Document of The World Bank PROJECT PAPER ON A PROPOSED ADDITIONAL FINANCING CREDIT TO THE REPUBLIC OF MALI FOR THE MULTI-SECTORAL HIV/AIDS PROJECT

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Finance and Private Sector Development Western and Central Afiica Africa Region Document of The World Bank FOR OFFICIAL USE ONLY PROJECT PAPER ON A PROPOSED ADDITIONAL FINANCING CREDIT IN THE AMOUNT OF SDR 4.1 MILLION (US$6 MILLION EQUIVALENT) TO THE REPUBLIC OF MALI FOR THE MULTI-SECTORAL HIV/AIDS PROJECT April 28, 29 Report No: 4859-ML This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

2 CURRENCY EQUIVALENTS (Exchange Rate Effective March 1,29) Currency Unit = FCFA US$1 = 489FCFA FISCAL YEAR January 1 - December 1 ABBREVIATIONS AND ACRONYMS AFA AfDB AIDS ART ARV ASCC CAS CBO CDC CMA CNPM CPAR CSCOM cso DGA DHS EO1 ES/HNAC FARAH FBO FHI FMA FMR FSW GOM GPlM GPN GPRS HNAC/HNLS HDI HPC HN IAS IAPSO ICB IDA IEC IEG HIV/AIDS Agenda for Action African Development Bank Acquired Immune Deficiency Syndrome Anti-Retroviral Therapy Anti-Retroviral Drugs HIV/AIDS Sector Control Committee Country Assistance Strategy Community-Based Organization Centers for Disease Control and Prevention (Atlanta) Contract Management Agency (Agence de maitrise d'ouvrage dlllgude) National Council of Malian Employers (Conseil National du Patronat Malien) Country Procurement Assessment Report Community Health Center (Centre de santd communautaire) Civil Society Organization Development Grant Agreement Demographic and Health Survey Expression of Interest Executive Secretariat of the High National Council on HIV/AIDS Financial Accounting Reporting and Auditing Handbook Faith-Based Organization Family Health International Fiduciary Management Agency Financial Management Report Female Sex Workers Government of Mali General Project Implementation Manual General Procurement Notice Growth and Poverty Reduction Strategy High National Council on HIV/AIDS (Haut Conseil National de Lutte contre le Sida) Human Development Index Highly Indebted Poor Country Human Immunodeficiency Virus International Accounting Standards United Nations Inter-Agency Procurement Services Office International Competitive Bidding International Development Association Information, Education, Communication Independent Evaluation Group

3 FOR OFFICIAL USE ONLY IFR INRSP ISBS KPI MAP MARP MOH MDG M&E MTEF MWMP NCB NSF NEPAD NGO 1 OVC PDO PIM PLWHA PMTCT PNLS PRSP QAG QCBS SME SOE STI SPN UNAIDS UNDP UNFPA UNGASS UNICEF USAID VCT WHO Interim unaudited Financial Report National Public Health Research Institute (Institut National de Recherche en Sad Publique) Integrated Sexually transmitted infections disease prevalence and Behaviour Survey Key Performance Indicator Multi-Country (Multi-Sector) HIV/AIDS Program Most-at-risk-population Ministry of Health Millennium Development Goal Monitoring and Evaluation Medium Term Expenditure Framework Medical Waste Management Plan National Competitive Bidding National HIV/AIDS Strategic Framework New Partnership for Africa's Development Non-Governmental Organization Opportunistic Infection Orphans and other vulnerable children Project Development Objective Project Implementation Manual People Living with HIV/AIDS Prevention of mother-to-child transmission National Programme against HIV/AIDS (Programme national de Lutte contre le SIDA) Poverty Reduction Strategy Paper Quality Assurance Group Quality and Cost-Based Selection Small and Medium Enterprise Statement of Expenditure Sexually Transmitted Infection Specific Procurement Notice Joint United Nations Program on HIV/AIDS United Nations Development Program United Nations Fund for Population United Nations General Assembly Special Session on HIV/AIDS United Nations Children's Fund United States Agency for International Development Voluntary Counseling and Testing World Health Organization Vice President: Country Director: Sector Director: Sector Manager: Task Team Leader: Obiageli K. Ezekwesili Habib Fetini Marilou Uy Iradj Alikhani Amadou Dem This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.

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5 REPUBLIC OF MALI MULTISECTORAL HIV/AIDS PROJECT ADDITIONAL FINANCING.. I I1 I11. N. V. VI.. VI1 VI11. TABLE OF CONTENTS INTRODUCTION... BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING IN THE AMOUNT OF US$6 MILLION... PROPOSED CHANGES... CONSISTENCY WITH CAS AND PRSP... APPRAISAL OF PROJECT ACTIVITIES... EXPECTED OUTCOMES... BENEFITS AND RISKS... FINANCIAL TERMS AND CONDITIONS Annexes Annex I: Proposed Activities under the Additional Financing and Estimated Cost... Annex 11: Revised Result Framework... Annex 111: Mapping of Donors Intervention in HIVIAIDS... Annex IV: Withdrawal of the Proceeds of the Credit.,... Annex V : Financial Management Arrangements... Annex VI : Procurement Arrangements... Annex VII: Safeguard Policy Issues... Annex VIII: Project Preparation Team... Annex IX: Republic of Mali at a Glance.,

6 PROJECT PAPER DATA SHEET Country: Mali Project Name: Multisectoral HIV/AIDS Project (Additional Financing) Sector Directormanager: Marilou Uy/ Iradj Country Director: Habib Fetini Responsible agency: Executive Secretariat of the High National Council on HIV/AIDS - Revised project development objectives/outcomes: Yes Does the scaled-up or restructured project trigger any new safeguard policies? No For Additional Financing [ Loan [X Credit [I Grant For Loans/Credits/Grants: Total Bank financing (US$m.): 6. Proposed terms: Standards IDA Credit terms Borrower IBRD/IDA Others Total Additional Financing Plan (US%m.) Source Local I Foreign I Total

7 I. INTRODUCTION 1. This Project Paper seeks the approval of the Executive Directors for the following proposals: (i) provide additional financing credit in the amount of SDR 4.1 million (US$6 million equivalent) to the Republic of Mali for the Multi-Sectoral HIV/AIDS Project (H99-MLI); (ii) a modification in the wording of the original Project Development Objective, in accordance with new Regional requirements for HIV/AIDS operations; and (iii) a two year extension of the project closing date from July 1, 29 to July 1, 211, needed for the completion of the project activities proposed under this additional financing request. No changes in the project components or implementation modalities are proposed. 2. The proposed Additional Financing would: (i) address the lack of funds that are necessary to achieve all the project.objectives, and contribute to filling the financing gap between the current project closing date (July 1, 29) and the availability of the Global Fund (GFATM) financing expected in the second half of 21; (ii) realign project development objectives and key performance indicators to the regional HIV/AIDS scorecard; and (iii) focus on developing country capacity in measuring the effectiveness of its national HIV/AIDS program. The proposed Additional financing will support priority activities with specific focus on improving access to HIV/AIDS services for most-at-risk-populations (MARP) including female sex workers and their clients, injecting drug users, men who have sex with men, miners, trucks drivers, seasonal workers, female ambulatory vendors, and female household workers.. The proposed Additional Financing is consistent with the umbrella restructuring of eight MAP projects in Africa' approved by the Board on absence-of-objection basis in June 27, 27. It will provide additional resources to the project which has made considerable strides toward reaching the Project Development Objective (PDO). In addition to supporting the Government in bridging the financing gap, the Additional Financing will capitalize on lessons learned from the past four years of project implementation and from overall regional experience. It will also capitalize on the Africa Region HIV/AIDS Agenda for Action (AFA), endorsed by the Board in November 27, which has four pillars: (i) focus the response, through evidence-based and prioritized HIV/AIDS strategies; (ii) scale up targeted multi-sectoral and civil society responses; (iii) deliver more effective results through increased country Monitoring & Evaluation capacity; and (iv) harmonize donor collaboration. 11. BACKGROUND AND RATIONALE FOR ADDITIONAL FINANCING IN THE AMOUNT OF USS6. MILLION Country context 4. Mali is one of the poorest countries in the world due to its limited resource base, landlocked status, vulnerability to external shocks, poor infrastructure, low levels of human development and weak administrative capacity. Its average income per capita was estimated at IDA proposed Umbrella Restructuring and Amendment of the Financing Agreements for the Projects under Multi-Country HIV/AIDS Program for Africa (May 27) 1

