Document of The World Bank Report No: 21350-UG PROJECT APPRAISAL DOCUMENT ONA PROPOSED CREDIT IN THE AMOUNT OF SDR 37.3 MILLION (US$ 47.5 MILLION EQUIVALENT) TO THE REPUBLIC OF UGANDA FOR AN HIV/AIDS CONTROL PROJECT December 28, 2000 Human Development 1 Country Department 4 Africa Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective November 30, 2000) Currency Unit = Ugandan Shilling Shilling I = US$0.0005376 US$1 = 1860 Shillings FISCAL YEAR July I - June 30 ABBREVIATIONS AND ACRONYMS ACP AIDS Control Program CHAI Community-led HIV/AIDS Initiative CBC Community Base Care CBO Community Base Organization CSO Civil Society Organization FM1 Financial Management Initiative FMM Financial Management Manual HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome IAPSO Inter-Agency Procurement Services Office of the UNDP IDA International Development Association IEC Information, Education and Communication MACA Multi-Sector Approach to the Control of HIV/AIDS MAP Multi-Country HIV/AIDS Program for Africa MOH Ministry of Health NCPA National Committee for the Prevention of AIDS NGO Non-governmental organization PCT Project Coordination Team POM Project Operational Manual PEAP Poverty Eradication Action Plan PLWHA People Living with HIV/AIDS PMR Project Management Report PRSC Poverty Reduction Support Credit PSO Private Sector Organization STD Sexually transmitted disease STI Sexually transmitted infection SWAP Sector wide approach UAC Uganda AIDS Commission UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations International Children's Fund USAID United States Agency for International Development VCT Voluntary Counseling and Testing WHO World Health Organizatioin Vice President: Callisto E. Madavo Country Manager/Director: James W. Adams Sector Manager/Director: Dzingai B. Mutumbuka Task Team Leader/Task Manager: Alexandre V. Abrantes UGANDA HIV/AIIDS CONTROL PROJECT CONTENTS A. Project Development Objective Page 1. Project development objective 2 2. Key performance indicators 2 B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project 3 2. Main sector issues and Government strategy 4 3. Sector issues to be addressed by the project and strategic choices 6 C. Project Description Summary 1. Project components 8 2. Key policy and institutional reforms supported by the project 11 3. Benefits and target population 11 4. Institutional and implementation arrangements 12 D. Project Rationale 1. Project alternatives considered and reasons for rejection 16 2. Major related projects financed by the Bank and other development agencies 17 3. Lessons learned and reflected in proposed project design 19 4. Indications of borrower commitment and ownership 21 5. Value added of Bank support in this project 22 E. Summary Project Analysis 1. Economic 22 2. Financial 23 3. Technical 24 4. Institutional 24 5. Environmental 25 6. Social 26 7. Safeguard Policies 27 F. Sustainability and Risks 1. Sustainability 27 2. Critical risks 28 3. Possible controversial aspects 30 G. Main Credit Conditions 1. Effectiveness Condition 30 2. Other 30 H. Readiness for Implementation 31 I. Compliance with Bank Policies 31 Annexes Annex 1: Project Design Summary 32 Annex 2: Detailed Project Description 35 Annex 3: Estimated Project Costs 46 Annex 4: Monitoring and Evaluation 47 Annex 5: Financial Summary 50 Annex 6: Procurement and Disbursement Arrangements 56 Annex 7: Project Processing Schedule 66 Annex 8: Documents in the Project File 67 Annex 9: Statement of Loans and Credits 69 Annex 10: Country at a Glance 72 Annex 11: Uganda WrV/AIDS Brief 74 MAP(S) IBRD 25052R1 UGANDA HIV/AIDS Control Project Project Appraisal Document Africa Regional Office AFTHI Date: December 28, 2000 Team Leader: Alexandre V. Abrantes Country Director: James W. Adams Sector Manager/Director: Dzingai B. Mutumbuka Project ID: P072482 Sector(s): HA - HIV/AIDS Lending Instrument: Specific Investment Loan (SIL) Theme(s): Health/Nutrition/Population; Poverty Reduction Poverty Targeted Intervention: Y Project Financing Data [ ] Loan p[q Credit [1 Grant [ I Guarantee [ 1 Other: For Loans/Credits/Others: Amount (US$m): 47.50 Proposed Terms: Standard Credit Grace period (years): 10 Years to maturity: 40 Commitment fee: 0.5% Service charge: 0.75% Financing Plan: Source.Xe- Y ocal - . Foreign ; JTota - BORROWER 2.50 0.00 2.50 IDA 26.50 21.00 47.50 Total: 29.00 21.00 50.00 Borrower: THE REPUBLIC OF UGANDA Responsible agency: GOVERNMENT AGENCIES Address: Uganda AIDS Commission, Plot No 213 Sentema Rd, Mengo, P.O. Box 10779, Uganda Contact Person: Dr. David N. Kihumuro Apuuli Tel: +256 41 273 538 Fax: +256 41 258 173 Email: uacnadic@imul.com Estimated disbursements ( Bank FYIUS$M): wFtY >202E i K 00 3 2005 -W005 006 Annual 6.00 10.00 12.00 11.00 11.00 Cumulative 6.00 16.00 28.00 39.00 50.00 Project implementation period: 5 years Expected effectiveness date: 04/18/2001 Expected closing date: 12/31/2006 OCS PAD F-.: Rw. h ,d., O A. Project Development Objective 1. Project development objective: (see Annex 1) The project will support the goals of the Government of Uganda's National Strategic Framework for HIV/AIDS which aims to: a) reduce the spread of LlV infection; b) mitigate the health and socio-economic impact of HIV/AIDS at individual, household and community levels; and c) strengthen the national capacity to respond to the epidemic. The Strategic Framework proposes to attain these goals by financing a multi-sector response including all line ministries, civil society, the private sector and communities. 2. Key performance indicators: (see Annex 1) The following constitute the summary indicators for outputs, process, and impact of the project. It may be difficult to detect significant changes in impact indicators during the five years of project implementation due to the nature of the HIV/AIDS epidemic, therefore, intermediate outcome measures are also included. A more extensive list of indicators is included in the logical framework (see Annex 1). A. Output Indicators 1. By 2006, 60 percent of secondary schools apply the secondary school curriculum that incorporates HIV/AIDS information. 2. By 2006, increase from 13 to 100 percent the proportion of districts implementing TB DOTS. 3. By 2006, increase from 6 to 50 percent the proportion of hospitals providing prevention of mother to child transmission services. 4. By 2006, increase from 0 to 50 percent the number of identified orphaned children (by sex) that are receiving social support from the project. 5. Increase from 30 to 50 percent the proportion of people living with HIV/AIDS identified by district health registers that are receiving some form of home or community based support. 6. By 2006, increase by 50 percent (from 80 million to 120 million) the number of condoms sold through social marketing outlets or distributed in Uganda. B. Process Indicators 7. By 2006, all relevant line ministries (13) have incorporated HIV/AIDS prevention or mitigation activities in their regular work-plans and are implementing them. -2 - 8 By 2006, increase from 0 to 45 the number of districts that are implementing integrated l1V/AIDS work-plans. 9. By 2006, increase from 0 to 80 percent the proportion of district hospitals reporting no stock-outs of essential drugs for managing sexually transmitted infections in the last 6 months. 10. By 2006, increase from 20 to 80 percent the proportion of districts that have IIV/AIDS voluntary counseling and testing centers. 11. The amount of project funding disbursed under community-led HIV/AIDS initiatives (CHAIs) will account for at least 25 percent of all project funds disbursed in the previous 12 months. C. Impact Indicators 12. By 2006, reduce from 49 to under 40 percent the proportion of 15-19 year old boys and girls that are sexually active. 13. By 2006, reduce from 14 to 10 percent the proportion of sexually active people reporting non-regular sexual partners. 14. By 2006, reduce from 15 to 5 percent the rate of reported sexually transmitted (urethritis) infections in men aged 15-49 in the last 12 months. 15. By 2006, reduce by 30 percent the drop-out rate of orphaned children in primary school. 16. By 2006, increase from 30 to 50 percent the proportion of men/women aged 15-49 who report using a condom in their last act of sexual intercourse with a non-regular partner. 17. By 2006, reduce I-UV prevalence from 9 to below 6 percent among women attending prenatal care services. B. Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1) Document number: IDA/R200-187 Date of latest CAS discussion: November 16, 2000 The latest Country Assistance Strategy (CAS) for Uganda was issued on October 24, 2000. The focus of the CAS is on: a) increasing the ability of the poor to raise their incomes; b) improving the quality of life of the poor; c) enabling the environment for economic growth and structural transformation, and d) ensuring good govemance and security. -3- To improve the quality of life of the poor, the Bank will focus on improving access to basic services such as health care, clean water and quality primary education through its lending and non-lending services. Bank support will include: a) Poverty Reduction Strategy Credit to improve the delivery of education, health and sanitation services and support cross-cutting reforms in public sector management; b) HIV/AIDS Control Project to support Uganda's effort in combating the epidemic; c) International Finance Corporation investments in social sectors, supporting private initiatives in health and education; d) Sector studies in the education, health and water sectors; and e) World Bank Institute Workshops on population, reproductive health and health sector reform; on gender, health and poverty reduction; and on World Links for development. 2. Main sector issues and Government strategy: 2.1 Main sector issues. Uganda was one of the first countries to be affected by IRV/AIDS and remains one of the worst affected countries. Since the onset of the epidemic, about 2.2 million people have been infected, 800,000 have died, and over 1.1 million children have been orphaned. Currently, AIDS is responsible for 12 percent of annual deaths, surpassing malaria and other conditions as the leading cause of death among the population aged 15-49. The epidemic has forced women, elderly, children and youths into heading households; has forced children and youths out of school and into early labor; and has devastated the numbers of professionals in key sectors such as education and health. The HIV/AIDS epidemic affects women more than men in Uganda. HIV infection rate among girls aged 15-19 is three to six times more than that of boys; and among people aged 20-24, the rate for women is twice as high as among men. In addition to the greater risk of being H1V infected, women are also more likely to bear the burden of caring for the sick and orphans. Since the epidemic mainly affects the productive age group, socioeconomic consequences have devastated every aspect and segment of national development. This has imposed an unsustainable and mounting burden on households, communities and the society as a whole. Uganda stands out as one of the few countries in Africa that has made progress in reversing the spread of the epidemic. Currently, the level of awareness is over 90% in the general population, and demand for preventive services has increased, with over 50,000 voluntary counseling and testing (VCT) sessions conducted and 60 million condoms distributed annually. The median age at first sexual contact has increased by two years among youths aged 15-24, 16.6 for girls and 17.4 for boys. There has been an overall decline in the FLV sero-prevalence rates from 18.5% in the early 1990s to 8% in 1999. The relative success of Uganda in controlling the spread BIV has been attributed to: a) a lower proportion of 15-19 old males ever having sex; b) a higher proportion of 15-19 old males having sex within marriage only; and c) substantially lower numbers of non-regular sexual partners for all ages, particularly for the non-married. -4 - The relative success has also been attributed to better social communication strategies, which make more use of open personal communication networks, leading to enhanced social capital and cohesion. Despite Uganda's success, HIV prevalence still remains unacceptably high at 8% in the adult population, and the extent of behavioral change is still limited compared to the level of awareness. In the absence of a cure or preventive vaccine, a further change in sexual behavior remains the most important approach toward preventing WV infection. A "social vaccine" including reinforcement of existing social information, education and communication strategies, with a focus on open personal networks and social cohesion, needs further refinement and new ones must be developed. The present services for VCT, sexually transmitted disease (STD) treatment, and provision of condoms remains largely in urban areas, leaving rural areas under-served. Experiences in Uganda have shown that where more actors were involved in HIV/AIDS activities, the results are better. Although 12 line ministries are already implementing HIV/AIDS control activities, the activities need to be strengthened and expanded to under-served areas. The challenge thus is in building capacity in all sectors and institutions to respond to the epidemic in a coordinated manner. In addition, orphans and households thrown into poverty due to HIV/AIDS need care and social support. 2.2 Government strategy. Uganda's response has been characterized by a broad partnership involving government, non-governmental organizations, religious groups, communities, people living with HIV/AIDS (PLWHA), and local and international donors. This was underpinned by openness, commitment and strong leadership from the highest level of government in addressing the epidemic. As a first step, the government established the National Committee for the Prevention of AIDS in 1985 and, in October 1986, set up the AIDS Control Program in the Ministry of Health to spearhead the national response. With the realization that HIV/AIDS had ramifications beyond the health sector, the government adopted a multi-sector approach to the control of HIV/AIDS in 1992 and established the Uganda AIDS Commission (UAC) by Act of Parliament. The key mandate of UAC is to coordinate national policy formulation, provide oversight functions and carry out advocacy with regard to HIV/AIDS. Further, efforts were undertaken by the government to mobilize and unify the response to the epidemic at national, district and community levels. These efforts included: development of a National Operational Plan (1993-1997), establishment of 12 AIDS Control Programs in line ministries, establishment of District AIDS Coordination Committees, and strengthening of collaboration and partnership at all levels, but especially with the non-government sector. The government has continued refining and improving the multi-sector approach in order to mainstream HIV/AIDS control activities within the various line ministries and organizations based on their mandates. In the Poverty Eradication Action Plan, reduction of WV prevalence is identified as a key priority; and all line ministries, districts and organizations are expected to mainstream HIV/AIDS activities. The Ministry of Health has mainstreamed AIDS control activities into its sector wide program, to be financed from different sources via direct budget support. The current National Strategic Framework 2000/1-2005/6 builds upon the previous AIDS programs, uses existing institutions and implementation arrangements, and places the HIV/AIDS in the broader context of social and economic development. The National Strategic Framework 2000/1-2005/6 calls for a greater emphasis on community implementation, improved integration and cross-sector collaboration, encouraging wider stakeholder participation and more effective interventions. The following are the main areas to be addressed in the WV/AIDS National Strategic Framework, to: - 5 - a) Consolidate the prevention of transmission of HIV and sexually transmitted infections; b) Promote integration of HV/AIDS interventions into sexual and reproductive health; c) Mitigate the impact of 1IV/AIDS on people affected and infected; d) Address the economic, social and cultural impact of HI-V/AIDS; and e) Strengthen national capacity at all levels to respond to the epidemic with increased emphasis on the community. The Government of Uganda has requested access to IDA resources within the framework of the first phase of the Multi-Country HIV/AIDS Program (MAP) for the Africa Region approved by the Board of Directors of the World Bank Group on September 12, 2000. Uganda is eligible for MAP funding in that it has satisfied the four MAP eligibility criteria: a) Satisfactory evidence of a strategic approach to HIVIAIDS. Uganda already has a coherent national, multisectoral strategy and action plan for HIV/AIDS prevention, care and treatment that has been developed through a participatory approach; b) A high level HIV/AIDS coordinating body. Uganda has created the Uganda AIDS Commission, which is directly under the Office of the President, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS, to oversee and coordinate the implementation of the National Strategic Framework; c) Government agreement to use appropriate implementation arrangenents. Government has agreed to accelerate project implementation by channeling funds directly to civil society organizations and to communities that would be coordinated at the district level. In addition, Government has agreed to contract out important implementation mechanisms, in particular in the areas of financial management, procurement and monitoring and evaluation; and d) Government agreenent to use andfund multiple implementation agencies. Government has agreed within the public sector to expand HIV/AIDS activities to a broad range of ministries, departments and parastatals, as well as to fund activities undertaken by the private sector, the civil society organizations including non-government and community-based organizations, and AIDS service providers. Government has agreed to further expand HIV/AIDS activities to community level and to support community-led HIV/AIDS initiatives. 3. Sector issues to be addressed by the project and strategic choices: 3.1 Sector Issues. The project addresses four key issues: a) the need to scale up activities and coverage; b) the need to further mainstream the war on HIV/AIDS into all sectors in the government and into civil society; c) the need to focus on what has worked, i.e. strengthen social capital by empowering communities in - 6 - fighting against the epidemic, and favoring open interpersonal communication networks; and d) the need to strengthen coping mechanisms including offering a safety net for orphans and for female, child and elderly headed households, due to deaths of husband, parents or guardians. This project will address the need to scale up activities by extending activities to all districts, by further engaging other line ministries beyond the Ministry of Health, by empowering communities to take the fight against H[V/AIDS into their own hands, and by enhancing civil society participation including, non-governmental organizations, churches, farmers associations, unions, student associations, and private enterprises. The project will mainstream HIV/AIDS activities, by supporting line ministries and districts to plan and implement their H1V/AIDS action plans, and by encouraging civil society to take the matter into its own responsibility. The project will focus and improve what has worked best in the past, i.e. will reinforce social capital and cohesion, by empowering communities through support to Community-led HIV/AIDS Initiatives. These will cover health promotion, the establishment of open interpersonal communication networks, home-based care, social and spiritual support to HIV/AIDS- affected families and by bringing traditional birth attendants and traditional practitioners into playing a greater role in the fight against HIV/AIDS. The project will offer impoverished orphans and female-, child- and elderly-headed households an economic safety net in the form of targeted orphan support, i.e. it will provide material and other forms of support including cash grants to families impoverished by AIDS to keep orphans in school and to reduce child labor, using existing organizational mechanisms. Tlhe implementation of the multisectoral strategy has met challenges. Notably, the implementation of a strong coordination mechanism has not been as successful as desired both at the center and in districts. The key challenges were with establishment of clear linkages between the line ministries and the Uganda AIDS Commission, in the development of HV/AIDS sector specific strategies for mainstreaming HlV/AIDS control to the other line ministries and the establishment of adequate coordination in the context of a very decentralized government system. The project will support such capacity building effort. 3.2 Strategic choices. The main strategic choices faced in project design were as follows: a) a choice between a single standing sector investment credit versus program financing via budget support under the Poverty Reduction Support Credit; and b) a choice between a specific project to be financed by the Bank versus support to the overall Uganda IV/AIDS Programn, by expanding ongoing activities and fnancing activities which are not yet covered by the existing program or by other bilateral or multilateral development agencies. The project is structured as a free-standing sector investment credit, under the second phase of the Multi-country HWV/AIDS Program for Africa because: a) what is needed is a "war-like" effort, a scale up of activities which are well beyond "business as usual" or small incremental efforts; b) it would otherwise be difficult to mainstream IWV/AIDS activities into national and district agencies, - 7- into civil society, the private sector and communities; and c) such effort needs close monitoring and ongoing evaluation to check progress and identify problems in a timely fashion. A free-standing operation is the instrument of choice for such a scenario. Budgetary support through a broad poverty reduction support program and a sector wide approach will finance the traditional HIV/AIDS control activities in the Ministry of Health. The project will support the Uganda HIV/AIDS Program, scaling it up and covering some of the activities that have not yet funded from other sources, as opposed to a Bank-specific HIV control project, a project which would be parallel to the regular AIDS control program. The reasons for this choice are that: a) the Ugandan Government has shown in the past the commitment and the capacity to run a successful program, indicated by a 50 percent reduction of HIV prevalence over the last ten years; and b) the proposed Uganda National Strategic Framework for HIV/AIDS Activities 2001/2006 is well justified and planned. C. Project Description Summary 1. Project components (see Annex 2 for a detailed description and Annex 3 for a detailed cost breakdown): This project, under the regional Multi-Country AIDS Program for Africa, will finance a US$50 million share of Uganda's National Strategic Framework for HIV/AIDS Activities 2000/1-2005/6. The project will scale up the existing HIV/AIDS Control Program by mainstreaming program activities into line ministries and other non-health government agencies at national and district levels, and by making better use of the capacity of community-led and civil society organizations, including churches, farmers' associations, trade unions and private businesses. The project will support FHV control activities coordinated by the Uganda AIDS Commission and directly carried out by line ministries, by districts and by community-led organizations, or contracted out to civil society organizations or to the private sector, including: a) Health promotion and prevention to reduce the rate of HIV transmission; b) Diagnosis, treatment, care and support to mitigate the impacts of HIV/AIDS; and c) Research, surveillance, monitoring, evaluation and program management to strengthen the national capacity to respond to the epidemic. 1.1 Project Component 1: Nationally Coordinated Initiatives (US$25 million, 50 percent of total project costs) Under this component, the project will support HIV/AIDS control activities coordinated by the Uganda AIDS Commission and directly carried out by different line ministries or central governent agencies, or contracted out to civil society organizations or the private sector. At appraisal, IDA agreed with the government on the specific actions plans for the first year of project implementation, to scale up and - 8 - mainstream HIV/AIDS activities at the: a) Uganda AIDS Commission; b) Ministry of Health; c) Ministry of Education and Sports; d) Ministry of Gender, Labor and Social Development; e) Ministry of Agriculture, Animal Industry and Fisheries; f) Ministry of Works, Housing and Communications; g) Ministry of Defense; h) Ministry of Internal Affairs; i) Ministry of Local Government; j) Ministry of Public Service; k) Ministry of Justice; and 1) Other ministries. Other Ministries will be assisted to draft the respective HIV/AIDS action plans during the first year of project implementation. Each line ministry's work plan will include HIV/AIDS prevention and mitigation activities for its staff as well as for the public that it directly serves. Many of these activities will be contracted at national level but will be directly benefit districts and communities. For example, diagnostic kits and pharmaceuticals will be financed under this component but will mostly benefit district based health services. 1.2 Project Component 2: District Initiatives (US$ 10 million or 20 percent of total project costs) Under this component, the project will support activities which are directly carried out by district authorities, or are contracted out to civil society organizations or to the private sector, including activities to: a) Raise awareness of district leadership, teachers, school management teams and community leaders; b) Train and support district- and community-based staff and leaders, including teachers, home-care givers and counselors, traditional healers and traditional birth attendants, and rural extension workers; c) Provide HIV/AIDS related health promotion and prevention services at all district hospitals and clinics; d) Provide HIV/AIDS related diagnosis, treatment and care at referral district hospitals; -9- e) Promote community-led and civil society-led HIV/AIDS initiatives and manage the respective selection, contracting, financing and supervision; and f) Provide HV/AIDS related information, education and communication and condom distribution to the district work force. Many of the activities financed under this component will directly support activities carried out at community level, i.e. advocacy, training, promotion of community-led HIV/AIDS Initiatives. 1.3 Project Component 3: Community-led HIV/AIDS Initiatives - CHAIs (US$ 10 million, 20 percent of total project costs) Under this component, the project will support community-led HIV/AIDS control activities directly carried out, or contracted out, by community-based organizations, such as: a) Targeted support to orphans, guardians of poor orphans and AIDS stricken impoverished households, including those headed by females, children and elderly due to death of spouse, parent or guardian, conditional to families keeping school aged children at school, for a minimum amount of time. In addition, pre-school and out-of-school orphans will be supported to attend day care centers and vocational training; b) Community-based information, education and communication; and c) Home-based care. The project operational manual includes a full menu of eligible sub-projects, a list of sub-projects and activities which Af Ill not be financed under the project, as well as a description of how to get technical assistance to develop a sub-project, how to apply for a grant, how sub-projects will be selected and approved, how funds will be transferred, and how a sample of sub- projects will be supervised audited and evaluated. 1.4 Unallocated The project has $5 million IDA credit unallocated, which will be allocated to District Initiatives or Community Initiatives based on progress review and project needs. 1.5 Estimated Project Costs Total project costs are estimated at US$50 million, including US$21 million in foreign costs and US$29 million in local cost equivalent. The project will be funded by a US$47.5 million IDA Credit and by US$2.5 million from the Government in cash (in addition, the Govemment will cover taxes and duties associated with imports related to the project). (See Annex 3, Estimated Project Cost Summary.) - 10 - s~~~~~~~~~~~~~: B -- Nationally Coordinated Activities 25.00 50.0 24.00 50.5 District Activities 10.00 20.0 9.00 18.9 Community-Led 10.00 20.0 9.50 20.0 HIV/AIDS Activities Unallocated 5.00 10.0 5.00 10.5 Total Project Costs 50.00 100.0 47.50 100.0 Total Financing Required 50.00 100.0 47.50 100.0 2. Key policy and institutional reforms supported by the project: This project is a multi-sector operation that is not intended to address long-term sector and institutional reforms within any one sector, or to include conditions linked to macroeconomic or sector policies. However the project will strengthen the following key policy and institutional changes: a) Making the National HIV/AIDS Program truly multi-sectoral by mainstreaming HIV/AIDS control into the action plan of every Government agency and by strengthening capacity of the Uganda AIDS Commission for national coordination; and b) Ensuring the National HIV/AIDS Program is truly participatory by encouraging private sector participation in HIV/AIDS control and empowering communities to be key players in the HIV/AIDS control program. 3. Benefits and target population: 3.1 Benefits. The project will provide the following benefits to Uganda: a) Reduced number of new HIV/AIDS cases, by reducing the rate of transmission of W1V through: i. changing WRV-related behaviors; ii. irnproving accessibility to condoms; iii. reducing the rate of sexually transmitted diseases; and iv. reducing the number of WIV infections transmitted from mother to child; b) Extended productive life of people living with AIDS by: i. improving the prevention and treatment of opportunistic infections; and ii. providing nutritional supplements for people living with HIV/AIDS; c) Improved economic prospects of orphans and poor HIV-stricken families with school aged children by providing the respective households cash transfers on the condition that children attend school; - 1 1 - d) Improved diagnosis, treatment and care for people living with HIV/AIDS by: i. expanding voluntary counseling and testing to every district; ii. disseminating standard protocols, and training both professional and traditional health care providers on the clinical management of sexually transmitted infections and opportunistic infections, and of HIV; and iii. improving planning, procurement and distribution of essential diagnostic kits and pharmaceuticals; and e) Improved ability of communities, households and individuals to prevent or cope with the impact of HIV/AIDS, through comnmunity-led HIV/AIDS initiatives. 3.2 Target population. The project is designed to target: a) Groups that are known to be particularly vulnerable to HIV infection such as young people (in particular teenage girls), pregnant women, long distance truck drivers, road and power construction workers, traders, fishermen, the military, and the prison population; b) Groups which engage in high risk HIV-related behaviors, such as commercial sex workers and their clients, men who have sex with men and intra-venous drug users; c) Key sectors such as agriculture, industries, road construction, power and energy, and d) Impoverished orphans and HIV-striken households, with a focus on those headed by women, elderly and youths. 4. Institutional and implementation arrangements: 4.1 Institutional arrangements. The Uganda AIDS Commission (UAC) and its Secretariat, which is under the Office of the President, will coordinate the overall National HEV/AIDS program and project activities. The UAC Director General will be the Project Director, to whom a Project Coordinator will report. The Project Coordinator will lead a Project Coordination Team (PCT), which will be contracted to support additional work generated by project-related management, monitoring and evaluation. A Project Steering Committee, to be chaired by the Permanent Secretary of the Office of the President will be established as an advisory board and include representatives from key sectors and institutions, as well as representatives from key civil society organizations, including those which represent people living with HIV/AIDS. The Project Coordinator will be the Secretary of the Project Steering Committee. A Technical Resource Network, which is composed of technical staff from different sectors, line ministries and other agencies, and a Stakeholders Network, which is composed of representatives of civil society organizations as well as other multilateral and bilateral agencies, have been established. These Networks will support the Uganda AIDS Commission to mobilize line ministries, districts and communities for HIV/AIDS initiatives and to review technical aspects of annual sector HIV/AIDS plans and evaluation reports. - 12 - Line ministries will implement their respective HIV/AIDS plans and report regularly to the UAC on agreed input and output indicators. The day to day implementation will be carried out within the existing structure rather than creating a new structure. Districts will be at the forefront of project implementation. District HIV/AIDS work plans will reflect various sector activities to be implemented at the district level. Line ministries will provide the relevant guidelines, coordination, training, monitoring and evaluation, and resource mobilization in line with existing working arrangements with the districts. A formal contract with agreed input and output indicators will guide the relationships between districts and the PCT. Each district will establish a District WIV/AIDS Committee, composed of heads of department, municipal and town councils, and relevant civil society organizations. Communities will organize themselves, present their proposals to the respective district or the Project Coordination Team, and will execute Community-led W[V/AIDS Initiatives. Communities may want to contract assistance from civil society organizations to prepare, and implement their sub-projects. Community-led initiatives will be funded separately from district workplans. Communities will contribute in kind to sub-project financing, their contribution amounting to at least five percent of total sub-project costs. Civil Society Organizations -- CSOs (including, non-governmental organizations, Religious Organizations, farmers' associations, unions, student associations and private enterprises) and Private Sector Organizations -- PSOs, will be contracted to implement project activities. District budgets will include funds earnarked by the project for CSO and PSO based sub-projects. The UAC and the Stakeholder Network will organize a process to pre-qualify bonafide HV/AIDS civil society organizations. The project will coordinate with other IDA funded projects and with other WV/AIDS related projects financed by other bilateral and multilateral organizations. At national level, coordination will be achieved through the Stakeholder Network and the Enlarged UNAIDS Thematic Group. At district level, coordination will be achieved through the District WIV/AIDS Committee. 4.2 Project implementation. The project will finance a series of HIV/AIDS plans presented by line ministries and districts, as well as a large number of Community-led HIV/AIDS Initiatives. Planned activities for the first year of project implementation were integrated into an annual Project Implementation Plan (PIP). At Appraisal, the Bank reviewed and was satisfied with the draft first year PIP. The project will be implemented in an incremental manner, starting with those ministries and districts which already have WIV/AIDS workplans. Project coverage will be scaled up and expanded to more sectors, as the project assists ministries and districts in strengthening their implementing capacity. Line ministries and districts will present annually WHV/AIDS plans for the following fiscal year. The UAC/PCT will coordinate these plans and, when needed, will provide assistance to improve programs and eliminate duplications. In each district, a lead civil society organization will promote CHAIs on behalf of the project. Community beneficiaries, i.e. rural or urban community residents, and community-based organizations -- CBO will be eligible to present community-led WHV/AIDS initiatives. CBOs may contract an Implementing Partner to assist communities in subproject preparation and processing, and counseling in implementation. The cost of such assistance will be reimbursable, up to a maximum of 10 percent of total sub-project costs. There will be a list of "standard sub-projects" for which review, approval and financing will be streamlined and - 13- almost automatic, and a list of activities which will not be financed under the component. Communities may present non standard subproject proposals. If one particular type of non-standard proposal is frequently submitted, it will become part of the standard list. Civil Society Organizations and Private Sector Organizations may present 1HV/AIDS Initiatives to the UAC/PCT, to the relevant line ministries or the District Project Coordinators. If relevant, they will be incorporated into the respective workplans and budgets. The Project Operational Manual (POM) describes in detail the project's institutional and implementation arrangements. At appraisal, IDA reviewed and was satisfied with the project's draft POM. Annex 2 describes project's institutional and implementation arrangements in more detail. 4.3 Project monitoring, supervision and evaluation. Project monitoring and evaluation will be based on a broad range of measures, including impact indicators and more intermediate process and output measures to capture project performance in the more immediate term. Project impact will be measured employing data from the H[V sentinel surveillance, baseline and end-line population-based surveys on knowledge, attitudes, practices and behavior and service utilization, and special studies commissioned to assess impact in specific areas not easily addressed by population- based surveys. Monitoring of the project will employ project-based data, beneficiary inputs, and program reviews. The UAC/PCT will monitor overall project implementation, assessing the performance of project implementation as well as the effectiveness and efficiency of implementation at sub-county, district and national levels. Line Ministries will monitor their own activities at the central level and provide the UAC SecretariatlPCT information on a minimal number of variables on a quarterly basis. Line ministries will also monitor district implementation within their respective sector mandates. Civil society organizations and community based organizations activities will be monitored based on their contracts and separate analyses will be conducted to assess the performance of these entities as well. The UAC/PCT will supervise overall project implementation and meet regularly with the Project Steering Committee to discuss progress under each implementing agency. Staff from the line ministries and project coordination team will make regular visits to the field to monitor the performance of districts and civil society organizations. District Technical Planning Committees, representing each sector and incorporating community-based and civil society organization representation, will supervise project activities at district and sub-county and community levels. The UAC/PCT will organize annual project reviews, a mid-term program review and the project completion review to assess the performance of the project, its components and its contribution to the national effort to reduce the spread and impact of HIV/AIDS. Project reviews will be carried out jointly by the UAC/PCT and an independent team of experts under previously defined terms of reference. Project reviews will culminate in stakeholder meetings that will form a basis for re-planning for the next two years. - 14 - The UAC/PCT and IDA will organize a joint project launch workshop within one month after project effectiveness. One of the main purposes of the workshop is to make further progress on project monitoring and reporting requirements. During the project mid-term review, various indicators will be used to assess project performance and needs for fund reallocation. The POM and Annex 4 of this report describe the project's monitoring, institutional and implementation arrangements in detail 4.4 Procurement Procedures. The UAC, line ministries and districts will procure works, goods and services in relation to the respective activities, in accordance with the Bank's Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995 and revised in January and August 1996, September 1997, and January 1999), in particular Section 3.15, Community Participation in Procurement. Consulting services by firms, organizations, or individuals financed by IDA will be contracted in accordance with the Bank's Guidelines: Selection and Employment of Consultants by World Bank Borrowers (January 1997, revised in September 1997 and January 1999). The Government will contract one or more procurement agents to carry out the procurement of large items packages, such as condoms, diagnostic kits and pharmaceuticals for the diagnosis and clinical management of HIV/AIDS, sexually transmitted infections and opportunistic infections, including tuberculosis. The implementing agencies will ensure adequate procurement capacity is established as per the government procurement reforms to carry out procurement within the respective agencies. Communities will use the Bank's simplified Procurement and Disbursement Procedures for Community-Based Investments to procure goods or services needed to implement their respective Community-led H[V/AIDS Initiatives. Since each CHAI will cost less than US$30,000, "local shopping" will be a standard procurement method. To facilitate speedy import of items valued at less than US$100,000 equivalent required urgently for diagnosis/treatment and institutional strengthening, contracts may be made based on international shopping and national shopping procedures, respectively, or through procurement from the United Nations. Given the urgency of the project, a wide-ranging General Procurement Notice for the first year of operations will be placed on the United Nations Development Business web site without a need for hard-copy publication. The Borrower will prepare a procurement plan for the first year of project operations to be included in the POM, and subsequently annual procurement plans. Procurement performance (including sub-project procurement activities) will be assessed on an annual basis (in the form of procurementlphysical audits by an external agency). In addition to the formal annual audits, ad-hoc procurement reviews will be conducted periodically. The POM and Annex 6 of this report describe the project's procurement and disbursement arrangements in detail. 4.5 Financial Management and Disbursement. The project will have a viable financial management and accounting system, including a comprehensive Manual of Financial Procedures, Chart of Accounts and fully integrated project financial and accounting system, using appropriate accounting software. The PCT will include a financial manager and controller and will put in place an appropriate financial and - 15 - accounting system for the project. Similar institutional strengthening measures will be taken with regard to capacity in line ministries and districts where such intervention is needed. Capacity building in financial management in communities will be supported through the collaborating civil society organizations and community based organizations. A Special Account (SA) will be opened and maintained in a reputable commercial bank. A Project Account will be opened in local currency in the same commercial bank. Sub-project accounts will be opened for different implementing agencies. After approval of annual plans and budgets the PCT will facilitate the transfer of funds to the various implementing agencies. Disbursements of the project proceeds will initially assume the traditional disbursement mechanisms for IDA assisted projects. However, the project will be expected to convert to Project Management Report-based disbursements mechanism under the Financial Management Initiative framework in a period not exceeding 18 months. The project will mainly use Statement of Expenditures (SOE) through the SA to access Credit funds, while direct payments and Special Commitments will be used for bulk procurement of goods and services. All disbursements against expenditures for contracts with the civil society organizations and the private sector will be made against SOEs and be subject to random ex-post financial, physical, and technical review by IDA missions and be audited by financial and technical consultants employed by the Uganda AIDS Commission. All procurement contracts not subject to IDA prior review will be disbursed against SOEs, and documentation will be retained by the PCT and made available for review by IDA and the project auditor. In the case of Community-led H1V/AIDS Initiatives, there will be pre-financing of expenditures, as communities are unlikely to start contracting without the assurance of funds. All disbursements against expenditures under the CHAIs will be subject to ex post review by IDA missions and the project auditor, on a sample basis. The project will be audited by independent auditors acceptable to IDA. Each implementing agency will submit quarterly financial reports to UAC. The PCT will consolidate all the project financial reports submitted by the implementing agencies and prepare the project financial statements for auditing purposes. Audited project financial statements and report thereon, inclusive of an auditor's opinion on the use of statement of expenditures will be submitted to IDA within six months following the end of the financial year. At appraisal IDA reviewed and was satisfied with financial management arrangements and the Financial Management Action Plan. The Project Operational Manual and Annexes 5 and 6 of this report describe the projects financial management and disbursement arrangements in detail including a detailed assessment of the fnancial management and internal control systems. D. Project Rationale 1. Project alternatives considered and reasons for rejection: This project is a Sector Investment Loan under the second phase of IDA's Multi-Country HIV/AIDS Program (MAP) for the Africa Region and is directly in accordance with the Bank's regional HlV/AIDS strategy, Intensi.fying Action against HIYVAIDS in Africa: Responding to a Development Crisis. The overall MAP design is a horizontal APL. Sector investment operations for individual countries and a "vertical" APL for Africa, in combination with the "horizontal" APL proposed, were two alternatives considered and rejected (see MAP project appraisal document for details). - 16 - Section B. 3. -- Sector issues to be addressed by the project and strategic choices, above, describes the reasons why the option of funding the Uganda H1V/AIDS Program through broad support to the national budget under the Poverty Reduction Strategy Credit was rejected. 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned). 2.1 Related project financed by IDA. IDA has supported two projects which are directly related to the HIV/AIDS Control Project: the Sexually Transmitted Infections Project (Cr.2603), and the District Health Services Project (Cr. 2679). In addition, IDA is preparing a direct budget support operation, the Poverty Reduction Support Credit (PRSC), which will provide budgetary support to some HIV/AIDS related activities is related to this operation. Sexually Transmitted Infection Project (STIP . The proposed HIIV/AIDS control project will follow up and scale up activities under the STIP project. It will strengthen the multi-sectoral approach dealing with HIV, and it will empower communities by financing community-led HlV/AIDS initiatives. The STI Project ($50m), began in 1995 and is due to close December 31, 2001. It supports the National AIDS Control Program, including IEC activities, surveillance and care and support. It developed syndromic management protocols for STI treatment and financed STI and tuberculosis drugs. Its performance is presently rated as satisfactory. District Health Services Pilot and Demonstration Project (DHSP . The proposed HIV/AIDS Control Project will take advantage of the capacity built at district level to implement integrated, multi-sectoral, district WV/AIDS action plans, and to promote and assist community-led HIV/AIDS initiatives. The DHSP project ($45m), began in 1995 and is due to close on December 31, 2002. It supports the development, financing, planning and management of district health services in a decentralized government system. It has also supported the restructuring of the public health system and the Ministry of Health including the development of health sector reform, civil service reform, manpower development at all levels, and important studies such as the burden of disease study. Its performance is presently rated as satisfactory. Poverty Reduction Support Credit (PRSC). The proposed HIV/AIDS Control Project will provide additional resources to what will be funded through the PRSC and will be used to scale up the war against WHV/AIDS. The PRSC ($225 million), currently under preparation, will provide direct budgetary support to the country with an emphasis on assisting priority sectors, one of which is the health sector, and cross cutting areas such as procurement, human resource and financial management. The fund is allocated by the Ministry of Finance using its normal budget processes. The Ministry of Health received an additional $3.3 million in this FY. The PRSC is to become the main mode of IDA support to Uganda and its contribution to the health sector, according to the Midium-term Expenditure Framework, is expected to grow substantially in coming years to over US$ 10 million annually. A part of the PRSC shall support the procurement of some large item packages, such as condoms and pharmaceuticals. In order to harmonize the PRSC with the HWV/AIDS Control Project, the Government of Uganda has agreed that the Uganda HIWV/AIDS Control Project will support the procurement of condoms, HIV and syphilis diagnosis kits, drugs for the prevention and treatment of opportunistic and sexually transmitted infections, including tuberculosis (TB), and for the prevention of mother to child transmission, on a declining basis. Funding for these large contracts would progressively be taken up by the regular PRSC/budget support financing - 17 - system. 2.2 Projectsfunded by other development agencies. The project also complements HIV/AIDS projects financed by other multi- and bilateral development agencies. The total amount of grant funds provided by these agencies is estimated at about US$16 - 17 million per year. These projects implement different HIV/AIDS control activities in a limited number of districts, often using civil society organizations as an executing agency. The Danish international development agency -- DANIDA supports different civil society-led and Rakai District-based HIV/AIDS control activities, in the area of health promotion and prevention of mother to child transmission, costing about US$500,000 per year. Ireland AID also supports H[V/AIDS control activities costing about US$500,000 per year, focused in three districts (Kibaale, Kiboga and Kumi), but is considering extending its support to some nationally coordinated activities as well. The Swedish international development agency -- SIDA supports a number of civil society-led HIV/AIDS control initiatives, costing about US$1,000,000 million per year. UNFPA is considering to finance HIV/AIDS control activities costing about US$275,000 per year, as integral parts of its reproductive health, population and development strategy and advocacy activities. US Government Agencies (US Agency for International Development -- USAID, Center for Disease Control -- CDC, and Department of Defense are very active in supporting different HIV/AIDS activities in Uganda. Activities have focused mostly in voluntary counseling and testing, and on medical care and support to people living with HIV/AIDS, partnering with two major Ugandan civil society organizations: the AIDS Information Center, and The AIDS Support Organization. Center for Disease Control is supporting HIV related monitoring and evaluation activities, while Department of Defense is actively preparing HIV vaccine trials, mainly in Rakai district. Total US Government contributions in 2000 are around US$14 million, but the US Government is considering an increase in funding to assist the Government of Uganda in scaling up HIV/AIDS control activities. Department for International Development UK (DFID) is also supporting a number of district based HIV control activities, in collaboration with civil society organizations, but at the time of appraisal it was not possible to quantify the magnitude of its investment. The European Union is also considering supporting Uganda's WV/AIDS Control program, but the magnitude and timing of such support is yet to be defined. The Uganda AIDS Commission will lead the coordination of the inputs provided by different bilateral and multilateral development organizations, through regular meetings of the Stakeholder Network and of the enlarged Uganda/UNAIDS Thematic Group. When relevant, there will be joint supervision and review missions, bringing together IDA staff with those of the bilateral and multilateral agencies involved in AIDS control. When this is not the case, the Bank mission will debrief the relevant bilateral and multilateral agencies on the results of the mission. These collaboration processes will contribute to sharing of learned lessons and contribute to continuing improvement of project design and implementation. - 18- Latest Supervkion Sector Issue Proect (PSR) Ratings ._____________________________ I ____.____. _________. ___ (Bank-financed pro only ) Implementation Development Bank-financed Progress (IP) Objective (DO) Re-established a collapsed health First Health Project S S system, focused on rehabilitation, (Cr. 1934-UG) _ closed policy reform and institutional strengthening; HIV/AIDS: prevention of sexual Sexually Transmitted Infections S S transmission of HIV; mitigation of the Project personal impact of AIDS; and (Cr. 2603-UG) institutional development. Policy development; piloting delivery of District Health Services Pilot S S essential package of health services; and Demonstration Project rehabilitation of facilities; and (Cr. 2679-UG) institutional development. Nutrition and early childhood Early Childhood Level S S development at community level Development Project (Cr. 3052-UG) Poverty reduction and improving living Poverty Reduction Support standards Credit (under preparation) Other development agencies EU Safe blood supply. UNDP AIDS commission, inter sector and community led initiatives. WHO Safe blood supply. UNFPA Regional and district based projects. UNICEF Idem. Focus on orphans DFID District based projects DANIDA District based projects GTZ District based projects USAID District based projects NORAD In Preparation IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: The Government of Uganda has 15 years of experience in undertaking H1V/AIDS control efforts and has had the best success story in Africa, as it halved the incidence of HIV/AIDS over a period of ten years. The Bank has been a major supporter to the Government in the fight against HIV/AIDS. In addition, the Bank is the largest source of international financial and technical assistance to IV/AIDS programs in the world, financing HIV/AIDS programs in Africa, Latin America, Central and Eastern Europe, South and East Asia. Lessons learned from both national and global experiences with HIV/AIDS epidemic have been incorporated in project design, as follows: - 19 - a) The major lessons from the Uganda AIDS control "success story" concern the importance of: i. Political commitment, government openness and strong leadership particularly from the Office of the President and Ministry of Health in addressing HIV/AIDS are critical; ii. Sexual behavior that reduces the number of sexual partners is key: i.e. lowering the proportion of 15-19 year olds ever having sex; higher proportion of 15-19 year olds having sex within marriage only; lower numbers of non-regular partnerships; iii. Open personal communication networks for acquiring knowledge about AIDS and having direct knowledge about people living with H1V/AIDS are key to changing behaviors, to reinforcing social cohesion and social capital; and iv. Increased use of condoms is important but cannot explain why Uganda has been more successful than Kenya, Malawi and Zambia in reducing the spread of the epidemic. The project will focus on strengthening social cohesion and social capital, by empowering communities to fight against AIDS, through support to a number of community-led initiatives. Open interpersonal communication networks will be fostered in order to maintain and reinforce behavior change, i.e. delaying the age of sexual debut, and reducing the number of sexual partners. Strong, continuous and well targeted information, education and communication campaigns have been instrumental in changing knowledge, attitudes and behavior mainly among the young, vulnerable and high risk groups. The project would finance continuing efforts in this area. b) Prevention of mother to child WHV transmission and chemo-prophylaxis of opportunistic infections may reduce the incidence of the disease and delay the progression from I-V infection to clinical AIDS. The project will scale up the existing pilots of mother to child transmission and support pilots to prevent opportunistic infections, under guidance from UNAIDS and WHO; c) Community participation in planning and implementation, and the inclusion of non-government organizations, such as community-led organizations and civil society organizations (including churches, farmers' associations, trade unions, student associations, and private businesses) could increase coverage of WHV/AIDS-related activities, widen the scope of services to be provided and increase sustainability of the program. The project will finance community-led and civil society organization-led WV/AIDS prevention and mitigation subprojects and will establish a ongoing discussion forum with civil society organizations to clarify the nature and requirements of a stronger partnership between government and civil society; d) The design of a multi-sectoral program requires gaining consensus among key actors early in project design, while mainstreaming of HIV/AIDS into non-health sectors and implementation of H1V/AIDS in a decentralized environment, requires substantial capacity building. The project will carry out a series of multi-sectoral workshops on overall project objectives and design and will have a component to support HWV/AIDS prevention and mitigation subprojects in different line ministries, as well as community-based.subprojects, and will invest substantial resources in building the necessary capacity in non-health sector government agencies and communities; e) Planning, procurement, distribution and availability of essential inputs, such as condoms, diagnostic kits, pharmaceuticals and other medical supplies have to be adequate to allow information, education and communication to have impact. It would be unfortunate to encourage people to use -20 - condoms, or to come forward for voluntary counseling and testing, only to find that there are no condoms available, or that the VCT center has run out of tests. The project will contract out to a procurement agent with proven expertise in the procurement and distribution of such essential inputs; f) An adequate HIV/AIDS surveillance system is essential for effective monitoring and evaluation of the impact of HIV/AIDS interventions. The project will include a component to support improved program monitoring, evaluation and management, including strengthening of the HIV/AIDS surveillance system. Care has to be taken not to take "good" news on the incidence or prevalence of the disease as an excuse to relax the effort to control HIV/AIDS. The media has to be well educated into interpreting epidemiological data correctly. The project will invest in improving the relationships between the Uganda AIDS Commission and the media; g) Many civil society organizations do not have adequate project and financial management skills and systems. The project will finance training and assistance for civil society organizations working for HIV/AIDS control in the area of project and financial management; and h) Political support from the highest level in the country, especially the Presidents own lead in the fight against HIV/AIDS, is very important but needs to be accompanied by the same level of leadership and commitment at the district level given the important role of political and administrative leadership of the districts under decentralization. The project will support to build linkages between national leadership and local implementation agencies. 4. Indications of borrower commitment and ownership: The Government presented a satisfactory National Strategic Framework for HIV/AIDS Activities Uganda, 2001-2006. The strategy is coherent, multi-sectoral, and includes a specific action plan covering prevention, treatment and care for those infected and affected by HIV/AIDS. Strategy formulation and the preparation of program implementation have involved significant stakeholders and social assessment techniques. The Government has had a National Committee for the Prevention of AIDS since 1985 and has had an AIDS Control Program in the Ministry of Health to spearhead the national response since 1986. In 1988 Uganda recognized that HIV/AIDS had ramifications beyond the health sector, and this led to the adoption in 1992 of a multi-sectoral approach to the control of HIV/AIDS and the establishment of the Uganda AIDS Commission under the Office of President for national coordination of HIV/AIDS related activities. The country's Poverty Eradication Action Plan (PEAP) has put the reduction of HIV prevalence as one of its high national priority. The AIDS Control Program already executes some of its activities through multi-sectoral government agencies and through community-led and civil society organizations. Different approaches will be further integrated at district level into district-based HIV/AIDS programs and community-led HIV/AIDS initiatives. Participatory consultations with civil society, the regions, donors, and community representatives were held to seek guidance, build up ownership, and encourage local initiatives. At pre-appraisal, the UAC organized a log-frame workshop, involving key members of its Technical Resource Network, to gain consensus around the project concept document, project design and implementation arrangements. It also organized a town hall meeting, involving its Stakeholder Network, to gain consensus around the mission aide memoire and next steps which were needed to complete project preparation, as well as organized a seminar for members of Parliament, to raise awareness about the upcoming Credit and facilitate the respective legislative approval process. In addition the project operational manual and the -21 - project implementation plan was prepared with extensive stakeholder collaboration, during a series of multi-sectoral workshops. 5. Value added of Bank support in this project: IDA is in a unique strategic position to support the Government of Uganda HIV/AIDS program including the mobilization of external resources. The project will bring Uganda: a) Knowledge and lessons learned from international experiences in AIDS programs; b) IDA's international experience in the implementation social funds and in targeted cash transfers will also add value in the implementation of community led HIV/AIDS initiatives in general and in the implementation of targeted support for orphans; and c) A substantial injection of resources and technical assistance from the international community. E. Summary Project Analysis (Detailed assessments are in the project file, see Annex 8) 1. Economic (see Annex 4): O Cost benefit NPV=US$ million; ERR = % (see Annex 4) o Cost effectiveness * Other (specify) 1. I Economic (see MAP Annex 5). The detailed economic analysis on HIV/AIDS has been carried out under the MAP, which includes an overall assessment on the impact of HIV/AIDS on economic development and poverty and a cost-benefit analysis of HIV/AIDS interventions. The data used in the analysis included the Uganda HIV/AIDS information. This section only highlights some key points for the Uganda HIV/AIDS Control Project. The HlV/AIDS epidemic in Africa has gone beyond health and has become a serious socioeconomic development issue. HIV/AIDS affects an economy through (a) reducing productivity, domestic savings and economic growth, and (b) increasing costs of treatment and care for both affected households and the society as a whole. Uganda is one of the severely-affected countries. Despite recent progress made in controlling HIV infection, about 8 percent of Uganda's adult population is HIV positive. About 800,000 have already died from AIDS and left over 1.4 million orphans. It is estimated that Uganda loses 1 percent point of Gross Domestic Product (GDP) every year directly from HIV/AIDS. AIDS strikes people in their most productive age, reducing both the size and growth of the nation's labor force. Care and treatrnent for AIDS impose enormous costs on households and the society at large. Households with AIDS patients are likely to lose the income of their members (often the main breadwinner) in addition to facing an increase in medical expenses. Some households are forced to withdraw their children from schools in order to save money as one of their coping strategies. One survey in Kampala found that about 47 percent of households with orphans did not have enough money to send their children to school. One study in Rikai district showed that households spent up to a third of their annual income on medical care in one month or on one funeral. -22 - The economic benefits of the proposed AIDS control project are multifold (See C.3. above). First, since this project aims to scale up interventions in HIV/AIDS control and mitigation, the majority of Ugandans will directly and indirectly benefit from increased access to H1V/AIDS prevention, treatment, care and mitigation activities. Secondly, new HIV infections will be reduced, due to an expansion in coverage of the package of HIV/AIDS prevention activities supported by the project. Thirdly, people living with HIV/AIDS can lead a longer and more productive life by benefiting from better management of opportunistic infections and access to nutritional supplements; and therefore, less loss in productivity and income and reduced costs for treatment and care. Fourthly, orphans will have improved economic prospects with increased schooling. As the data analysis showed in Annex 5 of the MAP, a reduction in AIDS-related death rate would likely increase the growth rate of GDP. The targeted interventions will benefit vulnerable groups such as teenage girls and pregnant women by imnproving access to VCT, treatment and care. The cash transfer program will keep orphans from poor families fed and in school, therefore improving human capital in the long term. 2. Financial (see Annex 4 and Annex 5): NPV=US$ million; FRR = % (see Annex 4) (Not applicable) Fiscal Impact: The fiscal impact of the project is likely to be small. Some US$10 million are estimated to be disbursed annually, representing less than 1.5% of the total Government budget in FYOO/0 1. Counterpart funds are not expected to be unduly heavy. Most of the counterpart fund requirement applies to civil works and operational expenses. Civil works in this project will be restricted to the renovation of existing health centers and reference laboratories and thus limit the anticipated requirement for recurrent cost support. The project will cover some of the incremental operating expenses (estimated to be 12% of total project costs), on a declining annual basis. The actual fiscal impact is even less since much of the project will be directly channeled to CSOs and PSOs and communities which are required to generate their own counterpart contributions equivalent to 5% of the cost of their proposals. Nevertheless, the government is expected to assume responsibility for the maintenance of project investmnents with the closure of the project. In the past, Uganda has faced difficulties in meeting counterpart fund and recurrent cost requirements of its health programs. To prevent this problem, an annual review will be carried out to assess the adequacy and availability of operating and maintenance costs before the beginning of each year's budget planning cycle. Incidence offiscal expenditures: Ex-ante, the project is designed to be targeted to the poor. However, ex-post analysis of previous health projects in Uganda indicates that the benefits of public health interventions are often captured disproportionately by better-off rather than poor households. For instance, the analysis done by Gwatkin, et al (May 2000) using 1995 Demographic and Health Survey data show high concentration ratios (i.e., high inequality of access) for such health services as use of contraception, birth delivery by trained health staff, and antenatal care by doctors. Knowledge of HIV/AIDS, however, is generally more equitably spread. These conclusions argue for better targeting of project resources, especially for government-funded public health interventions. This could be achieved under the project through reduction of the physical distance to a health facility (for every additional 1 km. of distance to a facility, use of health services drops by 1% (Hutchinson, et al: 1999); a more intensive information and communication campaign to inform the populace of the availability of health services; commnunity involvement in determining their own health needs; and improving the quality of care, which appear to be the single most important determinant of the -23 - poor's decision to utilize health services. 3. Technical: The project will finance health manpower training and supplies for the use of standard clinical management protocols developed by government and as recommended by UNAIDS or WHO. Such standards will be used in voluntary testing and counseling, in prevention of mother to child transmission, in prevention of opportunistic infections, and in the clinical management of sexually transmitted diseases and opportunistic infections. The project will finance communities to support orphan's education and social welfare, using targeted conditional transfer programs, which have been shown in several Latin America (Brazil, Mexico, Hondur as, Nicaragua, and Ecuador) and in Sub Sahara Africa (Tanzania) to be successful in: a) targeting the poor, b) increasing school attendance and reducing school drop-outs, and c) protecting the structurally poor during economic crisis (i.e. providing them with an assured source of income which smoothes income shocks), encouraging human capital investments, and preparing the next generation for facing future shocks. 4. Institutional: 4.1 Executing agencies: The experience of the different implementing agencies is diverse. The Uganda AIDS Commission has been active for several years, but has little project implementation experience. The capacity of coordinating HIV/AIDS activities nationwide is still very limited. The project will finance on a declining basis the strengthening of its capacity, and will support a project coordination team for the duration of the project. The project coordination team will include several consultants who have good IDA-related project implementation experiences (i.e. in procuremnent and financial management), acquired in other IDA funded projects, such as the Sexually Transmitted Infections, and the District Health Services Pilot Project. Among line ministries, the Ministry of Health which has the largest HIV/AIDS action plan, has good experiences in implementing IDA-funded projects. Other line ministries, such as Education and Sports, Gender, Labor and Social Development, have HIV/AIDS action plans, but little experience in mainstreaming HIV issues in their operations. The Uganda AIDS Commission and the project will make sure that they will proceed step by step, with realistic targets and will support them as necessary. Districts will be key to the success of this operation, as they will implement a large part of the project and will integrate multi-sectoral efforts into cohesive district action plans. Of all sub-Saharan countries, Uganda is the country which has been most successful in decentralizing government to the district level, and many districts already have experience in the implementation of IDA and other donor funded projects. Other districts have limited capacity and will have to be assisted. UNAIDS and UNICEF are presently financing a District Response Initiative to strengthen the capacity of districts to handle the challenges of HIV/AIDS pandemic. The project will complement and scale up such efforts, as required. Communities in Uganda have a long and strong tradition of community organizations and community-led -24 - initiatives. The Government of Uganda, however, does not have an ongoing social development fund, through which the project could support Community-led HIV/AIDS Initiatives (CHAIs). The project will therefore opt for using district government structures, or civil society organizations, and very simple procedures to channel funds to CHAIs. Civil society organizations (CSOs) in general, and HIV-related CSOs in particular, are quite strong in Uganda, both at national and district level. Some of them are strong umbrella national organizations, such as TASO, the AIDS Information Center, and the churches, -- while other are smaller and district based CSOs. In both cases, most have experience with IDA or other bilateral or multilateral development agency funded projects. They will be key in the implementation of many project sub-components and activities. 4.2 Project management: The Uganda AIDS Commission, under the Office of the President, is well placed for coordinating the National HIV/AIDS program and the project, and for providing a multi-sectoral perspective. The project will assist the UAC in recruiting its core technical staff and, in addition, will contract a project coordination team, to cope with the additional requirements generated by project management. Each line ministry and district will manage the implementation of its own 1RV/AID plans and ensure its ownership. The FIV/AIDS Technical Resource Network and the Stakeholder Network, will assist the UAC in mobilizing and coordinating the different implementing agencies. 4.3 Procurement issues: The project will contract a procurement agent, on a competitive basis, to procure large contracts. In addition, the UAC project coordination team will include procurement specialists at national and district levels. 4.4 Financial management issues: TIhe financial management capacity in UAC requires strengthening. The project will take various measures to strengthen institutional capacity of UAC including recruiting a financial management specialist for the Project Coordinating Team and develop an adequate computerized financial management information system. In the interim, the project will put in place the financial management system that has already been implemented under the IDA supported Sexually Transmitted Infections Project. A Financial Management Action Plan will be implemented to allow the project to convert to Program Management Report-based disbursement. 5. Environmental: Environmental Category: C (Not Required) 5.1 Summarize the steps undertaken for environmental assessment and EMP preparation (including consultation and disclosure) and the significant issues and their treatment emerging from this analysis. The project is not expected to generate any adverse environmental effects. Possible environmental risks include inappropriate handling and disposal hazardous medical waste and inadequate management of the respective disposal sites in urban or peri-urban areas, where domestic and medical waste may be mixed and where scavenging is a livelihood. The project will finance training of health care professionals, of traditional birth attendants and traditional healers, and of community workers delivering care to HIV/AIDS patients. This training will include instruction on appropriate separation, transport and disposal of hazardous medical waste. The project will finance the revision of existing health sector guidelines on appropriate management of hazardous medical waste at medical facilities and at disposal sites to include the relevant dispositions regarding HIV/AIDS. - 25 - 5.2 What are the main features of the EMP and are they adequate? NA 5.3 For Category A and B projects, timeline and status of EA: Date of receipt of final draft: NA 5.4 How have stakeholders been consulted at the stage of (a) environmental screening and (b) draft EA report on the environmental impacts and proposed environment management plan? Describe mechanisms of consultation that were used and which groups were consulted? NA 5.5 What mechanisms have been established to monitor and evaluate the impact of the project on the environment? Do the indicators reflect the objectives and results of the EMP? NA 6. Social: 6.1 Summarize key social issues relevant to the project objectives, and specify the projects social development outcomes. The project is expected to have a positive social impact by assisting and empowering people and institutions to deal more effectively with the HIV/AIDS epidemic. People living with HIV/AIDS and their families face continued violations of their economic and human rights. The project will assist preparing the legislative initiatives that would make it more difficult for such violations to continue, and will finance advocacy, information, education and communication activities to raise awareness and acceptance of the human and economic rights of people living with HIV/AIDS. 6.2 Participatory Approach: How are key stakeholders participating in the project? The Uganda AIDS Control Project was developed on the basis of the Uganda HIV/AIDS Strategic Plan and following a process of consultation with key government, non-government, and international stakeholders, and groups of people living with HIV/AIDS. During project preparation, the Uganda AIDS Commission convened several consensus-building exercises to involve in major stakeholders, including a log frame workshop to gain consensus around the project concept document, project design and implementation arrangements and a town hall meeting, involving its Stakeholder Network, to gain consensus around the mission aide memoire and next steps which were needed to complete project preparation. It also organized a seminar for members of parliament, to raise awareness about the upcoming Credit and facilitate the respective legislative approval process. The Uganda AIDS Commission, which will coordinate project implementation, is supported by a Technical Resource Network including representatives from relevant line ministries and districts, and by a Stakeholder Network which includes civil society organizations, people living with HI-V/AIDS and bilateral and multilateral development agencies. In addition the project will support an ongoing series of participatory processes in which project achievements and shortcomings will be shared with key stakeholders and technical specialists. This process will contribute to raising awareness, and to building consensus around project design and implementation. 6.3 How does the project involve consultations or collaboration with NGOs or other civil society organizations? - 26 - Civil society organizations have been consulted during project preparation and appraisal and will execute a significant part of the project, supporting government agencies and community-led initiatives. Civil society organizations will also be consulted in annual project reviews, in the mid-term and the end of project evaluation. 6.4 What institutional arrangements have been provided to ensure the project achieves its social development outcomes? The Uganda AIDS Commission integrates representatives from different Government agencies, from civil society and from people living with AIDS and is supported by a Stakeholder Network which will assist in mobilizing different sectors in society. 6.5 How will the project monitor performance in terms of social development outcomes? Gender specific and orphan specific indicators have been included among the project performance indicators (See section A.2. and Annex 1.) 7. Safeguard Policies: 7.1 Do any of the following safeguard policies apply to the project? ROlP A b Environmental Assessment (OP 4.01, BP 4.01, GP 4.01) 0 Yes 0 No Natural habitats (OP 4.04, BP 4.04, GP 4.04) 0 Yes * No Forestry (OP 4.36, GP 4.36) C Yes *No Pest Management (OP 4.09) 0 Yes 0 No Cultural Property (OPN 11.03) O Yes * No Indigenous Peoples (OD 4.20) 0 Yes 0 No Involuntary Resettlement (OD 4.30) 0 Yes 0 No Safety of Dams (OP 4.37, BP 4.37) O Yes 0 No Projects in International Waters (OP 7.50, BP 7.50, GP 7.50) 0 Yes * No Projects in Disputed Areas (OP 7.60, BP 7.60, GP 7.60) 0 Yes 0 No 7.2 Describe provisions made by the project to ensure compliance with applicable safeguard policies. The project complies with all Bank's safeguard policies, including those described above. F. Sustainability and Risks 1. Sustainability: The project is expected to be sustainable institutionally in the medium term because it is built upon the strong government ownership and supports the ongoing and already strong Uganda National HIV/AIDS Program. The project will scale up the existing program by mainstreaming activities into all government sectors, civil society, and communities. The project emphasizes institutional capacity building at national and local level which would further enhance the sustainability of the project and its local sub-projects. As far as its financial sustainability, it is unlikely that the Government will be able to fully finance the program in the medium-term. But it is realistic to expect that bilateral and multilateral development agencies will continue to finance the program beyond the period of project implementation. -27 - 2. Critical Risks (reflecting the failure of critical assumptions found in the fourth column of Annex 1): _MOk Risk Rftfng Risk MitiatiOn Measure From Outputs to Objective Central and Regional Government, sector M UAC, with all partners will continue to create ministries and community leaders may not demand and commitment at all levels, including honor their commitment to participatory the participatory development of comprehensive development and to the creation of an national HIV/AIDS strategies and action plans. enabling environment for local responses to HIV/AIDS. The decentralized and participatory implementation will help sustain the political commitment. Denial due to cultural, religious and other M This will be addressed by developing and reasons may limit the capacity of the implementing sub-programs and sub-projects in country to scale up action. a fully transparent and participatory manner. All these processes will include civil society and in particular people living with 1HV/AIDS. From Components to Outputs Some regions and districts may lack the S The processes and documentation required for capacity and resources needed to design, sub-programs and subprojects will be simplified coordinate, and evaluate their respective and standardized. components of the comprehensive programs. Decentralized implementation entities and S Program design will emphasize capacity communities may lack the capacity to building through training of executing entities propose and mange their sub-programs and technical support at all levels. and sub-projects. Allocation of small grants will permit generalized learning by doing. Performance based replenishment weeds out implementing entities whose capacities are not improving. Simple procurement and disbursement procedures for community-based investments will be used for a large part of the program. - 28 - Slow disbursement of project operations: S Where necessary, outsourcing of fund * Due to limited financial management management and financial reporting procedures capacity and control will be agreed upon. And the * Due to inadequate procurement necessary contracts initiated prior to IDA credit procedures and capacities effectiveness. Procurement of large ticket items * Due to delays in appraisal and will be procured and distributed by extemal approval of sub-programs and procurement agents. sub-projects. Appraisal and approval of intermediate and small sub-programs and sub-projects will be decentralized to regional and local coordinating committees. Poor inter-sector collaboration at national, M Strengthen institutional capacity of UAC and regional and local levels. establishment of HV/AIDS coordinating bodies and committees at local level will improve coordination. The highly decentralized implementation M Some mechanisms will be built into the project mechanisms will result in unmanageable design: fiduciary problems, including misuse of (a) Accountability to end users via participation funds. in project design and implementation, and via transparency rules; (b) Contracting out of financial management, where necessary; (c) A random financial technical and process audit of all small executing entities, and mandatory publication of all audit results, complemented by audits triggered by beneficiary complaints; (d) Financial audits of all large scale executing entities; and (e) Integrated reports from executing entities which link performance to financial report. Overall Risk Rating M Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N(Negligible or Low Risk) The overall project risk is estimated to be moderate because there is good Government and civil society ownership, the existing HIV/AIDS program is relatively strong, and because the project implementation team, under the Uganda AIDS Commission, benefits from the experience of staff who successfully managed the Sexually Transmitted Infection Project. - 29- There is however a substantial risk that the project will not be able to scale up all operations right from the start because some line ministries and a number of districts have insufficient experience with multi-sectoral initiatives and limited experience in HIV/AIDS control. In addition, the project will have to set up a new system to channel funds to community-led initiatives, given that Uganda does not yet have an established social fund system. Under normal project preparation circumstances, these risks would have been reduced by intense project preparation inputs, but given the urgency to respond to the HIV/AIDS epidemic, the project was prepared in a very short time without the level of technical support, which would usually accompany project preparation and appraisal. To minimize the risk and ensure the success implementation of this project, IDA will have to: a) provide adequate resources for supervision which is above the standard supervision coefficients; b) conduct supervisions with the team consisting of specialists from multisectors and specialists in key areas such as financial management, procurement and monitoring and evaluation; and c) collaborate closely with internal and external partners and stakeholders. 3. Possible Controversial Aspects: 3.1 ExternaL The project is not expected to spark major external controversy. 3.2 Internal. Outsourcing of key functions such as procurement of key inputs may be controversial as it may be perceived as coming at the expense of capacity building. As the availability and timeliness of key inputs are essential for the success of the operation, outsourcing may be the only way to ensure speed in procurement and distribution, and adequate accountability. G. Main Credit Conditions 1. Effectiveness Condition a) The Borrower has adopted the Project Implementation Plan and Project Operations Manual satisfactory to IDA; b) The Borrower has appointed a project implementation team coordinator, a financial manager and financial controller, a monitoring and evaluation specialist, and a procurement specialist, all satisfactory to IDA; and c) The Borrower has established an accounting and financial system satisfactory to IDA. 2. Other [classify according to covenant types used in the Legal Agreements.] None - 30 - H. Readiness for Implementation D2 1. a) The engineering design documents for the first year's activities are complete and ready for the start of project implementation. Z 1. b) Not applicable. D 2. The procurement documents for the first year's activities are complete and ready for the start of project implementation. C1 3. The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. C 4. The following items are lacking and are discussed under loan conditions (Section G): At appraisal IDA reviewed and was satisfied with: a) draft Project Implementation Plan, including the first year work plan for participating sectors; b) draft Project Operations Manual; c) draft procurement documents for the first year's activities; and d) a Financial Management Action Plan. i. Compliance with Bank Policies 1 1. This project complies with all applicable Bank policies. II 2. The following exceptions to Bank policies are recommended for approval. The project complies with all other applicable Bank policies. Alexandre '(. Abrantes ji7 Dzingai B. Mutumbuka JmeR W. Adams Team Leader l Sector Manager t ry Director Shiyan Chao Co-team Leader - 31 - Annex 1: Project Design Summary UGANDA: HIV/AIDS Control Project Sector-related CAS Goal: Sector Indicators: Sector/ country reports: (from Goal to Bank Mission) To increase the quality of life Life expectancy will begin to The supported programs will of the poor by imnproving their increase. enable the mobilization of access to basic services such sufficient financial and human as health care, including resources to support increased access to HIV multi-sector and sustainable related diagnosis, treatment or national responses to the care. HIV/AIDS epidemic. To mitigate the impact of HIV/AIDS epidemic in Uganda. Project Development Outcome I Impact Project reports: (from Objective to Goal) Objective: Indicators: Reduce the spread of HIV By 2006, reduce from 49% to KAPB Survey conducted every Multi-sectoral activities infection under 40% the proportion of 2 years, DHS Survey financed will lead to 15-19 year old boys and girls conducted in 2000 (and likely attitudinal and behavior that are sexually active (by in 2006). change regarding prevention sex). and care. By 2006, increase from 30%/O Idem. Availability and willingness of to 50% the number of local NGOs and CBOs to men/women aged 15-49 who implement the reported using a condom in community-level initiatives. their last act of sexual intercourse with a non-regular partner. By 2006, reduce from IS% to Idem. Motivated public and private 5% the reported sexually sectors implementing transmitted (urethritis) HIV/AIDS activities. infections in men aged 15-49 in the last 12 months. By 2006, reduce HIV Sentinel Surveillance System Interest and commitment from prevalence from 8.5 to below beneficiaries and local 6 percent among women of governments. childbearing age as measured in women attending prenatal care services. Mitigate the health and Reduce by 30% the drop out Special Studies of subset of The rate of orphanhood does socio-economic impact of rate of orphaned children in districts. not outpace the rate of HIV/AIDS at individual, primary school. providing assistance to household and community orphans. levels Increase from 30% to 50% the Special Studies of subset of PLWA are not afraid of proportion of PLWHA districts. providing their name and identified by District health home address when attending registers that are receiving health services for treatment. some form of home or community based support. - 32 - Strengthen the capacity of By 2006, increase from 0 to 45 Project Data All districts are aware of the communities, civil society and the number of districts urgency to take action government to respond to the implementing integrated multisectorally. epidemic HIV/AIDS work-plans. Output from each Output Indicator: Project reports: (from Outputs to Objective) Component: 1) National Initiatives By 2006, all relevant (13) line Project Data There is no resistance to ministries will have addressing HIV/AIDS in all incorporated HIV/AIDS sectors. prevention and impact mitigation activities in their annual work plans and are implementing them. By 2006, applied in 60% of Project Data There are sufficient staff to secondary schools the provide the necessary training. secondary school curriculum that incorporates HIV/AIDS. By 2006, increase by 50% Project Data There are no obstacles to (from 80 to 120 million) the procuring a sufficient supply number of condoms sold of condoms. through social marketing outlets or distributed in Uganda. 2)District Initiatives By 2006, increase from 20% Project Data-MOH All sub-counties have the to 80% the counties that have necessary capacity to provide voluntary counseling and the services. testing centers. By 2006, increase from 13% Project Data-MOH The necessary drugs are to 100% the number of available. districts implementing TB DOTS. By 2006, increase from 0% to Project Data-MOH Improved capacity of District 80% the proportion of district health services. hospitals reporting no stock-outs of essential drugs for managing sexually transmitted infections in the last 6 months. By 2006, train 60 percent of Project data-Ministry of There is no resistance among agriculture and fishery Agriculture ministry staff to discuss the extension workers on subject. HIV/AIDS. By 2006, increase from 6% to Project Data--MOH Staff are adequately trained 30% the proportion of and provide mothers with hospitals providing prevention adequate breastfeeding of mother to child alternatives. transmission services. 3) Community -led Initiatives By 2006, 509/o of the identified Project data District and sub-county HIV/AIDS orphaned children governments effectively (by sex) , receiving support manage local welfare from the project. programs for orphans. - 33 - By 2006, increase by 40% the Project data PLAs come break the silence number of associations of and organize to support each people living with HIV/AIDS other. that are generating subprojects. By 2006, increase by 80% the Project data Civil society and the number of community led community are aware of the initiatives targeting importance of targeting youth. adolescents. The amount of project funding Project data Sufficient community disbursed under CHAI will response will be obtained. account for at least 25% of funds disbursed in the previous 12 months. Project Components I Inputs: (budget for each Project reports: (from Components to Sub-components: component) Outputs) 1) National Initiatives US$ 25.0 million Project data 2) District Initiatives US$ 10.0 million Project data 3) Community -led Initiatives US$ 10.0 million Project data 4) Unallocated US$ 5.0 million Project data - 34 - Annex 2: Detailed Project Description UGANDA: HIVIAIDS Control Project The project will finance a US$50 million share of Uganda National Strategic Framework for HIV/AIDS Activities 2000/01-2005/6. The project aims to improve a) access to 1HV/AIDS prevention, care and treatment programs; b) the quality and efficiency of care provided to V/AIDS patients, and c) the country's capacity to cope with the epidemic. The project will scale up activities by mainstreaming program activities into line ministries and non-health government agencies at national and district levels, and by making better use of the capacity of community- led and civil society organizations, including churches, farmers' associations, trade unions and private businesses. By Component: Project Component I - US$25.00 million NATIONALLY COORDINATED INITIATIVES Under this component, the project will support HIV- control activities coordinated by the Uganda AIDS Commission, which will be directly carried out by different line ministries and other national government agencies, or contracted out to civil society organizations or to the private sector, including: a) Uganda AIDS Commission/Project Coordination Team i. Strengthen the capacity of the Uganda AIDS Commission (UAC). This would include enhancing UAC's capacity to provide national leadership on HIV/AIDS, especially its role to guide a coordinated National strategy, to overcome social and cultural barriers to I-V/AIDS, and to mobilize sector ministries, religious and cultural organizations, people living with HIV/AIDS, women's groups, youth groups, the private sector, and other key stakeholders. The project will finance UAC's annual meeting and the periodical meetings of national HIV/AIDS-related committees; ii. Promote legal initiatives concerning the legal, ethical and human rights issues related to HIIVIAIDS. Such initiatives will include measures to promote the integration of people living with AIDS in schools, to reduce their discrimination in the workplace, to facilitate their access to care, and to ensure the confidentiality of medical information; iii. Coordinate project support to HIV-related research and knowledge management. Research sub-projects which will be selected on a competitive basis. A HIV/AIDS Research Committee will assist UAC in managing calls for proposals. Proposals to be financed by the project will be cleared by the relevant line ministry and the Uganda National Council for Science and Technology. The project's operational manual describes the relevant implementation arrangements; iv. Coordinate capacity buildingfor line ministries and districts in the integration of HIV/AIDS sections into their respective Poverty Reduction Strategy Programs, and in the design, management and implementation of HIV/AIDS programs at different levels. The UAC/PCT will coordinate/package the relevant technical assistance for those districts with less capacity for responding to the epidemic, bringing together expertise from its Technical Resource Network, including the relevant line - 35- ministries; and v. Monitor and evaluate different program components. The UAC/PCT and the Project Steering Committee will review the results every six months and share the information to the society at large b) Ministry of Health . Contract mass media campaigns, in collaboration with UAC and other relevant partners, to enhance further the awareness and understanding of the means of transmission and prevention of HlV/AIDS and sexually transmitted infections, and to promote the use of condoms; ii. Expand voluntary HIV counseling and testing -- VCT, to at least 80 percent of districts. The Ministry of Health, will provide the relevant technical guidelines, will collaborate with district authorities in training all staff involved, including those of civil society organizations, and provide the necessary equipment and supplies. Through campaigns, increase the demand for voluntary counseling and testing services; iii. Improve national HIVIAIDS reference centers, including reference laboratories, day care centers, ambulatory care network and sexually transmitted infection testing and counseling centers; iv. Review and disseminate natonwide clinical protocols for the management of HIV (including the use of anti retroviral drugs), of sexually transmitted and opportunistic infections, including tuberculosis, and for home care support, and carry out the relevant training for district-based trainers of health sector staff; v. Improve blood supply safety and quality control and guarantee the availability of the relevant diagnostic kits (HIV, hepatitis and syphilis) in the entire blood transfusion network; vi. Improve the procurement, stock management and distribution of essential supplies, such as gloves, disposable materials, laboratory reagents, male and female condoms, HV-related diagnostic kits and pharmaceuticals for management of sexually transmitted infections, opportunistic infections, including tuberculosis, prevention of mother to child transmission, and prophylaxis of opportunistic infections, both in the public and private markets; vii. Inprove safe handling of laboratory and medical materials and waste. The Ministry of Health will develop an bio-safety program for at least 80 percent of health care facilities, revise the relevant technical guidelines and train the relevant personnel; viii. Expand the prevention of mother to child transmission, and pilot the prophylaxis against opportunistic infections, in health settings with the relevant capacity. These activities will be expanded and developed as part of family planning and reproductive services, pediatric and prenatal care, and in the management of infectious diseases; ix. Strengthen the HIVIAIDS surveillance system. This will include the improvement of the notification of HIV/AIDS and of sexually transmitted infections, the expansion of sentinel surveillance sites, beyond the prenatal clinics to also include voluntary counseling and testing centers, military facilities, prisons, tuberculosis and sexually transmitted disease clinics, and blood banks; - 36 - x. Monitor HIV-related behavior trends, in collaboration with the UAC and other relevant partners; xii. Produce and distribute an HIVIAIDS Epidemiological Report and Newsletter. The Report, produced biannually will include in-depth epidemiological analysis and behavioral data, and will target health professionals. The Ministry will also edit a simpler IV/AIDS Newsletter targeted to the general public; xiii. Provide line ministries and districts with the HIV/AIDS-related technical assistance, when requested; and xiv. Provide HIV-related information, education and communication and condom distribution to mfinistry workforce. c) Ministry of Education and Sports i. Review education sector policies regarding access to school of children and teachers with HWV/AIDS, sanctions against sexual harassment and sexual abuse by teachers and others; ii. Review primary, secondary and tertiary school curricula to include appropriate reproductive health and HIV related education, produce and distribute the relevant educational materials, and train teachers in their use; iii. Focus resources on effective school health- FRESH. Lessons will be developed which seek HIV-related knowledge and behavioral change through a teaching approach which will target both skills and knowledge and will include: negotiation, resisting peer pressure, self-esteem, communication and assertion. Lessons will be developed through teacher training colleges and "key trainer workshops", which will also provide a cadre of trainers to transfer lessons learned down to district level workshops; iv. Promote school- and student association- led initiatives, in primary, secondary and tertiary education institutions (to be financed under Part C); V. Expand HIV/AIDS and sexually transmitted infections related counseling and testing to schools, colleges and institutions of higher education, using peers and parents as key resources; vi. Monitor and evaluate the impact of HIV/AIDS in the education sector, in collaboration with the Ministry of Public Service, the Ministry of Gender, Labor and Social Welfare and other relevant agencies; and vii. Provide HIV-related information, education and communication and condom distribution to ministry workforce. d) Ministry of Gender, Labor and Social Development i. Prepare and promote legislation on the rights of orphans, widows and people living with HIVIAIDS as bonafide members of communities they live in, to avoid disinheritance and discrimination. This activity will be carried out in collaboration with UAC, Ministry of Justice, the Parliament, the National Council for Children, civil society organizations representing people living with HIV/AIDS, women associations, and other relevant agencies. This activity will be accompanied by the - 37 - relevant advocacy and information, education and communication activities; ii. Promote workers-, youth-, women-, civil society- and community-led HIVWAIDS initiatives. These initiatives will be financed under part C and include: company-led, employer-led, workers associations-led and union-led 1I1V/AIDS initiatives at workplaces. These activities will be targeted at particularly vulnerable professional groups such as long distance truck drivers, migrant laborers, traders, fishermen, hotel and tourism industry workers (to be financed under Part C); youth-led HIV/AIDS initiatives, including recreation, sports club and adolescent reproductive life and health-related initiatives; women-led initiatives focusing on the empowerment of women, counseling on the use of condoms, awareness on the risks posed by genital mutilation, early and forced marriages, defilement, and the rights of people living with H1V/AIDS. This activity will be carried out in collaboration with women's organizations; and civil society or community-led HIV/AIDS initiatives in the area of education and welfare of orphans, people living with HIV/AIDS, and for female, child and elderly headed households due to deaths of husbands, parents or guardians (to be financed under part C); and iii. Review conditions of microfinance programs, to accommodate the special needs of women, children and elderly led households, foster homes, social groups supporting and caring for orphans; and iv. Provide HIV-related information, education and communication and condom distribution to the ministry and related agencies workforce. e) Ministry of Agriculture, Animal Industry and Fisheries i. Train district trainers of agriculture an dfishery extension workers, on HI V/AIDS counseling and testing, and on improved nutrition, with an emphasis on locally grown foods; ii. Promote community-led andfarmers' association-led HIVIAIDS initiatives in the area of improved nutrition, with an emphasis on locally grown foods (to be financed under part C); and iii. Provide HIV-related information, education and communication and condom distribution to the ministry workforce and affiliated agencies. f) Ministry of Works, Housing and Communications i Ensure aUl construction contracts include HIV/AIDS prevention and mitigation activities for the work force; ii. Promote company- and union-led HIV/AIDS initiatives, targeted to transport sector workers ( to be financed under Part C); and iii. Provide HIV-related information, education and communication and condom - 38 - distribution to the ministry workforce and affiliated agencies such as the Uganda Airlines, Uganda Railways and the Civil Aviation Authority, and to associated high risk groups like long distance drivers. g) Ministry of Defense i. Provide HIV and sexually transmitted infection related prevention, care and mitigation services for aU military personnel, including: information, education and communication; voluntary counseling and testing; social marketing and condom distribution; and diagnosis and treatment of sexually transmitted infections and of opportunistic infection, including TB. ii. Train Ministry of Defense health care providers, care givers and social workers and counselors on HIIV/AIDS prevention, diagnosis, clinical management and social support; and iii. Train Ministry of Defense managers in HIV/AIDS control activity management. h) Ministry of Internal Affairs i. Provide HIV related prevention, care and mitigation services for all police and prison populaions including: information, education and communication; voluntary counseling and testing; social marketing condom distribution; and diagnosis and treatment of sexually transmitted infections and tuberculosis; and ii. Provide HIV-related information, education and communication and condom distribution to the ministry workforce; iii Train Police and Prison health care providers, care givers and social workers and counselors on HIV/AIDS prevention, diagnosis, clinical management and social support; and iv. Train Police and Prisons managers in HV/AIDS control activity management. i) Ministry of Local Government i. Review, harmonize and supervise the application of district-based policies and regulations concerning HIV/AIDS; ii. Provide HIV-related information, education and communication and condom - 39- distribution to the ministry workforce. j) Ministry of Public Service i Incorporate andpromote the implementation of new public service management rules and practices that address legal, ethical and social rights of persons living with HIV/AIDS, including policies on recruitment, leave, deployment, training, pay, exit, and welfare of public officers; ii. Monitor trends and the impact of HIV/AIDS in the civil service and assist the respective ministries plan for future resource shortages; and iii. Provide HIV-related information, education and communication and condom distribution to the ministy workforce. k) Ministry of Justice i. Provide HIV-related information, education and communication and condom distribution to the ministry workforce. I) Other Ministries Other Ministries will be assisted to draft I{V/AIDS action plans during the first year of project implementation. The project will finance the implementation of such action plans as they are approved by the UAC and IDA. Project Component 2 - US$10.00 million DISTRICT INITIATIVES District authorities will implement their own integrated HIV/AIDS and sexually transmitted infection control and prevention activity workplans, in accordance with the Uganda National Strategic Framework for HIV/AIDS Activities, 2001/2006. Under this component, the project will support activities directly which are carried out by district authorities, or are contracted out to civil society organizations or to the private sector, including activities to: a) Raise awareness of district leadership, teachers, school management teams and community leaders on prevention and mitigation of HIV/AIDS, on the rights of people living with HIV/AIDS, widows and orphans, and on the impact of several traditional or common practices on the spread of HIV/AIDS, i.e. early and forced marriages, female genital mutilation, early sex, multiple and irregular sexual partners, scarification, blood sharing and other forms of skin piercing, and other common practices such as defilement and alcohol abuse; b) Train and support district- and community-based staff and leaders, including i. teachers on life skills, on the prevention of 1IIV/AIDS and sexually transmitted infections; ii. home-care givers and counselors on voluntary counseling and testing, on prevention and -40 - mitigation of WIV/AIDS, on the prevention, management and referral of sexually transmitted diseases and opportunistic infections, including TB; iii. traditional birth attendants and traditional practitioners on the impact of traditional practices on the spread of WHV/AIDS (i.e. female genital mutilation, scarification, blood sharing and other forms of skin piercing, early sex, multiple and irregular sexual partners, early and arranged marriages, as well as other common practices such as defilement, and alcohol abuse), as well as on the diagnosis, first aid, and referral of AIDS, sexually transmitted and opportunistic infections; iv. rural extension workers including agriculture extension workers, community development assistants, health assistants, and civil society organization extension staff, etc., on the prevention of IIV/AIDS transmission and on nutrition (with emphasis on available foods and how to grow them), and on how to serve as community resource persons. c) Provide HIV/AIDS related prevention and care services at all district hospitals and clinics, including: i. information, education, communication; ii. social marketing and distribution of condoms; iii. voluntary counseling and testing for the overall population, with emphasis on high risk groups; d) Provide HIV related diagnosis, treatment and care at reference district hospitals, including: i. clinical management of sexually transmitted and opportunistic infections, including tuberculosis (Direct Observation Tuberculosis - DOTS); ii. prevention of mother to child HIEV transmission; and c). Pilot the prophylaxis of opportunistic infections in selected reference district hospitals and clinics; d). Promote community-led and civil society-led HIV/AIDS initiatives and manage the respective selection, contracting, financing and supervision. It is estimated that a number of districts will not initially have the capacity to carry out this activity. In such cases, the UAC will ensure that such activities will be carried out through contracts with civil society or private sector organizations; and e). Provide HIV-related information, education and communication and condom distribution to the district workforce. Project Component 3 - US$ 10.00 million COMMUNITY-LED HIV/AIDS INITIATIVES - CHATs Under this component, the project will support community-led and civil society-led H[V control initiatives. CHAIs will be promoted, facilitated and assisted by the relevant line ministries, by district authorities and/or by civil society organizations. CHAIs will include activities demanded by communities and which - 41 - they can implement directly or with assistance from the districts or civil society organizations, such as: a) Targeted support to orphans -- Targeted support to orphans, guardians of poor orphans and AIDS stricken impoverished households, including those headed by females, children and the elderly, conditional on families keeping school aged children at school. Under this initiative, communities, school management committees and headmasters will identify needy orphans and their respective guardians. Following registration of the orphan the guardians will receive a check which will assist the guardian finance the expenditures for one term associated with school fees, uniforms, books and materials, and nutritional supplements. In the next tern, the guardian can claim a second check, if she or he present evidence that the child or adolescent has attended school for a minimum amount of time. The size of the grant will vary by age of the orphan. The transfer for adolescents will be larger than for children, to offset the opportunity costs of not having the adolescent join the workforce. In addition, support will be provided to pre school and out of school orphans to attend day care centers and vocational training programs; b) Community-based information, education and communication on preventing the transmission of HIV/AIDS and of sexually transmitted infections, on the risks carried by traditional practices such as female mutilation, skin piercing and blood sharing, mother-to-child transmission and new legislation protecting HIV/AIDS patients and families, as well as social marketing and distribution of condoms. The project will support social support networks and persons living with HIV/AIDS to disseminate HIV/AIDS information; The project will also support initiatives led by groups of people who engage in high risk behaviors (commercial sex workers, men who have sex with men and intravenous drug users), or groups of people who are vulnerable to engaging in such behaviors, as well as initiatives led by civil society organizations which specialize in working with such groups; and c) Home-based care -HBC. This may include: i. information and education on the prevention of HIV/AIDS and sexually transmitted infections, and the prevention mother to child transmission; ii. distribution of condoms; iii. targeted food supplements; iv. voluntary counseling and testing; v. clinical management of sexually transmitted infections and opportunistic infections, including provision of home based kits; vi. social and spiritual support; and vii. training and support to care givers and community counselors. The home-based care will address the needs of people living with HIV/AIDS and their families. A training manual for home-based care staff will be developed and a patient care kit will be provided. Routine supervision and technical support will be provided by district teams or civil society organizations designated by them. A referral system between cornmunity based care and referral hospitals will be established. Civil society organizations may on their own initiative, or under contract with the UAC or with district -42 - authorities, promote community-led initiatives and provide the communities with whatever technical assistance is required to prepare a sub-project proposal, or to cany out the activities included in the sub-project proposal. UNALLOCATED The project has $5 million IDA credit unallocated. This amount will be allocated at mid term review to Part B -- District Initiatives or Part C -- Community-led HIV/AIDS Initiatives, based on the relative progress made in the implementation of district and community initiatives. Project Insitutional and Implementation Arrangements Institutional Arrangements. The Uganda AIDS Commission (UAC) and its Secretariat, which is under the Office of the President, will coordinate the overall National HIV/AIDS program and project activities. The UAC Director General will be the Project Director, to whom a Project Coordinator will report. The Project Coordinator will lead a Project Coordination Team (PCT), which will be contracted to support additional work generated by project-related management, monitoring and evaluation. The PCT will perform day to day project-related coordination and facilitation activities. The PCT will utilize expertise from previous IDA supported projects, such as the Sexually Transmitted Infections Project and the District Health Services Pilot and Demonstration Project. The project will finance PCT as well as strengthen the UAC Secretariat's capacity, on a declining basis. A Project Steering Committee, to be chaired by the Permanent Secretary of the Office of the President will be established as an advisory board and include representatives from key sectors and institutions, as well as representatives from key civil society organizations, including those which represent people living with HIV/AIDS. The Project Coordinator will be the Secretary of the Project Steering Committee. A Technical Resource Network, which is composed of technical staff from different sectors, line ministries and other agencies, and a Stakeholder Network, which is composed of representatives of civil society organizations as well as other multilateral and bilateral agencies, have been established. These Networks will support the Uganda AIDS Commission to mobilize line ministries, districts and communities for FIV/AIDS initiatives and to review technical aspects of annual sector HIV/AIDS plans and evaluation reports. Line ministries will implement their respective HIV/AIDS plans and report regularly to the UAC on agreed input and output indicators. In all line ministries, the respective Permanent Secretary will have overall responsibility for implementing the sector HIV/AIDS workplan. An HIV/AIDS focal person has been identified for the purpose of project coordination in each ministry. The day to day implementation will be carried out within the existing structure rather than creating a new structure. Since the Ministry of Health will carry out a significant proportion of the project activities, it may require technical assistance in areas such as procurement and financial management. Districts will be at the forefront of project implementation. District HIV/AIDS work plans will reflect various sector activities to be implemented at the district level. Line ministries will provide the relevant guidelines, coordination, training, monitoring and evaluation, and resource mobilization in line with existing working arrangements with the districts. A formal contract with agreed input and output indicators will guide the relationships between districts and the PCT. The Chief Administrative Officer will have overall -43 - responsibility for project implementation at district level. The CAO will identify from among existing district staff a District Focal Person who will be responsible for project coordination and management activities. Service delivery activities will be the responsibility of various of district line departments, civil society organizations, private sector and community based organizations. Each district will establish a District HIV/AIDS Committee, composed of heads of department, municipal and town councils, and relevant civil society organizations. The District Focal Person will chair the Committee. The Committee will nominate its secretary. The Committee will meet periodically to mobilize different stakeholders and facilitate project implementation. Communities will organize themselves, present their proposals to the respective district or the Project Coordination Team, and will execute Community-led H[V/AIDS Initiatives (CHAIs). Communities may want to contract assistance from civil society organizations to prepare, and implement their sub-projects. Community led initiatives will be funded separately from district workplans. Communities will contribute in kind to sub-project financing, their contribution amounting to at least five percent of total sub-project costs. Civil Society Organizations -- CSOs (including, non-governmental organizations, Religious Organizations, farmers' associations, unions, student associations and private enterprises) and Private Sector Organizations will be key partners of Government in scaling up and mainstreaming HIV/AIDS prevention and mitigation activities. Civil Society Organizations and Private Sector Organizations (PSOs) will be contracted to implement project activities. UAC/PCT and districts will enter into contracts with CSOs and PSOs. District budgets will include funds earmarked by the project for CSO and PSO based sub-projects. The UAC and the Stakeholder Network will organize a process to pre-qualify bonafide HIV/AIDS civil society organizations. Each district will contract a lead civil society organization with proven financial, project monitoring and community mobilization skills to promote community-led HIV/AIDS initiatives and assist communities in subproject preparation. The project will coordinate with other IDA funded projects and with other HIV/AIDS related project financed by other bilateral and multilateral organizations. At national level, coordination will be achieved through the Stakeholder Network and the Enlarged UNAIDS Thematic Group. At district level, coordination will be achieved through the District HIV/AIDS Committee. Implementation arrangements. The project will finance a series of HIV/AIDS plans presented by line ministries and districts, as well as a large number of Community-led HIV/AIDS Initiatives (CHAIs). Planned activities for the first year of project implementation were integrated into an annual Project Implementation Plan (PIP). At Appraisal, the Bank reviewed and was satisfied with the draft first year PIP. The project will be implemented in an incremental manner, starting with those ministries and districts which already have HIV/AIDS workplans. Project coverage will be scaled up and expanded to more sectors, as the project assists ministries and districts in strengthening their implementing capacity. Line ministries and districts will present annually HIV/AIDS plans for the following fiscal year. The UAC/PCT will coordinate these plans and, when needed, will provide assistance to improve programs and eliminate duplications. - 44 - Communities will organize themselves for the purpose of presenting proposals for Community-led HIV/AIDS Initiatives. In each district, lead civil society organization will promote community led HEV/AIDS initiatives on behalf of the project. Community beneficiaries -- CB, i.e. rural or urban community residents, and community-based organizations -- CBO will be eligible to present community-led HIV/AIDS initiatives. Community-based Organizations may contract an Implementing Partner -- IP to assist communities in subproject preparation and processing, and counseling in implementation. The cost of such assistance will be reimbursable, up to a maximum of 10 percent of total sub-project costs. There will be a list of "standard sub-projects" for which review, approval and financing will be streamlined and almost automatic, and a list of activities which will not be financed under the component. Communities may present non standard subproject proposals. If one particular type of non-standard proposal is frequently submitted, it will become part of the standard list. Communities will present their AIDS proposals to District Project Coordinators. District WHV/AIDS Committees will review sub-projects on the basis of agreed eligibility and selection criteria and make decisions on financing. Sub-projects over US$ 10,000 will need approval of the UAC Secretariat. Each CHAI shall not cost more than US$30,000. Annex 2 describes some representative CHAIs, and the Project Operations Manual describes them in detail. These initiatives will be financed through funds specifically earmarked for this component within the district budgets. Civil Society Organizations and Private Sector Organizations may present HIV/AIDS Initiatives to the UAC/PCT, to the relevant line ministries or the District Project Coordinators. If relevant, they will be incorporated into the respective workplans and budgets. The Project Operational Manual (POM) describes in detail the project's institutional and implementation arrangements. At appraisal, IDA reviewed and was satisfied with the project's draft Project Operational Manual. -45 - Annex 3: Estimated Project Costs UGANDA: HIV/AIDS Control Project Part A- Nationally Coordinated Initiatives 5.00 20.00 25.00 Part Ba-District Initiatives 29.00 1.00 10.00 Part C- Community-led Initiatives 10.00 0.00 10.00 Unallocated 5.00 0.00 5.00 Total Baseline Cost 29.00 21.00 50.00 Physical Contingencies 0.00 0.00 0.00 Ptice Conffngencies 0.00 0.00 0.00 Total Project Costs 29.00 21.00 S0.00 Total Financing Required 29.00 21.00 50.00 Civil Works 3.00 0.00 3.00 Goods 2.00 20.00 22.00 Consulting Services, training and audit fees 3 00 1.00 4.00 Operating costs 6.00 0.00 6.00 Grants for Subprojects under Part C of the project 10.00 0.00 10.00 Unallocated 5.00 0.00 5.00 Total Project Costs 29.00 21.00 50.00 Total Financing Required 29.00 21.00 50.00 All costs include contingencies. Identifiable taxes and duties are 0 (US$m) and the total project cost, net oftaxes, is 50 (US$m). Therefore, the project cost sharing ratio is 95% of total project cost net oftaxes. -46 - Annex 4 UGANDA: HIV/AIDS Control Project Monitoring, Supervision and Evaluation Responding effectively to HIV/AIDS requires sustained monitoring and evaluation of a broad range of measures, including impact indicators and more intermediate process and output measures to capture project performance in the more immediate term. Project impact will be measured employing data from the H1V sentinel surveillance, baseline and end-line population-based surveys on knowledge, attitudes, practices and behavior (KAPB) and service utilization, and special studies commissioned to assess impact in specific areas not easily addressed by population-based surveys. Monitoring of the project processes and outputs will employ project-based data, beneficiary inputs, and program reviews. Monitoring Monitoring of project progress under the Sexually Transmitted Infection Project was conducted through analyses of progress attained on annual district work plans. These work plans included all activities conducted at the district level, including those conducted by civil society organizations (CSOs) and community based organizations (CBOs). No management information system was established to monitor project activities. The Government's assessment of the current monitoring and evaluation of the national response to the epidemic noted the lack of monitoring information on many interventions and among those that did possess it, the type of information collected did not permit the association of project inputs with particular outcomes nor the achievement of particular objectives. Thus, while there is evidence, based on sentinel surveillance, that prevalence of HIV infection is declining, it is difficult to identify which interventions played a greater role in the decline. The project will support the design and implementation of a computerized management information system (MIS) based in the Uganda AIDS Commission -- UAC, containing key technical and financial input and process information for the Uganda HIV/AIDS Control Project. The Government's National Strategic Framework contains a very detailed log frame including a broad spectrum of input, output, outcome and impact indicators. Each line ministry that has developed a sector plan to respond to the HIV/AIDS epidemic has also developed its individual log-frame which is consistent with the national log-frame. Given the large number of implementing entities involved and the broad spectrum of activities, indicators to measure program progress and impact will be prioritized. Only those key variables that capture the necessary aspects of project implementation and impact will be retained, taking care that they include the relevant input and output variables, so that changes in outcomes and impact indicators can be explained during evaluation. Moreover, only variables that can be measured with existing data sources will be included. Project monitoring will assess the project implementation team performance in project implementation as well as the effectiveness and efficiency of implementation at sub-county, district and national levels. Thus, the MIS will contain key monitoring indicators identified in the Government's National Strategic Framework. Line ministries will monitor their own activities at the central level and provide the UAC Secretariat regular information on a minimal number of variables. They will do so on a quarterly basis. The bulk of information on sector and non-governmental activities will be gathered at the district and sub-county level. While CSO and CBO activities will be included in district work plans and will be measured at the district and sub-county levels, separate analyses will be conducted to assess the performance of these entities as well. -47 - Due to the multi-sectoral nature of the response, project-based data will be gathered from a number of sources, including service statistics from various ministries, observation during site visits, district work plans, and pre-defmed data provided by districts on a regular basis. The bulk of information on sector and non-govermnental activities will be incorporated into the progress reports submitted regularly by districts. Line ministries will provide separate reports. A system will be designed including standardized data collection forms to be employed at each level of decision making and clear protocols on information flows, collection and coding of the information. The use of standard reporting formns will simplify reporting procedures and ensure consistency and uniformity in the type and manner in which the data are collected. The design of the system will be subcontracted to a specialized firm as soon as the project becomes effective. A short list of qualified firms was prepared at appraisal. Careful monitoring of project activities and the groups they benefit will be crucial in the effective targeting of project inputs. At project start-up a mapping of high risk groups and their distribution across the national territory will be conducted. This mapping will be updated every six months on the basis of the activities financed and the populations benefited, allowing the UAC to identify gaps early on and encourage adequate coverage in those areas in subsequent work plan development. Monitoring will also allow improved targeting of vulnerable groups including women and adolescents. The project will also conduct focus groups or rapid assessments of beneficiaries' access and experience with the project to improve performance. In particular, sporadic assessments would focus on access to the program by the more vulnerable groups, including youth under 19 years of age and women in general, orphans and people living with HIV/AIDS. Supervision Project supervision will be carried out at the district and sub-county levels by the technical planning committees at the district and sub-county levels representing each sector and the Ministry of Local Government staff. These committees have CBO/CSO representation. However, since the main function of these is for planning and coordination, it is likely that capacity of staff at those levels may lack the necessary skills to adequately monitor the project. Given varying levels of capacity of staff, assessments will be made prior to initiating activities in the particular district. Training will be provided to strengthen their capacity. Staff from the project implementation team will make random visits to the field to monitor the performance of Districts and CSOs. Oversight of the overall program will be conducted by the UAC. The UAC will meet regularly with secretaries of the various ministries to discuss progress under each line ministry. Supervision by IDA will include regular supervision visits, program reviews, and the review of periodic progress reports including basic indicators. Program reviews will be held annually to assess the performance of the project, its components and its contribution to the national effort to reduce the spread and impact of H1V/AIDS. Specific areas of the review will include technical and operational aspects of project implementation. Program reviews will be carried out jointly by the UAC and an independent team of experts under previously defined terms of reference. The reviews will draw on the information generated from routine monitoring, the studies conducted and any other relevant information. Program reviews will cuiminate in stakeholder meetings that will form a basis for re-planning for the next two years. These meetings will be used to share information on trends, best practices and to provide general technical information. -48 - Evaluation Uganda has an established HIV/AIDS program evaluation system. Evaluation of program impact is currently measured through a sentinel surveillance system and periodic population based surveys. This includes 15 sites in antenatal clinics in 15 districts and one in the main sexually transmitted infections referral center. Additionally, data on prevalence of I-V are available from the AIDS Information Center (AIC), a voluntary counseling and testing (VCT) facility, and from the blood bank. Data from the latter two, however, are considerably less representative of the general population as the AIC tested individuals are self-selected, and blood bank data include only those with expected minimal risk as the blood bank screens donors before any tests are conducted to reduce resource waste. While antenatal samples are representative of the sub-population they target (i.e. young pregnant women) they do not capture men, or non-pregnant women (women unable to get pregnant because of age, infertility or current use of contraception). Moreover, data on high risk groups are limnited, relying solely on data derived from Mulago Hospital sexually transmitted infections clinic. Thus, sentinel sites targeting men, non-pregnant women and some high risk groups (CSWs, prison population, e.g.) need to be included. Plans are under way to establish some sentinel sites targeting the armed forces. The project will call upon the expertise gathered by The World Bank, the World Health Organization and UNAIDS, i.e. on the Guidelinesfor Second Generation HIV Surveillance (Geneva, CH: UNAIDS, May 2000). Within the country the project will rely on strong research oriented institutions such as the Makerere University and the Uganda Bureau of Statistics. Impact is also measured through a series of Knowledge, Attitudes, Behavior and Practice (KAPB) surveys conducted every two years. Under the STI project three population-based surveys were conducted in 7 districts (the last one is still to be applied in 3 districts). These provide data on key indicators on samples of approximately 1500 individuals aged 15-49 in each of the 7 districts. However, these contain primarily health related information and thus would not be adequate to measure a multi-sector response. Thus, the project will support the design and implementation of baseline and end-line population-based surveys to measure multi-sector knowledge, attitude, practices and behaviors. Sampling method will allow for representative samples at the district level. However, given the enormous sample size this would imply, the survey would be applied in 10-15 districts that represent Uganda. The final list of indicators to be measured in the baseline survey will be defined at appraisal on the basis of the Government's prioritized log frame for the Strategic National Response. The surveys will be subcontracted to an independent firn. Special in-depth surveys will be conducted from time to time to examine the impact on particular high risk or particularly vulnerable populations, or to assess the impact of specific interventions, including their cost-effectiveness. In addition, operations research will be conducted to solve particular implementation issues and bottlenecks identified during implementation. These can include, for example, pilots to identify the most effective way to provide home-based care under different situations (rural/urban, etc.). They will employ quasi experimental designs, with data collected from small samples of control and experimental groups and will be of short duration (3-12 months). These surveys would be sub-contracted out. The UAC will be responsible for overall program and project evaluation. Line ministries and districts will be responsible for monitoring the implementation of their respective action plans and activities, and will provide quarterly program management reports to the UAC Secretariat. The UAC will produce and share quarterly input and output program management reports to IDA, and will conduct a broader annual, mid term and end of project program review. For the mid-term and end-of-project review, the UAC will contract an independent program and project evaluation, including its impact on the agreed outcomes. The lessons learned from these evaluations and review will be fed back into program management, to improve program design and implementation arrangements. -49 - Annex 5: Financial Summary UGANDA: HIV/AIDS Control Project Financial Management The project will have an adequate financial management system by project effectiveness. The financial management framework will ensure appropriate safeguards are taken into consideration in the design of the financial management system from the Uganda Aids Commission (UAC) to the line ministries, districts and the community initiative component with the assistance of intermediaries (NGOs and CSOs) as needed. A Project Coordination Team (PCT) will be established with experienced and competent key project staff in UAC to coordinate and manage the implementation of the project, including putting in place an appropriate financial and accounting system for the project. It was agreed with the government at negotiations that an appropriate financial and accounting system for the project will be put in place by project effectiveness. The UAC will assume overall responsibility for oversight of the irnplementation of the project, and PCT as such will be held accountable for the proceeds of the entire Credit. A Special Account will be opened and maintained in a reputable commercial bank to be decided upon by the Ministry of Finance in consultation with IDA. It was agreed with the government at the negotiations that the initial deposit under traditional disbursement mechanisms will be set up at US$ 2.5 million, and the authorized special account amount under the Project Management Reports (PMR) based disbursement will be enhanced to US$ 6 million. A Project Account in local currency will be opened in the same commercial bank. Sub-project bank accounts will be opened for implementing agencies such as the UAC, line ministries and districts. After approval of annual plans and budgets the PCT will be responsible for facilitating the flow of funds to the various participating entities at all levels. The detailed procedures for fnancial management are outlined in the Financial Management Manual (FMM) of the project which will form an integral part of the Project Operational Manual (POM) to be ready by project effectiveness. -50 - Flow of Funds IDA Special Account in US$ in a Commercial Bank Project Account in Uganda Shillings in a Commercial Bank Districts UAC Secretariat Line Ministry National NGO Department/Com & PCT Accounts Project Accounts Accounts munity/NGO/CS O/CBO Accounts The financial management mechanisms which will be detailed in the FMM, will be based on the following understanding: a) UAC secretariat will not be involved in the implementation of the project, but will be responsible for approving line ministry and district workplans including CHAIs submitted for funding; b) PCT will receive and consolidate project expenditure returns from the various participating entities, which will be guided by reporting formats to be designed and included in the FMM. The retuns will be submitted to PCT by the tenth day following the end of the month for which the expenditure relates. PCT will monitor the process and help to improve capacity of participating entities that demonstrate delayed or inadequate reporting; and c) PCT will maintain adequate accounting and recording systems (accounts) using an appropriate tool (accounting software) to enable the preparation of quarterly financial reports and annual project financial statements in accordance with International Accounting Standards (IAS). The funds for CHAI activities will be pre-allocated to districts in aggregate for inclusion in the district plan and budget. The district authorities will be responsible for facilitating the flow of funds including signing off on the direct releases to the sub-projects. The release will be in tranches. The details of tranche releases are outlined in the Financial Management Manual. - 51 - Disbursements and Operation of Project Special Account Disbursements of the project proceeds will initially assume the traditional disbursements mechanisms for IDA assisted projects. However, the project will be expected to convert to Project Management Reports (PMRs) based disbursements mechanism under the Financial Management Initiative (FMI) framework in a period not exceeding 18 months after effectiveness. A time bound action plan has been agreed with the Government that PCT will pursue to implement RMRs. Replenishmefits of the Special Account will be determined by the level of eligible expenditure accounted for through the replenishment withdrawal applications submitted to IDA from time to time, and at least once in each month. Quarterly comprehensive project management reports, comprising implementation physical progress reports and financial reports together with procurement process progress reports should be submitted for review by UAC/PCT and IDA. Auditing Arrangement PCT will prepare consolidated annual project financial statements comprising the Project Account and Statement of the Special Account as well as a separate and distinct Statements of Expenditures for the entire project. For funds disbursed to line ministry project accounts, the ministries will submit their financial accounts to UAC. With respect to Community Sub Projects, whether facilitated by CBOs or not, supporting documents of accountability will be submitted to the District Project Offices. In turn the districts will consolidate the district reports and submit to the PCT project monthly expenditure returns as well as quarterly progress reports. The UAC, line ministries and districts will ensure that internal audit requirements are fulfilled. PCT will be expected to submit consolidated audited fnancial statements for the entire project and auditor's report thereon as well as auditor's management letter on the affairs of the project to IDA within six months following the end of the financial period being reported on. The project will be audited by independent auditors acceptable to IDA. The auditors are required to express separate opinions on both the SOEs and SA and follow the International Standards on Auditing. Project Financial Management System An effective financial management system is essential to the achievements of the project as well as to provide financial accountability with due diligence. The PCT under the guidance of the project Financial Controller, will be responsible for ensuring that financial management and reporting procedures for the project at UAC as well as at the various implementing entities will be acceptable to IDA. The project Financial Controller will be responsible for the fnancial management, accounting and disbursement functions of the project, including payments through the Special Account, maintaining accounts and making payments for eligible expenditures. The Financial Controller for the project will also oversee project financial management and accounting at the district level, and mentor project accountants both at UAC and at the district level. The UAC secretariat, with the assistance of the PCT, would be responsible for overall project management, including (i) monitoring the progress of the project (ii) coordinating project activities (iii) establishing and maintaining sound financial management and procurement systems (iv) Project Management and Progress Reports (inclusive of PMRs i.e. the physical, financial and procurement implementation progress), and liaison with IDA and other development partners. Successful implementation of the financial management action plan will allow the project to satisfy the Bank's minimum requirements under OP/BP 10.02. The Financial Management System would be able to produce the project financial management statements, including summary of sources and uses of funds, - 52 - uses of funds by project component, project account reconciliation statement, cash withdrawal statement, and cash forecast. The Chart of Accounts would facilitate presentation of summary expenditures by component, activity and disbursements category. Project Accounting Systemn The project will develop a viable financial management and accounting system, including a comprehensive Manual of Financial Procedures, Chart of Accounts, and a fully integrated project financial and accounting structure with a suitable system architecture using an appropriate accounting software. The accounting system will provide data to facilitate measurement for performance when linked to outputs of the project. The Chart of Accounts will ensure availability of information required and the consistence in account classification. The Chart of Accounts should be developed in a way that allows project costs to be directly linked to specific activities and outputs consistent with expenditure Disbursement Categories in Schedule 1 to the Development Credit Agreement. Manual of Financial Procedures. The project financial management system will be documented in the Manual of Financial Procedures, covering financial policies and procedures, accounting and internal control systems, fnancial planning and budgeting system, procurement and contract administration and monitoring system, financial reporting, flow of funds and auditing arrangements. The Manual should contain statements and explanation of the project's budgetary policies and procedures; describing responsibilities for the budget preparation, review and adoption, execution monitoring and reporting. The Manual of Financial Procures is being prepared by the government counterpart responsible for the financial management. This Manual should be ready by project effectiveness. In view of the complexity of this project, and the presence of several implementing entities of diverse structure, technical assistance in financial system development is needed in order to put in place a viable financial management system by project effectiveness. Table 1: Disbursement Table IYear 1 Year 2 Year 3 Year 4 Year 5 Total Financing Required Project Costs Investment Costs 4.0 6.0 6.0 6.0 6.0 Recurrent Costs 2.0 4.0 6.0 5.0 5.0 Total Project Costs 6.0 10.0 12.0 11.0 11.0 Total Financing 6.0 10.0 12.0 11.0 11.0 Financing IBRD/IDA 5.6 9.6 11.5 10.4 10.4 Governrunent 0.4 0.4 0.5 0.6 0.6 Total Project Financing 6.0 10.0 12.0 11.0 11.0 - 53 - Table 2. Financial Management Action Plan No Manual of Comprehensive Manual of Financial Procedures to Credit effectiveness Financial Procedures be developed (with help of short term local consultant ) describing accounting systems and procedures for the project as a whole. The Manual should include accounting basis, policies, standards and guidance for internal control and accounting with clear delegation and segregation of duties; funds flow processes, etc. No Dedicated Project Project Accounting System to be developed that can Credit effectiveness Accounting System produce project financial reports and statements that in UAC illustrate budgeted and actual costs, as well as provide financial data to enable measurement of performance possible through a monitoring system A Chart of Accounts should be designed, to provide Chart of Accounts information that reflects type of project, sources of Credit effectiveness finds, and the relevant expenditure accounts that is consistent with expenditure categories in the DCA, project components and sub-con ponents and activities There should be a fully integrated computer based Accounting System system to keep track, collect and provide information Credit effectiveness on sanctioned budgets, procurement, expenditures, sources of funds and outpu.s, measured by monitoring indicato's Staffing Suitably qualified anid competent key staff for overall Credit effectiveness coordination, finrancial management and procurement are mandatoiy requi1eler.t and should be identified and appointed. Training and Training program be developed for scaiing up skills By Credit effectiveness or Development of for the accounting staff in line ministry 1 iIV/AIDS disbursement date to the Accounting Staff Units and in the districts (where capacity is weak). affected line ministries and districts. Implementation plan 1for ski ls development should During implementation also be developed. l - 54- No Clear Reporting A reporting structure for both internal management Credit effectiveness Arrangements and external needs should be developed. Compliance with PMR reporting requirement should be taken into account under the FMI framework and as required under the Manual of Financial Procedures (MFP). Budgeting and Documented statements and explanation of budgetary Project implementation Budgetary Control policies and procedures to be included in the MFP. stage Also, the following should be well articulated in the MFP: (i) quarterly and annual program for budget preparation/review; (ii) format and content of monthly/quarterly and annual financial reports; and (iii) variance analysis with brief and clear explanation for significant variations should be given in financial reports. Monitoring and Need for policy for strict financial discipline required By Credit effectiveness Evaluation System at UAC and its affiliated project implementing and once in place, entities at various levels. Monitoring arrangements, process should be and clear remedial actions in the event of non continuously followed. compliance with established procedures. Auditing Terms of Preparation of Terms of Reference for the auditor Middle of the first year of Reference once the financial management system is designed project implementation and tested. - 55 - Annex 6: Procurement and Disbursement Arrangements UGANDA: HIVIAIDS Control Project Procurement General Although the type of activities to be financed under the project have been defined, the specific procurements (civil works, goods and services) to support these activities have yet to be defined precisely. This is particularly true for procurement to support activities at the district and community levels (more than 50% of the total program) which will be demand driven and determined on an annual basis through the district annual plans. The procurement plan for the first year will be prepared based on the initial needs of the UAC, the participating line ministries and the national Community Service Organizations (CSOs) that will have articulated their requirements. Procurements for subsequent years will only be indicative and based on a pre-determined menu of activities that will guide preparation of sub-projects by participating ministries, districts and communities. This being a multi-sectoral project, the annual plans will also need to be closely coordinated with other on-going operations in the various sectors including the Poverty Reduction Support Credit (PRSC) - Education, Health and Water and Sanitation; and the National Agriculture Advisory Services (NAADS) program. All civil works and goods would be procured in accordance with "Guidelines: Procurement under IBRD Loans and IDA Credits, January 1995, revised January and August 1996, September 1997, and January 1999". Bank's standard bidding documents for works and goods and standard evaluation forms would be used where practicable. Based on these Guidelines, simple procurement procedures for application at the community level would be developed in accordance with Section 3.15 - Community Participation in Procurement, as part of the Project Implementation Manual. All procurement of consultant services would be done in accordance with "Guidelines: Selection and Employment of Consultants by World Bank Borrowers, January 1997, revised in September 1997 and January 1999. " Bank's Standard Requests for Proposals and evaluation forms would be used where practicable. A General Procurement Notice (GPN) is mandatory and must be published in the UN Development Business and in a national newspaper as provided under the Guidelines, immediately after negotiations. The GPN would be updated on a yearly basis and would show all outstanding International Competitive Bidding (ICB) for goods contracts and all International Consulting Services. Specific Procurement Notices for goods to be procured under ICB and Expressions of Interest for consultant services estimated to cost the equivalent of US$200,000 and above will also be published in the Development Business. Details on project costs by procurement arrangements are presented in Table B. Monitoring and evaluation of procurement performance at all levels (national, district and community) will be carried out through annual ex-post procurement audits and regular ad-hoc reviews. Such audits would: (a) verify that the procurement and contracting procedures and processes followed for the projects were in accordance with the Development Credit Agreement (DCA); (b) verify technical compliance, physical completion and price competitiveness of each contract in the - 56 - selected representative samnple; (c) review and comment on contract administration and management issues as dealt with by participating agencies; (d) review capacity of participating agencies in handling procurement efficiently; and (e) identify improvements in the procurement process in the light of any identified deficiencies. Institutional Arrangements The overall coordination of the program implementation will be carried out by the Uganda AIDS Commission and the Project Coordination Team, with each line Ministry, district, community and CSO responsible for implementation of their relevant work programs. Procurement will be done at three levels: national, district and community. At national level, the UAC, through a strengthened Secretariat will be responsible for coordinating procurement of all the large ticket items. Procurement of medium and small size civil works, goods and services will be carried out by the relevant line ministry and district under their respective contract committees/tender boards. The project will support Community-based HIV/AIDS Initiatives (CHAIs) including minor repair works, purchase of drugs and supplies in small quantities (in emergency cases), care and maintenance for AIDS patients and orphans, AIDS prevention promotion, and other interventions at the community level. Work-programs under this activity will depend on applications received from communities against a standard menu of activities. Items which are essential for the execution of CHAls will be procured under simplified procurement procedures similar to those applicable to social funds. A procurement procedure manual is under preparation as part of the Project Implementation Manual. The thresholds for procurements at the three levels are presented below. Thresholds for Procurement at Different Levels iNational - UAC and Civil Works Upet 60,000 National Goods Over 30,000 Goods Up to 30,000 Consultant Up to 2,000 Services - 57 - Procurement methods (Table A) Table A: Project Costs by Procurement Arrangements (US$ million equivalent) 1. Works 0.00 0.70 2.70 0.00 3.40 (0.00) (0.50) (2.50) (0.00) (3.00) 2. Goods 16.80 2.20 5.50 0.00 24.50 (15.80) (2.10) (5.30) (0.00) (23.20) 3. Services 0.00 0.00 4.40 0.00 4.40 and Training (0.00) (0.00) (4.40) (0.00) (4.40) 4. Community Based 0.00 0.00 11.20 0.00 11.20 Initiatives (0.00) (0.00) (10.60) (0.00) (10.60) 5. Incremental Operating 0.00 0.00 6.50 0.00 6.50 Expenses (0.00) (0.00) (6.30) (0.00) (6.30) Total 16.80 2.90 30.30 0.00 50.00 __(15.80) (2.60) (29.10) (0.00) (47.50) IFigures in parenthesis are the amounts to be financed by the IDA Credit. All costs include contingencies I2tncludes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local govermment units. A general procurement capacity assessment has revealed limited of procurement capacity at all these levels and the need for strengthening such capacity. Since the UAC will be responsible for coordinating project implementation, the most critical action required is to strengthen its Secretariat through employment of suitable staff to coordinate activities of participating agencies, and provide procurement support and assist in financial management. There are a number of institutional arrangements that are being put in place to ensure that the capacity is strengthened. Firstly, the procurement experience gained through the Sexually Transmitted Infections (STI) project will be passed down to this project, at least initially, through sharing of the same staff to carry out the initial procurement activities for the UAC. Under these interim arrangements between the two projects, the STI project manager, the financial management specialist and the procurement specialist will start to support the activities under this project immediately. Secondly, a procurement agent with a proven record of delivering health sector goods and services would be contracted to procure items such as condoms, pharmaceuticals, diagnostic kits and other large ticket items. The need for such an agent was identified about two years ago and the Ministry of Health (MOH) had started the process of selecting such an agent but this was stopped due to a provision in existing MOH regulation that requires the Government (central and districts) to procure all drugs and pharmaceuticals through the National Medical Stores (NMS). The process of revising this regulation has started and the selection process for the agent is expected to commence immediately. This agent will support procurement activities in this project as well as procurement activities under the health component of the PRSC. It is critical that the process of procuring the procurement agent is expedited. Thirdly, a procurement specialist will be recruited to: assist participating line ministries to carry out procurement of their components; organize quality assurance for procurement activities in this project; and train staff at all levels. - 58 - Procurement capacity at district levels is particularly weak. Due to the importance and multi-sectoral nature of this project, the district administration will need to be suitably adapted to handle this project. Like the national level, there will be three critical functions that will be carried out at the district level: coordination; procurement and financial management. These functions would normally require three different individuals and each participating district will have to indicate how these functions would be carried out under the existing structure and staffing arrangements. The districts will also provide the necessary support for these functions at the community level. At this level, the communities, through their representative committees or CSOs, will be responsible for the procurement process using simplified procurement procedures. Sub-project proposals from communities will be required to indicate how procurement will be organized including any necessary support that will be necessary from the districts. In order to ensure that participating agencies (line ministries, districts communities and CSOs) are familiar with Bank procurement guidelines in general and the procurement procedures in this project in particular, UAC with the assistance of IDA, would provide a series of workshops, with the first workshop being organized before credit effectiveness. The subsequent workshops would be organized so as to coincide with the proposed procurement supervision missions where the Procurement Specialist would conduct the workshops as part of the supervision mission. The costs of these workshops will be included in the project. These workshops would also act as forums to review any procurement issues that have been experienced during implementation of the project and as vehicles for improving on the procurement arrangements in place. Procurement Methods for Works, Goods, and Consulting Assignments Civil Works. The civil works to be included in this project would be small and generally of rehabilitation nature such as rehabilitation of district laboratories, voluntary counseling centers, day care centers, or outpatient units, and rehabilitation of reference laboratories, HIV/AIDS specialized day care or outpatient centers, at community, district or central level. From experience obtained from the on-going DHSP and STI projects, the districts are capable of handling individual civil works contracts estimated to cost up to US$60,000 while the communities can only handle works that are less than US$5,000. Contracts for works estimated to cost US$60,000 or less, up to an aggregate amount of US$ 1,000,000 equivalent, may be procured under lump-sum, fixed-price contracts awarded on the basis of quotations obtained from three qualified domestic contractors invited in writing to bid. The invitation shall include a detailed description of the works, including basic specifications, the required completion date, a basic form of agreement acceptable to IDA, and relevant drawings where applicable. The awards will be made to the contractors who offer the lowest price quotation for the required work, provided they demonstrate they have the experience and resources to complete the contract successfully. For works estimated to cost less than US$300,000 per contract up to an aggregate of US$2,000,000 will be procured by the UAC using national competitive bidding. Goods. As indicated in the Table above, the UAC will coordinate the procurement of large ticket items. For goods, these goods will include items estimated to cost more than US$30,000 per contract. The items will include: condoms; diagnostic kits; pharmaceuticals for the clinical management of FHV/AIDS and opportunistic infections, including TB; vehicles and other project related supplies, reagents and IEC materials. To the extent possible, contracts for the large ticket items shall be grouped into packages estimated to cost US$100,000 equivalent or more and will be procured though International Competitive Bidding (ICB). ICB procurement will be coordinated by the UAC Secretariat for the whole program. Domestic preference will be applicable. Goods estimated to cost less than US$100,000 up to an aggregate amount US$2.2 million will be procured through NCB. The standard bidding document for NCB will be - 59 - submitted to IDA by UAC for prior review. The approved document will form the basis of all NCB procurements under this project. Goods estimated to cost less than US$30,000 equivalent per contract, up to an aggregate amount of US$5.5 million equivalent may be procured through shopping procedures by soliciting at least three quotations from different suppliers, in accordance with IDA Procurement Guidelines (Paragraph 3.5 and 3.6) and June 9, 2000 Memorandum "Guidance on Shopping" issued by the Bank. Contracts estimated to cost less than US$50,000, up to an aggregate of US$500,000 may be procured through United Nations Agencies (IAPSO, UNICEF, UNFPA, WHO) in accordance with the provisions of paragraph 3.9 of the Guidelines. National shopping for regular operation and maintenance will follow IDA guidelines. Procurement of goods and hiring of facilities for training purposes, such as workshops, will also be carried out through shopping procedures. Procurement of items under the CHAIs will be carried out in accordance with simplified procurement procedures (paragraph 5. Above) Urgent Requirements. Notwithstanding the general provisions of paragraph 10 above, given the urgency of the program, and to facilitate speedy procurement of urgently required drugs and items required immediately for institutional strengthening, specific contracts will be handled by UAC in the following exceptional manner: a) Drugs for opportunistic infections, IRV test kits, syphilis test kits, reagents for infection control and TB laboratory reagents, estimated to cost less than US$200,000 per contract, up to an aggregate of US$ 1,000,000, may be procured through international shopping; b) Computers and accessories, office and power equipment for new UAC Secretariat staff estimated to cost up to US$ 100,000 may be procured through shopping or contracted from the UN Agency (IAPSO); and c) Vehicles (up to an aggregate amount not to exceed US$350,000 equivalent) for initial management of the project may be procured from IAPSO and/or National Shopping procedures (preferably from' bonded warehouses' on a competitive basis). All contracts under the above stated 'Emergency Requirements' must be concluded within 12 months from the Credit effectiveness date. The list of these items and their estimated value will be agreed upon with IDA and incorporated in the Procurement Plan. The procurement and timely distribution of the goods will be the responsibility of the UAC. Consultancy Services. The total cost of consultant services and training is estimated at US$4.4 million equivalent excluding any services to be procured under the CHAIs. The consultant services required would cover the areas of AIDS research, AIDS education, trainers, community development specialists, public relations firms (Information Campaign), procurement, financial management, monitoring and evaluation, audit, and accounting. All consulting service contracts costing more than US$100,000 equivalent for firms will be awarded through Quality and Cost Based Selection (QCBS) method. Consulting service contracts estimated to cost less than US$100,000 for firms may be awarded through the Consultants' Qualifications selection method. For contracts of a routine nature estimated to cost less than US$ 100,000 and where well established practices and standards exist such as financial audits, Least-Cost selection method may be used. All consulting services of individual consultants will be procured under individual contracts in accordance with the provisions of paragraphs 5.1 to 5.3 of the Guidelines. In exceptional cases, Single-Source selection would be used in accordance with the provisions of paragraphs 3.8 to 3.11. To this effect, services procured at the district level under work plans satisfactory to the Association which are estimated to cost less than $5,000 equivalent per contract, up to an aggregate amnount not to exceed $500,000 equivalent may, with the Association's prior agreement, be procured on single-source basis. -60 - To ensure that priority is given to the identification of suitable and qualified national consultants, short-lists for contracts estimated under US$100,000 or equivalent may be comprised entirely of national consultants (in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines), provided that a sufficient number of qualified individuals or firms (at least three) are available. However, if foreign firms have expressed interest, they will not be excluded from consideration. Training, Workshops and Study Tours. Training, workshops, and study tours will be carried out on the basis of approved annual programs that would identify the general framework of training activities for the year, including the nature of training/study tours/workshops, the number of trainees, and cost estimates. Selection of training institutions for workshops/training should be based on a competitive process using the Quality- based method of selection. Prior Review Table C provides the prior review thresholds. Each contract for works estimated to cost more than US$200,000 equivalent or more, and each contract for goods estimated to cost US$100,000 equivalent or more, will be subject to IDA prior review as per paragraph 2 Appendix I of the Guidelines. Other contracts will be subject to post review in accordance with paragraph 4 Appendix I of the Guidelines. All consulting contracts costing US$100,000 equivalent or more for firms will be subject to IDA prior review. With respect to each contract for employment of individual consultants estimated to cost the equivalent of US$50,000 or more, the qualifications, experience, terms of reference and terms of employment of the consultants shall be furnished to IDA for its prior review. All single-source selection of consultants valued at US$5,000 and above will be subject to IDA prior review. Other procurements subject to IDA review will include: training workshops estimated to cost more than US$50,000; all overseas training; and any exceptional extensions to non-prior review contracts raising their values to levels equivalent or above the prior review thresholds. These limits must be monitored closely and should never be exceeded before clearance from IDA. -61 - Prior review thresholds (Table B) 1. Works Small works under Above NCB Above Work-programs US$60,000 US$200,000 US$60,000 and At least three Ex-Post less quotations from qualified contractors 2. Goods US$100,000 ICB All contracts Shopping will be and over permitted for " Emergency Less than NCB Ex-Post Procurements" required US$100,000 for setting up the [JAC Secretariat (Computers Less than US$ IAPSO Ex-Post and accessories; and 50,000 vehicles) and for meeting urgent drug requirements Less than Shopping Ex-Post for opportunistic US$30,000 infections 3. Consultancy Services US$100,000 QCBS All and over Firms Less than CQ Ex-Post Us$100,000 Less than LCS Ex-Post US$100,000 LCS to be used for contracts of a routine nature where well Individuals established practices and US$50,000 and Individual All standards exist such as over financial audits Less than Individual Ex-Post US$50,000 - 62 - Firms/Individuals Over US$5,000 Single-Source All All single-source Single-Source Ex-Post selection for contracts Less than over US$5,000 will be US$5,000 subject to IDA review 4. Training, US$50,000 and QBS All Workshops, Study over Tours Less than QBS Annual plans to US$50,000 be reviewed by IDA Total value of contracts US$12.00 subject to prior review: million OVERALL RISK ASSESSMENT: H I G H Refer to Paragraphs 6, 7 and 8 above. Prior Review Thresholds: Works US$200,000 equivalent Goods US$100,000 equivalent Consultancy Services (Firms) US$100,000 equivalent Consultancy Services (Individuals) US$50,000 equivalent Frequency of procurement supervision mission proposed: Once every 4 months in the first year and every 6 months in subsequent years. In addition ad-hoc reviews/audits will be carried out. -63 - Action Plan for Mitigating the High Procurement Risk 1.Strengthen implementation capacity Continuous All Implementing _ ~~~~~~~~ ~ ~~~~~~~~~Agencies 2. Produce Simplified Procurement Guidelines February 28, IDA 2001 3. Identify one focal person in each project district to February 28, UAC/Districts coordinate the district activities and to carry out 2001 procurement and financial management 4. Identify items currently under PRSC to be financed February 28, Ministry of Health under this project 2001 (MOH) 5. Assess capacity of implementing agencies through a February 28, MOH/PCO simple questionnaire 2001 Send Questionnaire Receive Questionnaire 6. Identify Sector Coordinators of Procurement Activities February 28, UAC 2001 7. Select a procurement agent May 15, 2001 UAC/MOH 8. Decide on remuneration of core UAC Secretariat team February 28, UAC 2001 9. Appointprocurement agent May 15, 2001 UAC/MOH 10. Core team start work at the UAC Secretariat April 30, 2001 UJAC/MOH 1l Emiiploy an assistant accountant April 30, 2001 UAC - 64 - Disbursement Allocation of credit proceeds (Table C) Disbursements of IDA funds will initially assume the traditional disbursements mechanisms for this project. However, the project will be expected to convert to Project Management Reports (PMRs) based disbursements mechanism under the Financial Management Initiative (FMI) framework in a period not exceeding 18 months after project effectiveness. A time bound action plan has been agreed with the Government that UAC/PCT will pursue over this period to make the project FMI compliant. Table C: Allocation of Credit Proceeds Works 3.00 90 % Goods 22.00 100% of foreign and 90% of local Consultant Services/Training 4.00 100% Community Based Initiatives 10.00 95% Incremental Operation Expenses 6.00 90% Unallocated 5.00 Total Project Costs 50.00 Total 50.00 Use of statements of expenditures (SOEs): All disbursements against expenditures contracts with the civil society organizations and the private sector will be made against statements of expenditure (SOEs) and is subject to random ex-post financial, physical, and technical audit to be carried out by financial and technical consultants employed by the Uganda AIDS Commission. All procurement contracts not subject to IDA prior review will be disbursed against SOEs and documentation will be retained by the Uganda AIDS Commission administrations and made available for review by IDA financial management and procurement specialists and project financial and procurement auditors. In the case of Community-led HIV/AIDS Initiatives (CHAIs), there will be pre-financing of expenditures, as communities are unlikely to start contracting without the assurance of funds. All disbursements against expenditures under the CHAIs will be subject to ex post financial and physical audits, on a sample basis, to be carried out by financial and technical consultants employed by the respective districts or by the Uganda AIDS Commission. Special account: To facilitate disbursements, the Government of Uganda will establish and maintain a Special Account in US dollars in a commercial bank acceptable to IDA. In order to ensure timely release of funds for the project activities, a Project Account in Uganda shillings will be maintained in the same bank. Sub-project bank accounts will also be maintained by the implementing agencies. It was agreed with the government at the negotiations that the initial deposit under traditional disbursement mechanisms will be set up at US$ 2.5 million, and the authorized special account amount under the Project Management Report based disbursement will be enhanced to US$ 6 million. -65 - Annex 7: Project Processing Schedule UGANDA: HIV/AIDS Control Project Time taken to prepare the project (months) 2 2 First Bank mission (identification) 10/09/2000 10/09/2000 Appraisal mission departure 12/04/2000 12/04/2000 Negotiations 12/11/2000 12/12/2000 Planned Date of Effectiveness 04/18/2001 Prepared by: The core project preparation team include Alexandre Abrantes (task team leader), Shiyan Chao (co-task team leader), Peter Okwero (health specialist at the Resident Mission), Norbert Mugwagwa (Lead Operations Health officer, community-led initiatives) and Sandra Rosenhouse (Senior Population and Health Specialist, monitoring & evaluation). Other multi sector specialists contributed to project preparation, including those listed below. Preparation assistance: Project preparation was assisted by Mary Green, Lori Geurts, and Vikki Taaka. Bank staff who worked on the project included: Alexandre Vieira Abrantes , AFTHl Lead Public Health Specialist. Project Preparation Team Leader Shiyan Chao, AFTHI Senior Economist. Project Preparation Co-team Leader Peter Okwero, AFMUG Health Specialist, in country liaison with Government, civil society and donors Norbert Mugwagwa, AFMUG Lead Operations Officer, community-led initiatives Anabela Abreu, LCSHD Sr. Public Health Specialist, project design Sandra Rosenhouse Sr. Population and Health Specialist, monitoring & evaluation Rogati Kayani, AFTQK Sr. Procurement Specialist, procurement John Nyaga, AFC05 Sr. Financial Management Specialist, financial management and disbursements Aberra Zerabruk, LEGOP Senior Counsel, credit agreement Ytzahk Kamhi, AFTTR Senior Highway Engineer, project design Shimwaayi Muntemba Senior Social Science Specialist, Gender, background and project design Mario Bravo, EXTRO Senior Communications Officer, IEC John Lambert AFTR2 Consultant, Traditional Medicine Oscar Picazo, AFTH I Senior Economist, economic and financial analysis Andrew Follmer, AFTH I Operations Analyst, editing and quality control Christian Hurtado, Consultant Senior Operation Specialist, Proj. Impl. Plan and Oper. Manual Christopher D. Walker, HDNHE Lead Specialist, peer review Johnathan C. Brown, AFTQK, ACT Lead Operations Specialist, peer review Africa Olusoji Adeyio, UNAIDS Senior Health Specialist, peer review - 66 - Annex 8: Documents in the Project File* UGANDA: HIV/AIDS Control Project A. Project Implementation Plan The draft project implementation and operational manual were reviewed at appraisal. Adoption of a project implementation plan and an operational manual acceptable to IDA is a condition of effectiveness. B. Bank Staff Assessments Aide Memoire and Annexes from October 2000 mission (pre-appraisal) Aide Memoire and Annexes from December 2000 mission (appraisal) Minutes of Negotiations from December 2000 C. Other 1. HTV/AIDS Surveillance Reports Ministrv of Health 1996, 1997, 1998. 1999 i2. Uganda AIDS Commission Statute Government of Uganda March ]1992 3. Report of the Technical Committee to Committee to Review October 1997 Review Roles and Functions of the Uganda the Roles and Functions AIDS Commission and Ministry of Health of the UAC 4. Report to the Uganda AIDS Commission By Committee on Review September 1999 the Committee on Review of the Commission's of the Commission's Institutional Location Institutional Location 5. The Socio-economic Impact of HIV on Rural FAO February, 1994 i Families with an Emphasis on Youth l 6. Health Sector Strategic Plan, 2001-06 Ministry of Health 2000 7. Proposal for Scaling-up and Widen the Ministry of Health October, 2000 Response and Confront new HIV/AIDS Challenges 7a. The National Strategic Framework for GoU, Uganda AIDS March. 2000 HIV/AIDS Activities in Uganda: 2000/1 - Commission, Joint UN 2005/6 Program on AIDS, other stakeholders in AIDS 8. HIV/AIDS Implementation and Strategies Ministry of Gender, October, 2000 Labor and Social Development | -67 - 9. HIV/AIDS Plan for Ministry of Education Ministry of Education September, 2000 and Sports and Sports 9a. HlV/AIDS Program in the Agriculture Ministry of Agriculture, September, 2000 Sector Animal Industry and Fisheries 10. Review and Incorporation of HIV/AIDS Ministry of Public October 2000 Concerns within Personnel Management Service 11. HIV/AIDS Plan for Ministry of Local Ministry of Local September 2000 Government, 2001-06 Government 12. The Strategic Plan for AIDS Information Makerere University April 2000 Center, 2000-2004 13. Culture and its Impact on IHIV/AIDS Makerere University May 2000 Prevention and Care: Uganda Experience 14. Open Secret: People living facing up to Action for AID July, 2000 HIV and AIDS in Uganda. Strategies for Hope 15. National Guidance & Empowerment NGENs June 1999 Network of People Living with HIV/AIDS 16. Operational Strategy and Plan of Action The AIDS Support 1999 Organization TASO 17. Support to the Health Sector Strategic Plan DFID, Ireland AID, May 2000 2000-2005 SIDA, World Bank 18. Country Program Strategy GoU - UNICEF November 1999 19. HIV/AIDS and Rights to Self-protection GoU -- UNICEF 2000 Program Plan of Operations 20. Adolescent Rights to Protection from UNICEF May 2000 HIV/AIDS and Access to Friendly Services 21. MRC/DFID, UVRI Program on AIDS in Medical Research May 2000 Uganda Council, Department of International Development & Uganda Virus Research Institute 22. Project Implementation Plan GoU December 2000 23. Project Operational Manual GoU December 2000 *Including electronic files -68 - Annex 9: Statement of Loans and Credits UGANDA: HlV/AIDS Control Project Dec-2000 Difference between expected and actual Original Amount in US$ Millions disbursements Project ID FY Purpose IBRD IDA GEF Cancel. Undisb. Orig Frm Rev'd P050439 2001 PRIVATIZATION & UTILITY SECTOR REFORM 0.00 48.50 0.00 0.00 47.41 0.00 0.00 P002992 2000 LOCALGOVDEVE.PROGRAM 0.00 80.90 0.00 0.00 65.06 -9.17 -9.17 P044679 2000 Second Economic and Fin. Mgmt. Project 0.00 34.04 0.00 0.00 29.85 5.47 -1.51 P069840 2000 Power III Supplemental 0.00 33.00 0.00 0.00 0.00 0.00 0.00 P035311 1999 PAMSU-GEF 0.00 0.00 2.00 0.00 0.00 1.64 0.00 P002970 1999 ROADS DEVT PROGRAM 0.00 90.98 0.00 0.00 86.43 5.26 -3.91 P044213 1999 FIN MKTS ASSISTANCE 0.00 13.00 0.00 0.00 12.93 8.62 0.00 P002941 1999 ICB-PAMSU 0.00 12.40 2.00 0.00 6.09 2.20 -7.94 P059127 1999 AGRIC.RES&TRNG. II 0.00 26.00 0.00 0.00 22.47 3.95 -2.16 P059223 1999 NAKIVUBO CHANNEL REH 0.00 22.40 0.00 0.00 19.68 10.42 -1.59 P040551 1998 NUTRIT.CHILD DEV 0.00 34.00 0.00 0.00 24.84 5.87 -7.63 P049543 1998 ROAD SECTIINST.SUPP 0.00 3000 0.00 0,00 22.80 24.70 -5.28 P002972 1998 EDUCSECTORADJCRED 000 80.00 0.00 0.00 0.00 1.95 -78.05 P057007 1998 ELNINO EMERG RD REP 0.00 27.60 0.00 0.00 23.36 24.49 -3.15 P002987 1997 SAC III 0.00 125.00 0.00 0.00 39.28 42.66 42.13 P046836 1997 LAKE VICTORIA ENV. 0.00 12.10 0.00 0.00 4.72 1.53 -6.97 P046870 1997 LAKE VICTORIA ENV. 0.00 9.80 9.80 0.00 6.07 3.27 -6.03 P002978 1996 ENVIRONMENTAL MGMT & CAPACITY BLDG 0.00 11.80 0.00 0.00 1.72 2.92 1.23 P037582 1996 AGSECMGTPROJECT 000 17.90 0.00 16.36 0.00 16.50 0.00 P035634 1996 PRIV. SECTOR COMPETI 0.00 12.30 0.00 2.18 2.58 5.68 -8.31 P002976 1995 INST. CAPACITY BLDG 0.00 36.40 0.00 0.00 4.10 6.39 -29.91 P002971 1995 DISTRICT HEALTH 0.00 45.00 0.00 0.00 631 2.71 -35.39 P039880 1995 SACII 0.00 0.60 0.00 0.00 0.00 000 0.00 P035584 1994 FINANCE SECTOR ADJUSTMENT 0.00 1.10 0.00 0.00 0.00 0.00 0.00 P002967 1994 SAC 11 0.00 80.00 0.00 0.00 0.00 -8.33 -86.33 P002963 1994 SEXUAL.TRANS.IN 0.00 50.00 0.00 0.00 5.26 6.01 -43.99 P002957 1994 SMALLTOWNS WATER 0.00 42.30 0.00 0.00 6,90 6.84 -34.50 P002923 1994 TRANSP. REHAB. 0.00 75.00 0.00 0.00 24.03 25.68 49.18 P002893 1994 Bwindi Forest & Mgahinga Gorilla Nat PK 0.00 0.00 4.00 0.00 0.00 0.02 -4.35 P002977 1994 COTTON SECTOR DEVELO 0.00 14.00 0.00 0.00 1.12 1.33 1.35 P002975 1993 ECON & FINANCIAL MAN 0.00 29.00 0.00 0.00 0.00 -1.33 -30.33 P002962 1993 FINAN SECTADJUSTCR 0.00 100.00 0.00 0.95 0.00 -2.92 -2.15 P002953 1993 PRIMARY EDUC. &TEAC 0.00 52.60 0.00 0.00 4.17 4.15 1.98 P002938 1993 AGRIC. RES & TRG. PHASE I 0.00 25.04 0.00 0.00 0.03 -0.17 -25.21 P002991 1993 AGRIC. EXTENSION PROGRAM 0.00 15.80 0.00 0.12 0.00 0.19 -15.60 P002996 1993 SAC I 0.00 1.40 0.00 0.00 0.00 0.00 0.00 P002968 1992 ENTERPRISE DEVELOPMENT 0.00 65.60 0.00 0.00 0.18 21.67 -2.08 P002947 1992 SAC I 0.00 125.00 0.00 0.00 0.00 -6.30 -131.30 P002990 1992 ECON RECOVERY II 0.00 1.60 0.00 0.00 0.00 0.00 0.00 P002981 1992 NORTHERN RECONSTRUCTION 0.00 71.20 0.00 0.00 0.00 -3.25 -74.45 P002980 1991 ECON REC II 0.00 2.00 0.00 0.00 0.00 0.00 0.00 P002929 1991 POWER III 0.00 125.00 0.00 0.00 17.20 -10.22 81.76 P002930 1991 LrVESTOCK 0.00 21.00 0.00 3.78 0.00 2,22 -0.14 P002933 1991 URBAN I 0°00 28.70 0.00 0.00 0.30 4.39 -29.09 -69 - Difference between expected Original Amount in USS Millions and actual disbursements' Project ID FY Purpose IBRD IDA GEF Cancel. Undisb. Orig Frm Rev'd P002974 1990 ERIC I SFA 0.00 0.00 0.00 0.00 0.00 0.00 0.00 P002969 1990 WATER SUPPLY II 0.00 60.00 0.00 0.02 0.00 -4.06 4.06 P002973 1990 ECON REC PROG 0.00 1.50 0.00 0.00 0.00 0.00 0.00 P002965 1989 ECONOMIC RECOVERY 0.00 1.70 0.00 0.00 0.00 0.00 0.00 Total: 0.00 1793.26 17.80 23.41 484.70 200.20 -609.30 - 70 - UGANDA STATEMENT OF IFC's Held and Disbursed Portfolio Dec-2000 In Millions US Dollars Committed Disbursed IFC IFC FY Approval Company Loan Equity Quasi Partic Loan Equity Quasi Partic 1996 AEF Agro Mgmt 0.60 0.40 0.00 0.00 0.55 0.40 0.00 0.00 1992 AEF Clovergem 0.84 0.00 0.00 0.00 0.84 0.00 0.00 0.00 1997 AEF Conrad Plaza 1.13 0.00 0.00 0.00 1.13 0.00 0.00 0.00 1998 AEF Exec. Invmnt 1.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 1999 AEF Gomba 1.40 0.00 0.00 0.00 1.40 0.00 0.00 0.00 1998 AEF Kampala Flwr 0.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2000 AEF Kasambya 0.99 0.00 0.00 0.00 0.00 0.00 0.00 0.00 AEF KiwaII 0.16 0.00 0.00 0.00 0.16 0.00 0.00 0.00 1997 AEF Ladoto 0.80 0.00 0.00 0.00 0.80 0.00 0.00 0.00 2000 AEF LongFreight 0.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2000 AEF Mosa Court 0.64 0.00 0.00 0.00 0.64 0.00 0.00 0.00 1998 AEF Nile Roses 0.16 0.00 0.00 0.00 0.16 0.00 0.00 0.00 1993 AEF Polypack 0.10 0.00 0.00 0.00 0.10 0.00 0.00 0.00 1994 AEF Rainbow 0.79 0.00 0.00 0.00 0.79 0.00 0.00 0.00 1995 AEF Rwenzori 0.35 0.19 0.00 0.00 0.35 0.19 0.00 0.00 1993 AEF Skay Electro 0.22 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1998 AEF Skyblue 0.51 0.00 0.00 0.00 0.51 0.00 0.00 0.00 1994 AEF White Nile 0.28 0.00 0.00 0.00 0.28 0.00 0.00 0.00 1998 AEF Wstern Hgh 0.50 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1999 Ccltel 0.43 0.64 0.80 0.00 0.43 0.64 0.80 0.00 1994 DFCU 0.00 0.60 0.00 0.00 0.00 0.60 0.00 0.00 1984/92 Jubilee 0.00 0.10 0.00 0.00 0.00 0.10 0.00 0.00 1993 Kasese Cobalt 13.33 3.60 0.00 0.00 13.33 3.60 0.00 0.00 1996 Tilda Rice 2.40 0.00 0.00 0.00 1.90 0.00 0.00 0.00 1998 Uganda Leasing 1.16 0.00 0.00 0.00 0.56 0.00 0.00 0.00 1995/96 Uganda Sugar 5.08 0.00 0.00 0.00 5.08 0.00 0.00 0.00 1983 Total Portfolio: 34.17 5.53 0.80 0.00 30.01 5.53 0.80 0 Approvals Pending Commitment FY Approval Company Loan Equity Quasi Partic 1998 AEF Ram Oil 1000.00 0.00 0.00 0.00 2000 CelTel Uganda 4000.00 0.00 700.00 0.00 Total Pending Commitment: 5000.00 0.00 700.00 0.00 -71 - Annex 10: Country at a Glance UGANDA: HIV/AIDS Control Project Sub. POVERTY and SOCIAL Sahevast Low- IUoanda Affica Income Development diamond 1999 Ponoilatinn mid-vear (millions) 21 5 842 2417 Life expectancy r.NP nAr canitn fAtlas method. USS) 32 s 5of 41t GrNP tAtlas method. USS billions) R 8 321 9#8 Averaae annual orowth. 1993-99 Pno lation (14) 2 9 2.1 1.9 Labor force fXf 27 2.8 2.3 GNP Gross Moat year ~~~~~~~~~~~~~~~~~~~~~~~~~~~~par primary Mostrcnt stImate (latest vtravil8t10 19S3-998 capita n rnilment Povertv (% of ooculation below naional oovertv line) 44 (Irbstn nonilatiina (% of total cooulatlon) 13 34 31 I Ufr eonectancv at birth tvears) 42 50 an Infant mortalitv JDer 1.000 llve births) 97 92 77 rhild malntitrition tX of children under 51 2f 32 43 Access to safe water Access to imoroved water source (# of cooulationl 41 43 64 illitAerat-v 9 ofoaoulation ace 15+1 38 39 39 Gross orimarv enrollment (%of school-aoe oooulationl 122 78 9Uganda Maie 12t as 102 Low-income group Femato 114 71 afi KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1979 1989 1998 1t99 Economic ratlos GDP (USS billions) 5.3 8.8 6.4 rrnss domestic invretment/GnP 11 I 1 SO 18.4 Exoorts of loods and servicesiGDP 8.0 10 3 1113 Trade rross domrestic savinas/GnP i 0 5.8 4 9 Gross national savinnslGflP 1 A 134 1n 5 Current accnount halanc/P)9 -PP10 4 1t Domestic IntA^rst navmants/G:nP 0 a n a Domestic Investment Total debt/GDP 38.2 53.6 54.3 Savings Total debt serviceaexoorts 25.1i S 1 Present value of debt/GDP 35.0 27.3 Presnt vatlue of dehtJ/eoorts 3WA.8 2S5 3 Indebt8dness 197S-89 1989-99 1998 1999 1999.03 laveraoe annual oawth) GPr) 34 71 5 R 74 ai3 Uganda GNP oer r.nita 0n9 41 2 8 4 B 3I3 ILow-income gou Eroortsofooodsandservices 1.2 148 -14.9 33.0 BA STRUCTURE of the ECONOMY 1979 1989 1998 1999 Growth of Investment and GDP(% (% of GDP) Anrictltiure Si R 44.6 44 4 Indlustrv 1n7 17 f 1786 40 Manijfarltirinn 5 9 8.9 8R7 20- qervices 32 5 37.8 37.8 Private cnnsnrmntion P2.0 84.8 85.2 -20 95 S6 97 9s go General nnvernment cnonsumntion 70 9.8 Pi 9 GDI - -GDP Imoorts of aoods and services 18.1 19.7 22.9 la verace annual orowthl 1979-89 1989-99 1996 1999 Growth of exports and imports I%) Anriculture 2.7 3.7 1.9 6.9 60,, Industrv 8 4 12 1 11 . 9 1 40 Manufacturino 3.6 13.5 14.4 11.3 Services 3 2 8 1 8.8 7 2 20 Private consumDtion 3.4 6.3 8.6 0.8 General oovernnrent consinmntion 0.n 8 2 R n 17.4 94 95 96 57 97 GCross dnmpstic investment 13 1 8 2 3 7 9.n -20 Imnorts of onods and sarvices 7 3 9 0 3 1 2 8 Exports e` lmports Gross national nroduct 3I 7 . 5i8 7 3 Note: 1999 data are preliminary estimates. The diamonds show four kev indicators In the countrv tin bold) comoared with its income-oroun averane. If data are missino. the diamond will he incomnle.te. - 72 - Uzanda PRICES and GOVERNMENT FINANCE 1979 1989 1995 1999 InatIon (%) Domestic prices n o (% change) 30 Consumer prices 131.0 5.8 -0.2 20 Implicit GDP deflator , 115.4 10.7 4 4 Government finance (% of GDP, includes current grants) 94 95 0e 97 sa Current revenue 5.5 10.3 10.9 -10 Current budget balance t. 3 0.9 0.9 GDPdeflator O CPI Overall surplus/deficit . 4.a -5.6 -5.9 TRADE (US$ millions) 7 1989 1998 1999 Export and Import levels (USS mill.) Total exports (fob) , 282 4568 49 .500 Coffee 276 269 307 Cotton ,.1) 11 11 Manufactures ,. Total imports (cif) 562 1,411 1,376 Food 5 Fuel and energy 78 84 65 Capital goods , Exoort odce index (1995s100) .. 92 74 67 ImDort orice index (1995=1001 79 106 101 *Exports UImports Terms of trade (1995=1001 117 70 67 BALANCE of PAYMENTS (USS millions) 1S1979 198t l9os 1999 Current account balance to GDP (%) Exports of goods and services 304 034 726 o Imports of goods and services 712 18,71 16,34 Resource balance -408 ,1,237 -1,107 Net income -0 -9 -14 * i* * Net current transfers 114 539 375 Current account balance . 360 -706 -746 Financing items (net) .. 342 840 780 Changes in net reserves 18 -134 -33 i_ Uemo: Reserves includino aold (USS millionsl .. 46 750 748 Conversion rate (DEC. locaUSSI ., 170.4 1,149.7 1.3620 EXTERNAL DEBT and RESOURCE FLOWS 1979 1989 1998 1999 (USg millions) Composition of 1999 debt (USS mill.) Total debt outstanding and disbursed , 1,903 3,631 3,480 IBRD 24 0 a F: 5S IDA 605 1,971 2,042 E: 644 Total debt service 172 179 IBRD 5 0 0 IDA 5 24 25 Composition of net resource nows D: 385 Official grants 36 177 433 277 B 2,042 Official creditors 22Q 188 Private creditors ,, 0 1 4 Foreign direct investment 2 2 200 230 C: 351 Portfolio equity 0 0 0 World Bank program Commitments Q 141 172 267 A -18RD E - Bilateral Disbursements 100 242 148 B-IDA D - Other multilateral F -Private Principal repayments 4 10 10 C- IMF G - Short-term Netflows 96 :31 138 Interest payments 6 14 15 Net transfers 9Q 217 123 Development Economics 919/00 -73 - Additional Annex No.: 11 UGANDA HIV/AIDS BRIEF HlV/AIDS Prevalence Ranking in Sub-Saharan Africa: 17 Baclsgr .uad M KJninpJhs, -ii ' prevalence among male STI patients increased from 42 percent in 1989 to 46 ncrccnt in 192. p.evalcnce among male STI patients in Kampala declined to 30 percent in 1998. In i 66 pr cen of sex workers tested at one rural site were HIV-positive. > -. t ; the epidemic has become increasingly generalized, though in some sites there are ,- 'al H-IV prevalence is declining. In non-urban areas of Uganda, prevalence among antenatal .I;^tc Aes decreased from 13 percent itn 1992 to 8 percent in 1998. HIV prevalence arnong uterkatal chinic attendees in Kampala increased from 11 percent in 1985 to 31 percent in 1990; wi QVever beginning in 1993, HIV prevalence among antenatal clinic attendees in Kampala started to decline, reaching 14 percent in 1998. I In 1998, undeT-hfve mortality was 24 percent higher than it would have been without AIDS. In '995, only 7.6 percent of women ages 20-29, who are most likely to get pregnant, report-ed a ;er using a condom. HP.'~~~~~~~~~~~~~~~~~~~~~R Prevalence among PregnaLnt cever using a ondom. MrWomen, Jrban (ercent) Country Response/Obstacles 30 > The Government and people of Uganda should be commended for their efforts in dealing with the 25 H: VlhI )S epidemic. H-o' Never, the Government needs to pay attention to the fact that HIV / prevalence remains high. > ,'he Covemnmvnt needs to correct the perception (among leaders and the general public) that the l- worst of the epidemic is over. HIV prevalence is high and also generalized in the pop-ulation, s neaning that any complacency now could lead to severe setbacks. o > Tke CGoverament needs to maintain HIV/AIDS as a priority issue on the agenda of both the central 1sF l%B 1990 IQ t9A 19 19T and district levels of government. I 1he Government should continue developing a strong multisectoral program to cover all sectors and partoers (including NGOs, which have played an important outreach role). tn thle health sector, procurement and logistics management problems are serious. Stock-outs of Hioro e serwiul commodities, including condoms, drugs for opportunistic infections, and medical supplies, 9000 continue to be experienced on a regular basis. A number of donor-assist-ed programs are coming to an Soao _ end, To avoid losing momentum, the Government needs to effectively implement its proposed program 6000 for HIV/AIDS. 5000 4000) 3000 Yes No 3~~~~~~~~~~000 Bank HIViAIDS Activities to Date loon 9 Yes Nio 19s5 1997 19t9 1991 1993 1995 Iks HiV/AIDS a regular part of our high-level dialogue with govt. and civil society? 4 Does HIVAIDS receive substantive treatmetnt in the CAS or its update? 4 the portfolio bee revie-wed for HIV/AIDS retrofitting? life lxpO withd 2d without ~~~~~~~itgtocopnns ..d,. AIDS, 1998 and 2010 grasrs) Don ll prot inld h eesar HIIV/AIDS-mitigation conmponcnts? unsderweay Dons the Bank reguiusa auttend UNAIDS mretings? v Project Name Approval Date IDS $M First Fleid'h Project 6/23/88 42.5 1.0 STI irojeei 4/12/94 50.0 50.0 Opportunities a ID Xi 40 so ef 70 [ThevFe shiould be identified by the Country Teamt.] Wthot AMS m With AiDS - 74 - A i----- --- F | IBRD 25052RW /32- 34/ 36 SUDAN f '' 1~~~~~~~~~~Tho / 2 4 )\o,oXx MZ't-~ -~~-- 1h v;_ \, 1 A3T30R ! {1 \ t O_,, * FERRIES DEMOCRATIC )~ REPU BLIC Jf <64vTks_7+a) ok_ J)._ < _rw-2 ~ lcn /p ! ALT P RIMARY BITUMEN ROADS OFCONGO NEBBI* MOROTO ---- PRIMARY GRAVEL ROADS I RAILROADS N, .NoikoU 2- SELECTED TOWNS AND VILLAGES NK.D-,, . W m9 JmoKa L, DISTRICT CAPITALS Lownpo cm' 'letp KUMI 7> * ~~~~~NATIONAL CAPITAL HOIMA- 'Ne A t DISTRICT BOUNDARIES' k-g. . ~ ~ ~ ~ ~ ~ ~ ~ ~ - REGION BOUNDARIES H }1 . . u \, l )felNorrolooni * g .... Ko sy TrhK * INTERNATIONAL BOUNDARIES UWER Mb ~~~~~ ~~~~~~~~~~~~~~~~~~~Diootnmes ,o,oolith DiOriot Copitols. with one r-t-,-/ t KiBALE > t K,,, \ ETt t ,tLUWER Mbuir4>,rlirr ,.> t g °1° ' /> Etcep-or F.rt Porftl is the District Cepitl f Kbhre Di riot v r zJ T Nt UYO 6 Blnm o,Kyn e b, / r i t ) 61FpRT'~ 6 * i _ - T.MUNDE Ktoroooo KILOMETERSO 50 100 150 PRTA tBo IGAGAj fff _rKl i-T__ K\.-MILES 0 50 100 K,I-b FONdli'' . KaA|. .-. RNF >' ].r- bon;o Buk AL T E KENYA t h h t. w. r o K pe:Nd I. ._,,,,,,AiA A: TQRhes,d. myon It p? o "' BUS FNYI C UGnyiudRf l RWANDA Iois II: ,, , AN A /6 __ eeF _ ._rs6olo4KLE . b^O K.. K. N~~NM .Okirf 7 ''.CNGO TANZiIAA~- 0 CT-. on T. B- eo4., 40~~~~0 towr si BA rirI 05,0 O~oo TANZANIA 'a, ~ ~ ~~~~orrws.r )n\?h 34- 30 JUNE 1998