Document of The World Bank FOROFFICIALUSEONLY ReportNo: T7698 - AF TECHNICALANNEX FORA PROPOSEDGRANT INTHEAMOUNT OF SDR6.60 MILLION (US$lO.O MILLIONEQUIVALENT) TO THE THE ISLAMICREPUBLICOF AFGHANISTAN FORA HIV/AIDS PREVENTIONPROJECT July 5,2007 HumanDevelopmentUnit SouthAsiaRegion This document has a restricteddistributionand may be usedby recipientsonly inthe performanceof their official duties. Its contents mavnot otherwisebe disclosedwithout WorldBank authorization. CURRENCY EQUIVALENTS (ExchangeRateEffectiveApril 30, 2007) CurrencyUnit = Afghani Af50 = US$1 US$1 = SDR 1.450 FISCALYEAR March21 - March20 ABBREVIATIONSAND ACRONYMS AHAPP AfghanistanHIV/AIDS PreventionProject ACBAR Agency CoordinatingBodyfor AfghanRelief AFGA AfghanFamilyGuidanceAssociation AIDS AcquiredImmunodeficiencySyndrome ANASF AfghanistanNational AIDS Strategic Framework ANCB AfghanNon-GovernmentalOrganisations CoordinationBureau AMI Aid MedicalInternational APWC AfghanPeace-seekingWomen's Council ARDS Afghanistan ReconstructionandDevelopment Services ART Anti RetroviralTreatment (Therapy) BCC BehaviorChange Communication BPHS Basic PackageofHealthServices CAF Children's AIDS Fund CBHC Community-basedHealthCare CBO Community-basedOrganization CRS CatholicReliefServices DA DesignatedAccount DaB DaAfghanistanBank DAC DevelopmentAssistance Committee DIC Drop inCentre EC EuropeanCommission FMA FinancialManagementArrangements EPAP EmergencyPublicAdministrationProject FSW Female Sex Worker GCMU Grants and Contracts ManagementUnit GDP GrossDomesticProduct GNP GrossNationalProduct GOA GovernmentofIslamicRepublic ofAfghanistan HACCA HIV/AIDS CoordinatingCommitteeofAfghanistan HIV HumanImmunodeficiencyVirus H-SWG HIV SurveillanceWorkingGroup H M I S Health ManagementInformationSystem HR HarmReduction I-ANDs InterimAfghanistanNationalDevelopment Strategy FOROFFICIAL USE ONLY IBBS IntegratedBiological and Behavioral Surveys IBRD International Bank for Reconstruction and Development IC-WM InfectionControl and Waste Management IDA International DevelopmentAssociation IDU InjectingDrugUse(r) IEC Information, Education and Communication IMF International Monetary Fund KAP Knowledge, Attitudes and Practices KOR Khatiz Organizationfor Rehabilitation M&E Monitoringand Evaluation MDGs MillenniumDevelopment Goals MOCN MinistryofCounter-Narcotics MOD MinistryofDefense MOE MinistryofEducation MOF MinistryofFinance MOHE MinistryofHigher Education MOHIA MinistryofHaj and IslamicAffairs M O I MinistryofInterior MOJ MinistryofJustice MOPH MinistryofPublic Health MORR MinistryofReturnees and Refugees M O U Memorandum of Understanding MOWA MinistryofWomen's Affairs MDM Medecins duMonde MSM Men who Have Sex with Men MSW Male Sex Worker NACP NationalAIDS ControlProgram NCA NorwegianChurch Aid NGOs Non Government Organizations OECD Organization for Economic Co-operation and Development 01 Opportunistic Infection PACBP Public Administration Capacity Buildingproject PEFA Public Expenditure and Financial Accountability PFM Afghanistan's Public Finance Management system PIP Program Implementation Plan PLWHA People Livingwith HIV and AIDS POP Program Operational Plan PPU Procurement Policy Unit SCA SwedishCommittee for Afghanistan SDU Special Disbursement Unit SGS Second Generation Surveillance SOEs Statement o f Expenses STI sw Sexually Transmitted Infection Sex Worker TIS Targeted Interventions TOR Terms o fReference UNAIDS Joint UnitedNations Programme on HIV and AIDS UNDP UnitedNations Development Program UNGASS UnitedNations Special Sessionon HIV and AIDS UNICEF UnitedNations Children's Fund This document has a restricted distribution and may be used by recipients only in the performance o f their official duties. Its contents may not be otherwise disclosed without World Bank authorization. UNODC UnitedNations Officeon Drugs and Crime VCCT Voluntary Confidential Counseling and Testing VCT Voluntary Counselling and Testing WADAN Welfare Association for Development of Afghanistan WHO World Health Organization Vice President: Praful Pate1 Country Director: Alastair McKechnie Sector Manager: Anabela Abreu Task Team Leader: Mariam Claeson iv AFGHANISTAN AfghanistanHIV/AIDSPrevention Project TABLE OF CONTENTS Page I. PROJECTRESULTSFRAMEWORK .............................................................................. 1 I1 PROJECTOBJECTIVESANDDESCRIPTION . ............................................................. 2 A. Objectives ........................................................................................................................... 2 B. Description of Project Components .................................................................................... 2 I11 IMPLEMENTATIONARRANGEMENTS . ....................................................................... 5 A. Institutional Arrangements.................................................................................................. . . 5 B. Financial Management. Disbursementand Audit Arrangements ....................................... 6 C. Procurement Arrangements ................................................................................................ 8 D. Monitoringand Evaluation Arrangements.......................................................................... 9 IV ENVIRONMENTAL AND SAFEGUARDPOLICIES . .................................................. 10 A. Environmental Assessment ............................................................................................... 10 B. Safeguard Policies............................................................................................................. 10 Appendix 1:ProjectCosts .......................................................................................................... 12 Appendix 2: EconomicandFinancialAnalysis ........................................................................ 13 Appendix 3: ProcurementArrangements andProcurementPlan ......................................... 23 Appendix 4: FinancialManagement ......................................................................................... 32 Appendix 5: Core services ofthe NationalHIV/AIDS PreventionProgram ........................ 43 Appendix 6: ProjectPreparationand Supervision .................................................................. 44 Appendix 7: MapsIBRD31643R1 ............................................................................................ 46 V I. PROJECTRESULTSFRAMEWORK Project Indicators Baseline Target End Frequency Data Y r 0 Y r 3* and Reports Collection Instruments 1. HIV prevalenceingeneralpopulation <0.5% <0.5% Every 2 years Modeling 2. HIV prevalenceamonghigh risk IDU: 3%* <=5%* Every 2 years IBBS groups (IDU,SW) 1I Project Key Performance Indicators: 3. Percentage o f IDUs reporting use of I I sterile injection equipment at last time --yo* 30 % agePoint Every2 yrs IBBS 1I injected increase 4. Percentageo f IDUsreporting use of condom at last time sex 20%agepoint increase Every2yrs IBBS 5. Percentageo f SW reporting use of a condomwith their most recent client -q0* 50% Every2yrs IBBS 6. Percentageof truckers reporting use of 20 YOage point a condom last time with sex worker --%* increase Every 2 yrs 7. Percentageof prisonerswho report access to sterile injectingequipment. --O/o* increase 8. Score on subset of National Composite -- Every 2 years Policy Policy Index (UNGASS)** assessment 9. Percentageof those aged 15-24 who --yo* 20 % age point Every 2-3 NRVA correctly identify ways of preventing HIV increase years transmission-measuredingeographic areas specific to program. Component 2. StrengtheningSurveillance 10. Percentageof urban centers which 3 cities 33% o f Annual NGO reports have done high risk group mapping provinces 11.Number of annualNACPreports and _ _ Every year Annual Annual report action plans informedby surveillance and andaction routine monitoring data. plan itions for at risk roups IDU: 60% Every 2 yrs; IBBS (e.g., IDUs,FSWs, truckers, prisoners) FSW: 50% reachedby HIV prevention program Trucker: 25% Annual Routine Prisoner: 80% monitoring 13. Percentageo f most at risk populations IDU:50% (e.g., IDUs, FSWs, truckers, prisoners) FSW: 50% who correctly identify 2 ways of --o/o* Trucker: 50% Every 2 yrs IBBS preventing HIV transmission Prisoner: 75% 14.Percentageo f T I sites meeting service IDU: 5 of 6 quality standard _- FSW 1of 1 Balanced Trucker: 1of 1 Annual score card assessment milding 15. Percentageof contractedsanctioned I implementationunits w/ uninterrupted -- 85% Annual GCMU fund flow and service delivery. reports to be adjustedusingresults of baselinesurveillance data, ongoing; **A subset ofAfghanistan policy priorities to be taken from UnitedNations Special Session on HIV andAIDS (UNGASS) Policy Index and developedinto a score. 11. PROJECT OBJECTIVES AND DESCRIPTION A. Objectives 1. The project will contribute to the national development goals of the Interim Afghanistan National Development Strategy (I-ANDs) of maintaining Human Immunodeficiency Virus (HIV) prevalencebelow 0.5 percent inthe generalpopulationand below 5 percent amongvulnerable groups at high risk of infection. The project's development objectives are to slow down the spread of HIV and build up the national capacity to respond to the epidemic. This will be accomplished by: (a) behavior change among vulnerable groups at high risk; and (b) improving knowledge of HIV preventionand reducingstigmarelatedto HIV and (AcquiredImmunodeficiencySyndrome) AIDS in the generalpopulation. 2. The key performance indicatorsthat will be usedto track the projectdevelopment objectives are: (a) the percent of injectingdrug users who have adoptedbehaviors that reducetransmission of HIV, that is, who useclean injectingequipment at last time injecting; (b) the percentof sex workers who reportusinga condom with their mostrecentclient; and (c) the percent of young people aged 15-24, in areas covered by the project, who correctly identifyways of preventingHIV transmission. B. Description ofProjectComponents Component 1: Communicationsand Advocacy 3. This component will strengthen the advocacy and communication capacity of the National AIDS Control Program (NACP) to create a policy environment that enables scaling up of targeted interventionsfor vulnerable populationsat highrisk, and reduces stigmaand discriminationrelatedto high risk behaviors. Specifically, informedadvocacy among policymakersand opinion leaders will aim to reduce stigma and harassment of vulnerable populationsand have leaders: (a) appreciate the threat of HIV to Afghanistan; (b) better understand the actions that can prevent a full-blown HIV epidemic; (c) becomeeffective sources of informationfor the rest of the community; (d) take actions themselves to assist their communities to avoid HIV; and (e) provide continuous support for the AIDS control program.It has been agreed that a national policy statement with commitment to the principlesof confidentialityand the voluntary nature of HIV testingwill be inplace at the start ofthe project, and that during the course of the project, appropriate substitution treatment policy for injecting drug users (IDUs) will be developed. The communications activities, including behavior change communicationand media activitiesdescribedbelow, will increase access to informationand appropriate knowledge of HIV prevention and other related health issues for vulnerable groups at highrisk, includingsex workers and their clients, truckers, andyouth in areas covered by the project. The behavior change interventionswill includea focus on the use of clean needles and syringes, and on condom use among IDUs and their partners; on consistent condom use among sex workers and their clients; and, on appropriateknowledge about HIVtransmission andways ofpreventingit among all vulnerable populationsat risk. 4. Activities will include (a) target audience research; (b) development of an advocacy strategy and activities such as high level meetings, training, and disseminationof evidence-based advocacy informationpackages;(c) development of core training and informationpackagesfor target audiences for use by service providers; (d) specific communication trainingfor Non Government Organizations (NGO) service providers, journalists, private practitioners and others; (e) gender- and culturally 2 appropriate communication media targeting vulnerable persons at risk; (f)audience surveys; and (g) reporting. To ensure a coherent approach and complementarity o f activities, one organization will be contracted to develop the plan and implement all elements o f the communication and advocacy component under the coordination and guidance o f the National AIDS Control Program (NACP). Component2: StrengtheningofHIV Surveillance 5. This component will build the evidence base for HIV and AIDS planning and help monitor and evaluate the effectiveness o f the program. Itwill buildNACP capacity to track the magnitude and trajectory o f the HIV epidemic in Afghanistan through the development o f second generation surveillance (SGS) system. The SGS system includes separate mapping and size estimation o f at risk populations, collection o f biological data from representative samples of the populations, and tracking the behaviors that contribute the most to HIV transmission dynamics. Based on the current understanding o f the epidemic, these behaviors are injecting drug use and unsafe sex. In addition to providing data for monitoring o f the epidemic, the wide array o f knowledge, behavioral, and service utilization data collected through SGS will provide the basis for future resource allocation and program management decisions to be made by NACP. All the SGS data will therefore be owned by, and readily available to, the NACP, and generated on an intermittent or routine basis, and not subject to the same internal review processes put in place for research and special studies. All surveillance activities involving HIV testing will follow the standard confidentiality and voluntary testing procedures o f the voluntary confidential counseling andtesting (VCCT) sites. 6. Epidemiologically relevant data in Afghanistan remain scarce; however some recent studies o f at risk populations will be used to refine the selection o f survey groups and locations for the baseline round o f the surveillance activities. As the baseline round o f surveillance data become available, adjustments and potential expansions o f the surveillance sites and target populations will be made as needed to more appropriately monitor the epidemic. Likewise, the preliminary targets established by the program (see results framework) will be adjusted based on available data. 7. The SGS activities will be implemented by an organization selected through international competitive bidding.This organization will work with the National AIDS Control Program (NACP), guided by an HIV Surveillance Working Group (H-SWG), to train its staff to conduct surveillance, obtain all necessary test kits and other materials, provide timely reports, and disseminate findings. The surveillance firm is given explicit responsibility for conducting national level capacity building on SGS methods and providing thorough documentation on the design and execution o f the various studies. The terms o f reference for surveillance include: (a) an initial desk review o f currently available information about location and size o f at risk populations, including characterization with respect to patterns o f mobility and intersection with other risk groups; (b) annual mapping and size estimation o f at risk populations in urban centers (up to 8 sites every second year or twice during the duration o f the project); (c) integrated biological and behavioral surveys (IBBS) o f IDU, female sex worker (FSW), prisoners, and truckers using probability based methods conducted twice during the Program Implementation Plan (PIP) period; (d) two rounds o f Knowledge, Attitudes and Practices ( U P ) surveys o f mainstream opinion leaders to assess the effectiveness o f the advocacy and communication component; (e) annual data synthesis and epidemic modeling o f available surveillance and other data to project the impact o f the epidemic onthe overall country scenario. 8. Due to the importance o f obtaining baseline measures for the core program indicators in order to measure project results, the data collection activity for the IBBS o f IDU, SWs, and prisoners should be completed within the first 6-9 months o f the project. The early development o f service quality standards and guidelines for different program components will also ensure that the survey instruments are specific and relevant to the program being implemented. 3 Component3: Targeted Interventionsfor HighRiskBehaviors 9. This component will support targeted interventions(TIS)to prevent further spread of HIV amongvulnerable groups at highest risk (see Appendix 5 for definitionof TI packages). The TISwill support safe practices and reduce risky ones. The targeted intervention for HIV preventionamong IDUs provides a comprehensive harm reduction package, including needle and syringe exchange, peer counselingand education, and condompromotion,deliveredat drop incenters andthrough other outreach services. The services will be delivered where HIV transmission is most likely to occur, basedon mappingof highrisk populationsand sero prevalence survey data, with flexibility to expand to new sites as they are identified. Proposals will be invited from NGOs for work with identified groups, such as IDUs and their partners, sex workers and their clients, and others as appropriate in selected sites startingwith the major urban areas. InKabul, due to the estimated size and spread of mainly street based IDUs, there will be three contracts covering different parts of the city and surroundingareas, while inthe other three cities with surrounding areas (Herat, Jalalabad andMazar) there will be one contract for each area. NGOs will provide the services under contract with the Ministry o f Public Health(MOPH). The Grants and Contracts Management Unit (GCMU) will have the managerialand financial responsibilitiesandtheNACPwill providethe technicalsupervision. 10. The terms of reference (TOR) for targeted interventions for IDUs, sex workers and their clients, truckers and prisoners will include (a) gathering of baseline data to estimate the size of the populationto be covered, on a case by case basis, taking into account local data needs and the data that is already available through social mapping; (b) establishment and operation of appropriate services such as, inthe case of HIV preventionamong IDUs, drop in centers (DIC), social support, needle and syringe exchange, condom distribution, sexually transmitted infections (STI) care, other medicalsupport, andVCCT; and(c) reporting.The contracts for IDUswill target groups in four cities and their surrounding areas with flexibility to expandto new sites each following year basedon data showingadditionalsites (hot spots) with concentrationof personswith highrisk behaviors.There will be only one contract each for HIV prevention among truckers, sex workers and their clients, and prisons.Procurementof this will be basedon competitivebidding.The prisonprogramand one ofthe IDU TISwill include operations research to assess the feasibility of alternative options for effective substitutiontherapy, to informnationalpolicy to be developed on substitutiontherapy. Ethnographic study will be conducted to learn more about MSMnetworks and how to design appropriate strategies for reachingMenwho have Sex with Men(MSM)with HIV preventioninterventions. Component 4: ProgramManagement,CapacityBuilding,Monitoringand InnovationActivities 11. This component will strengthen the core functions of the national HIV/AIDS prevention program, including program management, capacity development, and monitoring by NACP and the multi sector HIV oversight o f the HIV/AIDS Coordinating Committee o f Afghanistan (HACCA). This component will also provide funding of innovativeapproaches - an "Innovation Initiative" for mainstreamingof the national multi sector HIV response.Membership of HACCA is extensive and includesNGOs and civil society representatives as well as ministrieslisted below. Capacity building activities in this component will facilitate learning and include exposure visits, short term TA, training, including training of health services providers, and conferences leading up to policy development and review. The NACP will be supported though six national advisors, the program manager, and an international advisor - two of the national advisors will support the GCMU on financing and procurement. The Project will support NACP office operations and transport for monitoringand supervisionactivities, includingregular (monthly) visits to activity sites throughout the country. 12. This component will support the development of routine monitoring and service quality assessment, closely aligned with the existing Monitoring and Evaluation (M&E) and Health 4 Management Information System (HMIS) o f the MOPH, and including an action plan, timeline, and assigned responsibilities to the M&E advisor and other NACP staff. Standardized, routine monitoring indicators and formats will be developed for each program area. The principles and operations o f routine monitoring for NACP will be consistent with established practices o f the larger MOPHM&E and HMIS system for Basic Package o f Health Services/Emergency Project Health Services facilities. This includes emphasis on local units reviewing and analyzing their own data for program management purposes. In a few program areas, where other ministries or other M O P H departments (e.g., Ministry o f Counter-Narcotics (MOCN) or the M O P H demand reduction unit) play a role in managing NACP supported or externally funded activities, it will be critical to obtain consensus on routine monitoring standards and requirements so that NGOs receiving funds from multiple donors follow a single standard, and data can be analyzed across various types o f implementation units. 13. The Innovation Initiative for multi sector mainstreaming will invite proposals from sectors other than health. The Innovation Initiative will enable other line ministries, NGOs and the private sector to develop action plans in support o f the project development objectives, through a memorandum o f understanding with the MOPWNACP (line ministries) and through NGO contracts managed by the MOPWGCMU. This will enable innovative HIV prevention activities, for example among women, youth, refugees and returnees, and other initiatives to reduce stigma in different population groups. The grants under the Innovation Initiative will include: (a) baseline (if available); (b) appropriate innovation activity for an agreed target group in an agreed location; (c) monitoring and evaluation plan; and (d) reporting. The first round may cover several contracts for different audiences and/or target groups. The second and third round may extend these contracts and/or add contracts for additional audiences and/or target groups. 14. ProjectCosts. The estimated cost o fthe project with contingencies is about US$lO.O million over three years. The project costs summary and cost breakdowns by components are described in more detail inAppendix 1. 111. IMPLEMENTATION ARRANGEMENTS A. InstitutionalArrangements 15. The project will be implemented over a three year period by the MOPH. The institutional framework is in place, assigning the program coordination, management and technical roles to MOPWNACP and the financial management and procurement responsibilities to the MOPWGCMU, under the overall multi sector oversight o f HACCA. Technical working groups are being established (Le,, HIV Surveillance WG) by the NACP to guide its work program, drawing on available technical experts from professional, academic, research or other organizations within the country. These technical working groups will support and report to NACP, which in turn will present the recommendations o f the technical working groups to the H A C C A for endorsement. The M O P H will contract the surveillance and communications components o f the project to agencies that can carry out those functions while developing and transferring capacity in these areas. The targeted interventions for the prevention of HIV among IDUs, sex workers and their clients, truckers and prisoners will be contracted to NGOs and Community-based Organizations (CBOs) with experience inworking with the communities at risk.Non-health ministries, private sector and NGOswill be able support or implement HIV prevention programs, funded through the Innovation Initiative, by preparing proposals to be reviewed by a multi sector review panel led by the NACP, and reporting to the HACCA. Specifically, the roles ofthe NACP, GCMU and HACCA are as follows: 16. National AIDS Control Program will lead the implementation o f the proposed project, in close coordination with relevant departments within MOPH, Le., Reproductive Health, Mental Health/Drug Demand Reduction, Information, Education and Communication (IEC), Environmental 5 Health, and M&E Departments and with key non-health sectors. The targeted intervention activities will be contracted out to NGOs and CBOs. Working with NGOs and CBOs in the prevention, treatment and care o f HIV and AIDS is international best practice, and will: (a) facilitate access and use o f preventive services among vulnerable groups at highest risk through peer educators and other outreach strategies; (b) ensure the protection o f communities at highest risk; and (c) help sustain the program among communities at risk. The strengthening o f surveillance and the communications components will also be contracted to organizations with experience in carrying out and building capacity inthese areas. MOPHhas a good track record o f implementing the Health Sector Emergency Reconstruction and Development Project, which includes the NGO-contracting approach to service delivery. In fact, civil society involvement is even more relevant to HIV prevention efforts, because the vulnerable population groups are particularly difficult to reach through governmental channels and need to be involved for effective coverage and quality. The proposed multi sector Innovation Initiative under AHAPP will be managed by the MOPH, reporting to HACCA. A multi sector review board, chaired by the NACP, will approve proposals from non-health sectors, through the Innovation Initiative. 17. The NACP capacity will be strengthened. NACP is currently staffed by a Program Manager, an international advisor (supported by the project), and four officers, most o f whom need to further their skills and expertise in HIV/AIDS program management. The NACP i s in the process o f recruiting a total o f six national advisors to help build NACP and G C M U capacity in the following areas: (a) monitoring and evaluation; (b) advocacy and communication; (c) IDU interventions; (d) interventions for other vulnerable populations; (e) procurement; and (f') accountant/financial management. The NACP team will focus on the monitoring, coordination, quality control and management o f various activities proposed by the AHAPP, while the GCMU, which has a strong track record o f handling project financing and procurement, will manage those aspects o fthe project. 18. HIV/AIDS Coordination Committee of Afghanistan (HACCA) has been established by M O P H to ensure a broad-based and inclusive oversight mechanism. This multi sector committee is chaired by the Deputy Minister for Technical Affairs o f MOPH, and includes the participation o f key ministries, agencies from public and private sectors, civil society and external development partners. HACCA will have eight provincial representatives (representing all 34 provinces) and two representatives o f people living with HIV and AIDS (PLWHAs) to guide the national Program Operational Plan (POP) and the Project Implementation Plan (PIP), a subset o f the POP, and begin a deeper involvement o f various sectors and partners. HACCA will play a critical role inthe process o f developing a national policy on HIV/AIDS to be endorsed by key ministries and parliament, including support to the principles o f confidentiality and voluntary testing and the protection o f vulnerable groups at highrisk from stigma and discrimination. 19. Grants and Contracts Management Unit. The Head o f the accounting department for G C M U in MOPH will manage the financial transactions o f the program, such as the preparation o f M-16 forms (payment orders), coordination with other line ministries involved in the program, and overall contract and project management. This department is staffed with financial management (FM) personnel who are efficiently managing all current external grants including the (International Development Association (IDA) Health Sector Project. A qualified and experienced procurement specialist and an accountant are being recruited by MOPH to strengthen the financial management and procurement capacity o f GCMUto handle the additionalwork related to the AHAPP. B. FinancialManagement,Disbursementand Audit Arrangements 20. An Afghanistan's Public Finance Management (PFM) performance rating system has recently been developed for Afghanistan by the Public Expenditure and Financial Accountability (PEFA) multi-agency partnership program, which includes the World Bank, International Monetary 6 Fund (IMF), EC, and other agencies. Afghanistan's ratingsagainst the PFM performance indicators portray a public' sector where financial resources are, by and large, being used for their intended purposes as authorized by a budget that is processed with transparency and has contributed to aggregatefiscal discipline. 21. Financial management and audit functions for the proposed project will be undertaken throughthe agents contractedunder the Public AdministrationCapacityBuilding project.This is the primary instrument for continuing to strengthen the fiduciary measures put in place for ensuring transparency and accountability of funds provided by the Bank and other donors. Under these contracts, two advisers-Financial Management and Audit-are responsible for working with the government and line ministriesto carry out these core functions. The FinancialManagement Agent (FMA) is responsiblefor helpingthe Ministry of Finance(MOF) maintainthe accounts for all public expenditures, including IDA-financed projects and for building capacity within the government offices for these functions. 22. At the project level, financial management will be coordinatedby the NACP through the GCMU of MOPH. The financial management capacity in GCMU, which has experience in the managementof Bank projects, will be strengthenedby the recruitmentof an additionalqualified and experiencedaccountant. 23. Quarterly Financial Monitoring Reports will be prepared by the NACP/GCMU/MOPH accountingunit. Consolidated projectreports will be prepared, reviewed, and approved by the MOF, supportedby the FMA. 24. A DesignatedAccount (DA) with a ceilingof US$500,000 will be opened at DaAfghanistan Bank (DaB, Central Bank) in the name of the project on terms and conditions satisfactory to IDA. The DA will be maintained by the MOF. Withdrawal applications for reimbursement will be submittedmonthly.Financialmanagementarrangementsfor the project are detailedinAppendix 4. Fund Flows 25. Fund management for the Project will follow existing procedures. As with all public expenditure, all payments under the project will be routed through MOF. The FM Agent will assist the MOF in executing and recordingproject payments. In keepingwith current practices for other projects in Afghanistan, the DA will be operated by the Special Disbursement Unit (SDU) in the Treasury Department MOF. Requests for payments from DA funds will be made to the SDU by MOPH. In addition to payments from DA funds, MOPH can also request the SDU to make direct payments to contractors, consultants or consulting firms, and to request issuance of special commitments for contracts covered by letters of credit. Such requests will follow World Bank procedures. All withdrawal applications to IDA, including reimbursement, advances, special commitment and direct payment applications, will be prepared and submitted by MOF. GCMUMOPH will prepare statements of expenditures based on suggested formats given by the Bank. Accountingand Reporting 26. A Financial Management Manual will be prepared by MOPH documentingthe financial management arrangements for the project, including detailed arrangements and procedures for payments and reporting for those that will benefit from the InnovationInitiative. The manual will outline guidelines for project activities including specific requirementsfor line ministriesinvolvedin the program, and establish a project financial management system in accordance with standard Afghan government policies and procedures. This will include use of the Chart of Accounts 7 developedby the FMA to recordproject expenditure. Projectaccounts will be consolidatedcentrally inMOF, throughthe SDUand supportedby the FMA. ConsolidatedProjectFinancialStatementswill bepreparedfor all sources anduses of projectexpenditures. InnovationInitiative 27. An amount ofUS$l,OOO,OOO is to be set aside from the projectfunds for innovativeactivities that will strengthen multi-sector responses from government departments, community NGOs, and privatef m s accordingto the project'sresults framework and essentialpackagesof services.Budgets for the InnovationInitiative will form part of the total project budget for MOPH which will be the responsible line ministry for the expenditures incurred, irrespectiveofthe benefitinglineministry. 28. Disbursements for proposals approvedby the multi sector reviewBoardunder the Innovation Initiativewill requiresignedperformanceagreements(Le., MOlJsfor line ministriesandcontractsfor community NGOs and private firms) between the MOPH and the recipient institutions. The performance agreements will delineate each party's responsibilities, record procedures for procurement and financial management, and containa copy of the approvedfundingproposal.Itwill also define performance milestones in project implementationthat, when verified, serve as triggers for the release of additionalpayments, after the initial tranche payment made based on the proposal. For NGOs and CBOs, IDA is financingthe sub-grant on either a lump sum or tranched basis, with MOPH doing detailed monitoring of actual expenditures of sub-grant funds. For other Line Ministries,IDA is financingthe procurement contracts (for works, goods, services) awardedandthus, doing actual expenditure monitoring and requiring expenditures (use of sub-grant proceeds) to be providedvia either records (supportingdocumentation) or reports of statement ofexpenses(SOEs). 29. Forfinancial reportingfrom recipientinstitutions, reports will be submitted quarterlyor at the time of request for funds tranche release, whichever is earlier. The reports shall consist of financial and physicalprogress. MOPHwill designcommonreportingformats or templates, inorder to enable it to assemble financial information from a number of participating institutions into an aggregate reportfor onward submission to the Bank (as part ofthe quarterly interimun-auditedprojectfinancial reports). Detailsandformats wouldbe includedinthe project's financialmanagementmanual. DisbursementMethod 30. Disbursements from the IDA grant will be in accordance with the Bank's Disbursement Handbook for World Bank Clients and include advances reimbursement, direct payment, and payments under Special Commitments including records (full documentation) or against summary reports(statementsof expenditures), as appropriate. Audit ofProjectFunds 3 1. The Auditor General, supportedby the Audit Agent, is responsible for auditingthe accounts of all IDA-financedprojects. Annualauditedproject financial statementswill be submittedwithin six monthsofthe close ofGoA's fiscal year. C. ProcurementArrangements 32. Procurementactivitieswill be carried out by the MOPHthroughthe GCMU. 33. Procurementwill be in accordance with the World Bank's "Guidelines: Procurement under InternationalBank for Reconstructionand Development(IBRD)Loans and IDA Credits" (datedMay 8 2004; revised October 2006); "Guidelines: Selection and Employment o f Consultants by World Bank Borrowers" (dated May 2004; revised October 2006); and the provisions stipulated in the Development Grant Agreement. The Bank's Standard Bidding Documents, Requests for Proposals, and Forms o f Consultant Contract will be used. In case o f conflictlcontradiction between the Bank's procurement procedures and any national rules and regulations, the Bank's procurement procedures will take precedence. The summary o f the procurement capacity assessment o f the implementing agencies and precise arrangements are presented inAppendix 3, D. MonitoringandEvaluationArrangements MonitoringArrangements 34. M&E o f the national program will be NACP's responsibility, in cooperation with the M&E department o f MOPH, and aligned with the HMIS. The project will strengthen the capacity o f the NACP to monitor program implementation and evaluate progress towards the national HIV development goal, which is to keep national HIV prevalence below 0.5 percent among the general population and below 5 percent among the population groups with highrisk behaviors. Strengthening o f surveillance is a major component o f the project, since sero-prevalence and behavioral data are critically needed to inform policy, priorities and decision making. As part o f evaluation, the project is also considering support for a feasibility study o f piloted harm reduction interventions, to strengthen the evidence base for the most effective, feasible and appropriate substitutiontherapy options in the Afghanistan context. Other special studies include an ethnographic survey o f M S M and analysis o f the relationship between injecting drug use, poppy cultivation and counter narcotics policies. These evaluation data and special studies will supplement the routine monitoring system, which will collect and analyze data, contributing to, and using a compatible database platform as the existing M O P H HMIS system. 35. The project results framework (Section 1) was developed to ensure consistency between the PIP and the broader POP, and linkingproject components and major actions with expected outcomes. A checklist for the policy assessment index is being prepared to identify core policy issues necessary to create an enabling environment for HIV/AIDS control programs to be effective in Afghanistan. The checklist i s intended to award credit for partial achievements in advocacy considering the substantial effort required to pass policy and legislation. Scoring i s determined objectively according to whether policies are in place and supportive follow-up actions to enforce or apply such policies have occurred. 36. The ongoing social mapping o f high risk groups and the surveys o f sero-prevalence and behavioral determinants among those and other groups (University o f Manitoba and University o f California San DiegoNAMRU-3 respectively) will provide some results by mid 2007 and help build a baseline for the project. The ongoing exercise is also building skills in the country to map highrisk groups, skills essential for implementation and monitoring. 37. Project Monitoring will be carried out at different levels. At the level o f NACP, the Manager would conduct quarterly reviews with NACP staff and implementation partners (NGOs, CBOs, non- health line ministries that draw from the multi-sector fund and academic or research institutions that would carry out research studies). At the level o f MOPH, the Deputy Minister for Technical Affairs would conduct regular biannual reviews. HACCA will also review the progress o f project implementation at Annual Review meetings, including all development partners. A routinely collected set o f monitoring data and service quality assessments will comprise the basis o f these reviews. The specific indicators in both these sets will reflect the terms o f reference o f the program component, and the guidelines/operations manual developed for use by the implementationagencies. 9 38. Evaluation would be o f two types: (a) project evaluation, which would be carried out at the end o f the project; and (b) assessment o f the feasibility o f pilot activities planned under the project. The former would depend on baseline data, largely collected through the first round o f the planned SGS activities, at the beginning o f the project period; routine monitoring data and periodic progress reports through the life o f the project, a process monitoring based mid-term review 18 months into the project's life and an end-line measurement o f achievements. Feasibility studies o f pilots would be carried out by robust scientific methods, and would be built into the respective pilots themselves, in order to determine the programmatic effectiveness and feasibility o f each intervention being tested, and to learn lessons for incorporation incase the pilot intervention is deemed fit for scaling up. IV. ENVIRONMENTAL AND SAFEGUARDPOLICIES A. EnvironmentalAssessment 39. Provision o f preventive and diagnostic services under the HIV/AIDS project is expected to benefit the health situation in Afghanistan, however, it could generate infectious bio-medical wastes such as sharps (infected needles and syringes, etc.), infected blood, HIV test kits used in Voluntary Counselling and Testing (VCT) centers and laboratories and pharmaceutical wastes. These wastes, if not managed and disposed properly, can have direct environmental and health implications. 40. This project has been classified as category "B" as per the World Bank's Operational Policy on Environmental Assessment (OP 4.0 1) for environmental screening purposes given the risks associated with the handling and disposal o f medical waste and general health waste. Category B projects imply that the potential adverse environmental impacts o f the program are site-specific and, in most cases mitigatory measures can be designed readily and appropriately. An Environmental Management Plan, including an Infection Control and Waste Management (IC-WM) Plan has been developed by NACP which focuses on the establishment o f a sound management system for the treatment and disposal o f the waste related to the testing, treatment and prevention o f HIV/AIDS/STIs and includes generic guidance and protocols and alternative technologies for treatment, transportation and disposal in accordance with the size o f healthcare facilities. The details o f the Environmental Management Planare described in a separate Addendum to the TA. B. Safeguard Policies 41. This project has triggered OP 4.01 Environmental Assessment due to the potential adverse environmental impacts o f healthcare waste as discussed in the previous section. A limited environmental assessment was undertaken by different stakeholders and included consultations and field visits to some government run and some NGO run facilities. NACP does not have the necessary institutional capacity to implement the I C - W M Plan and will need to obtain appropriate support for components such as training, IEC and monitoring. An external independent evaluation is recommended before the midterm review o f the program, to ensure all activities are on track. It is the responsibility o f the NACP o f the MoPH to make the final version o f the Infection Control and Waste Management Plan (to be disclosed in the World Bank InfoShop) available to all relevant national stakeholders inthe local languages as well as on the relevant websites. 10 Safeguard Policies Triggered by the Project Yes No Environmental Assessment (OP/BP 4.01) [XI [ I Natural Habitats (OP/BP 4.04) [I [XI Pest Management (OP 4.09) [ I [XI PhysicalCultural Resources(OP/BP 4.11) [ I [XI Involuntary Resettlement (OPBP 4.12) [ I [XI Indigenous Peoples (OPBP 4.10) [ I [XI Forests (OPBP 4.36) [ I [XI Safety of Dams (OPBP 4.37) 11 [XI Projects in DisputedAreas (OPBP 7.60); [ I [XI Projects on International Waterways (OP/BP 7.50) [ I [XI * By supporting theproposedproject, the Bank does not intend toprejudice theJinal determination of theparties' claims on the disputed areas 11 Appendix 1:Project Costs PROJECT CO1 `S SUMMARY Local Foreign Total Project Cost by Component (US$ Million) (US$ Million) (US$ Million) 1. Communication and Advocacy 0.30 0.76 1.06 2. Strengthening HIV Surveillance System 0.50 1.11 1.61 3. Targeted Interventionsfor Vulnerable Groups at 0.60 3.46 4.06 HighRisk 4. Program Management, Capacity-Building, Monitoring and Innovation Initiative 1.10 0.70 1.80 Total Baseline Costs 2.50 6.03 8.53 PhysicalContingencies 0.40 0.60 1.00 Price Contingencies 0.00 0.47 0.47 Total Project Costs 2.90 7.10 10.0 Total Financing Required 2.90 7.10 10.0 COMPONENT DETAILS Component 1: Communication and Advocacy Component Item Year 1 Year2 Year3 Total Communication and Advocacy 100,320 658,480 504,400 1,263,200 Total 100,320 658,480 504,400 1,263,200 Component 2: Strengthening HIV Surveillance System Item Year1 Year2 Year3 Total Strengtheningof HIV/AIDS Surveillance 260,430 776,070 763,200 1,799,700 Total 260,430 776,070 763,200 1,799,700 Component 3: Targeted Interventions for Vulnerable Groups at HighRisk Component 4: Program Management, Capacity-Building, Monitoring and Innovation Initiative Item Year1 Year2 Year3 Total BuildingCapacity for Management andMonitoring 153,100 563,500 280,800 997,400 Multi-sector InnovationInitiative 200,000 400,000 400,000 1,000,000 Total 353.100 963.500 680.800 1.977.400 Costs including contingencies 12 Appendix2: Economicand FinancialAnalysis ProjectRelationto AfghanistanDevelopmentContext The project is well situated within the overall development context of Afghanistan as expressed inthe InterimAfghanistan NationalDevelopment Strategy (I-ANDS)and inthe "Afghanized" MDGtargets and indicators. The I-ANDS. One main pillar o f the I-ANDSis to improve the well-being o f the poor through social protectionas well as to mainstream cross-cutting issues ingender. The project approach to HIV/AIDS prevention and control will necessarily be cross-cutting due to the multi-sectoral nature of the response to this disease. Furthermore, HIV/AIDS presents a major economic shock for infected individuals and their families and preventing infections i s an important form of social protection. Costs of treatment for illness, and especially the death o f a household member, may push otherwise economically robust households into poverty (Wagstaff, 2005). One recent study from Vietnam estimated that, with the exception of households inthe richest quintile, all households with a PLWHA will fall below the poverty line as a result of the income and expenditure effects of HIV/AIDS (United Nations Development Program D D P ] , 2004). The project focus on targeted interventions (e.g., harm reduction programs) and advocacy efforts reflects another major theme of the I-ANDS. This theme looks to strengthen protection of human rights for all and assure redress for violations. Attempts to reduce the social stigma of, and provide health services to, at risk and vulnerable groups will have the additional advantage of improving the human rights situation for these socially marginalizedgroups. The "Afghanized" MDGs. The "Afghanized" MDGs, as they relate to HIV/AIDS, aim to halt and reverse the spread of HIV/AIDS by 2020 and the MDG monitoring includes monitoring of the condom use rate, the percent of the adult population with knowledge o f HIV/AIDS, and the HIV prevalence rate among groups at high risk. The MDGtargets also include the proportion of injecting drug users intreatment by 2015. Project activities will contribute to all o fthese outcome measures. Justification for GovernmentFinancing Public financing o f the project is justified because of the positive externalities associated with preventing HIV transmission and because of the public goods nature o f advocacy and other communication efforts, the establishment of a second-generation HIV surveillance system, and the piloting of treatment programs among vulnerable groups at high risk.Equity considerations are also relevant as part of the overall economic justification for the project; as suggested above the microeconomic impact of HIV infection on households is severe. An additional important externality of the project arises as a consequence of a reduction in the incidence of HIV/AIDS - an expected corresponding reduction in opportunistic infectious and costly diseases such as pulmonary tuberculosis will further reduce the burden on households and the Afghan health system. Given the public health nature of the interventions supported through the project andtheir large externalities, the GOAhas a central role insupportingactivities inthis area. EconomicAnalysis The project will fund activities in three broad HIV related components: (a) harm reduction programs and other behavioral interventions (including behavior change communication (BCC) focused on reducing stigma and discrimination) that aim principally to reduce the transmission of HIV; (b) the establishment of a second generation surveillance system; and (c) policy and program development on a pilot basis, including substitution treatment for IDUs. Each of these three components will be discussedseparately inthis economic analysis. 13 Harm Reduction Activities The cost effectiveness o f reducing HIV transmission has been demonstrated in numerous global settings. These findings are partly due to the simple fact that the disease largely affects prime age adults and the associated costs o f an adult death constitute the key microeconomic impact o f the HIV/AIDS epidemic. Over the course of the disease, household labor quality and quantity are reduced, initially as the infected person i s less productive, and subsequently with their death. This cost o f foregone earnings i s one major microeconomic cost o f the disease. These costs are exacerbated when there is more than one infectedperson inthe household, which is not unusual given the nature o f transmission. Other major costs include health care needs and the foregone earnings of family caretakers. The general success o f HIV prevention interventions, including harm reduction interventions for IDUs, is another reason for its general cost-effectiveness. International and regional evidence, including in resource constrained settings, demonstrate HIV prevention programs do indeed reduce HIV transmissions (Bertozzi et al., 2006). HIV prevention interventions are most timely -many more infections are preventable - in countries where the epidemic is growing rapidly rather than in countries where it i s stable or declining. This is the case in Afghanistan where the epidemic i s believedto be growing but concentrated in several key sub-groups, mainly IDUs. IDUshave been the starting point o f the HIV epidemic in many East and South Asian countries and the focus o f this project on the reduction in HIV transmission among IDUs as well as across to other groups i s well justified. Usingthe Asian Epidemic Model, Saidel et al., (2003) demonstrated that in countries where the epidemic among IDUsstarts in advance o f a generalized (non-IDU) heterosexual epidemic there i s a 171 percent increase over a 15 year period in infections if IDU prevalence i s not kept under control. The total costs o f the program are well-anticipated, yet the proposed program will occur in an environment with other donor supported HIV/AIDS activities coordinated under the National Framework and the POP. Bank-funded activities, however, will focus on reducing transmission (including the piloting o f substitution therapy) among the groups most urgently requiring interventions for the future health o f the country. Through the targeted interventions, the project will directly benefit socially excluded groups such as IDUsand SWs. This is true for harm reduction as stated above. It should also be true for behavioral change communication and stigma reduction since changing popular attitudes towards PLWHAs as well as attitudes towards vulnerable groups should at the very least increase the effectiveness o f harm reduction interventions. As these socially excluded groups find increased social acceptance, at least among important contact populations such as health workers, they will be more likely to respond to public or NGO sponsored interventions. The economic analysis here attempts to assess the net impact o f the program's package o f behavioral interventions. Towards this goal it adopts a cost-benefit approach couched in the general epidemiological patterns observed in Afghanistan's neighbors. This approach i s adopted because, largely as a result o f the longstanding conflict, the absence o f a surveillance system on HIV/AIDS in the country and current reliance on sporadic and unsystematic data make it very difficult to (a) determine the magnitude o f the actual epidemic today; (b) understand the dynamics o f transmission; and (c) assess the potential for its further diffusion. 14 However, what information exists suggests a potentialfor rapid increase indiseaseprevalence: (a) Countries experiencing war or in complex emergency states, like Afghanistan, are particularly vulnerable to rapid HIV transmission (Wollants et al., 1995; Smallman- Raynor and Cliff, 1991). Factors related to increased transmission during war include poverty, displacement of a population with high HIV prevalence to areas of lower prevalence, and sexual abuse or use of sex as a survival commodity. Additionally, populations within post-conflict states experience psychological effects that lead to increasedriskbehavior. (b) Limitedhealth care and education also contribute to the continuation of risk behaviors, particularly among IDUs. Displaced Afghan heroin users exhibit less knowledge regarding HIV transmission and engage in high-risk behavior when compared to Pakistani heroin users (Zafar at al., 2003). A recent study o f 464 IDUs in Kabul found that 35 percent claimed to have ever shared syringes, 76 percent had ever paid for sex with a woman, 27 percent had ever had sex with other medboys, 19 percent had ever been in prison, and 4 percent had ever been paid for donating blood. In this sample 3 percent were already HIV sero-positive and 37 percent carried the Hepatitis C virus (Todd et al., 2006). (c) Afghanistan is re-emergingas the leading supplier of opium inthe global market. Heroin use is widespread in Afghanistan and though injection i s not a common route of administration traditionally, this is increasing as displaced persons returnto Afghanistan with injection techniques learned in bordering countries (IRINews.org, 2004). UNODC estimates there are 50,000 narcotics addicts in Afghanistan, o f which 7,000 inject. They also estimate that a large number of people are injecting over the counter pharmaceuticals (e.g., pentazocin) which suggests there may be as many as 19,000 IDUs inAfghanistan at risk for acquiringHIV(UNODC, 2006). (d) Central and South Asia are experiencing a rapid increase in HIV cases introduced by injection drug use and the commercial sex trade (Joint United Nations Programme on HIV and AIDS [UNAIDS], 2006). Iranhasthe highest rate ofheroinaddiction per capita inthe world: 20 percent of Iranians aged 15 to 60 are engaged in drug abuse 9 to 16 - percent of whom inject drugs. Twenty-three percent of IDUs in Tehran are HIV positive (Zamani et al., 2006), this is an increase from 15 percentjust one year earlier (Zamani et al., 2005). The HIV/AIDS epidemic in the Islamic Republic of Iran appears to be accelerating at an alarming rate. The Iranian HIV adult prevalence rate in 2001 stood at less then 0.1 percent, roughly where Afghanistan stands today. By 2006 there were 66,000 HIV positive adults in Iran, or 0.2 percent of the adult population (UNAIDSAVorld Health Organization [WHO], 2006). The Iranian experience may be particularly relevant for the future of the epidemic in Afghanistan. A 2005 United Nations Office on Drugs and Crime (UNODC) report found that at least 50 percent of injecting drug users in Afghanistan reported to have started in Iran. In addition, the genotype o f the virus identified in a recent sero-prevalence study is identical to that found among IDUs in Iran (Todd et al., 2006). IfAfghanistan were to follow the Iranian example then an increasefrom less than 0.1 percentofthe general adult population (15-49) to 0.2 percent over five years represents a minimum o f 16,000 new infections (assuming a mortality rate of 15 percent over the next five years for individuals already or soon to be HIV-positive). This hypothetical course of the epidemic in Afghanistan serves as the baseline progression of the disease for this economic analysis. 15 The impact o f the project can be modeled as a series o f harm reduction interventions that affect the transmission rates within and across vulnerable groups as well as across to the general population. The likely impact o f the proposed interventions on transmission is treated as a random variable with hypothesized distributions. The analysis then adopts Monte Carlo methods to generate a distribution o f anticipated total benefits, at the national level, to compare with costs. The assumed impact ontransmission of the project inits entirety is set at the deliberately conservative expected value o f a 30 percent reduction in expected infections over the period 2007-2010 (approximately equal to 4800 infections averted). In other words, disease prevalence in the overall adult population in five years time would be 0.03 percent less as a result o f the program if the trajectory o f the epidemic would have followed the Iranian pattern. To account for heterogeneity in project outcomes, we assume a standard deviation o f 25 percent, or 1200 infections averted. In each simulation, a new draw o f infections averted is taken from this distribution in order to explore benefits o f the project under various levels o f effectiveness. The monetized benefits from a reduced number o f HIV infections are here determined as the sum o f three factors: the costs o f medical treatment foregone, the value o f lost earnings for PLWHAs given increased mortality, and the value o f lost earnings for the typically familial and unpaid caretakers. Table 1 gives the summary cost parameters used inthe analysis. The analysis makes no attempt either to directly value the years o f life lost due to premature mortality or to cost the pecuniary savings from a reduction intuberculosis and other opportunistic infections transmitted to HIV-negative individuals. Clearly, taking these values into account will substantially increase the estimated benefits depicted here. The number o f productive work years lost to premature HIV-related death is assumed to average 20 years across individuals. Wage and earnings information for Afghan workers are incomplete and often o f questionable validity. One careful small-scale longitudinal study conducted in three urban centers (Kabul, Herat, Jalalabad) estimates mean annual earnings to be US$425 (Beall & Schutte, 2006). Since this study spans a 12-month period it includes seasonal spells o f under- and un- employment. Approximately 80 percent o f earners are male, so this wage estimate is heavily weighted towards male earners. However this may not introduce much bias since the majority of IDUs are male and correspondingly many o f the infections in the next few years are expected to be male. Real wages are set to grow an average o f 3 percent a year (in-line with economic projections), with a standard deviation o f 0.5 percent. This additional source o f variation ensures that every simulation will have unique real wage growth rates. When infected individuals fall sick, they need care and the cost o f foregone earnings for the care- takers is another substantial cost. For example in Vietnam, three-quarters o f PLWHAs interviewed in a recent UNDP sponsored qualitative study claimed they required the assistance o f a caregiver on average for five hours a day. A quarter o f caregivers reported having to give up a job in order to spend time with the infected person (UNDP, 2004). This analysis sets the expected earnings loss for caregivers at one half o f annual earnings, and this loss occurs in the final year o f life for PLWHAs when they are most in need o f homecare. The expected lifespan, after infection, o f a PLWHA is assumed to be nine years and an enhanced level o f health care will be necessary in the final five years, with the final year o f life preoccupied with even greater medical care (Zaba et al., 2004). Little information on the costs o f care for PLWHAs, both out-of-pocket private expenditures and public sector spending, exists in Afghanistan. One linked facility and household survey estimates that 49 percent o f total Afghan health spending was out-of-pocket private expenditure (Johns Hopkins Unit, 2006). The same study estimates that the average monthly expenditure for a sick adult presenting to a health facility is US$20. This analysis 16 assumes that after an HIV positive individual begins to suffer from opportunistic infections and falls ill,bythe fifthyear ofinfection, s/he willpresentthreetimes annuallyto ahealthfacility, for an average private cost o f US$60 a year. The study further assumes an equal amount o f resources in the public sector are devoted to that individual's care (since the amount o f spending in the health system from private and public sources i s estimated to be roughly equal). It is to be expected that this level o f care, for the maintenance o f OIs, will be necessary for several years, while in the final year the costs are expected to rise substantially. The same UNDP sponsored Vietnam study referenced above found that the average per capita health expenditure per PLWHA rose seven fold in the final year o f life (UNDP, 2004). This study takes the same multiplier and applies it in the Afghan context. Hence, both public and private spending inthe final year o f life for a PLWHA averages US$420 each. The analysis also adopts a discount rate o f 5 percent, a typical value for the evaluation o f health projects. Table 2 presents the range o f benefit-cost figures as determined inthe Monte-Carlo analysis. The total gross program cost is US$10 million over three years, yielding a net present value o f US$9.40 million given the anticipated disbursement schedule. The median present value o f total costs averted i s estimated at US$30.8 million, yielding a gross benefit-cost ratio o f 3.28. Indeed almost every point in the range o f possible outcomes, depicted in the kernel density plot in Figure 1, i s associated with a substantially higher present value o f total costs averted. Inonly one simulation (out o f 500) is the estimated gross benefit less than cost. Where gross benefits exceed costs, the benefit- cost ratio ranges over the interval (1.16, 6.14). The median present value o f savings to the healthcare system due to reduced system expenditures on PLWHAs is estimated at US$2.04 million, resulting in a net program cost o f US$7.36 million and a net benefit-cost ratio o f 4.19. Where net benefits exceed costs (which occurs in 499 out o f 500 simulations), the benefit-cost ratio ranges over the substantially longer interval (1-25, 9.00). These ranges o f gross and net benefit-cost ratios calculated here are consistent with the ratios found in other countries in the region, especially when the conservative estimates o f program impact are taken into account. Even with these very conservative assumptions on program impact, made in a data scarce environment, the anticipated net benefits are substantial. StrengtheningHIV Surveillance The cost to Afghan society o f the proposed new surveillance system for HIV/AIDS, which the project would support over the first three years o f operation, would be the cost o f establishing the new system and subsequently the cost o f operating the system as per its design. This component is currently valued at a total cost o f US$1.6 million. Onthe benefits side, the economic benefits that would accrue to society from the new HIV surveillance system are those discussed above, namely the costs o f medical treatment foregone and the value o f avoided lost earnings for both HIV patients and unpaid caretakers. In practice, estimating distinct benefits as a direct result o f surveillance independent o f the overall package o f interventions and investments would be very difficult. Instead the influence o f the new system on actual health outcomes is reflected in the analysis above in so far as a functioning HIV surveillance system will increase the efficacy and targeting o f harm reduction programs. Indeed ifthe surveillance framework does substantially improve the effectiveness o f interventions, then the true benefits estimated above may be even greater than depicted. 17 Nevertheless, there are several dependent processes nested in the establishment and operation o f a surveillance system that need be made explicit. For any economic benefits to arise it would be necessary that: (a) Competent and qualified personnel are identified and recruited to the organizations charged with establishing and maintainingthe surveillance system. (b) The surveillance system collects reasonably accurate information on HIV/AIDS as per its design. (c) Relevant personnel process such information into meaningful reports and ensure the dissemination o f the reports in a timely fashion to those officials in place that are able to utilize them for policy purposes. (d) The reports result in effective action taken by the relevant decision makers inthe public or private sectors, which in turn improves the delivery o f services on the ground in a way that results inthe prevention o f a number o f cases o f the disease or a more effective treatment for those already afflicted. Program design must be such to ensure that these steps are accomplished. PilotTreatment Programsfor IDUs The program and policy component o f the project includes the establishment o f harm reduction and substitution treatment programs among IDUs. Given the current lack o f such programs, and the importance o f IDUs as a group in the transmission o f the disease, the need to develop cost-effective procedures to treat IDUs for substance dependency is an important component in GOA'Soverall response to the HIV epidemic. The chief economic benefit o f any pilot arises from the externalities from learning-by-doing. It i s expected that after several years o f experience with the treatment of IDUsGOAwill be able to implement effective substitution treatment programsfor IDUs.Because the value o f the pilot lies in the learning opportunities, a formal cost-benefit analysis i s not applicable unless the externalities are adequately understood and converted to a monetary value. However the analysis notes that the project should ensure as many key preconditions as possible so that the pilot exercise will indeed be a valuable learning tool for the GOA. The key preconditions for a successful IDU drug substitution pilot include the following: thorough training and adequate supervision and regulation o f clinic staff; a procurement and distribution system that can ensure timely delivery o f medication to groups in need; the medication being included in the essential drug list; a M&E system that is able to accurately forecast demand for services and to plan accordingly; and effective cross-sectoral cooperation among all involved ministries, including the Ministries o f Interior and Justice. FiscalSustainability The completion o f the project will bequeath modest recurrent costs to GOA.The estimated recurrent costs engendered by the project, listed separately by main areas o f activity, are presented in Table 3. The burden o f recurrent government expenditures generated by the proposed project is estimated to equal US$2,976,000 per year after project completion. The uses o f recurrent expenditures falling to the central government include the continuing activities o f national BCC, the continued operation o f the HIV surveillance framework, and the on-going harm reduction activities. 18 This amount is relatively small (2.1 percent) in comparison with the total health sector Government spending, which is currently US$140 million per year (including donor support) and expected to increase substantially inthe comingyears. Real gross domestic product (GDP) growth is projected at 12 percent in 2007/08 and 10 percent from 2008/09 onwards. In addition, the share of government health expenditures in total GDP is expect to increase 40 percent by 2009/10 (IMF, 2006). This anticipated growth implies that the inherited recurrent spending will total only 1.2 percent of the public sector healthbudgetby 2009/10. Furthermore, the budgetary impact of the project recurrent expenditures may very well be over- estimated. The economic analysis for this project determinedthat the direct costs averted within the healthsector as a result of fewer infectionsmay also lessenthe budgetary burden. Figure 1. Distribution of costs averted as a result of harm reduction interventions sponsored by the AF-HIVIAIDS Prevention Project 0 20000000 40000000 60000000 Value of infections averted (USD) Dashed line depicts total discounted cost of project 19 Table 1.Cost parameters Average annual earnings of all workers $425.0 Mean annual real wage growth (random variable) 3.0% Standard deviation of annual real wage growth 0.5% Average wage loss for caregivers, in final year of illness $212.0 Average private health care costs, excepting final year of life $60.0 Average public health care costs, excepting final year of life $60.0 Average private health care costs in final year of life $420.0 Average public health care costs in final year of life $420.0 Assumed discount rate 5.0% 20 U m c 8 8 References Beall,Jo and StefanSchutte.2006. "Urban LivelihoodsinAfghanistan". AfghanistanResearchand EvaluationUnit, Synthesis Paper Series. Bertozzi, Stefan0 andothers. 2006. "HIWAIDS PreventionandTreatment". InDiseaseControl PrioritiesinDevelopingCountries, SecondEdition,editedby DeanT. Jamison andothers. Oxford UniversityPressandthe WorldBank. IMF.2006. "Islamic Republicof Afghanistan-Draft StaffReport for FirstReviewunderthe Three- Year Arrangement underthe PRGF". 1RINews.org.Accessed September 12, 2004. "Bitter-sweet harvest:Afghanistan's new war: IRIN web special onthe threat ofopiumto Afghanistan andthe region.Addiction: drugabuseinKabulcity andbeyond." UNOffice for the Coordinationof HumanitarianAffairs. http://www,irinnews.org/webspecials/Opium/addadd.asp Johns HopkinsUniversityThirdParty EvaluationTeam. 2006. "Health SeekingBehavior,Health Expenditures, and Cost SharingPractices inAfghanistan."Draftmanuscript. Saidel, T. et al. 2003. "Potential Impactsof HIV amongIDUson HeterosexualTransmissioninAsian Settings: Scenarios from the AsianEpidemicModel". International Journal ofDrugPolicy, 14: 63-74. Smallman-Raynor, M.R., andA.D. Cliff. 1991. "Civil war andthe spread ofAIDS in CentralAfrica." EpidemiolInfect, 107: 69-80. Todd, Catherine, AbdullahAbed, Steffanie Strathdee, Boulos Botros, NaqibullahSafi, andKenneth Earhart.2006. "Prevalence o f HIV, viral hepatitis, syphilis, andrisk behaviors amongIDUsinKabul, Afghanistan." Presentation. UNAIDS.2006. "Report onthe GlobalAIDS Epidemic 2006". WHO, Geneva. UNDPDraftConsultant Report.2004. Socio-EconomicImpactof HIVIAIDS inViet Nam. UNODC.GovernmentofAfghanistanMinistry of CounterNarcotics. AfghanistanDrugUse Survey 2005. UNODC. 2006 World drugreport.Geneva: UnitedNationsOffice on DrugsandCrime, 2006. Wagstaff, Adam. 2005. "The EconomicConsequencesofHealth Shocks". The World Bank, Policy ResearchWorkingPaper Series #3644. Wollants, E., M.Schoenenberg,C. Figueroa, G. Shor-Posner,W. Klaskala,andM.K.Baum. 1995. "Risk factors andpatterns ofHIV-1transmission inthe El Salvador military duringwar time." AIDS, 9: 12919-1292. Zaba, Basia, Alan Whiteside, andJ. Ties Boerma. "Demographic and socio-economic impactof AIDS: taking stock ofthe empiricalevidence". AIDS, 18(suppl2):Sl-S7. Zafar, T., Brahmbhatt, H.,Imam, G., ulHassan, S., Strathelee, S.A.2003. "HIV knowledgeandrisk behaviorsamongPakistaniandAfghani drugusers inQuetta, Pakistan." J. AcquiredImmuneDefic. Syndr.32:394-398 Zamani, S. et al. 2005. "Prevalence of andfactors associatedwith HIV-1 infectionamong drug users visitingtreatment centers inTehran, Iran." AIDS, 19:709-716. Zamani,S. et al. 2006. "High prevalenceof HIV infectionsassociatedwith incarcerationamong community-based injectingdrug users inTehran, Iran." JournalofAcquiredImmuneDeficiency Syndromes, 42:342-246. 22 Appendix 3: ProcurementArrangements and ProcurementPlan Country Context The Bank has gained substantial experience and understanding of the procurement environment in Afghanistanthrough its involvement in the interim procurement arrangements put in place through EmergencyPublic AdministrationProject(EPAP) as well as with the institutionssuch as Afghanistan Reconstructionand Development Services (ARDS) that is holding the current responsibility for government's procurement administration.As part of the broader review of PFM system, the Bank recently carried out an assessment of the procurement environment in the country based on the baseline and performanceindicatorsdevelopedby a group of institutions led by the World Bank and Organization for Economic Co-operation and Development (OECD)/Development Assistance Committee(DAC). The first key issue identifiedthroughthe procurementassessmentwas the need for ownership and a championin the Government for reform, deepeningof capacity, ensuring integrity inthe operation of procurement systems, andpromotingsoundprocurement amongministries. A new procurement law was adopted in November 2005 which radically transformed the legal and regulatoryframework for the procurement administrationof Afghanistan.While it provides a modern legal system for procurement, effective implementationof the law may encounter difficulties in the current weak institutional structure and capacity of the Government. A Procurement Policy Unit (PPU) has been established under MOF to ensure the implementation through the creation of secondary legislation, preparationof standardbiddingdocuments, provisionof advice and creation of the necessary information systems for advertising and data collection. Afghanistan Procurement ProcedureshavebeeneffectivesinceApril 12,2007. Proceduresfor ProcurementAppealand Review have been developed by PPU/MOF. Members have been appointed and the system has been functionalsince April 2007. In the absence of adequate capacity to manage procurement activities effectively, some interim arrangements have been put in place to improve the procurement management of the country. A central procurement facilitation service, ARDS, has been established under the supervision of the Ministry of Economy.The Bank and the Government have agreed on a program for country wide procurement reform and capacity building, leading to the transitionfrom centralizedto decentralized procurementservices. The Bank funded Public AdministrationCapacity Buildingproject(PACBP) is the primary instrumentfor implementingthe programto strengthen capacity of the line ministries to manage public procurement in an effective, transparent and accountable manner. However, the implementationof the procurementcapacity buildingstrategy has not made any significant progress yet due to lack of coordinationand delays indecision makingwithin the Government.The envisaged radicalchanges to the procurementmanagementenvironment expectedfrom the new law also require the urgent implementationof a comprehensivehuman resources and capacity development program. The implementationof the procurement reform component of the PACBP and the proposed Public FinancialManagementReformProject should be consideredwith due priority to ensurethat fiduciary standards are further enhanced and that capacity is developed in the Government to maintainthese standards. General The procurement administration of the project would be carried out in accordance with the World Bank's "Guidelines: Procurement under IBRD Loans and IDA Credits" dated May 2004, revised 23 October 2006, "Guidelines: Selection and Employment of Consultants by World Bank Borrowers" dated May 2004, revised October 2006, and the provisions stipulated in the Financing Agreement. The general description of various procurements under different expenditure categories are described below. For each contract to be financed by the Grant the different procurement methods or consultant selection methods, estimated costs, prior review requirements, and time frame agreed between the Grant Recipient and the Bank project team are described in the Procurement Plan. This Procurement Planwill be updated at least annually or at lesser time intervals as required to reflect the actual project implementation needs and improvements inthe institutional capacity. Procurementof Works: The proposed grant will not finance any works contracts. Procurementof Goods: Goods procuredunder this project would include vehicles. The procurement will be done usingthe Bank's SBD for all ICB and National SBD agreed with (or satisfactory to) the Bank. Other methods will be shopping and direct contacting. Threshold for NCB goods will be US$ 200,000 per contact and for shopping will be US$lOO,OOO per contract. Selection of Consultants: Consultant firms under the project will include: (a) Communication and Advocacy (CA); (b) Second Generation Surveillance (SGS); (c) Targeted Interventions (TI) IDU; (d) Targeted Interventions (TI) - Harm Reduction (HR) with Operation Research; (e) Targeted Interventions (TI) Sex workers (SW); (f) Targeted Interventions (TI) Prisoners with Operation Research; and (8) Targeted Interventions (TI) Truckers. Under Program Management and Capacity Buildingthe following national individual consultants will be recruited to help build NACP capacity: (a) Project Director; (b) Monitoring and Evaluation Advisor; (c) Communication and Advocacy Advisor; (d) Harm Reduction Advisor; (e) Vulnerable Reduction Advisor; (f) Procurement Specialist; and (g) Accountant. The above individual consultants would be recruitedusing the PPF funds and maintained using the project funds once it is approved. The Program Manager will be included inthe project budget when his present contract under the Health Sector Emergency Reconstruction and Development Project ends in September 2007. The selection methods for consultants will include QCBS, QBS, CQS, LCS, FBS, SSS and Section V of Guidelines for individual consultants. Short lists of consultants for services estimated to cost less than US$lOO,OOO equivalent per contract may be composed entirely of national consultants in accordance with the provisions of paragraph 2.7 of the Consultant Guidelines. Threshold for CQS will be below US$200,000 equivalent per contract. Specific qualification criteria for selection of consultants under Targeted Intervention will be incorporated in the TOR as well as in the EO1 for the assignments. All the assignments under Targeted Intervention will be advertised under one EO1and the option will be givento consultants to apply for one or more assignments. Consultants applying for more than one assignment should demonstratetheir capacity to implement the contracts. RPM Office through an email dated May 19, 2007 has issued a waiver to allow more than six qualified NGOs in the shortlist as the case may be and to allow a shortlist comprising more than two local firms for the TI assignments. Innovation Initiative: An amount of US$l,OOO,OOO has been allocated under the project. The procedure for use of the fund will be elaborated inthe PIP of the project. 24 Operational Costs which would be financed by the project would be procured using the implementing agency's administrative procedures which were reviewed and found acceptable to the Bank. Assessment of the agency's capacity to implement procurement Procurement activities will be carried out by the MOPH through GCMU. An assessment of the capacity of GCMU, the Implementing Agency, to implement procurement actions for the project, was carried out by World Bank procurement specialists in December 2006. The G C M U is a group o f individual consultants established in 2003 to carry out procurement activities for the Bank financed Health Sector Emergency Reconstruction and Development Project, HSERDP (P078324). The agency is staffed by 30 people and the procurement unit is staffed by four procurement officers. One o f the four procurement officers is working on procurement o f health sector goods and the three others are busy with hiring and managing consultant contracts under the Health Sector EmergencyReconstruction and Development Project. The procurement specialists responsible for hiring consultants do not have adequate experience. The procurement officer working on the procurement o f health sector goods i s involved only with procurement o f small contracts (less than US$200,000) o f health sector goods. Big contracts (more than US$200,000) o f health sector goods are procured through ARDS. ARDS i s a Government Procurement FacilitatingAgency. As previously indicated, the existing procurement personnel: (a) do not have adequate experience for procuring and managing large value contracts; and (b) are fully busy with their procurement activities under the Health Project. To mitigate the risk, the following arrangement will be adopted for the Project: (a) A competent procurement specialist will be hired under GCMU o f MOPH to procure small value goods, works and consultancy contracts. The procurement specialist will be responsible for managing procurement for the project based on technical specifications/TOR provided by NACP. The procurement specialist, if needed, will also get help from the procurement team already hired under the IDA financed Health Sector Emergency Reconstruction and Development Project (P078324). (b) To ensure compliance with World Bank policies and procedures, procurement documentation for complex and large value goods and consultancy contracts will be carried out in consultation with the ARDS. The overall project risk for procurement is high. Frequency of Procurement Supervision: In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment o f the Implementing Agency has recommended two supervision missions to visit the field to carry out post review o f procurement actions. As the overall project risk for procurement i s high, 20 percent o f contracts will be post reviewed. Procurementaudit: In addition to the prior review and post review supervisions to be carried out from Bank offices, an independent procurement audit will also take place duringthe project life. 25 Detailsof the ProcurementArrangementInvolvingInternationalCompetition Goods: All contracts estimated to cost above US$200,000 equivalent for goods per contract and all direct contractingwill be subject to prior review by the Bank. Consulting Services: (a) List of consulting assignmentswith short list of internationalfirms 1 2 1 4 1 5 6 7 Review by Expected Estimated Bank Proposals Descriptionof Cost per Selection (Prior / Submission Ref. No. Assignment Contract Method Post) Date Comments HIV/Con- Communication and Prior 1 Sep 07 Three years 1 Advocacy contract HIV/Con- Survey (Second 1 Sep 07 Three years 2 Generation Surveillance- contract SGS and Knowledge, Attitudes, andPractices- KAP HIV/Con- TargetedInterventions $473,200 QBS Prior 1 Sep 07 Three years 3 (TI) -Harm Reduction contract (HR) Kabul-District A HIV/Con- T I -HR Kabul-District B $473,200 QBS 1 Sep07 Three years 4 Prior contract HIV/Con- T I -HR Kabul-District C- $646,200 QBS 1Sep 07 Threeyears 5 with Oper Research Prior contract HIV/Con- TI HRCity B Mazari $473,200 QBS 1 Sep 07 Three years 6 Sharif Prior contract HIV/Con- TI HR City C-Herat $473,200 QBS 1 Sep 07 Threeyears 7 IIII IIII Prior contract HIV/Con- T I HR City D-Jalalabad $473,200 QBS Prior 1 Sep 07 Threeyears 8 contract HIV/Con- T I Sex worker (SW) City $308,300 QBS Prior 1 Sep 07 Three years 9 TBD contract HIV/Con TI Prisonerswith Oper $300,300 QBS Prior 1 Sep 07 Three years 10 Research contract HIV/Con T I Truckers $444,000 QBS 1 Sep 07 Three years 11 I 1 Prior contract 26 (b) Consultancy services estimated to cost above US$lOO,OOO per contract and all Single Source selection of consultants (firms/individual) will be subject to prior review by the Bank. Procurement Plan General The Borrower, at appraisal, developed a Procurement Planfor project implementation which provides the basis for the procurement methods. This plan was agreed between the Borrower and the Project Team on May 31,2007 and i s available at GCMU inthe MOPH, Wazir Akbar KhanMina, Charahi-i- Masood. It will also be available in the Project's database and on the Bank's external website. The Procurement Plan will be updated in agreement with the Project Team annually or as required to reflect the actual project implementation needs and improvements ininstitutional capacity. Projectinformation: Country:Islamic Republic o fAfghanistan ProjectName: Afghanistan HIV/AIDS Prevention Project P101502 LoadcreditNo.: ProjectImplementingAgency (PIA): National AIDS Control Program, Ministryof Public Health. Bank's approval Date ofthe procurement Plan: [Original: May 31,20071 Date o f General Procurement Notice: May 7,2007 and the number is WB1779-703. Periodcovered by this procurementplan: 1July 2007 to 30 June 2010 Goods and Works and non-consultingservices Prior Review Threshold:Procurement Decisions subject to Prior Review by the Bank as stated in Appendix 1to the Guidelinesfor Procurement: ProcurementMethod Prior Review Threshold Comments 1. Goods us$200,000 2. Direct Contracting All Prequalification.Bidders for NIL shall be prequalified in accordance with the provisions of paragraphs 2.9 and 2.10 of the Guidelines. ProposedProceduresfor CDD Components(as per paragraph.3.17 of the Guidelines): NA 27 Reference to (ifany) Project ImplementationPlan (PIP)/ProcurementManual: Any Other SpecialProcurementArrangements: NIL ProcurementPackageswith Methodsand Time Schedule. 1 2 5 6 7 8 9 Ref. Contract Prequalifi Domestic Review Expected Comment No. (Descrip -cation Preference by Bid- tion) Method (yeslno) (yeslno) Bank Opening (Prior I Date Post) G-1 2 NO NO Post 30 Aug 07 (vehicles for NACP) I I Selection of Consultants Prior Review Threshold: Selection decisions subject to Prior Review by the Bank as stated in Appendix 1to the Guidelines Selection and Employment o f Consultants: Selection Method Prior ReviewThreshold Comment 1. Competitive Methods (Firms) us$100,000 2. Individual US$50,000 3. Single Source (Firmshndividual) All Short list comprising entirely of national consultants: Short list o f consultants for services, estimated to cost less than US$lOO,OOO equivalent per contract, may comprise entirely o f national consultants in accordance with the provisions o f paragraph 2.7 ofthe Consultant Guidelines. Any Other Special Selection Arrangements: Retroactive financing o f up to US$I.O million is envisaged for the reimbursing related to start-up activities between March 1,2007 and when the grant agreement is signed. The retroactive fmance can be disbursed only after the grant becomes effective. 28 Consultancy Assignmentswith SelectionMethodsand Time Schedule 1 1 1 2 3 4 5 6 7 Estimated Cost Ref. No. Descriptionof per Contract Selection Review Expected Comments Assignment Method by Bank Proposals (Prior I Submission QBs Post) Date HIVICon-1 Communicationand US$1,063,200 Prior 1 Sep07 Three years Advocacy contract HIVICon-2 Survey (Second Threeyears Generation contract Surveillance-SGS and Knowledge, Attitudes, and Practices-KAP HIVICon-3 Targeted US$473,200 QBS Prior 1 Sep07 Three years Interventions(TI)- contract Harm Reduction (HR) Kabul-District A HIVICon-4 TI -HR Kabul- I US$473,200 QBS I 1 Sep07 Three years contract HIVICon-5 Three years District C-with Oper contract HIVICon-6 Three years contract HIVICon-7 Three years contract HIVICon-8 Three years contract HIVICon-9 Threeyears contract HIVICon Three years 10 contract HIVICon Threeyears 11 contract HIVICon- Hiredunder 12 healthproject HIVICon- To be hired 13 under PPF HIVICon- To be hired 14 under PPF HIVICon- To be hired 15 under PPF HIVCon 16 To be hired under PPF HIVICon To be hired 17 under PPF HIVICon Accountant To be hired 18 under PPF Agreed Procedures for NationalCompetitiveBidding In order to ensure economy, efficiency, transparency and broad consistency with the provisions of Section Io f the Procurement Guidelines, the following criteria will be followed in procurement under National Competitive Biddingprocedures: 29 (a) Standardbiddingdocumentsapprovedby the World Bankwill be used. (b) Invitationsto bidwill be advertised inat least one (1) widely circulatednationaldaily newspaperandbiddingdocumentswill bemadeavailable to prospective bidders, at least twenty eight(28) days priorto the deadline for the submissionofbids. (c) Bidswill not be invitedonthe basis ofpercentagepremiumor discount over the estimatedcost. (d) Biddingdocumentswill bemade available, by mail or in person, to all who are willing to pay the requiredfee. (e) Foreignbidderswill notbeprecludedfrom bidding. (f) Qualificationcriteria(incase pre-qualificationswere not carriedout) will be statedon the biddingdocuments, and ifa registrationprocessis required, a foreignfirm determinedto bethe lowestevaluatedbidderwill be givenreasonable opportunityof registering,without any hindrance. (g) Biddersmay deliverbids, at their option, either inpersonor by courier service or by mail. (h) All bidderswill providebidsecurity as indicatedinthe biddingdocuments.A bidder's bidsecurity will apply only to a specific bid. (i)Bidswill be openedinpublic inone placepreferablyimmediately,but no laterthan one hour, after the deadline for submissionofbids. 6) Evaluationofbids will bemade in strict adherenceto the criteriadisclosed inthe biddingdocuments, ina format, andwithinthe specifiedperiod, agreedwith the Association. (k) Bidswill not be rejectedmerelyon the basis of a comparisonwith an official estimate without the prior concurrenceofthe IDA. (1) Split awardor lotteryinawardofcontractswill notbe carriedout. Whentwo (2) or morebidders quote the same price,an investigationwill be madeto determine any evidenceof collusion, followingwhich:(a) ifcollusion is determined, the parties involvedwill be disqualifiedandthe awardwill then be madeto the next lowest evaluatedandqualifiedbidder;and(b) ifno evidence of collusioncan be confirmed, thenfresh bids will be invitedafter receivingthe concurrenceofthe IDA; (m) Contracts will be awardedto the lowestevaluatedbidderswithin the initial periodof bid validity so that extensionsare not necessary.Extensionof bidvalidity may be sought only underexceptionalcircumstances. (n) Extensionof bidvalidity will not be allowedwithoutthe prior concurrence ofthe IDA (a) for the first requestfor extensionif it is longerthan eight (8) weeks; and(b) for all subsequentrequestsfor extensionsirrespective ofthe period. (0) Negotiationswill not be allowedwith the lowest evaluatedor any other bidders. 30 (p) Re-biddingwill notbecarried out withoutthe IDA'Sprior concurrence; and (9) All contractors or supplierswill provideperformancesecurity as indicatedinthe contract documents.A contractor's or a supplier's performancesecurity will apply to a specific contract under whichit was furnished. 31 Appendix 4: FinancialManagement Country Issues The Bank has gained substantial experience and understanding of the financial management environment inAfghanistanthroughthe large number of projectsunder implementationover the past four years. The PACBP is the primary instrument to continue and enhance the fiduciary measuresput in place duringthe past years to help ensure transparency and accountabilityfor the fundingprovidedby the Bank and other donors. A PFM performance rating system using 28 high-level indicators that was developed by the Public Expenditureand FinancialAccountability (PEFA) multi-agencypartnership program was applied in Afghanistan in June 2005. PEFA is comprised of the World Bank, IMF, EC, and severalother agencies.The system is structuredaroundsix core dimensions of PFMperformance: (a) budget credibility; (b) comprehensiveness and transparency; (c) policy-basedbudgeting; (d) predictability and control in budget execution; (e) accounting, recording, and reporting; and (f) external scrutiny and audit. Afghanistan's ratings against the PFM performance indicators generally portraya public sector where financial resourcesare, by and large, being usedfor their intended purposes. This has been accomplished with very high levels of support from internationalfirms; this assistance will continue to be needed over the medium term if these ratingsare to be maintained. There is also muchroomfor improvement. In spite of undeniable gains made in reconstructionsince the end of 2001, the challenges facing Afghanistanremainimmense; not least becauseofthe tenuous security situationinthe regionand continued prevalence of a large illegal and illicit economy. The policy framework benchmarks have not yet been fully costed so various priorities are funded through the annual budgeting process. The rising costs of the security sector constitute the major constraint on attainment of fiscal sustainability. With regard to executive oversight, the national assembly will play an increasinglyactive role.All in all, the new national strategy has created high expectations of the executivewhich couldproveto be quite difficult to meet. The public sector, in spite o f considerable efforts to reform its core functions, remains extremely weak outside of Kabul.The lack ofqualifiedstaffinthe civil service andthe absenceof qualified counterparts in the government after 30 years of war and conflicts is a bindingconstraint.Delays in reformingthe pay structure and grading of civil servants have severely crippled the public administration of the country. Domesticrevenues lag behind expenditures by a factor of ten to one. Large-scalecorruptioncould emerge to underminethe government's efforts to enhance aid flows through national accounts. Capacities to track expenditures and monitor expenditure outcomeshave improved, butthey needrapidand substantialstrengtheningifprogresstowardthe attainment of nationaldevelopment targets is to be monitored.Currently, 75 percent of external revenuesbypassgovernment appropriationsystems. The World Bank is financing a FinancialManagementAdvisor to assist the Ministry of Finance, an Audit Advisor to assist the Control and Audit Office, and a ProcurementAdvisor to assist in Procurement-related activities. Also an Internal Audit function is being developed within the Ministry of Finance with World Bank financing. USAID, and earlier the IndianAid Assistance Program, is financing a team of consultants and advisors to assist the Da Afghanistan Bank in local as well as foreign currency operations. The activities carriedout under the existingPublic Administration projects have helped the Government to ensure that appropriate fiduciary 32 standards are maintainedfor public expenditures, includingthose supported by the Bank and the donor community. Progress has beenslower than expected in shiftingfrom operations support providedby the three Advisors to capacity development and knowledge transfer to the civil servants. Giventhat, it is expected that the Advisors will continue to be required for the medium term. Challenges still remaininattainingthe agreed upon fiduciary standards and also to further enhance them. And to make matters more complex, the regulatory environment in Afghanistan has advanced significantly in the past three years. Unfortunately, even mastery of basic skills in the early environment does not fully qualify the civil servants to work effectively in the new emerging environment. RiskAssessmentand Mitigation The table below identifiesthe key risksthatthe projectmay face and indicateshowthese risks are to be addressed. Risk Risk RiskMitigation Measures Rating Risk negotiations, Boardor Effectiveness M Source PFM study - H Minimize use of Designated Risk Account, maximize direct paymentsto consultants; all procurementthrough ProcurementAdvisor PerceivedCorruption H Governmentcommitment, internal controls andnew internal audit will help to reduce the high level of perceived corruption Overall Inherent Risk H 2. CONTROLRISK 1. Weak Implementing Entity H Bulk ofthe implementation will be through contracts issued to NGOs and CBOs. Recruitment of International Advisor to strengthenthe management capacity at NACP. MOPHhas adequate staffing in GCMUto implement the program; however, a qualified accountantwill be recruited to strengthenthe financial management capacity at GCMU. Eachline ministry involvedin the programwill havea 33 dedicatedmanager and accountingstaff to maintain minimal records andreport on their transactions. 2. FundsFlow Payments will be madeto consultants, suppliers, Innovation window recipients, etc. from the Designated Account (DA) by SDU-MoF. Inaddition to paymentsout of DA funds, the implementing entities can also request the SDUto make i)direct paymentsfrom the Credit Account to consultants or consulting f m s , and ii)special commitmentsfor contracts coveredby letters of credit. These paymentswould only be made by SDUafter due processesandproper authorization from the respectivecomponent implementing entities. 3. Budgeting A budget committee will be appointedto coordinatethe preparationof annualwork plan andthe derivation of annualbudgetthere from. Representativeswill be from HACCA, NACP, GCMU and MOPH, and shall report to the HACCA. 4. Accounting Policies and Will follow international Procedures standards. Project accounting proceduresand details ofthe F Marrangements will be documentedinan F MManual to be approvedby the Bank 5. Internal Audit Newly-created internal audit departmentwill review project internal control systems 6. ExternalAudit Will be auditedby CAO with S N support from Audit Advisor 7. Reporting and Monitoring Strengtheningthe SDU is a S Y priority underthe new FM Negotiations Advisor contract, to provide information that will comply with agreed format of financial reports. 34 OVERALL CONTROLRISK H S DETECTION RISK S Adequate accounting, M N recording, and oversight will be provided inproject procedures. AccountingRecordingIoversig htby SDU-MOF of all advanceshl-16 supportedby Financial Management Advisor. RISK RATING.' H=HIGHRISK; S=SUBSTANTIAL RISK; hf=MODEST RISK: L-LOWRISK Strengths and Weaknesses Strengths The Government provides assurance to the Bank and other donors that the measures in place to ensure appropriate utilization o f funds will not be circumvented. The Government support for PACBP is strength in itself to enhance financial management in Treasury operations, public procurement, internal audit inthe public sector, and external audit by the Auditor General. This i s the second IDA- funded grant for MOPH so the agency has experience in implementing Bank projects and following Bank procedures. Weaknessesand ActionPlan The main weakness in this project, as in many others in Afghanistan, is the ability to attract suitably qualified and experienced counterpart staff especially for Financial Management. The additional staff to be funded by the project, together with intensive training programs included in this project, is expected to strengthen the fiduciary arrangements. ActionPlan Significant Action Responsable Agent Completion Weaknesses Date Shortage of qualified Appointment of an FMS in MOPH 15" June 2007 And experiencedFMstaff GCMU and an International Advisor inNACP. Project internal controls and Financial ManagementManual 15" June proceduresneedto be defined I - MOPH developed I2007 reauired &formation I renort formats c o n f i e d I(DBER'I I negotiations I ImplementingEntity The institutional framework i s in place, assigning the program coordination, management and technical roles to MOPWNACP and the financial management and procurement responsibilities to the MOPWGCMU, under the overall oversight o f the multi sector HACCA. Technical working groups are being established (Le., HIV Surveillance WG) by the NACP to guide its work program, drawing on available technical experts from professional, academic, research or other organizations within the country. These technical working groups will report to NACP, which inturn, presents the recommendations o f the technical working groups to the HACCA for endorsement. The MOPH will contract the surveillance and communications components o f the project to agencies that can carry 35 out those functions while developing and transferring capacity in these areas. The targeted interventions for the prevention of HIV among IDUs, sex workers and their clients, truckers and prisons will be contracted to NGOs and CBOs with experience working with the communities at risk. Non-health ministries, the private sector and NGOs will be able support or implement HIV prevention programs, funded through the Innovation Initiative, by preparing proposals to be reviewed by a multi sector review panel ledby the NACP, and reportingto the HACCA. Specifically, the roles of the NACP, GCMU and HACCA are as follows: National AIDS Control Program. NACP will lead the implementation o f the proposed project, in close coordination with relevant departments within MOPH, Le., Reproductive Health, Mental HealtWDrug Demand Reduction, IEC, Environmental Health, and M&E Departments and with key non-health sectors. The targeted intervention activities will be contracted out to NGOs. The strengthening of surveillance and the communications components will also be contracted to organizations with experience in carrying out and buildingcapacity inthese areas. MOPH has a good track record of implementing the Emergency Health Project, which includes the NGO-contracting approach to service delivery. In fact, the civil society involvement i s even more relevant to the HIV/AIDS prevention efforts, because the vulnerable population groups are particularly difficult to reach through governmental channels and needto be involved for effective coverage and quality. The proposed multi sector Innovation Initiative under AHAPP will be managed by the MOPH, reporting to HACCA. A multi sector review panel, chaired by the NACP, will approve proposals to the InnovationInitiative from non-healthsectors. HIVIAIDS Coordination Committee of Afghanistan. HACCA has been established by MOPH to ensure a broad-based and inclusive oversight mechanism. This multi sector committee is chaired by the DeputyMinister for Technical Affairs of MOPH, and includes the participation of key ministries, agencies from public and private sectors, civil society and external development partners. While HACCA ensures multi sector coordination and oversees the broad Program Operational Plan (POP), the MOPHhasthe technical lead role, and provides the programmatic accountability for NACP. Grants and Contracts Management Unit.The head of the accounting department for GCMU inMOPH will take responsibility for the financial management activities of the program. GCMU will carry out the day-to-day financial management operations of the project, preparation of M-16 forms (payment orders), preparation of summary reportshimplified statements of expenditures, coordination with other line ministries involved in the program and overall contract and project management. This department is adequately staffed with FMpersonnel who are efficiently managing all current external grants including the IDA Health Sector Project. However, a qualified and experienced procurement specialist and accountant are being recruited by MOPH to strengthen the financial management and procurement capacity of GCMU to managethe additional contracts under this project. Budgeting A PlanningCommittee will be appointed to coordinate the preparation o f annual work plans and the derivation of annual budgets. This committee will be made up of representatives from the HACCA, NACP, GCMU, and MOPH and shall report to the HACCA. The Planning Committee shall also coordinate quarterly budget reviews to ensure adequate budget discipline and control. The committee will be responsible for ensuring that project expenditures for each fiscal year are captured in the Governmental Development budget of that fiscal year. The MOPH must get approvals from the presidential office and the parliament and attach them to B27 and PCS forms at the time of requesting yearly allotments for contracts under the project to avoid delays in payment processing. 36 FundsFlow The standard funds flow mechanism inAfghanistan will be followed inthis project. Project funds will be deposited in the DA to be opened and maintained at the D a Afghanistan Bank (DaB). The DA, in keeping with current practices for other projects in Afghanistan, will be operated by the SDU in the Treasury Department o f MOF. Requests for payments from the DA will be made to the SDU by the G C M U M O P Hwhen needed. In addition to payments out of DA funds, the GCMUMOPH can also request the SDU to make (a) direct payments from the Grant Account to contractors, consultants or consulting firms; (b) transfer sub-grant amounts to beneficiaries (awarded out o f the Innovation Initiative component); and (c) request issuance o f special commitments for contracts covered by letters o f credit. These payments will follow World Bank procedures. All project payments will be made to either international firms, local firms or individuals or sub-grant recipients that have bank accounts in DaB, a local commercial bank, or an overseas bank. All payments will be made either through bank transfers into the account o f such firms or by check. Expenditures for each component will be paid centrally from MOPH in accordance with the approvalmechanisms documented inthe HIV/AIDS project FMManual. Payments to line ministries, community NGOs and the private sector from the Innovation window will be based on the approved performance agreement, Le., memorandum o f understanding (MOU) for line ministries and contracts for NGOs and private firms. The request for payments should be authorized by the line ministry's designated representative to enable NACP and G C M U to commence processing the payments. Release o f first tranche payments, where necessary will be based on the terms o f the performance agreement. Subsequent release o f funds will be dependent on the achievement o f performance milestones stated in the agreement, submission o f SOEs to G C M U M O P H by sub-grant recipients and relevant supporting documents (if required), and submission of financial and physical progress reports to G C M U M O P H as o f that date. Where it i s observed by NACP and G C M U that a recipient has utilized the funds to finance activities other than those stated inthe approved work plans, these would be considered as ineligible expenditures and the amounts would need to be refundedto the project. Cash advances may be taken from the Designated Account, and held and managed by MOPH. This agency's controls, holding, accounting, and preparation o f SOEs have been satisfactorily assessed. New cash advances will only be made when all other prior cash advances have beenjustified through submission o f SOEs to the SDU. Retroactive financing o f up to SDR 657,000 (US$l.O million equivalent) is envisaged for expenditures between March 1, 2007 and when the grant i s signed. Retroactive financing can be disbursed only after the grant becomes effective. 37 FUNDSFLOW CHART F Y Direct Payments to consultants, Innovation Initiative /sub- grants recipients (NGOs/CBOs), suppliers, etc. after approval o f Designated Account in W.A initiatedby DAB denominated inUSD " the project and .submitted through SI31J I Project transactions processed through SDU and paid to suppliers and Sub-grant recipients (NGOdCBOs) Legalrequirementsfor authorizedsignature Ministry of Finance has authorization to disburse funds from the Grant. Specimen signatures of authorized signatories inMOF are on file. Accounting The SDUwill maintaina proper accounting systemof all expendituresincurred along with supporting documents to enable IDA to verify these expenditures. The FM staff of GCMU in MOPH will: (a) supervise preparation of supporting documents for expenditures; (b) prepare payment orders (Form M16); (c) obtain approval for M-16s by the Minister or Deputy Minister depending on the payment amount; and (d) submit them to the Treasury Department in MOF for verification and payment. Whilst original copies of requiredsupporting documents are attached to the Form M16, the project is required to make and keep photocopies of these documents for records retention purposes. The FM Advisor in the MOF/SDU will use the government's computerized accounting system, AFMIS, for reporting, generating relevant financial statements, and exercising controls. 38 G C M U FM staff will maintain essential project transaction records using Excel spreadsheets and generate requiredmonthly, quarterly, and annual reports. At each o fthe line ministries involved inthe program, the assigned accounting officer will maintain essential project records and prepare basic financial reports (Receipts and Payments Account) on their activities. GCMU FM staff will prepare summary reports (statements o f expenditures), reconcile the designated account and ensure accuracy o f DaB statements and monitor procedural compliance for Sub-grants disbursed under the Innovation Initiative. The FM Manual, to be prepared by MOPH and approved by the Bank, will include: (a) roles and responsibilities for all FM staff; (b) documentation and approval procedures for payments and release o f funds to each o f the Innovation Initiative recipients; (c) project reporting requirements; and (d) quality assurance measures to help ensure that adequate internal controls and procedures are in place and are being followed. Internal Control& InternalAuditing Project-specific internal control procedures for requests and approval o f funds will be described in the FM Manual to be developed before disbursements begin including segregation of duties, documentation reviews, physical asset control, and cash handling and management. Adequate procedures, guidelines, and controls on payments to line ministries involved in the program will also be included in the FMManual. The Head o f the FM unit o f G C M U will be responsible for coordinating FM activities of the project with the SDU. Annual project financial statements will be prepared by S D U M O F detailing activities pertaining to the project as separate line items with adequate details to reflect the details o f expenditures within each component. The project financial management systems will be subject to review by the newly-established internal audit directorate o f the MOF, according to programs to be determined by the Director o f Internal Audit usinga risk-based approach. ExternalAudit The project accounts will be audited by the Auditor General, with the support o f the Audit Advisor, with terms o f reference satisfactory to the Association. The audit o f the project accounts will include an assessment o f the: (a) adequacy o f the accounting and internal control systems; (b) ability to maintain adequate documentation for transactions; and (c) eligibility o f incurred expenditures for Association financing. The audited annual project financial statements will be submitted within six months o f the close o f fiscal year. All agencies involved in implementation and maintaining records o f expenditures would need to retain these as per the IDA records retention policy. The following audit reports will be monitored each year in the Audit Reports Compliance System (ARCS): 39 I ResponsibleAgency I Audit I Auditors I Date I MoF, supportedby Special SOE, Project Accounts and Auditor General Sep 22 DisbursementUnit DesignatedAccount FinancialReporting FinancialStatementsandProjectReportswill beusedfor projectmonitoringandsupervision. Based uponthe FMarrangementsofthis project,FinancialStatementsandProjectReportswill beprepared quarterly and annuallyby the GCMUinthe MOPH.Thesereports will beproducedbasedonrecords kept on Excelspreadsheets after due reconciliationto expenditure statementsfrom SDU(as recorded inAFMIS) andbank statementsfrom DaB. The quarterly ProjectReports will show: (a) sources and uses of funds by project component; and (b) expenditures consolidated and compared to governmental budget heads of accounts, MOPH will forward the relevant details to SDU/DBER with a copy to IDA within 45 days of the end of each quarter. The government and IDA have agreed on a pro forma report format for all Bank projects; a final customizedformat for HIV/AIDSwas agreedprior to projectnegotiations. The annual projectaccountsto be preparedby SDU from AFMIS after due reconciliationto records maintainedat the GCMUwill form part ofthe consolidatedAfghanistanGovernmentAccounts for all development projects.This is done centrally inthe Ministry of FinanceTreasury Department, supportedby the FinancialManagementAdvisor. DisbursementArrangements Disbursements procedures will follow the World Bank procedures described in the World Bank Disbursement Guidelines and the Disbursement Handbook for World Bank Clients (May 2006). Table 1shows the allocationof IDA proceedsin a single, simplifiedexpenditurecategory.The single category for "goods, works, consultancy services, training, Sub-Grants (under the Innovation Initiative) and operating costs" is defined in the financing agreement to facilitate preparation of withdrawal applications and record-keeping. Project funds will be disbursed over 36 months. The closingdate ofthe projectwill be December31,20 10with a final disbursementdeadline four months after the closingdate. Duringthis additional4-monthgraceperiod, project-relatedexpenditures incurredprior to the closing dateare eligible for disbursement. 40 Table 1: IDA Financingby Category of Expenditure (SDR million) ExpenditureCategory Amount of the Grant Financing Allocation (SDR) Percentage (1) Goods, consultants' services, training, sub grantsand 6,502,000 100 % IncrementalOperatingCosts' (2) PPFRefmancing 98,000 Total 6,600,000 SummaryReportslRecords.Summary reports inthe form of Statements ofExpenditurewill be used for expenditures on contracts below US$25,000; for all training programs, operating costs and all Sub-grants (to NGOs/CBOs) financed from the Innovation Initiative regardless of whether Bank procurementprior review is required or not. Records (supporting source documentation) are required only for contracts for goods, works and servicesexceedingUS$25,000 including procurementcarried out by other Line Ministries relatedto the Innovation Initiative. Designated Account. A single DesignatedAccount with a ceiling of US$500,000 will be opened at DaB representingthree months of estimated expenditures. The SDU in MOF will managepayments from and new advances/reimbursementsto this account. Cash advances may be taken from the Designated Account, and held and managed by MOPH in accordance with MOFMOPH procedures. This agency's controls, holding, accounting, and preparation of SOEs have been satisfactorily assessed. New cash advances will only be made when all other prior cash advances have been justified through submissionof SOEs to the SDUMOF. The DesignatedAccount will be reconciled and a reimbursementapplicationpreparedon a monthly basis. Direct Payments. Third-party payments (direct) and Special Commitments will be permitted for amounts exceeding 20 percent of the advance in the DA (US$lOO,OOO). All such payments require supporting documentation in the form of records (copies of invoices, bills, purchase orders, etc.). In the event a direct payment of a Sub-grant to an NGO/CBO is made under the Innovation Initiative, then copies of the relevant Sub-grant agreement are required. For any tranche or installment payments, other appropriate records (progress reports, as required under terms of the Sub-grant agreement) would be required. Preparation of Withdrawal Applications. MOPH will prepare Summary Reports (simplified Statements of expenditures based on those in "A Guidance Note on Disbursement Procedures - World Bank HIV/AIDS Program") and forward those reports to the SDU for further processing as a reimbursementapplication. The SDUwill review withdrawal applications for quality and conformity to Treasury procedures, and then obtain signature. Selected MOPH and SDU finance staff will be registeredas users of the World Bank Web-based Client Connection system, and take an active hand inmanagingthe flow of disbursements. 'Incremental Operating Costs refers to project-related incremental expenses incurred on account of project implementation support and management including the rental of office space; the operation, maintenance, rental and insuranceof vehicles; fuel; communications supplies and charges; advertisements; books andperiodicals; office administrationand maintenance costs; bank transaction charges; utility charges; domestictravel and per diem but excluding salaries of officials and staff of the Recipient'scivil service. 41 FinancialManagementCovenants (a) MOF shall submit audited financial statements for the project within six months of the end of each fiscal year. The Project's auditreportwill cover the financial statements,the DA, and SOEs, inaccordancewith terms of reference agreedwith the Association. (b) Un-auditedproject interimfinancial reports will be submittedby MOPHon a quarterly basis to the World Bank and a copy to SDU-MOFwithin 45 days after the end of each quarter. (c) MOPH will ensure that the new Financial Management Specialist to be employed is retained throughout the duration of the project in order to ensure smooth project implementation. SupervisionPlan During project implementation, the Bank will supervise the project's financial management arrangements.The team will: Review the project's quarterly un-audited interim financial reports as well as the project's annual auditedfinancialstatementsand auditor's managementletter. Reviewthe project's financial managementand disbursement arrangements(includinga review of a sample of SOEs and movements on the DA and bank reconciliations) to ensure compliance with the Bank'sminimumrequirements. Review agency performance in managing project funds to ensure that it is timely, accurate, and accountable. Particular supervision emphasis will be placed on asset managementand supplies. Reviewof financial managementrisk ratingandcompliance with all covenants. Conclusion The FM arrangements, including the systems, processes, procedures, and staffing are adequate to support this project- subject to implementationofthe items listedinthe actionplan. 42 Appendix 5: Coreservicesof the NationalHIV/AIDS PreventionProgram Intervention Core services Sample Monitoring Multisector partners Indicators (actual and potential) 1. Reproductive Tract *Syndromic management of % STI cases who are Integratedinto Essential Infections/ STI case STI correctly assessed& treated Health ServicesPHC management NGOPrivate sector 2. HIV preventive *Promotion ofknowledge & % of generalpopulation Integration into essential services ingeneral consistentcondomuse with knowledge about HIV health services/ PHC population, including *Voluntary Counselingand transmission andprevention Ministry of Education, vulnerablegroups at high Testing, PMTCT, RTI, %consistent condom use Strategic communications/ risk *Community based BCC, Transport sector, responses Prisonhealth services 3. Refugees, Returnees *Referral for VCCT and YORefugees& Returnees Ministry of Refugees and and Migrant workers STI, with appropriate knowledge Returnees.Transport sector support centre *BCC peer education regarding HIV 4. Blood safety program *Voluntary non- % HIV prevalenceinblood RedCross/RedCrescent remuneratedblood donation transfusions Integratedinto Essential *Rational use of blood % oftranshsed bloodunits Health Services / PHC *HIV testing of Bloodunits screened for HIV /QA Bloodbanks 5. Youth Friendly *Life skills (sexuality, YOHIV prevalenceamong Education sector, Social Services & programs substance abuse) adolescents Development *Health education& social %youth knowing about Ministry of Religious Afairs, services HIV Prevention Ministry of Education 6. HIV preventive *Voluntary Counselingand % sex workersfclients FSW and MSW programs services involving sex Testing reporting use of condom NGO/CBO Peer education workers andtheir clients *Community basedresponse with their most recent Prison services & othervulnerable *Promotion ofknowledge & clienthex worker groups at highrisk (Le,, consistentcondomuse truckers & other migrant % prison inmateswith labor, refugeesand access to HIV preventive returnees, prison services populatiois) 7. ComprehensiveIDU *Needle syringe program %HIV prevalenceamong Community based services program *Oral substitution (inpilot InjectingDrugUsers NGO/CBO Peer education programs) YOIDUswho usedsterile BCC Communications *Referral (01, DOTS, STI, equipment intheir last sensitizationofpolice & VCCT, ART, drug de- injection legal system addiction ) prison health services Social serviceseeer Ministry of Counter education& Counseling on Narcotics HIV prevention, condom promotion 8. Workplace program, *Workplace policy & % of employees, including Transport sectorltrucking including migrant labor, protocols implemented truckers, with access to companies, private sector, long distance bus and (HIV/AIDS code, referral HIV/AIDS information & labor unions, business truck drivers VCCT, IEC, non services corporations-with large discrimination migrant populations 9. Treatment and care for AIDS case management % PLWHA seeking care Integratedinto public health PLWHA appropriate care, non who are correctly managed services discrimination, community (including ART) support 43 Appendix 6: ProjectPreparation and Supervision ProcessingSchedule: Planned Actual PCNreview 9/29/2006 1013112006 Initial PIDto PIC 10105/2006 11/02/2006 InitialISDS to PIC 1011012006 1111112006 Appraisal 0411512007 0411512007 Negotiations 0513112007 0513112007 BoardRVP approval 0713112007 Planneddate of effectiveness 0813112007 Planneddate of mid-termreview 0313112009 Plannedclosing date 1213112010 Key institutionsresponsible for preparationof the project: National AIDS Control Program, Ministry o f Public Health Other relevant departments inthe Ministry o f Public Health (M&E Department, IEC Department, Environmental Health Department, DrugDemand ReductionDepartment, ReproductiveHealth Department). Ministry of Finance Other relevant line ministries (Counter-Narcotics, Education, Higher Education, Women's Affairs, Labor and Social Affairs, Haj and Religious Affairs). Bank staff and consultantswho worked on the project included: ~ Name Title Unit Mariam Claeson Regional HIV/AIDS Coordinator & Task-Team Leader SASHD Sundararajan S. Gopalan Senior HNP Specialist SASHD Deepal Fernando Senior Procurement Specialist SARPS Kenneth 0.Okpara Senior FM Specialist SARFM Asha Narayan Financial Management Analyst SARFM David Freese Senior Finance Officer KE3LwB Laura Kiang Operations Officer SASHD Sheila Braka Musiime Counsel LEGMS Martin M. Serrano Counsel LEGMS Jed Friedman Economist DECRG Ghulam Dastagir Sayed Public Health Specialist SASHD Rahimullah Wardak Procurement Analyst SARPS Mohammad Arif Rasuli Environmental Specialist SASES Alex Wodak Consultant SASHD Nagaraju Duthaluri Consultant SARPS Nilufar Egamberdi Consultant HDNGA Silvia M.Albert Program Assistant SASHD Hasib Karimzada Team Assistant SASHD 44 Bankfunds expended to date on projectpreparation: 1. Bank resources: US$120,000 2. Trust funds: Nil 3. Total: us$120,000 EstimatedApproval and Supervisioncosts: 1. Remaining costs to approval: US$80,000 2. Estimatedannual supervision cost: us$100,000 45 Afghanistan HIV/AIDS PreventionProject Addendum to TA: EnvironmentalManagement Plan Environment Provisiono f preventive and diagnostic services underthe HIV/AIDS project i s expected to benefit the hygiene and sanitation situation inthe country however it could generate infectious bio-medical wastes such as sharps (infected needles and syringes, etc), infected blood, HIV test kits usedinVCT centers, blood banks and laboratories and pharmaceutical wastes. These wastes, ifnot managed and disposed properly, can have direct environmental and public health implications. The proposed project has been classified as category "B" as per the World Bank's Operational Policy on Environmental Assessment (OP 4.01) for environmental screening purposes given the risks associated with the handling and disposal o f medical waste and general health waste. Category B projects imply that the potential adverse environmental impacts o f the program are site-specific and inmost cases mitigatory measures can be designed readily and appropriately. The MoPH and the NACP team are feeling that under this project we are focusing on the Infection Control and Waste Management issues only inthe activities pertaining to this current HIV/AIDS project but it could be a good start and foundation stone for a more comprehensive Waste Management Framework with other programs and institutions inthe country inthe future. An Infection Control and Waste Management (IC-WM) Planhas been developed by NACP which focuses on the establishment o f a sound management system for the treatment and disposal o f the waste related to the testing, treatment and prevention o f HIVIAIDS STI and includes generic guidance and protocols and alternative technologies for treatment, transportation and disposal inaccordance with the size o f healthcare facilities. Safeguard Policies This project has triggered OP 4.01 Environmental Assessment due to the potential adverse environmental impacts o f healthcare waste as discussed inthe previous section. A Limited environmental assessment was undertaken, by different stakeholders, by visiting some government runand some NGOs runfacilities, which included field visits and consultations. NACP does not have the necessary institutional capacity to implementthe IC-WM Plan and would needto obtain appropriate support for components such as training, IEC and monitoring. An external independentevaluation i s recommended before the mid term review ofthe program to ensure all activities are on track. The final version, ofthe Infection Control and Waste Management Plan should be disclosed inthe World Bank InfoShop prior to Appraisal and also it i s the responsibility o f the NACP and the MoPH to make it available to all relevant national stakeholders inthe local languages as well as inthe relevant websites. 1 SafeguardPolicies Triggered by the Project Yes N o Environmental Assessment (OP/BP 4.01) [XI [ I Natural Habitats (OP/BP 4.04) [ I [XI Pest Management (OP 4.09) [ I [XI Physical Cultural Resources (OP/BP 4.11) [ I [XI Involuntary Resettlement(OP/BP 4.12) [ I [XI Indigenous Peoples (OP/BP 4. IO) [I [XI Forests (OP/BP 4.36) [I [XI Safety o f Dams (OP/BP 4.37) [ I [XI Projects inDisputedAreas (OP/BP 7.60) [ I [XI Projects on International Waterways (OP/BP 7.50) [ I [XI Activities and Responsibilitiesof NACP NACP i s the platform where the following Activities must take place: Development, revision and implementation o f AfghanistanNational HIV/AIDS Strategic Framework; Establishmentandrunning VCCT centers indifferentparts o fthe country; Development and adaptation o f differenttypes o f guidelines and protocols; Establishmentand co-ordination o fHIV/AIDS Co-ordinationCommittee of Afghanistan(HACCA) ; Supervising different surveys and studies regarding HIV/AIDS; and Fundraising for smoothrunningofProgram. Provision o f preventative and treatment services under the NACP i s expected to generate infectious bio-medical wastes such as sharps (infected needles and syringes, equipment,IV sets) infected blood, HIV test kits used in VCT centers, blood banks and laboratories and pharmaceutical wastes. These wastes, if not managed and disposed properly, can have direct environmental and public health implications. Healthcare workers (HCWs) are at great risk as most bloodborne occupational infections occur through injuries from sharps contaminated with blood through accidents or unsafe practices. Systematic management o f such clinical waste from source to disposal i s therefore integral to prevention o f infection and control o fthe epidemic. In this context, governments have an obligation to implement the provisions of the 2001 UnitedNations Declaration o f Commitment on HIVIAIDS, which include a commitment to strengthen health-care systems and expand treatment, as well as to respond to HIVIAIDS in the world of work by increasing prevention and care programs in public, private and informal work-places. 2 HIV/AIDS ControlProgram in Afghanistan The first HIV positive case was identifiedincentral blood bank in 1989. As the country was inconflict inthat time the Government o f Afghanistan responded to it by launching awarenessprograms. In2003 the Government o f Afghanistan formed National AIDS Control Program (NACP) inMoPH. The first National HIV/AIDS Strategic Plan was developed which was revised in2006. Now the six functional VCCT centers are functioning throughout the country. Afghanistan National Development Strategy has a statement regarding HIV/AIDS which indicate a high political commitment on government side. Environment and Public Health Impactsof the Program Provision o f preventative and treatment services under the HIV AIDS project i s expected to generate infectious bio-medical wastes such as sharps (infected needles and syringes, surgical equipment, IV sets) infected blood, HIV test kits usedin VCT centers, blood banks and laboratories and pharmaceutical wastes. These wastes, if not managed and disposed properly, can have direct environmental and public health implications. Healthcare workers (HCW) are at great risk as most blood-borne occupational infections occur through injuries from sharps contaminated with blood through accidents or unsafe practices. Systematic management o f such clinical waste from source to disposal i s therefore integral to prevention o f infection and control o f the epidemic. In this context, governments have an obligation to implement the provisions of the 2001 United Nations Declaration o f Commitment on HIV/AIDS, which include a commitment to strengthen health-care systems and expand treatment, as well as to respond to HIV/AIDS in the world of work by increasing prevention and care programs in public, private and informal work-places. The NACP projects specially world bank supported project for the first time, has been classified as Category "B" as per the World Bank's Operational Policy on Environmental Assessment (OP 4.0 1). Category B projects imply that the potential adverse environmental impacts o f the program are site-specific and in most cases mitigatory measures can be designed readily and appropriately. NACP i s developing an Infection Control and Waste Management Plan which defines a structured a systematic approach to institute best practices in managing health and environmental risks effectively. Also the ministry has developed guidelines on Auto-Disable Syringes Use and Disposal. Auto-Disable (AD) syringes have beenintroduced inthe country as part o f the Universal ImmunizationProgram. Accordingly, the MoPHhas laid down the National Guidelineson use and disposal o f AD syringes. Inthe following are some rules for Bio-medical Waste Management to be followed during the project Implementation. 3 Table 1: Bio-medical Waste Manag nent Rules Category Waste Category Treatment and disposal 1 Human Anatomical Waste (human tissues, Incineratiorddeep burial organs, body parts). 2 Animal Waste (animal tissues, organs, body parts Incineratioddeep burial carcasses, bleeding parts, fluid, blood and experimental animals used in research, waste generated by veterinary hospitals colleges, discharge from hospitals, animal houses). 3 Microbiology & Biotechnology Waste (wastes Local autoclavingimicrowaving from laboratory cultures, stocks or specimens o f /incineration micro-organisms live or attenuated vaccines, human and animal cell culture used in research and infectious agents from research and industrial laboratories, wastes from production o f biological, toxins, dishes and devices used for transfer o f cultures). 4 Waste sharps (needles, syringes, scalpels, blades, Disinfection (chemical glass, etc. that may cause puncture and cuts. This treatment/autoclaving/microwaving includes both used and unused sharps). and mutilation/shredding) Discarded Medicines and Cytotoxic drugs Incineration, destruction and drugs (wastes comprising o f outdated, contaminated disposal in secured landfills and discarded medicines). Solid Waste (Items contaminated with blood, and Incineration/autoclaving body fluids including cotton, dressings, soiled /microwaving plaster casts, lines, beddings, other material contaminated with blood) 7 Solid Waste (wastes generated from disposable Disinfection by chemical treatment items other than the waste sharps such as tubing, /autoclaving /microwaving and catheters, intravenous sets etc). mutilation shredding Liquid Waste (waste generated from laboratory Disinfection by chemical treatment and washing, cleaning, house-keeping and and discharge into drains disinfecting activities). IncinerationAsh (ash from incineration o f any Disposal in municipal landfill bio-medical waste). 10 Chemical Waste (chemicals used in production Chemical treatment and discharge o f biological, chemicals used in disinfection, as into drains for liquids and secured insecticides, etc.). landfill for solids Notes: (1) Chemicalstreatment using at least 1% hypochlorite solution or any other equivalent chemicalreagent. It must be ensured that chemicaltreatmentensures disinfection. (2) Mutilationishredding must be such so as to preventunauthorizedreuse. (3) There will be no chemicalpretreatmentbefore incineration. Chlorinated plastics shall not be incinerated. (4) Deep burial shall be an option available only intowns with population less than five lakhs and in rural areas. 4 Institutionaland AdministrativeFramework National AIDS Control Program was established in 2003 as a unit in MoPH to lead the country response to the epidemic o f HIV/AIDS. NACP has the responsibility o f steering, supporting, coordinating and overseeing the activities carried out for HIV/AIDS control program. HIV/AIDS Co-ordination Committee o f Afghanistan (HACCA) i s the entity which oversees NACP. NGOs form an important element o f targeted intervention. NGOs undertake HIV prevention activities through the public health system as well as through targeted interventions. Thus while the bulk o f VCTCs, STD clinics are inthe public sector, targeted interventions are implementedthrough NGOs who work with the high risk groups. For the most, these NGOs also make testing services available through the same public networks. BASELINE DATA AND CURRENT PRACTICES OF IC-WM Sites and FacilitiesVisited and StakeholdersConsulted The facilities visited includedprimary, secondary and tertiary health-care facilities (government-run), VCCTCs, Blood banks, and STD Clinics (including associated laboratories). The stakeholders consulted during site visits included: (a) HACCA; (b) NGOs; (c) Health-care workers at blood banks, VCCTs, blood banks, and STD clinic; (d) .Primary/secondary/tertiary health-care facilities; (e) ,Local communities, including patients, peer educators, commercial sex workers; and ( f ) Waste management facilitators (private organizations). PrevailingIC-WM Practices Survey Findings The findings from the site visits and primary data collection have beengrouped intwo categories: (a) Government-runFacilities ("Government Facilities") that include primary, secondary and tertiary healthcare facilities; and 5 (b) NGO-runFacilities ("NGO Facilities") that include VCTC and STD clinics. Government-runFacilities Overview Most o f the government-run facilities surveyed had poor standards o f hygiene and inadequate IC-WMpractices. Although awareness o f the Bio-medical Rules and Hospital Waste Management Guidelines i s high (over 90% o f the facilities visited), lack o f funds, irregular supply o f barrier protection and PEP(Post Exposure Prophylaxis) and human resource shortage were cited as the main reasons for poor implementation o f IC-WM practices. Though more than 90% o f the facilities visited were aware o f the Applicable statute and guidelines, specific compliance requirements were not known to the majority o f the HCWsinterviewed. Inmost ofthe facilities surveyed, hospital infectioncontrol committees had not been constituted. Even inthose facilities inwhich IC-WM committees were present, the authorities admittedthat these were not very active. Few or none IEC material were observed inmost of the facilities visited. Additionally, there i s no evaluationprocess to assess the quality of training imparted and its outcome in terms o f improved IC-WMpractices. Employment of InfectionControlMeasures The general assessment was that a large number o f nurses, paramedics were found to be ignorant o f good practices. Since these H C W also will work with HIV/AIDS patients, the lack o f availability o f barrier protection, disposable needles and PPE becomes a critical issue. In several instances the staff admitted to not using gloves during blood handling procedures. They also admitted to using the same disposable syringe for several patients and thus needle recapping was a common practice. AD syringes could not be observed at any of the facilities visited. On the contrary glass syringes were being used at several places for which the general practice i s reuse after sterilization. Needle Cutters were rarely available and were mostly electric ones which are prone to beingunderutilized during power cuts or being damaged due to voltage fluctuations. It was observed that HCW either did not utilize the needle-cutters or instead broke the needles with their bare hands, or by using a heavy object, or even not at all. In majority o f the instances the intact syringes or mutilated needles were not immersed in 1% hypochlorite solution as required. H C W in several o f the secondary and tertiary facilities did report accidents due to needle stick injuries. However, the incidence o f reporting was low, with only 30-40 percent o f the total injuries being reported. 6 In PHCs, no waste segregation and disinfection practices could be observed. The general standards o f sanitation and hygiene were found to be very low. Infectious waste (blood- soaked cotton, used un-mutilated syringes, worn gloves) was seen scattered under the patients' beds, in the corridors and washrooms. All infectious and non- infectious waste was observed to be collectively disposed in shallow open pits. Insecondary and tertiary facilities partial waste categorization and segregation practices were observed though awareness o f statutory (Regulatory) requirements was largely absent. Even if known, non-availability o f appropriately colored poly-bags and bins, leads to improper segregation with waste being generally handledwithout any barrier protection. NGO-run Facilities Overview In general, all NGO run-facilities demonstrated awareness of and adherence to good IC- WM practices, partial or complete. These facilities typically had regular training, sufficient funds, regular supply o f barrier protection and PEP and human resources. Awareness o f NACP publications was also high as these form the basis o f training and functioning o f these facilities. Since the funding o f NGO facilities i s separate from that o f Government facilities, hence selective training and equipmentavailability could be observed. Employment of InfectionControlMeasures Due to systematic training and re-training, the awareness is significantly higher in these HCW. NGO have been providing barrier protection, PEP, disposable needles and needle cutters (electrical type) on a regular basis. Accident Reporting i s also observed to a large extent and most workers had been vaccinated against HBV. Employment of Waste Management Measures The fact that the waste disposal for NGO facilities i s dependent on the host facility's disposal practices further compounds the problem o f waste management. In instances where waste management i s being carried out by third parties (such as at Common Treatment Facilities) there is a higher degree o f conformance to Biomedical Rules. RECORD OF CONSULTATIONLDISCUSSION WITH RELEVANT STAKEHOLDERS Two types o f consultations were held during the course o f this study: (a) Consultation with individual stakeholders during the site visits; and (b) Consultation convened by the NACP design team and facilitated by environmental department o f MoPH. 7 The IC-WM Plan proposed below is based on existing documentation, observations during site visits, review o f existing practices amongst other health initiatives and discussions and consultations with stakeholders. INFECTION CONTROL AND WASTE MANAGEMENT PLAN The IC-WM Plan("Plan") provides a consolidated, reference material on IC-WM good practices that may be further tailored to suit the facility's needs. The Plan i s build on the following framework: (a) Section I : Infection Control and Waste Management; , (b) Section 11: Capacity Building; (c) Section 111: Institutional Framework; (d) Section IV:Monitoring and Evaluation; and (e) Section V: Implementation Schedule. Section I: InfectionControland Waste Management Healthcare workers involved in the NACP face the highest occupational risk due to the nature o f their work dealing with testing and treatment o f HIV/AIDS cases. Infectious waste from AIDS related activities include primarily: needles and sharps, blood and blood bags, used test kits, culture samples and slides and other related infectious waste such as swabs, gloves, bandages, sputumcups etc. Thus it i s imperative that good IC-WM practices are implemented. This activity should not be restricted only to certain sections of the healthcare facility likeVCTC, PPTCT, but extend to all facilities runnedby NACP. 1. Waste Segregation and On-siteStorage Segregation at source i s the most critical step towards a well- functioning waste management system. Separation o f infectious and non- infectious waste becomes impossible once mixed, resulting in greater risk to all concerned. The Bio-medical Rulesprovides color coding for waste segregation and their respective treatment options, as listed below inTable 2. 8 Color coding Waste Category Treatment option Yellow Plastic bag Cat. 1, Cat. 2, and Cat. 3, Cat. 6. Incineratioddeep burial Red Disinfected container/plastic bag Cat. 3, Cat. 6, Cat.7 Autoclavinghlicrowaving / Chemical Treatment Blue / White Plastic bagipuncture proof Cat. 4, Cat. 7. Autoclavinghlicrowaving / Translucent Container Chemical Treatment and Destructionishredding Black Plastic bag Cat. 5 and Cat. 9 and Cat. 10. Disposal in secured landfill (solid) The facility should ensure that there are designated segregation points, as close to the generation points as possible. Segregation requires appropriate consumables, such as good quality and adequately sized containers, non-chlorinatedplastic bags, needle cutters and safety boxes. The specifications and color-coding provided inthe Biomedical Rules need to be strictly followed. 2. Collectionand Transportationof Bio-medicalWastes Transportation o f bio- medical wastes, within and outside the healthcare facility needs to be secure and well-managed. Spills and leakages can be risky for patients and the community, but can also result inpilferage and reuse o f potentially infectious items such as syringes etc. Specific steps to be taken by each facility include: (a) Waste should be collected from various sources and transported to a central location; (b) Within the facility, special waste routes should be designated to avoid patient care areas. Special timing should be identified for transportation o f bio-medical waste to the central point; (c) Dedicatedwheeled containers, trolleys or carts should be usedto transport the waste to the collectiodtreatment site. These should be such that the waste can be easily loaded and emptied and remain secured during transportation. They should not have any sharp edges and be easy to clean and disinfect; (d) Ifdisposal is done within the premises o fthe healthcare facility, care should be taken that different categories o f waste are disposed of accurately (sharps in sharps pit, anatomical waste in deep burial pits etc) as designated inthe Biomedical Rules; and 9 (e) Waste handlers should be properly trained and should use barrier protection duringtransportation. 3. Treatment and Disposalof Bio-medicalWastes (a) Used sharps (needles, slides, scalpels etc), blood bags, syringes and other infectious plastic and liquid wastes (Categories 4, 7, 8, and 10 of the Biomedical Rules) need to be disinfected by immersion in 1% hypochlorite solution or any other equivalent chemical reagent. It must be ensured that chemical treatment ensures disinfection; (b) Waste containers should contain freshly prepared disinfectant solution and be kept closed all the time. At all times, the waste container should not be more than 3/4th full; (c) The waste containers should be emptiedat least once everyday; (d) Infected linen in the hospital should be carefully packed in plastic bags, and disinfected before being sent for washing. Personnel involved in laundering infected linen should take adequate precautions to prevent the exposure to infections; (e) A log o f quantity o f waste generated by type, name o f waste handler, time o f emptying waste container, time o f cleaning container and pouring disinfectant should be maintained; and (0 Disposalas recommended inthe Rules,should be as follows: (i) Sharps intheir puncture proof containers should be drained of the disinfectant and disposed inthe sharps pit, constructed within the premises; (ii)Infectedorganicwaste should be disposed o f inthe deep burial pits also constructed withinthe facility and covered with a layer o f lime and soil; and (iii)Infectedrecyclablessuchasplasticsandmetals,canbesentfor . recycling but only after disinfection and/or autoclaving. All equipment used for bio-medical waste treatment should be periodically subjected to maintenance checks to ensure its functioning. Both preventive and corrective maintenance schedules and records should be retained in the facility. As a general practice o f maintaining good hygiene, the floors o f the facility should be first swabbed with a wet cloth, then swept to remove grits to avoid dust carrying pathogens from rising into the air and, finally, swabbed with a disinfectant solution. The swab cloth should be washed with detergent after every use. The housekeeping personnel should employ use o f protective barriers to prevent exposure to infection. 10 4. Sharps Management Given the high risk of infection from infected sharps, a separate section on the safe use and disposal o f sharps i s being detailed. Sharps are anything that may cause puncture and cuts. Sharps include needles, scalpels, blades, broken glass, slides, lancets, sutures, and IV catheters. Infectedneedles, sharps and blood, if improperlyhandled, can be a source of infection for the HCWs. Although the risk o f infection from contaminated sharps i s high for all categories o f HCW, those most at risk o f exposures are nurses, medical staff and clinical laboratory staff (blood collectors). Physicians are at some risk, but surgical and dental staff, although at high risk o f injury, have a lower risk o f infection. It must be remembered that all health care personnel (including cleaners, laundry staff and waste contractors) may be exposed to inappropriately discarded sharps. While emergency rooms and operating theatres pose high risk for HCW, it has been found that a) the majority o f exposures have occurred in general ward areas and b) a larger number o f exposures which would be classified as high risk have occurred in medical wards. The following measures must be taken to ensure sharps safety inthe work-place: Barrier protection must always be usedwhen handling sharps; Sharps must be segregated and stored inpuncture-proofcontainers at the point o f generation; Sharps must be mutilated before treatment and disposal. Useddisposable or Autodisable (AD) syringes should be mutilated by usingneedle cutters/ destroyers and hub-pullersand dropped into a puncture-proof container. Clipping, bending or breaking o f needles by hand or re-capping should be avoided as this may cause accidental injuries; ,Usedsharps should not be left untreated or carelessly on counter tops, food trays, or beds, as this can pose a risk to all concerned; Mutilated sharps should be immersedin 1 percent hypochlorite solution or any other equivalent chemical reagent for disinfection. Treatment by autoclaving / microwaving is also approved; and Final disposal should be ina secured landfill. Wherever this i s not available everywhere,sharps pits or encapsulation should be used. A sharps pit is a circular or rectangular pit, where sharp wastes are disposed. These pits are lined with brick, masonry or concrete rings. The pit shouldbe covered with a concrete slab. When the pit is full, it should be sealed completely and another pit i s prepared. Encapsulation i s another method. When a container (puncture and leak proof containers) is three-quarter full, material such as cement mortar, bituminous sand, plastic foam or clay i s 11 poured untilthe container i s completely filled. After the mediumhas dried, the containers are sealed and disposed inlandfill sites. No. Steps/ Stages 1 Severe needles from disposable syringe immediately after administering injection usinga needle cuttedhub-cutter that removes the needle from disposable syringesor cuts plastic hub o f syringe from AD syringes. 2 The cut needles get collected inthe puncture proofcontainer of the needlecutteri hub- cutter. The container should contain an appropriate disinfectant and the cut needles should be completely immersed inthe disinfectant 3 Segregate and store syringes and unbroken (but discarded) vials in a red bag or container. 4 Send the collected materials to the common bio-medical waste treatment facilities. If such facilities do not exist, then go to the next step. 5 Treat the collected material in an autoclave. Ifthis is unavailable, treat the waste iii 1% hypochlorite solution or boil inwater for at least 10 minutes. It shall be ensured that these treatments ensure disinfection. 6 Dispose the autoclaved waste as follows: (i)Dispose the needles and broken vials in a pit / tank, (ii)Send the syringesand unbroken vials for recycling or landfill. 7 Wash the containers properly for reuse. 8 Make a proper record o f generation, treatment and disposal o f waste. I 5. Blood safety in Laboratory Blood i s the single most important source o f HIV, HBV, HCV and other blood borne infections for HCWs. It i s mandatory to screen blood units for five transmissible infections: Hepatitis B, Hepatitis C, HIV, syphilis and malaria. The Rules in the country also require for testing procedures, quality control, standard qualifications, and experience for blood bank personnel, maintenance o f complete and accurate records, strict guidelines for holding of blood donation camps etc. and to be further improved. Careful donor screening, discouraging use o f paid donors, stringent screening o f donated units of blood to prevent HIV transmission through blood and blood products. Another important action taken by MoPHhas beento modernize the blood banks inthe country. Risk of infection varies with a number of factors, including type and number of exposures, amount of blood involved in the exposure, amount o f virus in the patients' blood etc. Modes o f exposure to blood borne pathogens ina laboratory have beendefinedas below: 12 Modesof Exposureto Blood-bornePathogens in the Laboratory Procedure HCW at risk SourceIModesof Transmission Collection of Laboratory technician 3Needle stick injury blood/body fluid 3Broken specimen container 3Blood contamination o f hand with skin lesiondbreach Transfer o f specimen Laboratory technician Contaminated exterior o f and transport worker container CBroken specimen container GSpillshplashes of specimen Processing of Laboratory personnel Puncture o f skin specimen :Contamination o f skin from spills, splashes, glassware and work surface 0Faultytechniques OPerforated gloves Cleaning /Washing Laboratory support c1Puncture o f skin staff OContamination o f skin from spills, splashes, glassware and work surface Disposal o f waste Laboratory support - LContact with infectious staff waste, specially sharps, broken containers Specimen Transport/postal staff Brokedleaking container or transportation/mailing packaging As per the Bio-medical Rules, infected blood and blood samples is characterized as liquid waste and should be disinfected with hypochlorite solution. . Screened positive blood bags, contaminated test kits and items are categorized as infected solid waste and should be disinfected by chemical treatment / autoclave and mutilated before disposal. 13 Transport o f specimens should be done ina diligent manner. The sample should be kept first inprimary container with enough absorbent material around it. The primary container should then be placed in secondary container. Staff should take care that the secondary container i s also leak-proof, properly sealed and labeled. Uprightposition must be maintainedat all times. 6. InfectionControl The four key areas o f infection control for the NACP are: (a) Immunizationagainst nosocomial infections; (b) Availability and use o f barrier protection; (c) Management o f PEP; and (d) Awareness. (i) Activities o f highrisk include invasive diagnostic and therapeutic procedures, wound dressing, operation theatre procedures, handling o f bloodherumhody fluids and tissues etc. and special attention should be paid to ensuringsafety precautions during these activities; (ii)Barrierprotection(gowns, masks,caps,gloves,shoes)shouldbe maintained to prevent contact with contaminated blood/body fluids; (iii)HCWworkinginhighriskareasshouldbeimmunized,attheminimum, . against HBV; (iv) .Daily cleaning o f facility premiseswith appropriate disinfection should be done; (v) Spills are an important source o f infection and should be cleaned up immediately. The spill should be covered with absorbent material, disinfectant poured around the spill and over the absorbent material. The surface should be wiped again with disinfectant. H C W must utilize barrier protection, especially gloves, whenmanaging spills; and (vi) General observance o fpersonal hygiene is important. All staff must be , neat and clean always, with clean uniforms, nails, short or tied-up hair, etc. PEP i s requiredwhen there has beencontact with known HIV/AIDS infected materials resulting from: (a) Percutaneous inoculation (needle stick, cut with a sharp, etc.); (b) Contamination of an open wound; 14 (c) Contamination o f breached skin (chapped, abraded, dermatitis); and (d) Contamination o f a mucous membrane including conjunctiva. (i)Inallsuchinstancesimmediatepost-exposuremanagementiscrucialto reducing the risk o f acquiring infection. This should be done inthe manner prescribed by the above mentionedguideline to be developedby NACP; and (ii)Allaccidentswhetherneedlestickinjuriesorspillsshouldbereported. Section 11: Capacity Building and Awareness Training and sensitization o f various HCWs and functionaries within and outside the health care system i s vital for the successful implementation o f any IC-WM Plan. The training should focus on Universal Precautions, principles of waste management, identification o f roles and responsibilities for implementation, monitoring and reporting. All awareness, training and communication initiatives should be oriented towards providing knowledge / information, building skills and competencies and bringing about a fundamental, mindset change in the attitudes o f staff and personnel. The Training Plan and budget should be included into the MoPH PIP and into NACP PIP and program budget. The following steps should be followed for implementing training: Conduct baseline assessment o f training needs for HCWs involved inthe implementation o f AIDS Control Program. For an integrated approach; A Training Planneeds to be developed basedupon existing capacity and training needs. At the outset, this plan should distinguishbetween trainers and non-trainers and elaborate the criteria for identifying trainers and their requirementfor training; Training should be provided to all HCWs, including doctors, nurses, ward boys, paramedics, laboratory technicians, and Class IV and/or housekeeping staff; and Training should be imparted through: (i)Disseminationof Information,EducationandCommunication (1EC)material that will sensitize HCWs and create general awareness on importance o f IC-WM; and (ii)TechnicaltrainingforHCWswithspecificresponsibilitiesfordiscrete activities related to IC-WM. Training inInfection Control and inWaste Management should be a comprehensive package as the two are closely inter-twined; 15 The Train the Trainer program will have to be undertaken at two levels - state and district levels. Training should be provided on an annual basis, with refresher courses annually or biannually; Inadditionto classroom typetraining, IEC material and awareness-creating activities also needto be employed for training the HCW. Training should preferably be provided on site; Eachfacility should keep records o f training provided to employees, by category o f employee; and The IEC material must be prepared inthe local language on both IC and W M and should beprominently displayed at various places. It should serve as a reminder for all the trained employees as well as sensitize patients visiting the facility. Section 111: Reporting,Monitoringand Evaluation Monitoring & evaluation will be done through a mix o f internal and external approaches. The internal reporting and evaluation mechanism on the IC-WM implementation should be integrated with overall NACP reporting. Management Information Systems (MIS) indicators pertaining to the IC-WM will be developed during implementation. External monitoring inthe form o f IC-WM implementation audits is also beingrecommended. 1. Quarterly monitoring Each facility must establish a robust system o f monitoring through regular documentation and assessments. Ideally, each facility should designate one senior employee responsible for documentation and another for internal evaluation. Inthe case o f VCTC, PPTCT and blood banks, the laboratory technician should maintain records o f waste sharps, gloves, etc. and infectious waste. The records must be maintained on a daily basis and internal assessments should be conducted on a monthly basis. The monthly report from NGO should directly be send to NACP. 2. PeriodicImplementationReview Periodic implementationreview o f the IC-WM should be undertaken, and as far as possible, this review should be inbuilt into the regular review process o f the NACP. This review should focus on consolidated information and reporting from individual facility level. To facilitate regular and sustained monitoring, each NGO implementing HIVIAIDSprogram develops annual Action Plans specifically for IC-WM, which should be includedinto the MoPHPIPS. 16 3. PerformanceIndicators NACP envisages a robust nationwide Strategic InformationManagement System (SIMS) with focus on implementation, monitoring, evaluation and strategic surveillance, appropriate standards for measuring performance, analyzing variances, identifying bottlenecks, alerting program managers and facilitating corrective measures. Some generic Performance Indicators o f the IC-WMPlan have beenrecommendedbelow, which should be integrated into the NACP SMIS. (a) Implementationo f all components o f the IC-WMPlan; (b) Timely procurement and distribution o f IC-WM consumables and equipment; (c) Regular and timely training programs undertaken; (d) Regular evaluation o f training effectiveness and assessment o f employee behavioral practices; (e) Timely interventions and coordinationwith host facility on significant issues which could hinder effective implementation o f IC-WMPlan; and (f) Timely and regular reporting and evaluation undertaken, with corrective measures when necessary. 4. ExternalImplementationAudits The NACP will be responsible for hiringo f an external technical consultant/firm to undertake an independent evaluation o f the program and its implementation. The agency to conduct this technical review should be chosen on the basis o f their technical expertise and established experience in Bio-medical waste management and environmental auditing. Such an independent audit review will be undertaken once duringthe life o f the program, preferably before a mid-term evaluation is conducted. 17 MAP SECTION 55° 60° 65° 70° 75° 80° 85° 90° Zaysan AFGHANISTAN & KAZAKHSTAN CENTRAL ASIA Saryshagan Karamay 45° 45° Tyuratam Aral TOWNS Sea Urumqi NATIONAL CAPITALS Syrdar'ya Yining (Gulja) RIVERS Almaty PROVINCE BOUNDARIES Uxxaktal Nukus INTERNATIONAL Bishkek Chimkent (Frunze) BOUNDARIES Yuli (Lop Nur) He Chirchik UZBEKISTAN KYRGYZ Aksu Yarkant 40° Tashkent 40° REP. 0 100 200 300 400 500 Fergana KILOMETERS TURKMENISTAN Samarkand Kashi Amu Ashgabat Dar Dushanbe TAJIKISTAN C H I N A ya 50° 35° Hotan Tehran BALKH N HS HA Kermanshah Mashhad Mazar-e KONDOZ D AK Sharif SAMANGAN TAKHAR B A 35° FARYAB JOWZJAN BAGHLAN AKSAI JAMMU & BADGHIS KAPISA KONAR CHIN BAMIAN PARVAN LAGHMAN Herat GHOWR Kabul Tabas VARDAK KABOL KASHMIR Esfahan HERAT NANGARHAR IRAQ LOWGAR Peshawar Srinagar ISLAMIC ORUZGAN PAKTIA Islamabad AFGHANISTAN GHAZNI Rawalpindi Al Basrah REPUBLIC FARAH Gar 30° Khorramshahr OF IRAN PAKTIKA ZABOL Kuwait Helmand Lahore Qandahar Faisalabad 30° KUWAIT Shiraz Kerman NIMRUZ HELMAND KANDAHAR Bushehr Quetta Multan New Delhi NEPAL Kathmandu Ganges Dhahran Manama PAKISTAN Indus BAHRAIN Agra Lucknow 25° Jaipur Doha Kanpur QATAR Patna Dubai Bandar 25° Allahabad Varanasi Abu Dhabi Beheshti Hyderabad U.A.E. Karachi I N D I A Muscat This map was produced by the Map Design Unit of The World Bank. Jabalpur IBRD The boundaries, colors, denominations Bhuj and any other information shown on MA OMAN Arabian Sea Ahmadabad Indore this map do not imply, on the part of 31643R1 Y The World Bank Group, any judgment 2003 on the legal status of any territory, or 20° any endorsement or acceptance of 50° 55° 60° 65° 70° 75° Nagpur such boundaries. 85°