Public Disclosure Authorized THE WORLD BANK GROUP infoshop Tbc WXi,-d liuk AWori1I Frou of Povorty Integrated Safeguards Data Sheet (Updated) Report No AC74 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Date Prepared/Updated: 05/15/2003 Section I - Basic Information A. Basic Project Data Country: MALAWI Project: Multi-sector AIDS Program (MAP): Support to the Malawi National AIDS Strategic Framework Authorized to Appraise Date: March 19, 2003 Bank Approval: June 24, 2003 Project ID: P073821 Task Team Leader: Christine E. Kimes IBRD Amount ($m): IDA Amount ($m): IDA GRANT FOR HIV/AIDS 35 Managing Unit: AFTOS Sector: Other social services (100%) Lending Instrument: Specific Investment Loan (SIL) Theme: Fighting communicable diseases (P); Social Status: Lending risk mitigation (S) I.A.2. Project Objectives: The development objective of the national HIV/AIDS program, which the proposed MAP will support, is to reduce the transmission of HV, to improve the quality of life of those infected and affected by AIDS, and to mitigate the impact of IlTlV/AIDS in all sectors and at all levels of Malawian society. I.A.3. Project Description: The Government of Malawi, through its National AIDS Commission (NAC), is putting in place management systems and funding mechanisms that will enable the public sector, private businesses, and civil society to mobilize and implement a multi-sectoral response at the national, district, and community level. The overarching principles guiding the national response are contained in the National Strategic Framework 2000-04 (NSF), which was adopted following a participatory consultation process in 1998-99. The objectives of the NSF are to reduce the transmission of HIV, improve the quality of life of those infected and affected by HIV/AIDS, and mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society. As the NSF is entering into its final year, the NAC and national stakeholders have developed a programmatic framework to guide interventions during the next five years of the national response - the Strategic Management Plan (SMP). The SMP includes those interventions which are coordinated and directly funded by the National AIDS Commission It is expected that a new NSF 2004-2009 will be formulated before the end of the current NSF. The NAC has invited its external development partners to provide their financial assistance in support of the SMP, on the basis of ajoint annual work plan, using joint financial, procurement, and reporting mechanisms, rather than funding multiple HIV/AIDS projects each requiring parallel systems for tracking and reporting on individual donor's funds. The SMP is composed of seven major subprograms: i)
2 advocacy and prevention; ii) sectoral mainstreaming; iii) treatment, care and support; iv) impact mitigation; v) capacity building and partnerships; vi) monitoring evaluation and research; and vii) national leadership and coordination. The SMP includes those activities for which the NAC acts either as financier (through the I[V/AIDS grants facility) or as a direct manager of coordination/ leadership activities. The first six subprograms enumerated above cover those activities which will be implemented by stakeholders, while the seventh subprogram will be NAC managed and implemented. The estimated cost of the five year, first phase SMP program is estimated at $221 million. In addition to the Government of Malawi itself, the external development partners who will contribute financially to the implementation of the joint program of work are: the Global Fund for AIDS, Tuberculosis and Malaria (GF), UNDP, AfDB, Centers for Disease Control, CIDA, DffD, IDA, NORAD, and SIDA. "Rules of engagement" between NAC and the development partners have been discussed extensively, and are captured in a multi-donor Memorandum of Understanding (MOU) and supporting Operational Guidelines. Within the MOU framework, pooling of funds in a common basket will be one of the financing modalities available to development partners. The partners who plan to participate in the basket pooling arrangement are: CIDA, DflD, IDA, NORAD, SIDA and the GOM. Distribution of basket funding among the subprograms will be agreed each year on the basis of rolling annual work plans and stakeholder decisions. IDA support will be disbursed into the common hard currency basket account on the basis of PMRs, to fund those elements of the SMP which are not being funded by ear-marked contributions from the GF, UNDP, AfDB or CDC. The IDA allocations per subprogram shown below are indicative, for the reasons explained above, and are proportionate to IDA's share in the basket (48%). Components: 1. Advocacy and Prevention: This subprogram covers a broad range of activities and services aimed at changing behavior and preventing transmission of HIV. Activity clusters include: IEC/BC for target populations, promotion of safe sex (including condoms), voluntary counselling and testing (VCT), prevention of mother to child transmission (PMTCT), and prevention of nosocomial infections (blood safety, injection safety, and health care waste handling). 2. Sectoral Mainstreaming: This subprogram will enable public institutions, private companies, and civil society organizations to mainstream HIV/AlDS in their workplace and in their core business, thereby mitigating the epidemic's impact on labor productivity and service delivery. 3. Treatment, Care and Support: This subprogram covers a range of health based interventions aimed at reducing the morbidity and mortality associated with HIV/AIDS. The category comprises two main activity clusters: a) clinical care and treatment, and b) community / home-based care. 4. Impact Mitigation: This subprogram aims to mitigate the impact of the T1-V/AIDS epidemic on particularly vulnerable members of society: orphans and other vulnerable children (OVCs), girl-children, widows and widowers, and the dependent elderly. Activities could include educational support and training activities for OVCs, income generation activities for vulnerable households, community-based and institutional care for orphans, and psycho-social support for affected families. 5. Capacity Building & Partnerships: This subprogram aims to build the capacity of stakeholder partners to implement a multi-sectoral response to the epidemic. Interventions will assist NGOs, FBOs, CBOs, sector institutions, local governments, and private companies to develop long term visions, operational frameworks, and technical skills to address the epidemic.
