Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB4740 Project Name ML-HIV/AIDS MAP Additional Financing Region AFRICA Sector Health (35%); Central government administration (35%);Other social services (30%) Project ID P115491 Borrower(s) REPUBLIC OF MALI Implementing Agency Executive Secretariat of the High National Council against HIV/AIDS Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared April 27, 2009 Date of Appraisal Authorization April 22, 2009 Date of Board Approval May 19, 2009 1. Country and Sector Background Mali is one of the poorest countries in the world due to its limited resource base, land-locked status, vulnerability to external shocks, poor infrastructure, low levels of human development and weak administrative capacity. Its average income per capita was estimated at US$380 in 2007. It is ranked 168 out of 179 countries in the 2008 UNDP Human Development Index. With a population currently estimated at about 14 million people, poverty seems to decrease as illustrated by the headcount index of poverty which declined from 68 percent to 64 percent between 2001 and 2006. According to the 2006 Demographic and Health Survey (DHS), effort to combat HIV/AIDS is encouraging, but needs to be sustained. The national prevalence rate declined from 1.7 in 2001 to 1.3 percent in 2006 according to the DHS. However, new challenges have emerged with the progression of the prevalence rates in two regions, Mopti and Gao, and among vulnerable and high risk groups including commercial sex workers. These challenges need to be effectively and urgently tackled to sustain the overall good performance achieved and prevent the disease from spreading dramatically. 2. Objectives The revised project objective is to contribute to the recipient’s multisectoral efforts to control the spread of the HIV/AIDS epidemic by improving access to prevention, treatment and care particularly for the most-at-risk-population (MARP) and those infected with or affected by HIV/AIDS. This objective will be achieved by: (a) strengthening the Recipient’s national response to the HIV/AIDS epidemic by improving its evidence base, coordination, implementation, and monitoring and evaluation capacity; (b) raising the level of awareness on HIV/AIDS through the implementation of a comprehensive sensitization plan targeting MARP in particular; (c) providing access to testing and counseling facilities; and (d) providing access to treatment, care and psychosocial support to persons infected with or affected by HIV/AIDS. 3. Rationale for Bank Involvement The Additional Financing will respond to the Government of Mali’s (GOM) request to continue providing support to address the lack of funds required to consolidate and strengthen progress made towards Page 2 achieving the PDO. It will help refocus the project on priority interventions and provide the resources and time required to support key essential services based on the findings of the 2006 DHS, which highlights that, although the seroprevalence rate is decreasing at the national level, it is increasing among high risk groups (sex workers) and in some cities such as Mopti and Gao. The Additional Financing under OP 13.20 is an appropriate tool to keep the momentum to fight against HIV/AIDS in Mali, maintain dialogue and provide advice to the Government to ensure sustainability. 4. Description Component 1 : “Support to public sector response”. ARVs drugs are now more available in Mali with support from the Global Fund but the capacity of health facilities especially outside Bamako and main cities is still insufficient to effectively deliver the drugs to the patients. Support under the Additional Financing is expected to be limited and focus mainly on a new activity which consists in the provision of critical equipment and training to a selected and small number of public health facilities to become HIV/AIDS treatment facilities in targeted regions with poor access to ARVs and health services such as Mopti and Kayes. Support will be provided where critically needed and in line with the Government’s health development program (PRODESS) supported by the Bank. This is expected to contribute to increasing the number of patients under ARVs. In the past, the MAP mainly focused on supporting the preparation of action plans of several ministries and providing support for sensitization of Ministries’ staff. The additional financing will identify key line ministries that would have substantial impact on the MARP and will strengthen these ministries capacity such as ministries of education, agriculture, mining, and communication . Resources will also be provide to increase the number of reference centers (CSREF) and community health facilities (CSCOM) which have means to dispose of medical waste. Component 2: “Support to the response of the private sector”. The private sector is now playing a greater role in the multisectoral fight against HIV/AIDS in order to complement public sector’s effort. Its resources and capacity are being leveraged to combat the epidemic. Continued support to this component is needed to consolidate the achievements such as better sensitization of workers and better quality of HIV related health services, and position the private sector as a key partner. The Additional Financing will focus on the following main activities. The Additional financing will continue to support on a declining basis part of the operating costs of the newly established business coalition which is still in its incubation phase. This will enable the coalition to work more effectively with employers’ associations to mobilize a greater number of members/firms, improve its resources base through more membership fees, and with the goal of becoming self-financing. At this stage, member fees do not fully cover the operating costs and do not allow an effective implementation of the Coalition’s action plan which focuses on sensitizing firms’ workers and scaling up isolated successful interventions to comprehensive national programs. The coalition’s capacity will also be strengthened with the recruitment of local consultants when needed to assist in the preparation of comprehensive toolkits to guide the development of customized Mali HIV/AIDS workplace programs, and to assist firms in the preparation of their action plan. Page 3 Support will