8 US$8 in 27. It is ranked 168 out of 179 countries in the 28 United Nations Development Programme 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 21 and 26. According to the 26 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 21 to 1. percent in 26 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. Epidemiological context 5. The first Acquired Immune Deficiency Syndrome (AIDS) case in Mali was recorded in By the end of 25, it was estimated by the United Nations Programme on HIV/AIDS (UNAIDS) that 1, people, including 16, children, were living with HIV/AIDS in 25; and that 11, adults and children had died of AIDS by end To monitor the evolution of the epidemic, the Government uses various instruments including the sentinel antenatal clinic (ANC) surveillance among pregnant women. This ANC surveillance has been carried out in 19 sites and has shown a stable prevalence rate among pregnant women at around. to.5 percent since 2. This represents a significant overestimation of the actual prevalence in the general population, estimated at 1. percent (1.5 percent among women and 1. percent among men) according to the 26 Demographic and Health Survey. This is partly due to the fact that rural areas are very much under-represented in the ANC surveillance. 7. There is a very large differential in Human Immunodeficiency Virus (HIV) prevalence between the general population and the MARP, especially female sex workers (FSWs), where HIV prevalence was 5 percent at the national level in 26, a figure more than 2 times higher than HIV prevalence in the general population of women. Furthermore, there is no region of Mali where population-based HIV prevalence was over 2 percent in the 26 DHS and it was under 1 percent in about half of the regions. It thus appears that the epidemic in Mali has more characteristics of a concentrated epidemic than of a generalised one. 8. It appears that the epidemic in Mali is mature and even in a declining phase. Indeed, HIV prevalence in the general population significantly decreased from 1.7 percent in 21 to 1. percent in 26. In addition, HIV prevalence declined or remained relatively low between 2 and 26 in most groups covered by the Integrated Sexually transmitted infections disease prevalence and Behaviour Survey (ISBS). A notable exception relates to FSWs where HIV prevalence increased from 29 percent in 2 to 5 percent in 26. In Mali, in relation to religious and cultural norms, women get married with men who are on average 7.5 years older than they are, and polygamy is frequent. In addition, female literacy rates are among the lowest in West Africa. Women (especially young women) are thus particularly vulnerable in general, and vulnerability factors may bring some of them to prostitution. With the increase in poverty, 2

9 FSWs may themselves have become more vulnerable with time, especially in a poverty context where condom use is far from being the norm among men, thus leading to the observed increase in HIV prevalence among FSWs. 9. With such an increase among FSWs, despite the favourable trends observed in the general population over the last years, there is a real risk of resurgence of HIV spread to the general population in the near future, especially in the context of recent and upcoming increase in investments in the agricultural sector, in mines, in hydro-electric dams and in petrol extraction that will bring many men into migration for work and geographical celibacy. 1. Finally, although no data are currently available on HIV epidemiology among men who have sex with men (MSM) in Mali, recent behavioural data on this population suggest that they constitute a highly vulnerable population that could also act as a bridging group for HIV spread in the general population. Government response to HI V/AIDS 1 1. The initial response to the HIV epidemic in Mali was implemented in 1987, and until 2, it was solely under the responsibility of the Health Ministry, through the PNLS (National AIDS Programme). 12. In 24, Mali established a High National Council for HIV/AIDS (HNAC), under the Office of the President, to plan, coordinate and implement the country s multi-sectoral effort to combat HIV/AIDS. This was in response to the limited effectiveness of previous effort to fight HIVIAIDS due to the fact that the response was primarily framed as a health issue, but not a critical development issue engaging virtually all sectors and elements of society. The public sector, the private sector, and civil society including people living with HIV/AIDS (PLWHA) are equally represented in the High Council. The Executive Secretariat of the HNAC (SE/HNAC) was established, with the new structure based on the Three Ones principles advocated by UNAIDS. 1. A Letter of Sector Policy was prepared in 24 and provided guidance for the preparation of a National HIV/AIDS Strategic framework (NSF) to fight HIV/AIDS which covered the period. The strategic framework has three strategic axes: (i) to promote a favourable environment for the appropriation, durability and good governance of the response; (ii) to reduce risks and vulnerability linked to the epidemic; and (iii) to mitigate the social, economic and cultural impacts of the epidemic. All development partners including UNAIDS, World Health Organization (WHO), UNDP, United Nations Children s Fund (UNICEF), USAID, Canada, the Netherlands, the World Food Programme (WFP), UNFPA, UNESCO, GTZ, France and the World Bank were involved throughout the preparation process. In the NSF 26-1, the total budget needed for implementation was estimated at $US One National AIDS Coordinating Authority, with a broad-based multisectoral mandate; One agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; One agreed country-level monitoring and evaluation system.

10 296 million, Of this, 4 percent is for prevention; 4 percent for treatment and care and 2 percent for coordination. Project Background 14. The Mali MAP is consistent with the strategic framework of the World Bank strategy, IntenszJLing Action against HIVIAIDS in Africa, endorsed by the Board in 21. It is one of the few MAP projects managed by a non-hd sector unit, in this case Finance and Private Sector Development (AFTFP). Prior to its approval and effectiveness, the Government agreed to use exceptional implementation arrangements by recruiting two external private sector firms to handle all financial management and procurement issues to ensure rapid implementation of the project. 15. The current stage of the project implementation requires that adjustments be made to capitalize on lessons highlighted in the World Bank s MAP Interim Review (24), OED Evaluation of Global HIVprojects (25), and Quality Assurance Group (QAG) reviews of MAP projects and lessons learned from the implementation of the Mali MAP. These lessons, which are presented in paragraph 26, guided the restructuring of eight MAP projects in Afiica approved by the Board in 27. The Mali MAP was not included in the restructuring package because, at the time, the team had already received the preliminary results of the fourth Demographic and Health Survey indicating that the country s prevalence rate had declined, which is consistent with the stated PDO. Refinements to the results framework were envisioned to take place during the mid-term review initially scheduled for 27, but this was delayed because of (i) the prevailing political situation throughout 27 which was a presidential and parliament election year; and (ii) the late completion of the mid-term review report by the Government. Project Performance 16. Progress toward achievement of project development objectives (PDO) has been consistently rated satisfactory since the project became effective. It was recently downgraded to moderately satisfactory to reflect the gaps in a few overambitious targets as presented in paragraph 24. The HIV/AIDS prevalence rate was at 1. percent in 26 (below its 21 level of 1.7 percent) as documented in the latest demographic and health survey (DHS, 26). As summarized in the following paragraphs and presented in greater detailed in Annex I1 (a), access to testing facilities, treatment and care has considerably improved. The country s capacity to address the epidemic has also been strengthened. Overall, MAP has been successful in developing country systems that have been used by other development partners. The Global Fund has for instance financed 6 sub-projects using the Contract Management Agency and the Financial Management Agency, both recruited by the HNAC under MAP. Development partners also rely on the Monitoring and Evaluation (M&E) system that MAP has contributed to building. 17. Key achievements: Key achievements of the national HIV/AIDS response, to date, are presented below. 4