3 6. Monitoring, Evaluation and Research: This subprogram will cover the range of interventions needed to enable the NAC to track the epidemic and national response and to understand which interventions are proving most effective under different local and cultural conditions. Activities included in the M & E work plan will include biological and behavioral surveillance, poverty analysis (to measure socio-economic impacts of the epidemic), programme activity monitoring, and specialized studies. 7. National Leadership and Coordination: This subprogram consists of two main activity clusters: a) national leadership and coordination, and b) program management. I.A.4. Project Location: (Geographic location, information about the key environmental and social characteristics of the area and population likely to be affected, and proximity to any protected areas, or sites or critical natural habitats, or any other culturally or socially sensitive areas.) National in scope. B. Clheck Environmental Classification: B (Partial Assessment) Comments: Classified as 'B' because of potential irnpacts of medical waste. C. Safeguard Policies Triggered Policy Applicability Environmental Assessment (OP/BP/GP 4.01) 0 Yes 0 No Natural Habitats (OP/BP/GP 4.04) Forestry (OP/GP 4.36) 0 Yes 0 No Pest Management (OP 4.09) Cultural Property (OPN 11.03) Indigenous Peoples (OD 4.20) Involuntary Resettlement (OP/BP 4.12) Safety of Dams (OP/BP 4.37) Projects in International Waterways (OP/BP/GP 7.50) Projects in Disputed Areas (OP/BP/GP 7.60)* *By supporting the proposed project, the Bank does no! intend to prejudice the final determination of the parties' claims on the disputed areas Section II - Key Safeguard Issues and Their Management D. Summary of Key Safeguard Issues Please fill in all relevant questions. If information is not available, describe steps to be taken to obtain necessary data II.D.la. Describe any safeguard issues and impacts associated with the proposed project. Identify and describe any potential large scale, significant and/or irreversible impacts. Safe collection, storage, and disposal of medical wastes is the key environmental issue associated with scaling up the national HIV/AIDS response. Currently, Malawi does not have a policy framework and defined technical standards for managing health care wastes. -As input into the development of such a national policy/action plan, an assessment of injection safety (IS) and health care waste management (HCWM) within the public and private healthl services was carried out in November/December 2002, supported by technical and financial assistance from UNICEF, WHO, and the World Bank. With respect to injection safety, the assessment found that injection recipients in Malawi were at risk as a
4 result of serious breaks in infection control practices and reuse of injection equipment in the absence of sterilization. Many injections in the curative sector were unnecessary and might have been given more safely and with equal efficacy in an oral formulation. Inadequate collection and disposal methods for used injection equipment exposed health workers and the community at large to risks of injury and infection from contaminated sharp waste. Major deficiencies in HCW management were observed throughout the collection, storage, transportation, and treatment cycle. The major weaknesses found include: lack of planning or internal management procedures; absence of viable data about HCW production and characteristics; no monitoring system or staff member designated to monitor HCW management; insufficiency of secure collection materials and protective gear; mixing of HCW with household and office waste; and inefficient local incinerators. As a result, health care workers, non-technical health facility staff, municipal landfill workers, and landfill scavengers are at serious risk of infection. While paramedical staff (doctors, midwives, nurses) were observed to be informed and demonstrate fairly good HCWM practices, the general public's knowledge of risks linked with the handling of HCW was found to be very weak. II.D. I b. Describe any potential cumulative impacts due to application of more than one safeguard policy or due to multiple project component. N/A II.D. I c Describe any potential long term impacts due to anticipated future activities in the project area. N/A I1.D.2. In light of 1, describe the proposed treatment of alternatives (if required) N/A II.D.3. Describe arrangement for the borrower to address safeguard issues Based on the assessment described above, a draft FICWM policy and a draft HCWM Plan of Action were prepared. The goal of the HCWM Plan of Action (POA) is to prevent and mitigate the environmental and health impact of HCW on health care staff and the general public. The objectives of the Plan of Action are to: (i) reduce infections due to HCW; (ii) improve service in HCWM and mitigate the impacts of HCW on individuals and communities; and (iii) establish a well-managed multi-sector institutional framework for co-ordination and implementation of HCWM measures. The HCWM Plan of Action recommends: a) revisions and improvements to the legal and regulatory framework (including defining technical standards and roles and responsibilities), b) upgrading HCWM treatment systems at the health facility level (system selection was based on technical feasibility in view of staff skills, cost, and ease of maintenance), c) training activities for workers who come into contact with HCW; d) public awareness activities for the general public who may come into contact with HCW, e) development of private-public partnerships for HCWM, and f) monitoring and evaluation activities. The HCWM Plan of Action also defines implementation responsibilities, timetable and cost estimates. Within the Ministry of Health, the Department of Preventive Health Services (DPHS) through its Environmental Health Service (EHS) will take the lead in managing implementation of the HCWM plan. The Health Education Unit of the Ministry will also be involved in training and public awareness activities. EHS/DPHS will work closely with the Department of Environmental Affairs at the Ministry of Natural Resources and Environmental Affairs, which is responsible for developing appropriate standards
5 for environmental impact assessments involving waste management, including HCW. At the district and local levels, managers of health facilities will be responsible for implementation, working closely with landfill managers (where they exist). Il.D.4. Identify the key stakeholders and describe the mechanisms for consultation and disclosure on safeguard policies, with an emphasis on potentially affected people. Key stakeholders include managers of health facilities and health sector workers (including traditional healers/mid-wives), local government officials responsible for municipal landfills and municipal landfill workers, family and community members caring for PLWAs and providing traditional burial practices, and street scavengers who may be exposed to inadequately disposed of medical wastes. The assessment team visited 80 health facilities in the public and private sectors for the injection safety portion of the survey, and followed up with in-depth visits at 29 facilities to refine information on health care waste data and practices. In addition to meeting with staff at the health facilities surveyed, about 250 members of the general public were randomly interviewed at markets and other public locations in the community around each of the 80 health facilities (the sample was artificially stratified to ensure equal representation of age groups and gender). In addition to the health facility staff and members of the public, the assessment team also met individually with key stakeholder institutions/departments: (i) MOI-fP (Departments of Preventive Health: EPI, Environmental Health and Health Education Units, Clinical Services, Health Planning, Technical Unit and Administration); (ii) Malawi National AIDS Commission; (iii) Malawi Bureau of Standards; (iv) MNREA (Department of Environmental Affairs); (v) City Assemblies (Lilongwe and Blantyre); (vi) Training Institutions (Polytechnic/Department of Environmental Health, College of Health Sciences, Kamuzu College of Nursing, College of Medicine); (vii) NGOs (JHPIEGO, SafeMotherhood, Medecins Sans Frontieres, MACRO); and (vii) Cooperation Agencies (UNICEF, WHO, WB, JICA, GTZ, EU). These meetings were organized to collect information on stakeholder responsibilities, understandings, programmes and activities in the field of IS and HCWM, and constraints faced. Upon completion of the field visit phase in December 2002, the assessment team provided a debriefing for stakeholders in Lilongwe on its preliminary findings. This initial debriefing was followed in January 2003 by a two day National Stakeholder Meeting and by district level consultations in February 2003 in seven of the eight districts which had participated in the field survey to review assessment findings and preliminary recommendations. Participants at the national and district consultations confirmed the main findings, agreed with the thrust of recommendations, and emphasized the importance of implementing the preliminary recommendations. The draft HCWM Plan was disclosed to local stakeholders and development partners in March 2003, and a national workshop is planned for May 2003 to review the draft national policy and draft action plan, make recommendations for finalization of these documents, and agree on the next immediate steps. E. Safeguards Classification Category is determined by the highest impact in any policy. Or oln basis of cumulative impacts from multiple safeguards. Whenever an individual safeguard policy is triggered the provisions of that policy apply. [ ] S1. - Significant, cumulative and/or irreversible impacts; or significant technical and institutional risks in management of one or more safeguard areas [X] S2. - One or more safeguard policies are triggered, but effects are limited in their impact and are technically and institutionally manageable
6 [ ] S3. -No safeguard issues SF. - Financial intermediary projects, social development funds, community driven development or similar projects which require a safeguard framework or programmatic approach to address safeguard issues. F. Disclosure Requirements Environmental Assessment/Analysis/Management Plan: Expected Actual 2/21/2003 3/7/2003 3/7/2003 3/19/2003 3/7/2003 3/19/2003 Date of distributing the Exec. Summary of the EA to the ED (For category A projects) Resettlement Action Plan/Framework. Expected Actual Indigenous Peoples Development Plan/Framework: Expected Actual Pest Management Plan: Expected Actual Dam Safety Management Plan: Expected Actual If in-country disclosure of any of the above documents is not expected, please explain why. Signed and submitted by Name Date Task Team Leader: Christine E. Kimes May 6, 2003 Project Safeguards Specialists 1: Project Safeguards Specialists 2: Project Safeguards Specialists 3: Approved by: Name Date Regional Safeguards Coordinator: Charlotte S. Bingham May 6, 2003 Sector Manager/Director: John Roome May 6, 2003 For a list of World Bank news releases on projects and reports, click here SEARCH I EEDAuKk I LSJr`rlA' I W