also be provided on a declining basis to the successful public private partnership (PPP) arrangement under which a private laboratory has provided quality services to monitor the health condition and treatment needs of more than 7000 patients, which allowed them to access ARVs. This PPP is considered by the Government as a way to complement the capacity of the public laboratories, which is improving but remains weak. Before project closing, the Government will prepare a sustainability plan on how to continue to provide the services either through the public sector or through the same PPP arrangement. Technical assistance will be provided to evaluate the PPP arrangement to guide the Government and other development partners in the development of the sustainability plan. Also, Additional funds will be provided, on a declining basis, to strengthen the mechanisms established under the project to enhance access to ARVs for both adults and children through the private sector (import and distribution). Technical assistance will also be provided to evaluate the mechanism and guide the Government in its strategic decision to continue its partnership with the private sector. Finally, the Additional financing will continue to provide basic equipment and training to a small number of major companies with health centers to enable them to provide VCT services to their employees, their employees’ families and the community. The companies will be selected based on a set of criteria including concentration of MARP in the community, geographical location, existence of other donors’ intervention, and poor access to VCT services in the community. Under MAP, such support has been provided to a major textile company in Segou. A special focus will be on two major sectors of the Malian economy, the mining and cotton sectors. Component 3 : “Support to the Response of the Civil Society”. Given that Mali isa low prevalence country, the additional financing will focus more on prevention targeting high risk groups and the main drivers of the epidemic. The Additional Financing will provide more support for sensitization and VCT services to the MARP. A particular focus will be on female sex workers, a group which recorded an increase in prevalence rate from 29 to 35 percent between 2001 and 2006. Based on lessons learned under MAP which highlighted that proposals of sub-projects submitted by Civil Society Organizations (CSOs) for financing do not always respond to the priority needs in terms of geographical coverage and targets, the ES/HNAC (Executive Secretariat of the High National Council against HIV/AIDS) will be more proactive by preparing terms of reference which clearly target the MARP and cities where sub-projects should be implemented. The terms of reference will be guided by a mapping of other donors’ interventions and the concentration of MARP. Contracts with clear performance indicators will be signed with a core group of experienced CSO to implement result-oriented sub-projects. Support will also be provided to combat stigmatization of people living with HIV/AIDS (PLWHA) by strengthening their associations. Technical assistance will be provided to review the relevant legal framework against stigmatization in the workplace, the community and the national levels, with a special focus on both PLWHA and MARP (essentially an audit of relevant laws and policies), disseminating the findings; and implementing an active communication Page 4 campaign against stigmatization. This is expected to encourage individuals to access to testing, treatment and care, which are important to effectively fight the epidemic. Component 4 : “Project Coordination, Monitoring and Evaluation”. The Executive Secretariat of the High National Council on HIV/AIDS (ES/HNAC) in Bamako, created under the project, is effectively leading the fight against HIV/AIDS and the dialogue with all the development partners. The Government recently created regional Executive Secretariats in all the regions to decentralize and better coordinate the fight. The ES/HNAC was assisted by a Financial Management Agency (FMA) which was recruited under the original MAP to manage all the financial aspects of the project. Its responsibility will be reduced to the preparation of the quarterly financial reports of the ES/HNAC given the reduction in the number of sub-projects to be financed under the additional financing. It is expected to assist the ES/HNAC until project closing. The responsibility of the Contract Management Agency (CMA), which was also recruited under the MAP to assist the ES/HNAC in the evaluation and monitoring of all sub- projects, will be phased out given the reduction in the number of sub-projects. The CMA is currently strengthening the capacity of the ES/HNAC to enable it to continue to manage the sub- projects after the end of the CMA’s contract, which is expected no later than July 31, 2010. The Additional Financing will continue to partly support the Executive Secretariat in Bamako to enable it to: (i) continue to coordinate the country’s multi-sectoral effort to combat HIV/AIDS; (ii) promote the mainstreaming of the fight against HIV/AIDS in government programs; (iii) guide and coordinate the activities of the new and still weak regional secretariats; (iv) develop the country capacity to assess and understand the drivers of the epidemic by strengthening its monitoring & evaluation system focusing on the enhancement of the mechanism to collect short term data and conducting selected priority studies required to evaluate the project; and (v) strengthen its financial programming capacity in order to better plan for the medium term, identify gaps and guide the Government in its resources allocation to support the mainstreaming agenda. 5. Financing Source: ($m.) BORROWER/RECIPIENT 0 International Development Association (IDA) 6 Total 6 6. Implementation The institutional arrangements remain unchanged from the original project. The Executive Secretariat of the HNAC will continue to coordinate the implementation of the National Strategic Plan to fight HIV/AIDS, working closely with the Ministry of Health. The overall coordination of the HIV/AIDS program by a single and fully dedicated body in accordance with the “three ones” principles of UNAIDS, is seen as a good institutional measure to ensure that the Government strategic orientations are systematically implemented and effectively monitored. It will coordinate the mainstreaming of HIV/AIDS in government programs and ensure their implementation. It will also coordinate the decentralization Page 5 effort to fight the disease. This is expected to strengthen the Government’s system to combat HIV/AIDS in a more sustainable manner. 