11 18. Support to the public sector responses. All ministries have elaborated and are implementing their sectoral action plan. 9 percent of their employees have been sensitized on HIV/AIDS which is above the 8 percent initial target. The Ministry of Health which has the largest sectoral plan (mainly financed by the Global Fund), launched activities related to capacity development within the health sector. Access to public health services has improved. About 8 Public health centers (centres de reference and centres de sante communautaire) are now providing Voluntary Counseling and Testing (VCT) services (compared to 15 before the project was approved). This is however below the target of 45 public health centers. While this target seemed achievable in the beginning because of the presumed ease of scalability, the continued shortage of skilled staff in these public health centers proved that it was nevertheless overambitious. 19. Support to the private sector responses. This component targets the business community, including all firm sizes, throughout the country. In addition to demand-driven initiatives, a strategic option was made to initiate a business coalition which was created in 25. The coalition now has 4 members, most of which have developed HIV/AIDS action plans. In addition, other initiatives have been implemented by 18 firms outside the coalition. Most of the activities have been geared towards awareness raising. Due to the limited cooperation from key business associations such as the Chamber of Commerce and the Employers Association so far, the target of 1 firms that were expected to have developed HIV/AIDS action plans has not been reached yet. Access to HIV/AIDS related health services provided by the private sector is also improving. A private laboratory has provided quality services to monitor the health condition and treatment needs for more than 7, patients which have allowed them to access Anti-Retroviral Drugs (ARVs). A private pharmacy/importer has been selected to import and deliver ARVs drugs to private pharmacies. This will enhance access to ARVs which have been so far imported and distributed only through the public sector. 2. Support to the Civil Society responses. Civil Society Organizations (CSOs) are now more involved in combating HIV/AIDS. About 28 CSOs have benefited from the project and provided counselinghesting services as well as HIV/AIDS prevention campaigns. A total of 27 sub-projects have been implemented among commercial sex workers. This is below the project target of 75 which has not been reached due to the fact that several sub-projects targeting highrisk groups submitted to the MAP for financing were not approved because they were located in cities where the Global Fund was already providing support. (In total, the Global Fund supported 6 sub-projects, including 9 sub-projects targeting commercial workers, youth, uniformed services, and truckers) Project coordination, monitoring and evaluation. Project Management and Implementation progress (IF) are rated satisfactory. The project has now disbursed about 95 percent of the grant. The disbursement rate was low during the first two years of project implementation, but quickly increased as the ES/HNAC became more effective and the beneficiaries became more familiar with the procedures. The ES/HNAC is now coordinating This includes Centers supported by the Global Fund. 5

12 effectively the implementation the country s multi-sectoral effort to combat HIV/AIDS in close coordination with the Ministry of Health. It has made significant progress to design and implement the monitoring & evaluation system, but data collection, especially at the decentralized level, is still difficult due to lack of human and financial resources. Financial Management and Procurement performance are rated satisfactory. Finally, the project is in compliance with the legal covenants; the audits and financial management reports have been submitted. Procurement audits have been undertaken annually by independent auditors with unqualified audit opinions. There are no major fiduciary issues. 22. Key challenges. Significant progress was made in the fight against HIV/AIDS in Mali, but several challenges presented below remain to be addressed mainly in two critical areas: (i) better targeting MARP; and (ii) mainstreaming of HIV/AIDS in Government programs. (a) Targeting MARP. The challenge is to better and quickly implement interventions targeting MARP, especially commercial sex workers for which the prevalence rate has increased. In the past, interventions were not well focused. Not enough sub-projects were prepared by CSOs to implement communication and Voluntary Counseling and Testing (VCT) activities targeting MARP. There is now an urgent need to implement well targeted and evidence-based prevention program. (b) Mainstreaminri. Mainstreaming the fight against HIV/AIDS in Government programs is not yet fully effective. The capacity of the Government to mainstream needs to be strengthened, especially now that the World Bank is increasing budgetary support operations. HIV/AIDS action plans are now available for all the ministries. But the Ministry of Finance and the ES/HNAC need to work more closely to identify and cost priorities and reflect it in the budget. Rationale for Additional Financing 2. 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 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 26 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. 24. To avoid interruption in the provision of essential services, the proposed Additional Financing will focus on critical activities for which support needs to be continued until Government capacities are improved and the Global Fund provides its additional support expected in the second half of 21. The resources required to implement the additional activities to fully reach all the targets initially set in the MAP project have been estimated at approximately US$18 million4. This represents a relatively large financing gap which, as The additional financing does not provide US$18 million because a few unrealistic targets will be revised downward. 6

13 presented in paragraph 26, reflects the misalignment between the scope of project activities and the available International Development Association (IDA) funding which characterized most of the MAP projects. Ambitious targets which were set in the original result table include mainly: (i) the number of public and private VCT centers; (ii) the number of health facilities with means to dispose of medical waste; and (iii) the percentage of men age aware of their serologic status. As presented in Annex 11, the unit costs of these activities were also underestimated. As indicated in paragraph below and annex I1 (a), a few targets for the key performance indicators will be revised downward The Additional Financing will strengthen the institutions and country systems supported so far with the objective of accelerating the mainstreaming of the fight in Government programs in order to contribute to sustainability after the project closes. 26. The Additional Financing will capitalize on the lessons learned from the implementation of MAPS across the Africa region6. The lessons are summarized as follows: - HIVIAIDS 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 World 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 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 coordinatiofiarmonization 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. 27. The Additional Financing under OP 1.2 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 PROPOSED CHANGES 28. In line with the 27 umbrella restructuring of MAP projects, several changes are proposed to take into account the lessons learned. The proposed changes are presented below. 29. The Project Development Objective (PDO) remains substantially the same, but its wording has been slightly refined. The depreciation of the dollar against the Franc CFA has also contributed to increasing the actual cost of goods and services which was initially estimated in dollars. 1 World Bank s MAP Interim Review (24) and OED s evaluation of global HIV/AIDS projects (25). 7

14 Current Project Development Objectives. The current project objective is to support the Recipient s multi-sectoral efforts to control the spread of the HIV/AIDS epidemic and provide sustainable access to treatment and care to 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; (b) raising the level of awareness on HIV/AIDS through the implementation of a comprehensive sensitization plan targeting high risk groups, such as the youth, sex workers and truck drivers; (c) providing sustainable access to testing and counseling facilities; (d) providing access to treatment, care and psychosocial support to persons infected with or affected by HIV/AIDS; and (e) strengthening the Recipient s capacity to address the HIV/AIDS epidemic and to maintain an effective monitoring and evaluation system. Proposed Project Development 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/AIDS8. 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 HN/AIDS.. The project results matrix will be revised to align it with the new World Bank HIV/AIDS scorecard. The indicators of the HIV/AIDS Scorecard are mainly drawn from the set of international indicators adopted during the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) that all countries have agreed to report on. The scorecard complies with the Paris Declaration to reduce burden on the countries and take into account indicators from the Global Fund and U S Government s PEPFAR. The prevalence rate as a PDO indicator is inappropriate and will be eliminated as recommended by the 24 World Bank s MAP interim review. The result table will also be revised by adding new PDO level indicators which were obtained from the previous intermediate indicators, and by introducing indicators for monitoring of activities targeted to MARP. A few targets for the key performance indicators (KPI) will be revised downward. This stems from the fact that, given the lack of knowledge that prevailed during project preparation, several original targets were set at overambitious levels which were then found to be unrealistic to reach with the available fund. The revised result table with the new PDO level indicators and KPI is presented in Annex The main changes are: (i) an emphasis that the project will contribute to the effort, (ii) the use of the word MARP to stress that the project will focus on vulnerable groups; and (iii) the merging of objectives (a) and (e) of the current PDO. * Infected people are also targeted by prevention activities to mainly sensitize them on how the virus is transmitted. Orphans are among those most affected by HIV/AIDS and will continue to be supported by the additional financing. They are included in the Africa Region HIV/AIDS Result Scorecard as an important indicator whch needs to be monitored. 8

15 11. The result table also shows the performance gaps which the additional financing will address. The KPI which will be dropped either because they have been achieved or are not realistic are also presented in the same annex. The summary list of KPIs for the period of additional financing only is listed in section VI (Expected Outcomes). 1. The proposed new activities to be supported are presented below and take into account ongoing or expected support from other donors including the Global Fund. They are summarized in a table presented in Annex I, which also relates each activity with the KPI to be monitored. 2. Component 1: Support to public sector response (US$2.5 million). 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 communicationg. 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. 4. Component 2: Support to the response of the private sector (US$1.2 million). 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. 5. 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 Technical discussions highlighted that the Ministries of Education and Communication are important because of their potential role in communicating about HIV/AIDS; the ministries of Agriculture and mining are also important because a large part of the population, including high risk groups, is employed by their sectors. lo Conseil National du Patronat Malien (CNPM), Chambre des mktiers, Chambre du Commerce 9

16 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. 6. 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 7, 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. 7. 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 : Support to the Response of the Civil Society (US$1.4 million). Given that Mali is a 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 5 percent between 21 and 26. 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 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. 1

17 9. 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 campaign against stigmatization. This is expected to encourage individuals to access to testing, treatment and care, which are important to effectively fight the epidemic. 4. Comvonent 4: Project Coordination, Monitoring and Evaluation (US$ 1.5 million). 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. The FMA s 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 1, 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. 42. The Additional Financing will also assess the impact and effectiveness of the governance arrangements, particularly with respect to social accountability. This would help in the efforts to mainstream the activities in Government programs and ensure sustainability. Before the end of the project, the Government will prepare and start to implement a strategic plan to sustain the Executive Secretariat and the national program after project closing. 4. Extension of closing date and budget allocation. The proposed Additional Financing will extend the closing date by two years from July 1, 29 to July 1, 21 1 to provide sufficient time to implement the new activities. 11

18 44. The cost and financing allocation for the original operation and for the proposed additional financing are presented, by project component, in Table 1 below. As previously noted, the US$6. million Additional Financing will cover activities that the Government considers most urgent, and that can be implemented during the time available under the timefi-ame of the extended MAP. Other priority activities will be supported by the budget and by resources the Government is expected to mobilize from other development partners. Component Original Proposed Project Financing Additional Financing (US$ million) (US$ million) Support to the response of the public sector Support to the response of the private sector Support to the response of the civil society Coordinate, M&E IV. CONSISTENCY WITH CAS AND PRSP 45. As stated in paragraph 22 of the FY8-12 Country Assistance Strategy (CAS), Mali will probably meet its Millennium Development Goal (MDG) s HIV/AIDS targets if it maintains recent momentum. The MAP has contributed to this momentum. The Additional Financing will contribute to the achievement of one of the expected results of the CAS improve quality of HIV/AIDS related services, which is in line with the third pillar of the Growth and Poverty Reduction Strategy Framework (GPRSF), strengthening the social sector. V. APPRAISAL OF PROJECT ACTIVITIES 46. Project Implementation Arrangements. 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 effort to fight the disease. This is expected to strengthen the Government s system to combat HIV/AIDS in a more sustainable manner. 47. Project analyses. The activities to be supported under the additional financing were discussed and selected during technical discussions with the public sector, the civil society and the private sector. The discussions took into account QAG and the Independent Evaluation Group (IEG) recommendations on HIV/AIDS programs to improve their effectiveness. The Additional Financing will mainly focus on priorities and will take into account ongoing or 12

19 expected support from other donors, including the Global Fund, presented in Annex 111. It will not affect the original economic, financial, technical and social aspects of the project. (a) Fiduciary Analysis. The financial management capacity of the Secretariat is now adequate. The Executive Secretariat in liaison with the Financial Management Agency (FMA) has performed satisfactorily under the original project and will carry out and oversee execution of the additional activities. During the.evaluation mission for the Additional Financing, financial management review was carried out by the World Bank and assessed as satisfactory. The staff is familiar with World Bank financial management procedures and has sound accounting and financial management systems in place. The Financial Management Agency and the Procurement Management Agency recruited under MAP will be phased out progressively since the number of sub-projects to be managed will be considerably reduced. The financial management aspects and arrangements are presented in greater details in Annex V. With respect to theflow of funds and disbursement Arrangements, funds will flow from the IDA credit account to the designated account to be opened in a Commercial Bank on terms and conditions acceptable for IDA under the responsibility of the Executive Secretariat. As the project s unit is familiar with the disbursement based on the FMR, IDA may disburse funds based on the report at effectiveness. The financial unit will have the responsibility to make sure that expenditures are eligible and to process payments and maintain the project accounts. The procurement unit is staffed by one procurement officer. Its performance has been rated satisfactory. It will need to be further strengthened with adequate procurement training to the procurement specialist, but also the relevant technical specialists which need to provide input in the preparation of procurement documents. As presented in paragraph 4, the CMA is already transferring its capacity to the procurement unit. A detailed procurement plan has been prepared for the Additional Financing. Procurement would be carried out in accordance with the World Bank s Guidelines: Procurement Under IBRD Loans and IDA Credits dated May 24, revised October 26; and Guidelines: Selection and Employment of Consultants by World Bank Borrowers dated May 24, revised October 26. A detailed analysis of the procurement arrangements is presented in Annex VI. (b) Economic Analysis. A cost benefit analysis was completed under the original project. It stressed the difficulty to measure the impact of the project on the economy given the complexity of the dynamics between HN/AIDS and the economy and the uncertainty about the evolution of the epidemiological situation. Nevertheless, a simple model was used, with conservative assumptions, to give a sense of the trends. Based on results achieved so far, mainly in terms of number of people who now have access to ARVs, the ongoing project and the Additional Financing are expected to contribute to positive benefits through reducing output/income losses due to depletion of human capital resulting from deaths and other impediments related to the disease (absenteeism, labor turnover, recruitment and training costs of new workers, health expenditures, decline in labor productivity). The Additional Financing is responding to the Government of Mali s (GOM) request to continue providing support to The main donors are the Global Fund, the World Bank and the African Development Bank (AfDB). The Global Fund supports the civil society and the public sector with a focus on prevention, strengthening health system and providing ARVs. It does not provide support to the private sector. AfDB provides mainly support in four regions (Mopti, Gao, Timbuktu and Kidal) and focus on supporting women education, income generating activities, and ARVs. 1

20 continue supporting key activities and bridge the gap with financing expected later from other donors. It will contribute to alleviating the fiscal burden that the Government would have faced, in its absence, to provide the necessary prevention and care which are important for economic and social welfare of infected and affected people. The capacity of the Government to collect data is expected to further improve with the additional financing and will allow the preparation of an ex-post cost benefit analysis. (c) Technical Analysis. The team carried out a thorough discussion of technical issues that are relevant to the project. These include the quality of the sensitization toolkits, the testing facilities, the laboratory services, and the provision of ARVs and other drugs. Quality of services from the private laboratory is satisfactory. The quality of testing services provided by non-government Organizations (NGOs) is confirmed and monitored by the Ministry of Health, through the National Institute of Public Health Research, and only experienced NGOs which meet the quality standards will be considered for support under the Additional Financing. Joint field missions are regularly conducted by the Ministry of Health and the ES/HNAC to control quality and assess the performance of the system. The Global Fund is providing support to strengthen the capacity of the Ministry of Health to control and enforce quality. ARVs, other drugs, and reagents are controlled by the Direction de la Pharmacie et du Me'dicament and the Laboratoire Nationale de la Sante' to ensure their quality and compliance with regulations as well as with sale authorization requirements. (d) Monitoring & Evaluation. An M&E system is now in place in Mali. It is coordinated by the ES/HCNLS. The quality of the data collected and reported has been reviewed by a technical mission from the Global Fund in September 28, which considered the quality as satisfactory. However, the capacity to collect short term data still needs to be enhanced to allow timely monitoring of epidemiological trends (e) Environmental Analysis. The proposed Additional Financing will not change the environmental category and will not trigger the social safeguards. The medical waste management plan (MWMP) prepared under the parent project, and redisclosed prior to appraisal of the additional financing, will continue to be implemented. Mali has reasonable capacity to implement the MWMP as demonstrated during the period of this project implementation. This has been confirmed by the findings of a recent review of the implementation of the existing MWMP by the Executive Secretariat of the High National Council against HIV/AIDS. Supervision conducted in the regions highlighted that considerable progress has been made since the beginning of the MAP. A total of 6 health centers have been supported by the project to enable them to dispose of medical waste. The Additional Financing will continue to provide support to more health centers by providing basic equipment and training to hundred health centers to enable them to dispose of medical waste adequately. The World Bank will remain engaged with active implementation support of safeguards-related issues. Also, there is a provision under this Additional Financing to further strengthen the capacity of the various actors involved in mitigation of related environmental risks and to finetune the institutional arrangements for better implementation of the project by continuing to support sensitization and awareness raising campaigns on environmental issues. 14

21 (f) Social Analysis. There will be no new construction or land acquisition which would trigger social safeguards, Building on the comprehensive set of data on sensitization, VCT, treatment and care services provided by the MAP, the Additional Financing will provide resource to conduct a detailed evaluation of the impact of these services on the targeted communities. This will feed into the implementation completion report. 48. Sustainability. Key issues related to the institutional, technical, and financial sustainability of the proposed Additional financing are summarized below. (a) Institutional sustainabilitv. The sustainability of the fight against HIV/AIDS is contingent on the quality of the institutional framework set up by the Government since 24 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 sustainabilitv. Financial sustainability of the effort continues to be a major risk for the program. Hence, GOM s commitment to adequate fbnding 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 21 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 ESEICNAC 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 World Bank is increasingly providing support through the budget. (c) Technical sustainabilitv. 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 World Bank are also expected to strengthen the health system including the health centers. VI. EXPECTED OUTCOMES 49. The additional financing is expected to: (i) refocus the project on prevention focusing on MARP and drivers of the epidemic; (ii) enable the project to reach realistic and measurable targets; and (iii) strengthen the institutional arrangements to better organize the fight against HIV/AIDS and mobilize resources. 15

22 5. The project will continue to monitor, track and report on results achieved through its support for public, private and civil society response to HIV/AIDS in addition to establishing a baseline for future tracking of results of HIV prevention efforts among MARP. A detailed review of results achieved to date has been conducted, new targets have been developed and agreed with the Government, and additional indicators have been proposed in order to ensure that the set of project KPIs is able to measure results on all aspects of the PDO. Annex I1 (a) provides a detailed summary of results achieved to date, proposed indicator changes and revised targets (as applicable). 51. Data on MARP is currently lacking and there is a need to further understand the context of risk and the drivers of the HIV epidemic in Mali. Through the Additional Financing, the project will support the establishment of rigorous mapping, ethnography and behavioral surveillance among MARP in order to (i) establish baseline for targeting and future results measurement for the project especially on activities focusing on MARF'; and (ii) to build the capacity of the Government to undertake similar studies in the future as part of its monitoring and evaluation system. Because of this current lack of data, it is difficult to estimate and/or propose targets related to the effect of the project interventions among MARP. 52. The Key Performance Indicators which will continue to be monitored under the additional financing are presented below: At least 15, orphans attend school regularly by July 1,21 1 At least 9, PLWA medically eligible for treatment (CD4 count less than 2) are under ARV treatment by July 1, At least 55, persons aged 15 and older received counseling and testing (VCT) for HIV and received their test results 6 percent o f HIV+ pregnant women assisted for prenatal care received ARV prophylaxis (PTME) by end of project 257 reference centers (circles & communes) and CSCOM offer testing and counseling by end of project 16 reference centers (circles & communes) and CSCOM structures have means to dispose o f medical waste by the end of the project At least 1 enterprises and business associations have implemented HIV/AIDS action plan by the end of the project Number of private centers offering VCT services increased from 15 to 25 7 patients have access to treatment monitoring services by private laboratory 15 commercial sex workers and other MARP receive services from subprojects At least 25 sub-projects implemented among commercial sex workers and/or high risk groups (truck drivers, ambulatory vendors, military/police, etc) annually VII. BENEFITS AND RISKS 5. Overall, the public sector, the private sector and the civil society will benefit from the Additional Financing. More specifically, ministries will be able to better mainstream the fight against HIV/AIDS into their program and mobilize resources from the Government budget. Private firms will be able to better sensitize their employees and better meet their corporate social responsibilities. The capacity of the civil society will be strengthened. As a result, the population will have a better access to HIV/AIDS related information, VCT, treatment and 16

23 care. At the country level, the institutional framework to coordinate, implement, monitor and evaluate the program will be enhanced. The strengthening of the advocacy role of the Executive Secretariat and its ability to show results will enable it to better mobilize resources. 54. Three main potential risks have been identified. First, the global financial crisis could lead to a reduction of donors assistance to support the national HIV/AIDS program which could hamper the sustainability of efforts to provide access to treatment and care. The Additional Financing, which focuses on prevention, has very limited resources allocated for ARVs. This risk is mitigated by Government s commitment to mobilize its budget to ensure availability of hnds to sustain people on ARV. Also, as previously noted, considerable effort has been made under MAP to prepare HIV/AIDS sectoral plans for the Ministries. The Ministry of Finance s Poverty Reduction Unit is working closely with the ES/HCNAC to ensure that HIV/AIDS is mainstreamed into government programs. This is expected to help the Government better plan and sustain its effort to fight HIV/AIDS especially since the World Bank is increasingly providing support through the budget. Second, there is a risk that the relatively high number of sub-projects targeting high-risk groups will not be implemented within the two years o f the additional financing. This risk is mitigated by the strategic choice to sign performance based contracts with a core group of experienced local CSOs which will be selected in a timely manner. Third, the Contract Management Agency (CMA) will be progressively phased out and replaced by the Procurement Department of the ES/HNAC. There is a risk that the procurement department of the ES/HNAC will not have the capacity to quickly take over from the CMA. This risk is mitigated by a strengthening of the capacity of the procurement department which has started with an increased collaboration between the procurement department and the CMA. In addition, the number of activities to be managed will be reduced sharply from more than to less than, approximatively. VIII. FINANCIAL TERMS AND CONDITIONS 55. The Additional Financing of US$6 million equivalent will be provided as a credit, according to the category allocations presented in Annex IV. 56. Only one special account will need to be opened under the Additional Financing. There are no conditions for disbursement. 17

24 Annex I: Proposed Activities under the Additional Financing and Estimated Cost1* Related KPI Additional Proposed Activities supported Financing (from annex II) ~S$OOO) I - Support to the response of the Public Sector 2,5 - Equipment and training for 25 health centers to become HIV/AIDS treatment centers (new activity) - Basic equipment and training for 1 health centers (CSREF and CSCOM) to offer counseling and testing (VCT) - Basic equipment and training for 1 health centers (CSREF and CSCOM) to dispose of medical waste - Technical assistance for selected ministries for HIV/AIDS mainstreaming and implementation of targeted sensitization campaigns - ARV prophylaxis (PTME) for pregnant women with HIV/AIDS 29 9,6 8 I I1 Support to the response of the private sector 1,2 - Operating cost and technical assistance for the Business coalition (the TA is a new 8 15 activity) - Technical assistance for members of the Business coalition (for action plan and 8 5 scale up of selected successful activities) - Senzitization campaigns for business coalition members Contract for Public Private Partnership in laboratory services (monitoring of 15 2,lO 4 patientdmonth) - Contract for Public Private Partnership in ARVs provision and distribution (1 2 patientdmonth) - Basic equipment and training for health centers in selected major private companies I11 - Support to the response of the civil society - 5 sub-projects for high risk and vulnerable groups 1,, Sensitization campaign against stigmatization Equipment and capacity building for Association of PLWHA 11 2 IV - Project Coordination, Monitoring and Evaluation 1,5 - Operating cost (Staff, CMA, FMA, Audit, system evaluation, HIV/AIDS MTEF) 8 Monitoring and Evaluation (survey and studies) 4-19 Surveillance system (sentinel sites for pregnant women) 1 Technical assistance for review of legal f?amework against stigmatization 5 1,4 l2 Annex I1 (b) presents the activities of the parent project which will not be supported by the additional financing. 18

25 M a El cr a U.% a.i 9.I H.I P a h a 1 a El Y.I E a a Y E E I 2 E cr d v) c, H B 8 a s.a 2 I I- O m F 2 8 ", d m z- c

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32 Annex IV: Withdrawal of the Proceeds of the Credit Category Amount of the Credit Allocated (Expressed in US Dollar Equivalent) % of Expenditures to be Financed (1) Civil Works, 4,9, Goods, 1% (2) Subprojects TOTAL 1.1, 1% of disbursed amounts 6,, 26

33 ~ Annex V: Financial Management and Disbursement Arrangements The inherent risk of the public financial management system in Mali is rated Substantial at the country level. The Government has adopted a framework to improve and modernize the country s public financial management (PFM) system. The Government s Action Plan for improving and modernizing public financial management (PAGAM-GFP) is a component of the larger program on institutional development (Institutional Development Program) that the authorities are implementing in the context of the country s growth and poverty reduction strategy. The 28 PEMFAR prepared by the World Bank and the European Union, shows that the reform program has yielded progress in PFM but a number of challenges remain, including: (i) strengthening the integration between the budget and the country s poverty reduction strategy towards the multiyear programming framework, (ii) eliminating delays in the consolidation of budget information and the production of comprehensive and regular in-year annual budget execution reports, and (iii) reinforcing the external audit by increasing the capacity of the Section of Accounts of the Supreme Court. Due to widely dispersed spending units with large number of small transactions, the inherent risk at entity level is rated Substantial as well as at project level. Therefore the overall inherent risk is rated Substantial. Risk Inherent Risks: Country: Poor governance Risks remain in term of quality and timeliness of in-year budget reports and annual financial statements and effectiveness o f external audit and legislative scrutiny of the annual budget law Entity: While institutional framework is in place, implementation may be hampered by political interference Project: Dispersed spending units with large number of small transactions Control Risks: Budgeting: Budgeting preparation process n clearly defined Accounting: Risk Rating S S S M M M M Risk Mitigation Measure The issue regarding delay in production of accounts is being resolved with the interconnection of the expenditure channel. Concerning external audits, discussions are in progress with the government to reinforce the capacity of the section of accounts Previous experience in follow up of transactions with AGF assistance 1 The existing software will be customized to fit the additional financing needs Residual Risk 1 Rating I s I M L 27

34 will be extend to carry out the external audit of the additional Overall R isk M M The overall control risk for the project is rated Moderate. The Executive Secretariat in liaison with the Financial Management Agency (FMA) has performed satisfactorily under the original project and will carry out and oversee execution of the additional activities. During the evaluation mission for the Additional Financing, financial management review was carried out by the Bank and assessed as satisfactory. The staff is familiar with World Bank financial management procedures and has sound accounting and financial management systems in place. The external auditor expressed an unqualified opinion on the 27 Financial Statements in compliance with International Standards on Auditing (ISAs). Some internal control weaknesses have been raised in the management letter referring to the absence of measures taken to save assets available to beneficiaries, and the non respect of training mechanism and beneficiaries supervision before the financing of sub projects. An action plan is being implemented to address these internal control issues. Strengths and Weaknesses Adequate staff, computerized accounting and financial management information systems are in place with a budgetary process. Nevertheless, the internal control system needs to be improved by a better supervision of transactions and coordination between fiduciary agencies. Information Systems A project-specific financial management system will be customized in the existing accounting software. The project chart of Accounts will accommodate the proposed additional financing to capture sources and uses of funds, assets and liabilities in sufficient detail. The system should integrate the Budgeting, Operating, and Accounting applications to facilitate monitoring and reporting. 28

35 Accounting Policies and Procedures Project accounts will be maintained on an accurate basis, augmented with appropriate records and procedures to track commitments and to safeguard assets. The Chart of Accounts will facilitate the preparation of relevant quarterly and annual financial statements, including (i) project expenditures, and (ii) total expenditures on each component/activity. All accounting and control procedures will be documented in the Administrative, Accounting and Financial Manual, a living document that will be regularly updated by the project s coordination unit. Internal controls The FMA will perform ex-post audits and the Executive Secretariat will take actions needed to ensure the continuing adequacy of the conformity with the project s procedures and other due process. External audits The external auditor newly recruited will carry the audit of MAP/HIV AIDS financial statements including the additional financing. The Terms of Reference (TOR) and scope of this audit will be expanded and the auditor s contract will be amended. A single opinion on the Project Financial Statements in compliance with International Standards on Auditing (ISAs) will be required. In addition to the audit reports, the external auditors will submit a Management Letter giving observations and comments, and providing recommendations for improvements in budgeting, accounting records, information systems, controls and compliance with financial covenants. Flow of funds and disbursement arrangements Funds will flow from the IDA credit account to the designated account to be opened in a Commercial Bank on terms and conditions acceptable for IDA under the responsibility of the Executive Secretariat. As the project s unit is familiar with the disbursement based on the FMR, IDA may disburse funds based on the report at effectiveness. The financial unit will have the responsibility to make sure that expenditures are eligible and to process payments and maintain the project accounts. Interim unaudited Financial Reports (IFRs) Quarterly consolidated IFRs (including additional financing activities) to be produced will include sources and uses of funds by project components/activities. They will also include a comparison of budgeted and actual project expenditures to date and for the quarter. Project Management will produce the IFRs by no later than 45 days after the end of each quarter. The project will produce Annual Financial Statements, and these statements will comply with International Accounting Standards (IAS) and World Bank requirements. These Financial Statements 2wiii comprise of: 2 It should be noted that the program financial statements should be all inclusive and cover all sources and uses of funds and not only those provided through IDA funding. It thus reflects all project activities, financing, and expenditures, including funds from other development partners and contributions in kind such as labor and accommodation, irrespective of whether the program implementing agency controls the funds for a particular aspect of the program. 29

36 a. b. C. d. A Balance Sheet reflecting the assets, liabilities and funding of the project based on the cash basis. A Statement of Sources and Uses of Funds / Cash Receipts and Payments, which recognizes all cash, receipts, cash payments and cash balances controlled by the entity for this project; and separately identifies payments by third parties on behalf of the entity. The Accounting Policies Adopted and Explanatory Notes. The explanatory notes should be presented in a systematic manner with items on the Balance Sheet and Statement of Cash Receipts and Payments being cross-referenced to any related information in the notes. Examples of this information include: A Management Assertion that project funds have been expended for the intended purposes as specified in the relevant financing agreements. Financial Covenants The Borrower shall maintain or cause to be maintained a financial management system including records, accounts and preparation of related financial statements in accordance with accounting standards acceptable to the Bank. The Financial Statements will be audited in accordance with international auditing standards. The Audited Financial Statements for each period shall be furnished to the Association not later than six (6) months after the end of the project fiscal year. The Borrower shall prepare and furnish to the Association not later than 45 days after the end of each calendar quarter, interim un-audited financial reports for the Project, in f om and substance satisfactory to the Association. The Borrower will be compliant with all the rules and procedures required for withdrawals from the Designated Account of the additional financing. Supervision Plan Supervision activities will include: (i) review of quarterly IFRs; (ii) review of annual audited financial statements and management letter as well as timely follow up of issues arising; (iii) and participation in project supervision missions, as appropriate. The Bank FMS in charge will play a key role in monitoring the timely implementation of the financial management arrangements. In the first year after effectiveness, two on-site FM visits will be undertaken. Subsequently, the intensity of on-site FM visits will be based on the assessed FM risk for the project, i.e. if the risk rating remains as moderate, there will be only one on-site visit per annum.

37 Annex VI: Procurement Arrangements A. General Procurement for the proposed additional financing for the Mali MAP project would be carried out in accordance with the World Bank s Guidelines: Procurement Under IBRD Loans and IDA Credits dated May 24, revised October 26; and Guidelines: Selection and Employment of Consultants by World Bank Borrowers dated May 24, revised October 26, and the provisions stipulated in the Legal Agreement. The general description of various items under different expenditure category is described below. For each contract to be 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 project team 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. National procurement system and ongoing reforms Mali adopted a Public Procurement Code in August 28, as part of the action plan of the update of the Country Procurement Assessment Report (CPAR) for Mali carried out in FY4. The legal framework is in line with the WAEMU s guidelines. In addition, the Country has also adopted a law for the creation of an independent procurement regulatory body responsible for policy and handling complaints from bidders and the procurement control body (being the actual DGMP - General Directorate for Public Procurement Control) responsible for the control of procurements transactions. However, only the DGMP is fully operational and has been decentralized at regional level inside the country. The Government intends to establish the regulatory authority in a short term period. As such, the project under the additional financing will benefit from the existence of the two bodies, and it is recommended that these bodies play their respective roles in procurement control and procurement regulation under the new financing on an agreed basis. In general, Mali s procurement laws and regulations do not conflict with IDA guidelines. However provisions related to the restriction of the eligibility of bidders to those coming from WAEMU countries only will not be applied. No special exceptions, permits, or licenses need to be specified in Credit documents since IDA procedures take precedence other those laws and regulations. Procurement of Works: Contracts for works if any will be very limited in number and in value. Hence,,no ICB or NCB are foreseen under the project. In the eventual case of ICB, the provisions of paragraphs 2.55 and 2.56 of the Procurement Guidelines, providing for domestic preference in the evaluation of bids, shall apply to works to be carried out by domestic contractors. However, a provision has been done for small works which would include, under component 1 of the project, maintenance and minor rehabilitation of some public health centers to become HIV/AIDS treatment center as well as reference centers (CSREF) and community health centers (CSCOM) for dispose of medical waste. These contracts, even in case of grouping of contracts, are estimated at less than US$5, equivalent per contract. Therefore, they will be procured through shopping on the basis of quotations obtained from not less than three () qualified domestic contractors (preferably more in order to obtain at least three comparable quotations) invited in writing to bid. 1

38 In exceptional cases in which large contracts may happen to be procured, the procurement will be done using the Bank s Standard Bidding Documents (SBD) for all ICB and National SBD agreed with (or satisfactory to) the Bank. In case of NCB, the following special requirements will be taken into account: (i) bids should be advertised in national newspapers with wide circulation ; (ii) any bidder is given sufficient time to submit bids (4 weeks); (iii) bid evaluation and bidder qualifications criteria are clearly specified in the bidding documents; (iv) no preference margin is granted to domestic manufacturers; (v) eligible firms are not precluded from the competition; (vi) prior to issuing the first call for bids, a draft standard bidding document is submitted to and deemed acceptable to IDA; and, (vii) the procedures also include the publication of the results of evaluation and of the award of the contract, and provisions for bidders to protest. Sub-projects under component 1 may include small works which will be procured in accordance with paragraph.17 of the procurement guidelines, dealing with Community Participation in Procurement. The Project Implementation Manual (PIM) would describe in detail the specific procurement arrangements of the Community sub-projects. Procurement of Goods: Goods procured under this project would include, (i) under component 1 of the project, equipments to enable some public health centers to become HIV/AIDS treatment center as well as reference centers (CSREF) and community health centers (CSCOM) for dispose of medical waste, (ii) under component 2, and 4, office equipment, fiuniture and materials, audio-visual and laboratory equipments, HIV/AIDS related health commodities, condoms, IEC materials, equipments for associations of people leaving with HIV-AIDS (PLWHA), equipments for sentinel sites for pregnant women, and other project related supplies under the community sub-projects. The procurement will be done using Bank s SBD for all ICB and National SBD agreed with (or satisfactory to) the Bank. In the case of ICB, the provisions of paragraphs 2.55 and 2.56 of the Procurement Guidelines, providing for domestic preference in the evaluation of bids, shall apply to goods manufactured in the territory of the Borrower. Some of the goods may be specific ones which may lead to the use of Limited International competitive Bidding (LIB) or direct contracting. In case of NCB, the following special requirements as will be taken into account: (i) bids should be advertised in national newspapers with wide circulation ; (ii) any bidder is given sufficient time to submit bids (4 weeks); (iii) bid evaluation and bidder qualifications criteria are clearly specified in the bidding documents; (iv) no preference margin is granted to domestic manufacturers; (v) eligible firms are not precluded from the competition; (vi) prior to issuing the first call for bids, a draft standard bidding document is submitted to and deemed acceptable to IDA; and, (vii) the procedures also include the publication of the results of evaluation and of the award of the contract, and provisions for bidders to protest. Sub-projects under component 1 may include purchase of small goods which will be procured in accordance with paragraph.17 of the procurement guidelines, dealing with Community Participation in Procurement. The Project Implementation Manual (PIM) would describe in detail the specific procurement arrangements of the Community sub-projects Procurement of non-consulting services: Non-consulting services to be financed under the Credit will include office and equipment maintenance, transport, insurance, etc. They will also include public-private partnership in laboratory services required to facilitate patients to access to ARV drugs treatment, as it has been possible under the ongoing MAP. Regarding the size o f most of the contracts which are not expected to be more than US$5,, the procurement process will be conducted under shopping process in accordance with the paragraph.5 of the procurement guidelines. 2

39 Selection of Consultants : Consulting services may include studies and surveys related to the monitoring and evaluation activities, trainers, community development specialists, public relations firms, IEC campaigns, financial and technical audits, strengthening of the Borrower s financial programming capacity, and selected studies required to better understand and control the epidemic. Short lists of consultants for services estimated to cost less than $2, equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Consultants will be selected through Quality and Cost Based Selection method, and if required, through other specific methods such as fixed budget selection, least cost selection, consultants qualifications, or single source under the relevant provisions of the Consultants Guidelines. Individual consultants may also be selected in accordance with the relevant provision of the Consultants Guidelines. The procurement method for each contract will be set in the procurement plan. Operational Costs: The Credit will finance part of the operating costs for implementation of the program. Operating costs will be procured using the executive agency s administrative procedures that were reviewed and found acceptable to the IDA. B. Assessment of the apencv s cauacitv to imulement procurement Procurement activities will be carried out by the ES/HNAC (SecrCtariat ExCcutif du Haut Conseil National de Lutte contre le SIDA), the same agency which is implementing the ongoing project. The agency is staffed by a project Coordinator who is the Executive Secretary o f the HCLNS, a pull of high level staff including HIV-AIDS related technical staff and fiduciary staff. The Procurement unit is staffed by one procurement officer. The actual project includes a Contract Management Agency (CMA) which bas both a technical role in the review and the implementation of sub-projects under the project, as well as a Financial Management Agency, and both agencies were selected on a competitive basis. The CMA is expected to phase out. Its contract will end no later than July 1, 29. It is currently building the capacity of the procurement unit of the ES/HNAC to ensure that the unit will adequately take over its responsibilities. An assessment o f the capacity of the Implementing Agency to implement procurement actions for the project has been carried out by Cheick A. T. Traore, Senior Procurement Specialist on April, 6*, 29. The assessment reviewed the organizational structure for implementing the project and the interaction between the project s staff responsible for procurement, the rest of the project implementation team, and the sectoral relevant department s central unit for administration and finance. Most of the issues/ risks concerning the procurement component for implementation of the project have been identified and include: - not enough implication of the PlU s technical staff in procurement matters especially for planning, the preparation of the technical aspects of procurement documents, e.g. Terms of reference, establishment of short-lists, criteria for the evaluation of technical evaluation, technical specifications, qualification criteria for goods, non-consulting services or works if any;

40 - frequent use of urgency in pointing out the character of urgency for HIV-AIDS related issues to argue for the use of exceptional procedures; - not enough anticipation in procurement planning; and - the needs to improve the quality of certain procurement documents. The corrective measures which have been agreed are: - adequate procurement training to be granted to all technical staff in charge of the project implementation in the PlU, and an advance procurement training to be granted to the procurement specialist, in order to have better planning and good quality documents; - specific attention to procurement planning and constant availability of an updated procurement plan; - technical audit especially for sub-projects. The overall project risk for procurement, with regard to the weaknesses listed above, is high. C. Procurement Plan The Borrower has prepared a procurement plan, which was reviewed by the Bank and found satisfactory prior to negotiations. The plan will also be available in the Project s database and in the Bank s external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements in institutional capacity. The Project Implementation Plan has been updated to reflect the Procurement Plan. D. Freauencv of Procurement SuDervision In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the Implementing Agency has recommended two (2) supervision missions per year to visit the field to carry out post review of procurement actions. 4

41 ~ ~~~~~ ATTACHMENT: DETAILS OF THE PROCUREMENT ARRANGEMENT I - General 1 - Project information: Mali, additional financing for the HIV-AIDS 2 - Bank s approval Date of the procurement Plan: Original: April 16, 29 Revision 1: April 17,29 - Date of General Procurement Notice: Immediately after the Board s approval 4 - Period covered by this procurement plan: August 29 - May Goods and Works and non-consultin9 services. 1. Prior Review Threshold: Procurement Decisions subject to Prior Review by the Bank as stated in Appendix 1 to the Guidelines for Procurement: Procurement Method I Prior Review Threshold I Comments 1 ICB and LIB (Goods) NCB (Goods) ICB (Works) NCB (Works) ICB (Non-Consultant Services), if any NCB (Non-Consultant Services) Shopping Direct contracting = or >US$5, ICB and LIB for goods will be used for US$5, and above The first two contract, irrespective of their cost estimate = or >US$5,, The first two contracts, irrespective of their cost estimate All, irrespective of the cost estimate NCB for goods will be used for less than US$5, ICB for works will be used for US$5,, and above NCB for works will be used for less than US$5,, = or >US$5, ICB for non-consultant services will be used for US$5, and above The first two contracts, irrespective of the cost estimate = or >US$5, and the first two contract under US$5, NCB for non-consultants services will be used for less than US$5, Shopping for works, goods and non-consultants services, will be used for less than or equivalent to US$5,. If more than US$5,, prior clearance is needed from IDA with relevant justifications. The cost estimate will not exceed US$lOO,OOO. None 5

42 2. Prequalification : Not applicable.. Proposed Procedures for CDD Components (as per paragraph..17 of the Guidelines: Not applicable. 4. Reference to Project Operational Manual: the Project Implementation Manuel and the Project Operational Manual will be elaborated upon the project approval by the Bank. 5. Any Other Special Procurement Arrangements: Domestic preference will be used in ICBs. 6

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45 111. Selection of Consultants 1. Prior Review Threshold: Selection decisions subject to Prior Review by Bank as stated in Appendix 1 to the Guidelines Selection and Employment of Consultants: Selection Method Prior Review Threshold 1. Competitive Methods (Firms) = or >US$2, I Single Source (Firms) All, irrespective of 2* the cost estimate. I Individual Consultants I = or >US$IOO,OOO 4' Single source for Individual Consultants I 5. Contracts for specific assignments such as contracts for the elaboratiodupdate of manual of the project implementation and the manual of procedures, contracts for monitoring and evaluation assignments; contracts for financial assistance assignments; contracts for financial audit; contracts for technical audit; contracts for environmental and social issues; contracts for legal assignments All, irrespective of the cost estimate All, irrespective of the cost estimate Comments None None None None Those contracts are not selection methods; but due to their sensitivity, they will be subject to prior review 2. Short list comprising entirely of national consultants: Short list of consultants for services, estimated to cost less than $2, equivalent per contract, may comprise entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines.. Any Other Special Selection Arrangements: None 9

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49 Annex VII: Safeguard Policy Issues Multi-Sectoral HIV/AIDS Project 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. 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. According to the report, current practices in health care waste management and contaminated health care waste handling, storage and disposal, in particular, raise serious environmental and social concerns. The need for sound management and disposal of contaminated medical waste is high, as health care related activities produce considerable amount of waste on daily basis -- some of which tend to be highly infectious -- as a result of preventive and curative service delivery. The composition of waste produced is in the form of sharps (needles, syringes, etc..), non- sharp materials, such as blood and other body fluids that could be infected, chemicals, pharmaceuticals and medical devises needing proper handling and disposal. Currently, there is potential for health care workers, waste handlers, users of health facilities and the general public to be exposed to and become infected by health care related waste, as a result of poor HCW management practices. 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 24. 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. 4