds: USDO 3. Total: USD95,OOO

Estimated Approval and Supervision costs:

1. Remaining costs to approval: USD30,OOO 2. Estimated annual supervision cost: USDl80,OOO

64

Annex 11: Documents in the Project File

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

In addition to the documents mentioned in the P A D o f the original project, the following documents are available in the project file:

A. Project Documents Manuel d 'exe'cution du Projet, Septembre 2002 e Manuel de proce'dures pour le financement des organismes communautaires de base, DCcembre 2003 e . Vers une compe'tence locale en matiBre de VIH/SIDA :Les Principes Gkne'raux, 2004 Vers une compktence locale en matikre de VIH/SIDA : Guide pratique a 1'usage des institutions et organismes chargks d 'appuyer les communes dans la Eutte contre le VIH/SID, Septembre 2004 Prbparer la rbponse locale face aux IST/VIH/SIDA Ci Madagascar, Madagascar, Octobre 2003 e c&feilleures pratiques )) pour la lutte contre les IST/VIH/SIDA et de'termination de leur niveau optimum p a r zone d 'intervention, Madagascar, Juin 2003

B. Bank Staff Assessments

BanWGovernment Aide Memoires: Mid-Term Review December 2004 Project Concept Note January 2005 Pre-Appraisal Mission March 2005

C. Other
Madagascar National H N / A I D S Strategies: Plan Stratkgique National de Lutte contre le VIH/SIDA 2001-2006, Madagascar 200 1 Politique nationale de prise en charge des personnes vivant avec le VIH/SIDA, Ministkre de l a SantC, Madagascar, Mars 2003 Strate'gie Nationale de Communication face aux IST/VIH/SIDA, Madagascar 2004-2006 Mise en oeuvre de la Stratkgie Nationale de Communication face aux IST/VIH/SIDA, Pre'sidence de la Rkpublique, CNLS, 2004 Plans Stratkgiques Locaux des CLLS, USAID, Madagascar, Novembre 2004 Notes de prksentation sur le programme PTME relative aux besoins d 'extension des sites pour 1 'annbe 2004, Madagascar, Septembre 2004 Priorities for Local AIDS Control Efforts (PLACE), U S A I D , M a y 2004 Document de Programme Conjoint d'Appui a l a Lutte contre le VIH/SIDA Ci Madagascar, Groupe Thkmatique Nations Unies pour l e V W S I D A , Madagascar, A v r i l 2 0 0 5 Stratbgie Nationale de la PlaniJication du PrbsewatiJ; Madagascar,' DCcembre 2003 Madagascar HN/AIDS related studies and activities o f N G O and civil society e Etude sur les problkmes des relations sociales des personnes vivant avec le VIH/SIDA, Madagascar, Octobre 2002

65

Une se'rie d 'outils pour la facilitation de discussions participatives sur les IST curables et le V I H S I D A , International H I V / A I D S Alliance, M a i 2005 Integrating Service Delivery and Behavior Change Communication to Improve Adolescent Reproductive Health in Madagascar, PSI Madagascar, Decembre 2004

National HIV/AIDS Surveys EnquZte De'mographique de Sante' 2003-2004, Madagascar, A v r i l 2 0 0 5 Enqukte de Surveillance Comportementale sur les Camionneurs h Madagascar, Madagascar

2004

EnquZte de Surveillance Comportementale sur les Travailleuses du Sexe a Madagascar,

e e

EnquZte de Surveillance Comportementale sur les Jeunes h Madagascar, Madagascar 2004 Enqukte de Surveillance Comportementale sur Ies Militaires h Madagascar, Madagascar Annuaire des Statistiques du Secteur Sa&,

Madagascar 2004

2004

M i n i s t h e de l a Sant6 de Madagascar 2002

General Documents Assessing Community Health Programs: Using LQAS for baseline surveys and regular monitoring, U S A I D January 2003 Activite's PTME re'alise'es au niveau des formations sanitaires, Ministere de l a Sante,

Access des Personnes vivant avec l'infection

Madagascar, Mars 2005

Ministbre de l a Sant6, 2004 AIDS in Africa: Three Scenarios to 2025, U N A I D S , M a r c h 2005 U N A I D S , September 2004

The Guttmacher Report on Public Policy :A policy Analysis for the ABC Approach to HIV Prevention, Washington DC, December 2003 Guide pour la prise en charge de l'infection h V I H chez 1'adulte et l'enfant h Madagascar,

Madagascar, Fevrier 2005

h VIH/SIDA aux ARV h Madagascar,

Madagascar: epidemiological fact sheets on HIV/AIDS and sexually transmitted infections, Report on the Global AIDSpandemic, U N A I D S , 2004 Reaching out to African Orphans, A framework for public action, African Region H u m a n

Development Series, W o r l d B a n k 2004

66

Annex 12: Statement o f Loans and Credits

MADAGASCAR: Second Multisectoral STI/HIV/AIDS Prevention Project

Difference between expected and actual disbursements Cancel. Undisb. 8.70 29.84 37.92 146.71 61.39 28.39 19.48 10.49 37.41 64.42 6.72 9.63 5.30 7.48 6.05 6.89 3.44 6.95 497.21 Orig. 0.83 3.21 -0.98 27.96 -1.27 0.38 9.20 -5.95 -74.04 -38.47 0.03 4.55 4.22 6.27 5.46 -3.92 3.06 9.69 Frm. Revd

Original Amount in U S D Millions ProjectID PO74236 PO74448 PO74235 PO82806 PO73689 PO76245 PO72 160 PO72987 PO55166 PO51922 PO51741 PO52208 PO52186 PO01559 PO01564 PO01568 PO48697 PO01533 FY 2004 2004 2004 2004 2003 2003 2002 2002 2001 2001 2000 2000 1999 1998 1998 1998 1997 1996 Purpose IBRD 0.00 0.00
IDA

SF 0.00

GEF 9.00

MG-GEF Environment Program 3 (FY04)

MG-Govemance & Inst Dev T A L (FY04) MG-Environment Program 3 (FY04) MG-Transport Infrastr Invest P i (FY04) MG-Rural Transport A P L 2 (FY03) MINERAL RESOURCES GOVERNANCE PROJECT M G - PSD 2 MG-MultiSec STI/HIV/AIDS Prev A P L (FY02) MG-Community Development Fund S I L (FYOl) MG-Rural Development Support SIL (FYOl) 2nd Health Sector Support M G Transp Sector Reform & Rehab MICRO FINANCE Educ. Sector Dev.

0.00
30.00

0.00
0.00

0.00
0.00

0.00
0.00

0.00
0.00 0.00

0.00
0.00 0.00 0.00 0.00

0.00
150.00 80.00 32.00 23.80 20.00 110.00 89.05 40.00 65.00 16.40 65.00 17.30 27.60 35.00 46.00 847.15

0.00
0.00 0.00

0.00
0.00 0.00

0.00
0.00 0.00 0.00 0.00

0.00
0.00

0.00
0.00

0.00
0.00 0.00 -23.15 -6.08 0.00 0.00 0.00 0.16 0.00

0.00
0.00 0.00

0.00
0.00 0.00 0.00 0.00 0.00

0.00
0.00 0.00 0.00

0.00 0.00

0.00
0.00

0.00
0.00

0.00
0.00

0.00
0.00

0.00
0.00

0.00
0.00 0.00

0.00
0.00

0.00
0.00

RURAL W A T E R SEC.PIL0
2nd Community Nutrition

0.00
0.00

0.00 0.00
0.00 9.00

0.00
0.00

0.00
3.16 9.68

URBAN INFRASTRUCTURE
MG-Energy Sec Dev Prj (FY05) Total:

0.00
0.00

0.00
0.00 0.00

0.00
0.00

0.00

49.77

16.23

MADAGASCAR STATEMENT OF IFCs Held and Disbursed Portfolio In Millions o f U S Dollars

Committed IFC
FY Approval
1997 1995 1992 1991 2000 2004 1983189 Company AEF G H M AEF Karibotel Aqualma
BNI

Disbursed IFC
Partic. Loan 0.73 0.20 Equity 0.00 Quasi 0.00 0.00 0.00 0.00 0.77 0.00 0.00 0.77 Partic. 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Loan 0.73 0.20

Equity

Quasi 0.00 0.00 0.00 0.00 0.77

0.00
0.00 0.61 2.61 0.82 0.00 0.14 4.18

0.00
0.00

0.00
0.61 2.61 0.82 0.00 0.14 4.1 8

0.00
0.00

0.00
0.00

0.00
0.00 0.00 1S O 0.00 2.43

BOA-M Cottonline Nossi-Be Total portfolio:

0.00
5.00 0.00 5.93

0.00
0.00 0.00 0.00

0.00
0.00 0.77

67

Approvals Pending Commitment

FY Approval
2004 2001 2001 2004 Company BP Madagascar Besalampy
COTONA 111
LGA

Loan 0.00 0.02 0.01 0.01 0.04

Equity

Quasi

Partic

0.00

0.00
0.00

0.00
0.00

0.00
0.00

0.00
0.00 0.00

0.00
0.00

0.00 0.00

Total pending commitment:

0.00

68

Annex 13: Country at a Glance

MADAGASCAR SECOND MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT

POVERTY and SOCIAL
2003

SubSaharan Madagascar Africa

6.9 290 4.9 703 490 347

Lowincome
2,30 450 1038

D e v e l o p m e n t diamond' Life expectancy

Population, mid-year (mi//ions) GNI per capita (Atlas method, US$) GNI (Atlas method, US$ billions) A v e r a g e annual growth, 1997-03 Population (%$ Laborforce(%)

3.0 3.2 71 27 55 84 33 47 04 06 02

2.3 2.4

19 2.3

M o s t recent e s t i m a t e ( l a t e s t year available, 1997-03) Poverty (% of population below nationalpo verty line) Urban population (%of total population) Life expectancyat birth (years) Infant mortality(per 1,OOOlive births) Child malnutrition (%of children under5) Access to an improvedwtersource (%ofpopulation) Illiteracy(%ofpopu/ation age 1 9 5 Gross primaryenrollment (%of school-age population) Male Female
1983 36 46 a3 58 35 87 94 80 30 58 82 44 75 39 92 99 85

GNI per capita

'

Gross primary nrollment

/'

1
Access to improvedwater source -(-Madagascar
-

Low-income group

KEY E C O N O M I C RATIOS and LONG-TERM T R E N D S

1993 3.4 114 15.3 2.1 3.6 -7.4 0.8 tT2.9 Q.3 2002 4.4 14.3 16.0 7.7 8.4 -6.2 0.7 02.7 9.6 318 184.8 2003 5.5 n.9 215 7.8 119 -6.0 16 83.8 Q .O 43 A 2002

GDP (US$ billions) Gross domestic investmentlGDP Exports of goods and services/GDP Gross domestic savings/GDP Gross national savings/GDP Current account balancelGDP Interest paymentslGDP Total debt/GDP Total debt serviceiexports Present valueof debWGDP Present value of debtlexports (average annual groMh) GDP GDP oercaoita

3.5 8.4 0.6 -14

14

Economic ratios*

-7.1 0.9 58.1 20.9

Indebtedness -Madagascar Lowincome group

1983-93 1993.03 14 -13 2.5 -0.5

2002 -Q.7 -15.2

2 0 0 3 2003-07 9.8 6.8

6.7 4.1

STRUCTURE o f t h e E C O N O M Y

(%of GDP) Agriculture Industry Manufacturing Services

Private consumption General government consumption Imports of goods and services

1983 35.8 13.5 50.7

1993 28.7 119 9.9 59.4 90.0 7.9 24.6

2002 317 14.4 Q.5 53.8 84.1 8.2 22.6 2002 -16 -20.8 -18.3 -15.4 -6.9 -13.5 -314 -310

2003 29.2 15.4 13.7 55.4 83.0 9.2 316 2003 13 14.5 P.8 9.5 8.6 28.8 57.2 129.8

..

69.0 9.6 V.5

(average annualgrovdh) Agriculture Industry Manufacturing Services Private consumption General government consumption Gross domestic investment imports of goods and services

1983-93 1993-03 2.5 2.1 0.5 11 0.3 -0.3 5.1 -0.8 19 2.4 2.9 2.9 2.9 2 .7 7.1 7.6

G r o w t h o f e x p o r t s a n d i m p o r t s (%)

50 0 -50
-100

P
3

-*--Exports

--O--lrrQOrtS

69

PRICES and GOVERNMENT FINANCE Domestic prices (%change) Consumer prices Implicit GDP deflator Government finance ( % o f GDP, includes current grants) Current revenue Current budget balance Overall surplus/deficit TRADE

1983

1993

2002

2003 -0.8 2.8

I n f l a t i o n (%)
20 j I20 T 15
10

1
I

2 15

9.2 P.1

15.8 25.3

116 -16
-0.1

8.8 -15 -6.8

13.1 17 -6.5

-5

----GDPdeilator

-e-CPI

(US$ millions) Total exports (fob) Coffee Vanilla Manufactures Total imports (cif) Food Fuel and energy Capital goods
Export price index (895-WO) Import price index(895=WO) Terms of trade (895=x]O) BALANCE of PAYMENTS (US$ millions) Exports of goods and services Imports of goods and services Resource balance Net income Net current transfers Current account balance Financing items (net) Changes in net reserves Memo:

1983 30 13 1 62 4% 73 98 90 90

1993 332 40 34 I75 599 51 85

140

2002 499 3 PO 227 729 61 217 92 02 92

2003 852 4 85 551 1,300 1 6 184 217 09 113 96

Export a n d i m p o r t levels (US$ mill.)

1,500 T

77 89 87

97

98

99

00

01
Q

02

ni

%ports

lTQ0rtS

O3

1983 368 509 -121 -118 -0 -249 228 21

1993 56 86 -300 -134 184 -250 270 -20 81 2914.3

2002 730 1029 -299 -71 99 -272 218 53 363 6.832.0

2003 1l71 1,720 -549 -80 302 -327 344

C u r r e n t a c c o u n t balance t o G D P

(Oh)

-n

Reserves including gold (US$ millions) Conversion rate (DEC, /oca//US$j

430.4

397 6.816

E X T E R N A L D E B T a n d RESOURCE FLOWS 1983 (US$ millions) 2,04 1 Total debt outstanding and disbursed IBRD 30 IDA 223 Total debt service IBRD IDA Compositionof net resourcefiows Official grants Official credit0 rs Private creditors Foreign direct investment Portfolio equity World Bank program Commitments Disbursements Principal repayments 83 3 2 77 218 74 4 0 62 37 2

1993 3,805 l7 932 78 4 12 257 97 -8 1 5 0 85 47 8

2002 4,518 0 1,652 73

0 6

2003 4,590 0 1,804 142 0 34

C o m p o s i t i o n o f 2 0 0 3 debt (US$ mill.)

G 231

66 149 0 8 0

P8 -8

130 63 6

222 174 22

4 - IBRD 3-IDA

3-IMF

D-Otkmltilatetal

E- Bilateral

F-Rivate G- Shart-term

70

Additional Annex 14: Detailed Monitoring and Evaluation Arrangements

M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project

Subcomponent 4.1 Monitoring

The M S P P I I Monitoring and Evaluation (M&E) subcomponent will ensure that the national M&E system used by all donors i s in place and operational. The subcomponent will finance the following five activities: (i) set ofproposed indicators to measure project performance and t o a introduction o f L Q A S to collect a subset o f the projects track the epidemiology o f the virus; (ii) key performance indicators; (iii) revision o f the projects M I S to effectively organize indicators

o f output, outcome and impact as well as financial, input and operational data; (iv) monitoring o f sub-project quality; and (v) reporting a n d use o f monitoring data.

Proposed indicators. The proposed M S P P I I indicators include several o f the performance indicators used during the MSPP project (Annex 1). The other indicators from the original project were dropped because they were either inappropriate, or data was not available. All proposed outcome indicators for M S P P I I are aligned with the national M&E plan and with indicators used in primary data sources to ensure that data will be available.

An important difference in the indicators proposed for M S P P I I is that they provide a comprehensive picture o f the outputs and outcomes associated with knowledge, attitude and behavior change in high-risk groups (commercial sex workers, truck drivers and miners) and in the population as a whole. The indicators also include indicators o n youth (girls 10-14 years o l d and boydgirls 15-24 years old) and o n risk groups, neither o f which were included in the M S P P I M&E plan. This change reflects the need t o monitor H I V / A I D S knowledge, behavior and ultimately prevalence among the specific population groups where the epidemic is currently
concentrated.

Lot Quality Assurance Sampling (LQAS). Under this sub-component, the M S P P I I will support the collection o f outcome and impact level, in part using L Q A S methodology. According t o the MSPPII intervention strategy, a limited number o f at-risk areas will be selected where HIV transmission i s suspected, or documented, to be high. These will be the priority intervention zones for the project where the project will measure outcomes using LQAS. Data will be collected at an aggregate level among intervention zones rather than at the commune level. Because M S P P I I will provide a small amount o f funding for general behavior change for communication activities in non target areas, a set o f these communes will be selected as control areas for the measurement o f outcomes. The control areas will be sampled to ensure that the data can be aggregated to represent the national catchments area. Data sources for all outcome indicators are displayed in Annex 1. Management Information System (MIS). The M I S will build o n the projects existing M I S , which i s in place at the UGP but not fully operational. There are two m a i n problems with the projects existing MIS system. The first i s the process for collecting data t o input to the system: regional data i s collected by the AGF, which takes extensive time to verify data quality, and which then provides monthly, quarterly and annual reports to the project. The data collected by the AGF i s outside o f the MIS. The project M&E team then manually inputs the AGF data into

71

the U G P central MIS. This process is laborious and time-consuming. The second problem i s that the M I S i s not fully functional. While some parts o f the system work individually, none are fully automated and the parts do not function together as a whole (see footnote).32 As a result, information does not flow effectively, there i s incomplete data at the central level, and there are delays in producing reports.

A series o f changes will be made to the MIS to allow it to function more effectively under the MSPPII. These include:
0

Dataflow. The MSPPII will correct the database problems in order t o address most o f the problems associated with the lack o f full automation o f the M I S and the lack o f a single, functioning system. The MSPPII will also address related problems in data flow, including delays in submission o f data (particularly the operational plan module) and inadequate use o f data at a l l levels o f the system. Financial, input and Operational datu. The current MSPP project will finance strengthening o f i t s existing MIS to allow for a more detailed analysis o f data below the province level, and to permit the consolidation of,all data at the MSPP central office. Through this process, the M I S sub-systems will be adapted t o include the new project activities and indicators in M S P P I I and to eliminate i t s duplication o f the accounting system. The M I S will also b e modified to include health center and V C T data to monitor access to H I V / A I D S services acquisition o f these data will be coordinated with the Global Fund. Outcome and impact datu. The introduction o f LQAS will allow the project t o collect k e y outcome and impact data for i t s intervention areas. Use o f L Q A S will allow the M S P P I I t o rigorously collect these indicators at minimum cost. A separate database will b e developed t o h o l d outcome and impact level data33 that can be exported and merged with the existing MIS.

Monitoring o sub-project quaZity. M u c h effort i s currently placed o n monitoring the cost and f completion o f sub-project activities, but not much emphasis i s placed o n monitoring the quality o f these activities. At the most basic level, because most output data have not been entered in the system at the level o f the MSPP, the M I S i s currently used mainly to track inputs. In the MSPPII, the MSPP team will focus o n using their output data to better manage the project. In addition, a technical M&E staff member will be hired and placed in eight o f the regional offices to serve as an extension o f verifying the accuracy o f the data the UGP M&E office. These staff will be responsible for: (i) submitted by promoters and CBOs; ( i monitoring the quality o f subprojects through periodic i) i isharing relevant data with partners in the region. site visits and formative supervision; and ( i )
32 T h e main issues are related to problems with the database design and functions and problems w i t h the flow o f information within the system. The MIS currently consists o f four sub-systems: 1) sector plans - well designed subsystem w i t h very little data because, except for the labor sector, sector plans have only recently been finalized; 2) sub-projects - data exist and are current at the central AGF but are not yet consolidated at the MSPP level due to numerous problems w i t h the design o f this subsystem; 3) program operations - this subsystem could work w e l l except for problems assigning the correct timeframe to the annual operational plans; for n o w the M&E team performs systematic tracking o f annual plans by hand; and 4) structures detailed financial data are available on the AGF, NGOs, subproject technical review organism; the subsystem functions w e l l except that the monetary unit i s s t i l l in Fmg rather than Ariary. 33 Impact level indicators w i l l be monitored based on epidemiological and behavioral data coming f r o m other surveys.

72

Reporting and use o data. f

The M&E unit will ensure that monitoring data are routinely reported to the public and to partners o f the H I V / A I D S program through regular dissemination workshops and distribution o f trimester, 6six month and annual monitoring reports. Regional U G P M&E staff will be responsible for conducting regular (six monthly) sessions with regional coordination staff to promote the use o f project output data for management decisions. To ensure that outcome and process data are used for decision making by the UGP, annual operational plans will be supported from data assembled from the M I S and associated databases. Similarly, MIS data will form the basis of quarterly and annual reviews o f project activities and progress. Monitoring data will also be used in the annual situation analysis and policy recommendations, described in the following section.

Subcomponent 4.2 Epidemiological data collection special studies, and situation analysis
This sub-component includes two parts. The first i s the projects contribution to a secondgeneration surveillance system as w e l l as other population-based surveys and large-scale studies; the second ,is the development of an annual Results and Strategic Re-Orientations report, which will compile data from the years surveys and make programmatic recommendations based upon analysis o f that data. Madagascars second generation surveillance system includes biannual behavioral surveillance surveys among high-risk groups (commercial sex workers, truck drivers, military, and youth) and the annual sentinel surveillance surveys o f clients at antenatal clinics (pregnant women, S T I patients, and commercial sex workers). Its population-based surveys and other large-scale studies include the cross-sectional HIV prevalence study (Enquete Nationale de Seroprevalance azipris des Femmes Enceintes) first conducted in 2003, the D H S planned for 2008/2009, and the annual replication o f the PLACES study, which maps high-risk sites and monitors r i s k behaviors in Madagascars at-risk communes. The M S P P I I will finance a portion of each o f these studies. The project will also support the inclusion o f an H I V / A I D S module in the survey instruments o f large scale surveys and studies undertaken by agencies external to the MSPP.34
Report on Results and Strategic Re-orientations . This sub-component will also support the Second generation surveillance; other population-based surveys and large-scale studies.

a development o f annual C N L S reports which will provide: (i) consolidated technical analysis o f data generated and studies carried out in the course o f the year; and ( i recommendations o n i) policy re-directions based o n the technical analysis. Each report will address the following issues: 1) estimates o f H N and S T I prevalence in Madagascar and their variation by age, sex, risk group, location and educational status; 2 ) best estimates and description o f the trends in the prevalence data; 3) summary information from sub-component 4.1 M I S data and national M I S data on the intensity o f prevention interventions in the identified risk groups; 4) a judgment regarding the success or lack o f success o f prevention programs in the various demographic and

The first application o f the MSPPiHIViAIDS module was included in the 2003/4 DHS. However, the questions proposed by CNLS and MSPP were not compatible w i t h M a c r o D H S survey formats. I t i s strongly recommended that future auxiliary survey instruments and methodologies be reviewed in collaboration with Macro or other agencies specializing in large-scale surveys, and that they are complimentary t o the main survey instead o f overlapping w i t h it.
34

73

r i s k groups and in the various parts of the country; and 5) implications for reorienting H I V / A I D S policy and programs.
The entire report, and in particular the last section, will be developed in close coordination with the CNLS in order to build their capacity to analyze national data and provide policy recommendations based o n this analysis. The reports will then be disseminated to and discussed with development partners, with a view to implementation o f the reports recommendations.

Subcomponent 4.3 Impact studies

For the benefit of the national fight against HIV/AIDS, as well as for global knowledge creation, the MSPPII project will support one or more (pending the availability o f fhding) impact studies. Theses studies will measure, for example, changes in H I V / A I D S prevalence and incidence, changes in A I D S related mortality, social norms, coping capacity in the community, or the economic impact. The study will be awarded only after technical review confirms that the study design has sufficient statistical power to test the study hypothesis.

74

Additional Annex 15: Supervision Plan M A D A G A S C A R : Second Multisectoral STI/HIV/AIDS Prevention Project General Supervision Strategy The project will require intensive supervision. A budget o f USD180,OOO i s allocated to supervise the project during the first 12 months o f project implementation. I t i s multisectoral, with multiple players operating at the national and decentralized levels. At the decentralized level, it will be implemented largely by many entities only recently established and whose capacity will need strengthening. The skills required for supervision are varied, given the multisectoral nature o f the project and the diversity o f issues surrounding H I V I A I D S . I t is, therefore, proposed t o establish a core supervision team, enhanced by specialists and other inputs o n an as needed basis. The core supervision team will be in the field twice a year and would rely o n U N A I D S Thematic Group partners for supervision o f activities during and between missions. A supervision mission would take, o n average, three weeks, and include about five people. Specialized inputs will be provided as required. Task team leaders o f related sectoral projects (mostly education and health) will be asked to devote at least h a l f a day during each o f their supervision mission on the MSPPII.

At the same time, the core supervision team will rely heavily o n the technical inputs and collaboration o f its partners in the U N A I D S Thematic group and the team m a y tap into U N A I D S expertise for the specialized inputs. Project progress reviews will be held annually to assess the performance o f the project and its contribution to the national effort t o reduce the spread and impact o f HIV/AIDS. They will be held jointly with the Conseil du PMPS and the U N A I D S thematic group. M&E information and conclusions o f site visits conducted by the supervision team will form the basis o f the discussions.
Progress reviews would include a presentation by the UGP o n progress attained, problems encountered, and h t u r e steps. A progress report will be prepared for annual review attendees t o be distributed at least one week prior to the meetings. The presentation will employ data derived from the project MIS and observations made during site visits. Other information available at the time, including studies conducted by the project o r other donors will be employed to complement M I S data. Progress reviews will culminate in stakeholder meetings that will f o r m a basis for replanning for the next two years. These meetings will be used to share information o n trends, best practices and to provide general technical information. Given the k e y role that M o H activities have o n the success o f the government's efforts t o reduce the spread o f HIVIAIDS, supervision missions will coordinate closely with the MoH's ongoing C R E S A N I I Project. Supervision Objectives The core team will be primarily responsible for the review of: (i) quality o f project management and implementation, and adherence to the procedures and implementation manuals; (ii) monitoring and evaluation results; (iii) financial management, including AGF performance,

75

procurement procedures, and technical and financial audits; (iv) spot-check quality, relevance and location o f sub-projects financed under the Fund component; (v) adherence to ARV treatment and STI treatment guidelines; (v) adherence o f health sector activities with health sector policy; and (vi) progress o n NSP update, communication action plan, and sector strategies and action plans.

Supervision Requirements
Core team: The core team would consist o f staff from the Washington office and from the country office. The following skills would be included: (i) task team leader; ( i a health i) a specialist; (iii) procurement specialist; (iv) a financial management/private sector specialist; and (v) team counterpart in country. A health specialist based in the field will participate in missions, and will focus year-round o n the collaboration with the M o H . During the first two years, a monitoring and evaluation specialist should be part o f the core team.

F o r the first and second years, 24 Washington-based staff weeks and 18 country office staff weeks are planned for the core team; to be gradually reduced in the third and fourth year.
Enhanced specialists and additional support: The core team will be enhanced by other specialists on a needed basis and at the discretion o f the task team leader. These specialists would be responsible for the following: (i) provide strategic support to the revision o f the NSP; ( iquality o f communication activities as a whole; (iii) i) occasional in-depth review o f particular subprojects focusing o n specific target groups; and (iv) impact evaluations.

F o r the first year, seven Washington-based staff weeks and six country office staff weeks are planned o n an ad-hoc basis. Collaboration will be sought with the team leaders o f relevant sectoral projects to provide time o n MSPP during each supervision mission in the field.

76

44

46

48

50

MADAGASCAR
12

SECOND STI/HIV/AIDS PREVENTION PROJECT

ANTSIRANANA
PAVED ROADS ALL-WEATHER ROADS RAILROADS RIVERS SELECTED CITIES REGION CAPITALS PROVINCE CAPITALS NATIONAL CAPITAL
Ambanja Ambilobe Iharana Vohimarina

12

DIANA

14

REGION BOUNDARIES PROVINCE BOUNDARIES

ANTSIRANANA
SAVA
Bealanana Analalava

vy Mahava
Andapa

14

Sambava

Antsohihy

Antalaha

SOFIA
Sofia

Befandriana Maroantsetra

Boriziny

MAHAJANGA

M A H A J A N G AAnjombo
16 Soalala Mitsinjo Marovoay Mampikony

Mandritsara

ny
Mananara

16

Be

ma

BOENY
Besalampy

Ambato Boeni Boinakely

riv

Maevatanana

ah M
Tsaratanana

aj am ba
Andilamena

ANALANJIROFO
SoanieranaIvongo Ambodifotatra

Mozambique
Ma

Vohitraivo

MELAKY
ah o Morafenobe na mb

Kandreho

BETSIBOKA
Ambatomainty

Andriamena

Vavatenina

Bet sibo ka

Amparafaravola

Lake Alaotra
Ambatondrazaka

Fenoarivo-Atsinanana

Mah ava vy

Channel
18

Maintirano

Bemahatazana

Ankazobe Fenoarivo be

ANALAMANGA
Anjozorobe

ALAOTRA MANGORO
Fanandrana

Vohidiala

18

TOAMASINA

BONGOLAVA
Antsalova

Tsiroanomandidy

A N TA N A N A R I V O
Miarinarivo

TOAMASINA
Perinet Ampasimanolotra

ANTANANARIVO
Manjakandriana Andramasin Moramanga

Manambolo

ITASY
Faratsiho Mandoto

ATSINANANA
Can al
Vatomandry

Belo Tsiribihina

Miandrivazo

Anosibe Antanifotsy

Antanambao-Manampotsy

Tsiribihin
20

VAKINANKARATRA

Antsirabe

Ma

MENABE
Morondava
Moron
Mahabo Fandriana Malaimbandy

ngo

ro

Mahanoro

20

Marolambo

dava

AMORON' MANIA
Ambatofinandrahana

Ambositra
lanes
Manandriana

Ikalamavony Manja Beroroha Morombe

Ambohimahasoa Alakamisin Ambohimaha

Vohiparara Ifanadiana Irondro

Panga

VATOVAVY FITOVINANI Vohilava

Nosy Varika

INDIAN OCEAN

Mananjary

FIANARANTSOA HAUTE MATSIATRA

Mangoky

FIANARANTSOA Ambalavao
IHOROMBE
Ihosy
Ivohibe Ankarmena Ikongo 22 Ankazoabo atm.

22

TOLIARA

Manakara
Vohipeno

ATSIMO ANDREFANA
ch a an
Sakaraha Iakora Benenitra Betroka

Vondrozo

Farafangana

TOLIARA

Fi

he

re

ATSIMO ATSINANANA
Vangaindrano Midongy-du-Sud

Betioky

Onilahy

ANOSY
24 Berakete Bekily

Befotaka 24

50

TANZANIA
ave
Manantenina

45

50

COMOROS
ndr
Mayotte (Fr)
Mahajanga

Antsiranana

B IQ

Ampanihy

Ma

UE

Ch an ne l

MADAGA SCA R

AmboasarySud Beloha Tsihombe

MO
Tolagnaro

ZA

ANDROY

15

15

Toamasina ANTANANARIVO
20

20

Mozamb iq u e

Ambovombe Androy

Fianarantsoa

This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries.

50

100 KILOMETERS

150

200
25

Toliara

IBRD 34097

JUNE 2005

25 40 45 50

44

46

48