7. Sustainability Key issues related to the institutional, technical, and financial sustainability of the proposed Additional financing are summarized below. (a) Institutional sustainability . The sustainability of the fight against HIV/AIDS is contingent on the quality of the institutional framework set up by the Government since 2004 with the creation of the HNAC and its Executive Secretariat under the leadership of the Head of State, and in close coordination with the Ministry of Health. There is a participatory approach in the functioning and decision making process of the HNAC with representatives of the public sector, the private sector and the civil society equally represented. All the stakeholders have been empowered under MAP and are expected to continue ensuring the quality and effectiveness of the institutional framework. (b) Financial sustainability . Financial sustainability of the effort continues to be a major risk for the program. Hence, GOM’s commitment to adequate funding from the budget of free ARV access for HIV/AIDS infected people and of other HIV/AIDS activities once the projects come to an end is critical for sustainability. The Global Fund additional support expected in the second half of 2010 would also contribute to sustainability. Considerable effort has been made under MAP to prepare HIV/AIDS sectoral plans for the Ministries. Based on these plans, the Ministry of Finance’s Poverty Reduction Unit is now working closely with the ES/HCNAC to ensure that HIV/AIDS is mainstreamed into government programs. The additional financing will support the ES/HNAC to accompany the mainstreaming process working closely with the Ministry of Finance. This is expected to help the Government better plan and sustain its effort to fight HIV/AIDS especially since the Bank is increasingly providing support through the budget. (c) Technical sustainability . The strengthening of the health system so that it can provide the needed support to the fight against HIV/AIDS after project closing is important. MAP has attempted to address this issue. It has contributed to the strengthening of the health system by providing support to the public system and promoting the private provision of health services. The additional financing will continue to support the system focusing on a core group of health centers. The Global Fund and the GOM’s program for health development (PRODESS) supported by the Bank are also expected to strengthen the health system including the health centers. 8. Lessons Learned from Past Operations in the Country/Sector The Additional Financing will capitalize on the lessons learned from the implementation of MAPs across the Africa region. The lessons are summarized as follows: - HIV/AIDS prevalence rate is not a realistic performance indicator mainly because it is affected by several factors (incidence and mortality) and is difficult to monitor on a yearly basis; several other performance indicators are also not realistic and need to be refined; - Because MAP projects were new Bank instruments and were prepared in a relatively short timeframe given the urgency of the situation, their performance has been affected by ambitious project design and institutional arrangements as reflected by (i) the misalignment between the scope of project Page 6 activities and the available IDA funding; (ii) the short project lifetime to strengthen HIV/AIDS-related systems and achieve meaningful results; (iii) the slow start in building strong M&E systems early in project implementation; (iv) the weak coordination/harmonization of donor financing; and (v) the inherent complexity of using the same implementing and coordinating structures for both the MAP project and the national HIV/AIDS program. 9. Safeguard Policies (including public consultation) As a category B project, the Government of Mali developed, during preparation of the parent project, a Medical Waste Management Plan (MWMP), in compliance with National and World Bank safeguard policies. This study has been conducted in order to assess project potential negative impacts resulting from project-related activities and to determine mitigation measures that would minimize those negative impacts. The MWMP was prepared by an international consultant, using a broad-based public consultation approach, involving stakeholder groups in Government organizations, private sector institutions, NGOs and local communities within the country. The MWMP includes a clear description of project components, a significant baseline information, policy, legal, administrative and institutional framework within which the project is to be implemented, an analysis of potential positive and negative impacts, institutional arrangements, with clear roles and responsibilities for implementing and monitoring the plan, along with its capacity building requirements to effectively mitigate project negative impacts, as well as enhance its positive ones. The MWMP benefited from a stakeholder workshop, which was in March 2004. This workshop had a dual purpose: (i) to foster ownership on the part of stakeholders; and (ii)to seek their input in order to improve the plan. The final draft of the plan, which reflected stakeholder comments and suggestions, has been reviewed and approved by ASPEN and judged satisfactory. It has been disclosed in-country and at Bank InfoShop prior to appraisal of the parent project. It was also redisclosed prior to appraisal of the Additional Financing. 10. List of Factual Technical Documents - Project Appraisal Document to the Republic of Mali for a Multisectoral HIV/AIDS Project - Medical Waste Management Plan - Country Assistance Strategy of the Republic of Mali 11. Contact point Contact: Amadou Dem Title: Economist Tel: (202) 458-7740 Fax: Email: adem1@worldbank.org 12. For more information contact: The InfoShop The World Bank 1818 H Street, NW Page 7 Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop