Document of The World Bank Report No:ICR0000360 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-34590 IDA-3459A) ON A CREDIT IN THE AMOUNT OF SDR 37.3 MILLION (US$47.5 MILLION EQUIVALENT) TO THE REPUBLIC OF UGANDA FOR AN HIV/AIDS CONTROL PROJECT June 29, 2007 Human Development I Eastern Africa Country Cluster 1 Africa Region CURRENCY EQUIVALENTS ( Exchange Rate Effective ) Currency Unit = Ugandan Shilling 1.00 = US$ 0.000607903 US$ 1.00 = 1645 Fiscal Year January 1 December 31 ABBREVIATIONS AND ACRONYMS ABC Abstain, Be faithful, use Condoms AIDS Acquired Immune Deficiency Syndrome ART Anti-retroviral Therapy ARVs Anti-retroviral Drugs BCC Behavior Change Communication CAS Country Assistance Strategy CDD Community-Driven Development CDOs Community Development Officers CHAIs Community-led HIV/AIDS Initiatives CSOs Civil Society Organization DAC District AIDS Coordination Committee DCA Development Credit Agreement DHSP District Health Services Pilot and Demonstration Project DOTS Directly Observed Treatment of Tuberculosis DPs Development Partners FM Financial Management FMR Financial Management Report GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GoU Government of Uganda HIPC Highly Indebted Poor Countries HIV Human Immunodeficiency Virus HMIS Health Management Information System HNP Health, Nutrition and Population IBRD International Bank for Reconstruction and Development IDA International Development Association ICR Implementation Completion Report IEC Information, Education and Communication ISR Implementation Status and Results LFA Local Funding Agent LQAS Lot Quality Assurance Sampling MAP Multi-country HIV/AIDS Program M&E Monitoring and Evaluation MIS Management Information System MOH Ministry of Health MTEFs Medium-Term Expenditure Framework MTR Mid-Term Review NGO Non-Governmental Organization NSF National Strategic Framework for HIV/AIDS NUSAF Northern Uganda Social Action Fund OVC Orphans and Vulnerable Children PAD Project Appraisal Document PCT Project Coordination Team PDO Project Development Objectives PEPFAR President's Emergency Program for AIDS Relief PLWHA People Living With HIV/AIDS PMTCT Prevention of Mother-to-Child Transmission PPF Project Preparation Facility PRSC Poverty Reduction Support Credit PRSP Poverty Reduction Strategy Paper QAG Quality Assurance Group RFA Results Framework Analysis STI Sexually Transmitted Infections STIP Sexually Transmitted Infection Project SWAP Sector-wide Approach TB Tuberculosis UAC Uganda AIDS Commission UACP Uganda HIV/AIDS Control Project UDHS Uganda Demographic and Health Survey UHSBS Uganda HIV/AIDS Sero-behavioural Survey UPHOLD Uganda Program for Human and Holistic Development USAID United States Agency for International Development VCT Voluntary Counseling and Testing Vice President: Obiageli K. Ezekwesili Country Director: Judy O'Connor Sector Manager: Dzingai B. Mutumbuka Project Team Leader: Peter Okwero ICR Team Leader: Son Nam Nguyen Uganda HIV/AIDS Control Project CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 5 3. Assessment of Outcomes.......................................................................................... 12 4. Assessment of Risk to Development Outcome......................................................... 20 5. Assessment of Bank and Borrower Performance ..................................................... 21 6. Lessons Learned........................................................................................................ 22 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners........... 24 Annex 1. Project Costs and Financing.......................................................................... 25 (c) Project Financing by Category (in US$ million equivalent).................................. 25 Annex 2. Outputs by Component.................................................................................. 27 Annex 3. Economic and Financial Analysis................................................................. 31 Annex 4. Bank Lending and Implementation Support/Supervision Processes............. 32 Annex 5. Beneficiary Survey Results........................................................................... 34 Annex 6. Stakeholder Workshop Report and Results................................................... 35 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 36 Annex 8. Comments of Co-financiers and Other Partners/Stakeholders...................... 40 Annex 9. List of Supporting Documents ...................................................................... 41 MAP A. Basic Information HIV/AIDS Control Country: Uganda Project Name: Project Project ID: P072482 L/C/TF Number(s): IDA-34590,IDA-3459A ICR Date: 06/29/2007 ICR Type: Core ICR THE REPUBLIC OF Lending Instrument: APL Borrower: UGANDA Original Total XDR 37.3M Disbursed Amount: XDR 37.2M Commitment: Environmental Category: C Implementing Agencies: Ministry of Health Uganda AIDS Commission Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 10/13/2000 Effectiveness: 05/14/2001 05/14/2001 Appraisal: 12/04/2000 Restructuring(s): Approval: 01/18/2001 Mid-term Review: 03/16/2004 Closing: 12/31/2006 12/31/2006 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Moderately Satisfactory Overall Bank Overall Borrower Performance: Satisfactory Performance: Moderately Satisfactory i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Yes Quality at Entry Satisfactory at any time (Yes/No): (QEA): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 15 20 General education sector 2 3 Health 77 70 Other social services 6 7 Theme Code (Primary/Secondary) Child health Secondary Secondary Gender Secondary Secondary HIV/AIDS Primary Primary Health system performance Secondary Secondary Participation and civic engagement Primary Primary E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Mary Kathryn Hollifield James W. Adams Sector Manager: Dzingai B. Mutumbuka Dzingai B. Mutumbuka Project Team Leader: Peter Okwero Alexandre V. Abrantes ICR Team Leader: Son Nam Nguyen ICR Primary Author: Son Nam Nguyen F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project supports the Government of Uganda's National Strategic Framework for HIV/AIDS which aims to (a) reduce the spread of HIV infection; (b) mitigate the health ii and socioeconomic impact of HIV/AIDS at individual, household and community levels; and (c) strengthen the national capacity to respond to the epidemic. Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Indicator 1 : By 2006, increase the number of women/men aged 15-49 who reported using a condom in their last act of sexual intercourse with a non-regular partner. Value 30% (UDHS 2001: 38% 47% women and quantitative or 50% 53% men (UHSBS Qualitative) women and 59% men) 2004/5) Date achieved 12/31/2001 12/31/2001 12/31/2005 Comments Against original baseline: almost achieved. Against UDHS 2001 (more reliable): (incl. % improved for women, but set back for males. At MTR, this indicator was achievement) changed to "% of sexually active persons.." and new target was set but not achieved (see Annex 2) Indicator 2 : By 2006, reduce the proportion of 15-19 year old boys and girls that are sexually active Value 49% (UDHS 2001: 52% 46% girls and 42% quantitative or 40% boys (UHSBS Qualitative) girls and 39% boys) 2004/5) Date achieved 12/31/2001 12/31/2006 06/11/2005 Comments Against original baseline: improved but not achieved. (incl. % Against UDHS 2001 (more reliable baseline): improved but not achieved for achievement) girls, set back for boys. Indicator 3 : By 2006, reduce HIV prevalence among women of childbearing age as measured in women attending prenatal care services. 5% for rural, 7% for urban (2005 Value HIV sentinel quantitative or 8.5% below 6% surveillance) Qualitative) 6.5% (UHSBS 2004/5) Date achieved 10/01/2001 12/31/2006 12/31/2005 Comments (incl. % Reduced but not achieved. HIV prevalence not a good indicator of project achievement) progress. Indicator 4 : By 2006 reduce the proportion of sexually active persons reporting non regular sexual partners (in the last 12 months) Value 14% (UDHS 2001: 11% 10% 15% women and iii quantitative or women and 21% men) 37% men (UHSBS Qualitative) 2004/5) Date achieved 12/31/2001 12/31/2006 12/31/2005 Comments (incl. % Against original baseline: achieved for women, set back for men achievement) Against UDHS 2001 (more reliable baseline): set back for both sexes Indicator 5 : By 2006 reduce the rate of reported STIs (urethritis) in men aged 15-49 in the last 12 months 21% with STI, or Value 15% (UDHS 2001: 6% genital discharge, quantitative or with STI, or genital 5% or Qualitative) discharge, or sore/ulcer ) sore/ulcer(UHSBS 2004/5) Date achieved 12/31/2001 12/31/2006 12/31/2005 Not achieved. Comments (incl. % This indicator was replaced at MTR with "% of reported STIs (urethritis and achievement) urethral discharge) in men aged 15-54". Target was not achieved with the revised indicator either (See annex 2) Indicator 6 : By 2006, reduce the drop-out rate of orphan in primary schools Value quantitative or N/A Reduce by 30% N/A Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments This was difficult to monitor and replaced at MTR with "the proportion of (incl. % orphans who attend school 5 days in the preceeding week", which was 70% at achievement) MTR and 71% in 2006 (below the target of 80%) (See Annex 2). (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Completion or documents) Target Values Target Years Indicator 1 : By 2006, increase the proportion of secondary schools applying the secondary school curriculum that incorporates HIV/AIDS information Value (quantitative 0% 60% 100% or Qualitative) Date achieved 12/31/1999 12/31/2006 12/31/2006 Comments (incl. % Achieved achievement) Indicator 2 : By 2006, increase the proportion of hospitals providing prevention of mother-to- child transmission service Value (quantitative 6% 50% 100% iv or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Achieved. achievement) Indicator 3 : By 2006, increase the proportion of identified orphans (by sex) that are receiving social support from the project Value (quantitative 0% 50% N/A or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments This was replaced after MTR with "the number of orphans identified through the (incl. % project that are receiving educational support from the project".The new target achievement) was achieved (see Annex 2) Indicator 4 : By 2006, increase the proportion of PLWHA identified by district health registers that are receiving some form of home or community-based support Value (quantitative 30% 50% N/A or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments This was replaced after MTR with "% PLWHA identified by CSO who received (incl. % psycho-social support by the project". This revised indicator increased from 70% achievement) at MTR to 86% in 2006, but was still below the target of 90% (See Annex 2) Indicator 5 : By 2006, increase the proportion of districts implementing TB DOTS Value (quantitative 13% 100% 100% or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Achieved achievement) By 2006, all relevant line ministries (13) have incorporated HIV/AIDS Indicator 6 : prevention or mitigation activities in their regular work-plans and are implementing them Value (quantitative 5 13 15 or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Achieved. achievement) Indicator 7 : By 2006, increase the number of districts that are implementing integrated HIV/AIDS work plans Value (quantitative 5 45 30 or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments This was achieved in all 30 UACP districts v (incl. % achievement) Indicator 8 : By 2006, increase the proportion of districts hospitals reporting no stock-out of essential drugs for STIs in the last 6 months Out of 23 reporting Value districts, 16 (or (quantitative 0% 80% 31%) had no stock- or Qualitative) out the last 3 months Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Not achieved achievement) Indicator 9 : By 2006, increase the proportion of districts that have HIV/AIDS voluntary counseling and testing centers Value (quantitative 20% 80% 100% or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Achieved. achievement) Indicator 10 : The amount of project funding disbursed under CHAIs will account for at least 25% of all project funds disbursed in the previous 12 months Value (quantitative N/A 25% 20% (for the entire or Qualitative) project period) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % CHAIs account for 20% of total project's funding. achievement) Indicator 11 : By 2006, increase the number of condoms sold through social marketing or distributed in Uganda Value (quantitative 80 million 120 million 120 million or Qualitative) Date achieved 12/31/2000 12/31/2006 12/31/2006 Comments (incl. % Achieved. achievement) G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 08/07/2001 Satisfactory Satisfactory 1.25 2 12/14/2001 Satisfactory Satisfactory 1.49 vi 3 03/18/2002 Satisfactory Satisfactory 1.72 4 10/10/2002 Satisfactory Satisfactory 5.63 5 01/16/2003 Satisfactory Satisfactory 7.55 6 06/26/2003 Satisfactory Satisfactory 11.71 7 12/15/2003 Satisfactory Satisfactory 18.16 8 05/28/2004 Satisfactory Satisfactory 26.56 9 11/29/2004 Satisfactory Satisfactory 33.85 10 05/09/2005 Satisfactory Satisfactory 41.74 11 10/20/2005 Satisfactory Satisfactory 45.93 12 04/14/2006 Satisfactory Satisfactory 50.56 13 10/05/2006 Satisfactory Satisfactory 50.56 14 12/21/2006 Moderately Satisfactory Satisfactory 53.36 H. Restructuring (if any) Not Applicable I. Disbursement Profile vii 1. Project Context, Development Objectives and Design (this section is descriptive, taken from other documents, e.g., PAD/ISR, not evaluative) 1.1 Context at Appraisal (brief summary of country and sector background, rationale for Bank assistance) At appraisal in December 2000, Uganda was considered to be one of the few countries in Africa that had made progress in reversing the HIV/AIDS epidemic. There was an overall decline in the HIV prevalence rate, from 18.5% in the early 1990s to 8% in 1999. The level of HIV awareness was high - over 90% in the general population. The median age at first sexual contact had increased by two years among youth. Other behavior indicators also improved, including a reduction in the numbers of non-regular sexual partners, particularly for the non-married. Despite these successes, Uganda remained one of the worst affected countries by HIV/AIDS. HIV prevalence was unacceptably high at 8% in the adult population. Since the onset of the epidemic, about 2.2 million people had been infected, 800,000 had died, and over 1.1 million children had been orphaned. AIDS was the leading cause of adult mortality and responsible for 12% of annual deaths. The socioeconomic consequences of HIV/AIDS have devastated every aspect of national development, imposing a mounting burden on households, communities and the society. The extent of behavioral change was still limited compared to the level of awareness. The services for Voluntary Counseling and Testing (VCT), sexually transmitted infections (STI) treatment, and provision of condoms remained largely in urban areas, leaving rural areas under- served. Orphans and households affected by HIV/AIDS needed care and social support. Although 12 line ministries were already implementing HIV/AIDS control, the activities needed to be strengthened and expanded to under-served areas. The challenge was to build capacity in all sectors and institutions to respond to the epidemic in a coordinated manner. Uganda's response had been characterized by a broad partnership with all stakeholders. The government adopted a multi-sector approach to the control of HIV/AIDS in 1992 and established the Uganda AIDS Commission (UAC) by an Act of Parliament. Other efforts to mobilize and unify the national HIV/AIDS response included the establishment of (i) 12 AIDS Control Programs in line ministries and (ii) District AIDS Coordination Committees. In the Poverty Eradication Action Plan, HIV/AIDS control was a priority; and all line ministries, districts and organizations were expected to mainstream HIV/AIDS activities. The National Strategic Framework (NSF) 2000/1-2005/6, built upon the previous AIDS plans, used existing institutions and implementation arrangements and placed HIV/AIDS in the broader context of social and economic development. It called for greater emphasis on community implementation, improved integration and cross-sector collaboration, encouraging wider stakeholder participation and more effective interventions. It aimed to: a) Consolidate the prevention of transmission of HIV and sexually transmitted infections; b) Promote integration of HIV/AIDS interventions into sexual and reproductive health; c) Mitigate the impact of HIV/AIDS on people affected and infected; d) Address the economic, social and cultural impact of HIV/AIDS; and e) Strengthen national capacity at all levels to respond to the epidemic with increased emphasis on the community. In this context, in 2000, the Government of Uganda requested IDA support for the Uganda HIV/AIDS Control Project (UACP) as part of the Multi-Country HIV/AIDS Program (MAP) for 1 the Africa Region, which started in the same year. UACP was in the first cohort of MAP projects and the only major source of external funding for HIV/AIDS in Uganda at the time. Rationale for Bank assistance: One of the objectives of the 2002 Country Assistance Strategy (CAS) was to help Uganda improve the quality of life of the poor through increased access to basic services such as health care, clean water and quality primary education. For health, its assistance would include a HIV/AIDS Control Project to support Uganda's efforts in combating the epidemic. Thus the project was in line with the CAS. According to the PAD, Bank assistance to Uganda in HIV/AIDS was to add values in terms of: a) Knowledge and lessons learned from international experience in HIV/AIDS programs; b) IDA's international experience in the implementation of social funds and in targeted cash transfers which can be applied to community-led HIV/AIDS initiatives and targeted support for orphans; and c) A catalyst for additional resources and technical assistance from the international community. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The project supports the Government of Uganda's National Strategic Framework for HIV/AIDS (NSF) which aims to: (a) reduce the spread of HIV infection; (b) mitigate the health and socioeconomic impact of HIV/AIDS at individual, household and community levels; and (c) strengthen the national capacity to respond to the epidemic. Key indicators: 1. By 2006, reduce from 49% to under 40% the proportion of 15-19 year old boys and girls that are sexually active. 2. By 2006, reduce from 14% to 10% the proportion of sexually active people reporting non-regular sexual partners. 3. By 2006, reduce from 15% to 5% the rate of reported sexually transmitted (urethritis) infections in men aged 15-49 in the last 12 months. 4. By 2006, reduce by 30 % the drop-out rate of orphaned children in primary school. 5. By 2006, increase from 30% to 50 % the proportion of men/women aged 15-49 who report using a condom in their last act of sexual intercourse with a non-regular partner. 6. By 2006, reduce HIV prevalence from 9% to below 6% among women attending prenatal care services. 1.3 Revised PDO and Key Indicators (as approved by original approving authority), and reasons/justification There was no revision to the PDO. At Mid-term Review (MTR), on the basis of better data available through the Uganda Demographic and Health Survey (UDHS) and the Lots Quality Assurance Sampling (LQAS) survey, the key project indicators and their targets were fine-tuned as follows1: 1Please see Annex 2 for the full list of the revised project indicators. It should be noted that (i) the revision of project indicators did not go through formal approval procedures, and (ii) the Project Implementation Status and Results (ISR) Reports continued to use the original indicators. 2 1. By end of 2006, increase the proportion of sexually active persons who report using a condom the last sexual act with a non-regular partner increases from 3.5% to 20% for female (15-49) and 42% to 60% for men (15-54). 2. By the end of 2006, reduce the proportion of 15-24 years old who report sex with non- regular partner in past 12 months from 30.2% to less than 20%. 3. By end of 2006, reduce the proportion of reported STIs in men aged 15-54 years in last 12 months from 18.8% to 10%. 4. By 2006, reduce HIV prevalence below 6% among women of childbearing age attending antenatal care (ANC). 5. By end of 2006, increase the proportion of orphans attending school 5 days in the preceding week from 71.6 % to 80 %. 6. By the end of 2006, increase the proportion of PLWHAs identified by CSOs that are receiving some form of psychosocial support to 90%. 1.4 Main Beneficiaries (original and revised, briefly describe the "primary target group" identified in the PAD and as captured in the PDO, as well as any other individuals and organizations expected to benefit from the project) a) Groups that are known to be particularly vulnerable to HIV infection such as young people (in particular teenage girls), pregnant women, long distance truck drivers, road and power construction workers, traders, fishermen, the military, and the prison population; b) Groups which engage in high risk HIV-related behaviors, such as commercial sex workers and their clients, men who have sex with men and intra-venous drug users; c) Key sectors affected by AIDS such as agriculture, industries, road construction, power and energy, and d) Impoverished orphans and HIV-striken households, with a focus on those headed by women, elderly and youths 1.5 Original Components (as approved) Component 1: Nationally Coordinated Initiatives (US$25 million, 50% of total project costs) This component would support HIV/AIDS control activities coordinated by the Uganda AIDS Commission and directly carried out by different line ministries or central government agencies, or contracted out to civil society organizations or the private sector. At appraisal, IDA agreed with the government on the specific actions plans for the first year of project implementation, to scale up and mainstream HIV/AIDS activities in the: a) Uganda AIDS Commission; b) Ministry of Health; c) Ministry of Education and Sports; d) Ministry of Gender, Labor and Social Development; e) Ministry of Agriculture, Animal Industry and Fisheries; f) Ministry of Works, Housing and Communications; g) Ministry of Defense; h) Ministry of Internal Affairs; 3 i) Ministry of Local Government; j) Ministry of Public Service; k) Ministry of Justice; and 1) Other ministries. Other ministries would be assisted to draft their respective HIV/AIDS action plans during the first year of project implementation. Each line ministry's work plan would include HIV/AIDS prevention and mitigation activities for its staff as well as for the public that it directly serves. Many of these activities would be contracted at national level but would be directly benefit districts and communities. For example, diagnostic kits and pharmaceuticals would be financed under this component but would mostly benefit district based health services. Component 2: District Initiatives (US$ 10 million,20% of total project costs). This component would support activities to be directly carried out by district authorities, or contracted out to civil society organizations or to the private sector, including activities to: a) Raise awareness of district leadership, teachers, school management teams and community leaders; b) Train and support district- and community-based staff and leaders, including teachers, home-care givers and counselors, traditional healers and traditional birth attendants, and rural extension workers; c) Provide HIV/AIDS related health promotion and prevention services at all district hospitals and clinics; d) Provide HIV/AIDS related diagnosis, treatment and care at referral district hospitals; e) Promote community-led and civil society-led HIV/AIDS initiatives and manage the respective selection, contracting, financing and supervision; and f) Provide HIV/AIDS related information, education and communication and condom distribution to the district work force. Many of the activities financed under this component would directly support community-level activities, including advocacy, training and promotion of community-led HIV/AIDS initiatives. Component 3: Community-led HIV/AIDS Initiatives (CHAIs) (US$ 10 million, 20% of total project costs) This component would support community-led HIV/AIDS control activities directly carried out, or contracted out, by community-based organizations, such as: a) Targeted support to orphans, guardians of poor orphans and AIDS stricken impoverished households, including those headed by females, children and elderly due to death of spouse, parent or guardian, conditional to families keeping school aged children in schools, for a minimum amount of time. In addition, pre-school and out-of-school orphans would be supported to attend day care centers and vocational training; b) Community-based information, education and communication; and c) Home-based care. Unallocated: The project has $5 million IDA credit unallocated, which would be allocated to District Initiatives or Community Initiatives based on progress review and project needs. 1.6 Revised Components None of the components was formally revised. 4 1.7 Other significant changes (in design, scope and scale, implementation arrangements and schedule, and funding allocations) Geographical Coverage for Components 2 and 3: The implementation of the district and community components started in 9 districts and was expected to be scaled up nationwide. By the second year, the project expanded to 30 districts (out of a total of 56 districts). However, due to (i) the availability of new sources of HIV funding for other districts2, (ii) the risk of stretching IDA resources and efforts too thin to make a difference, it was subsequently agreed that the two components would not be expanded beyond those 30 districts. Component 1 and the HIV/AIDS commodities procured at the national level benefited the whole country. Financing Anti-retroviral drugs (ARVs): Under the MAP framework, the PAD does not explicitly mention the financing of ARVs. However, during implementation, ARVs became much more affordable and the treatment agenda more prominent. In response to the changing situation as well as the GoU's request, UACP financed the first batch of ARV procurement for Uganda, and by doing so, helped jumpstart antiretroviral therapy (ART) in the country3. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry (including whether lessons of earlier operations were taken into account, risks and their mitigations identified, and adequacy of participatory processes, as applicable) Accelerated project preparation: The project was prepared in record time (less than three months). This "rush" was mostly due to IDA's internal deadlines and mandates, rather than the client's imperatives. The task team did its best to ensure quality at entry given this circumstance. However, despite the team's best efforts, there were unavoidable trade-offs such as (i) the depth of analysis; (ii) the elaboration of implementation arrangements, and (iii) the full understanding and buy-in of the project by some stakeholders, especially communities and other donors; all of which could have improved had the task team been given more time for preparation. For these reasons, project implementation was slower than expected in the first year. Positive aspects of project preparation and design include: Background analysis: UACP made good use of the country background analysis conducted by the GoU and stakeholders for (i) the NSF 200/1-2005/6 and (ii) Uganda's HIPC, PRSP and PRSC processes. UACP was built on: (i) the country's own extensive experience in its fight against HIV/AIDS; (ii) earlier related Bank-financed operations, e.g. the District Health Services Pilot 2 These include the Global Fund, the Uganda Program for Human and Holistic Development (UPHOLD) and the AIDS/HIV Integrated Model District Programme (AIM) supported by the US government. In addition, the IDA-financed Northern Uganda Social Action Fund (NUSAF) project also finances community HIV/AIDS activities in the north. 3In total, US$ 2.7 million of the project credit was used for ARVs. Subsequently, other development partners such as GFATM and USG became the major financiers of ARVs in Uganda. 5 and Demonstration Project (DHSP)4; and (iii) the international experience in financing community-driven interventions (which was new for Uganda at that time). The project conducted an inventory of HIV/AIDS activities supported by other partners as part of the preparation process. Project design: The project design was harmonized with the national response by supporting the NSF under the coordination of the Uganda AIDS Commission. This is in line with the "Three One" principles which would later emerge and be adopted by the international community in 2003. The project has three clear objectives (prevention, mitigation and capacity building), which are also among the objectives of the NSF. It has three distinct components organized by the type of implementers (national level, districts and communities) which correspond to the GoU's strategy to mobilize and unify the response to the HIV/AIDS epidemic at three levels in the context of decentralization. Under each component, activities to contribute to the PDOs were clearly identified, making a clear link between the PDOs and project components. On the other hand, the interface between the three components (e.g. the link between activities and implementers at different levels) was less well-defined. Innovative approach: Although Uganda had a long-standing tradition in multi-sectoral and community responses to HIV/AIDS, these approaches were not yet systematically operationalized, especially at the district level at the time. For this reason, it was innovative of the project design to: (i) support a multi-sector response that extends to the district level; (ii) finance community-led interventions using a social fund approach; and (iii) put the districts at the forefront of project implementation. Adequate safeguards: Similar to all first-phase MAP projects, the project was classified in category C for environment and therefore no environment assessment was required. Nevertheless, project design could have been further strengthened in some areas: The large number of multi-sectoral partners: As was common in all first-phase MAP projects, Component 1 aims to scale up and mainstream HIV/AIDS interventions in all line ministries. This represents a large number of implementers at the national level which (i) strained the capacity of the Project Coordination Team and (ii) to some extent, diluted the resources. A more focused multi-sectoral approach targeting a set of selected sectors which have the largest potential impact on the epidemic would have been more effective. Stakeholder involvement and participatory processes: The task team did its best to consult with stakeholders and facilitate the participatory process (e.g. through a national stakeholder workshop). However, had there been more preparation time, consultation could have been better, especially with development partners and lower-level stakeholders. Targeted interventions: In the discussion on project beneficiaries, the project discussed the targeted preventive intervention approach for HIV-vulnerable groups (e.g. truck drivers, mobile workers in the construction business, fishermen, military personnel, prisoners, commercial sex 4The IDA-financed Sexually Transmitted Infection Project (STIP) was still under implementation and its lessons were not available at the time of UACP preparation. 6 workers, men who have sex with men). This approach was technically sound and is still very much relevant today. However, the project design did not elaborate how the targeting would be actually carried out or monitored. Risks and mitigations measures: UACP identified seven risks which are of four types (i) GoU's commitment to HIV/AIDS control, (ii) low capacity of different implementers, (iii) poor inter- sectoral collaboration, and (iv) fiduciary risks. Among them, four were classified as modest, there substantial and none as high risks. Risk assessment therefore was on the optimistic side. In retrospect, other risks could have been identified and mitigation measures developed accordingly. These include: - a weak UAC unable to fulfill fully its coordinating mandates for the national HIV/AIDS response; - failure of implementers at the lower levels (especially districts and communities) to adopt the most effective interventions; - the failure to reach high-risk groups with targeted interventions; - complacency and erosion of prevention efforts in the context of introduction of treatment; - risk of escalation of the conflict in the north on project implementation; and - risks related to the project's sustainability. A Quality at Entry assessment by QAG concluded that UACP was prepared quickly and competently, and met all basic criteria for sound quality at entry. It therefore rated the project a solid 2 rating (fully satisfactory) with some elements representing best practice. 2.2 Implementation (including any project changes/restructuring, mid-term review, Project at Risk status, and actions taken, as applicable) The Project did not have the "at risk" status at any time during implementation. There was no project restructuring. The mid-term review (MTR) was conducted in May 2004. According to the MTR, the implementation of project activities were too ambitious and went beyond project capacity and original project cost. While the project objectives and components remained unchanged, it was agreed to give priority to the implementation of district and community interventions, with a special focus on improving the coverage of HIV interventions in the second half of the project. Positive factors and events which influenced the project's achievements More funding for HIV/AIDS control from other sources: At project appraisal, the total external earmarked support for HIV/AIDS control in Uganda was around US$ 17 million per year. During UACP implementation, the landscape of developmental aid for HIV/AIDS changed significantly, especially with the advent of the GFATM and PEPFAR. As a result, resources for HIV/AIDS increased significantly, particularly during the second half of the project. For example, the total public resource envelope (GoU resources plus development assistance) for HIV/AIDS was around US$ 38 million in 2003/04, rising by 150% to US$ 103 million in 2004/05, and again by almost 50% to US$ 151 million in 2005/06. The increasingly prominent ART agenda: Just like many other Sub-Saharan African countries, Uganda saw an increasingly prominent treatment agenda as ART became more affordable and feasible for large-scale implementation. 7 A capable Project Coordination Team (PCT): UACP inherited the PCT from STIP. The capable PCT was familiar with coordinating the implementation of an IDA-financed project as well as IDA procedures. Its strong team provided good operational and technical support to the implementers. To some extent, they helped filled in the gap caused by a not-so-strong UAC, especially in the first half of the project. A good Technical Resource Network: This was established early in the project to provide technical advice to the project and has proven to be a very effective mechanism Negative factors and events which influenced the project's achievements Poor coordination of developmental assistance for HIV/AIDS: While there has been a significant increase in external funding for HIV/AIDS as discussed above, financing modalities have been increasingly fragmented and not well coordinated. The majority of the funding is off-budget and earmarked for donors' perceived priorities in HIV/AIDS. This drives the HIV/AIDS agenda away from the country's ownership and leadership, as well as makes it very difficult to estimate actual expenditure levels and to effectively harmonize these resources. Mismanagement of GFATM resources: In August 2005, GFATM temporarily suspended five grants for Uganda (including those for HIV/AIDS) following an audit report by the Local Funding Agent (LFA) which showed mismanagement of funds. The suspension was lifted in November 2005 after the GoU ordered a judicial inquiry, which confirmed fraud. Although this was not related to the UACP5, and there was never any corruption or governance issue identified in the IDA project, this incident reflects unfavorably on the government's efforts in the fight against HIV/AIDS. Since both the GFATM grants and the UACP support the common NSF, the mismanagement and suspension of the GFATM resources represents a negative development which influenced UACP's achievements. Reduced emphasis on prevention compared to treatment and care: While the increasingly prominent ART agenda is a positive development, it might have some untoward implications as treatment and care in Uganda seemed to have been emphasized at the expense of prevention efforts6. In addition, with the advent of ART, there seems to be a reduced perception of HIV/AIDS as a threat demanding sustained response at all levels. The diminishing role of condoms as a HIV prevention strategy: Uganda's behavioral change strategy has become virtually synonymous with the ABC approach ­ Abstain, Be faithful, use Condoms. It is generally agreed that positive changes in A, B and C behaviors occurred and all of these contributed to the reduction of HIV in Uganda in the 1990s. However, during the last four years or so, there has been a controversial attempt by some stakeholders (outside the project's realm) to solely emphasize A and B and move away from C. This attempt sparked a major national and international debate in prevention strategies which is well documented in the HIV/AIDS literature. Although Uganda's official stance on ABC remained unchanged, and 5 The GFATM grants are managed by a Project Management Unit under the MOH, while UACP was managed by a Project Coordination Team under the Uganda AIDS Commission. 6 For example, the share of care and treatment in Uganda's total public expenditure on HIV/AIDS increased from 3% in 2003/4 to 40% in 2004/5. 8 UACP continued its support for condoms procurement, promotion and distribution; the effectiveness of condom intervention was diminished by such an unfavorable environment. Condom quality and shortage: Condoms in Uganda have been financed by many sources (GFATM, PEPFAR, UACP, etc.). Some batches of Engabu condoms (the type to be distributed free in health clinics, financed by UACP) imported in August 2003 were found to have quality issues when tested through sampling. As the result, they were withdrawn from circulation and destroyed. This incident resulted in (i) mistrust of the Engabu condom brand in the population and (ii) a temporary shortage of condoms while the problem was being resolved. UACP helped Uganda avert the crisis by supporting (i) post-shipment quality control for condoms with the financing of a condom testing machine and (ii) re-branding of the Egabu condoms which passed the quality test and their re-introduction into circulation. With the support of other development partners7, an emergency procurement of 20 million was also conducted. The problem was eventually overcome but, coupled with the de-emphasizing of condoms (discussed above), it certainly had untoward consequences on the effectiveness of prevention efforts in Uganda as indicated by the evidence in lower condom use discussed in section 3.2. Poor procurement planning and supply chain management: Procurement planning was poor for the national HIV/AIDS response as a whole. There was no prioritized procurement plan for HIV/AIDS commodities and this resulted in many emergency procurements. The capacity of National Medical Stores to distribute health commodities was increasingly constrained by the high volume of third party procurements. Under UACP, the issue of poor procurement planning was identified early and aggressively addressed by the Bank team, the PCT and implementers. Project procurement planning significantly improved after the mid-term review. Limited capacity of the UAC: UAC had limited capacity and was unable to fulfill its coordination and leadership mandates in the beginning. This was recognized as a significant constraint to the national HIV/AIDS response, and stakeholders (including UACP) worked hard to address this. A Partnership Committee and a Partnership Fund were established to support UAC in fulfilling its coordination roles. UAC became stronger in the second year of the project, and successfully conducted the annual HIV/AIDS Partnership Forum, Annual Joint Reviews, etc. However, challenges remained such as the need to better harmonize HIV/AIDS funding, inputs and activities from different initiatives. Cash flow problem: Due to the limited financial management (FM) capacity of a large number of implementers, especially at the lower levels, financial accountability reports were often delayed. This in turn affected the replenishment of the Special Account and resulted in a severe cash flow problem for the project. It was considered as the most important bottleneck in project implementation for the first half of the project. UACP addressed this problem by: (i) simplifying FM procedures and manuals for implementers; (ii) providing training and support in FM; (iii) contracting accounting firms to provide accounting services; (iv) increasing the size of the Special Account; and (v) switching to the Financial Management Report (FMR) disbursement system. This was solved by the end of 2003 and project disbursement significantly improved. Limited targeting of high-risk groups with preventive interventions: Although targeted preventive interventions were featured in the project design, implementation of this approach was limited. 7 DFID, DANIDA and Ireland Aid 9 The MTR pushed for socio-geographical mapping of high-risk groups to facilitate targeted interventions. This was carried out to some extent (e.g. the study of fishing communities around Victoria Lake), but in general, with regard to prevention, there was more focus on IEC/BCC for the general population. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E Design: UACP has a reasonable M&E logical framework and an elaborate set of indicators which were developed in close consultation with implementers. M&E arrangements were thorough. Methodologies and strategies for data collection were envisioned from the beginning. Roles and responsibilities of different implementers in M&E were well defined. In general, intermediate and outcome indicators were adequate to monitor progress toward the first and second PDOs (prevention and mitigation). However, there are some areas in the M&E design which could have been strengthened. These include: (i) HIV prevalence was used as one of the impact indicators. (This is a common problem for most of the first-phase MAP projects and being addressed by IDA through the restructuring of active MAP projects) (ii) Indicators for preventive interventions targeting high-risk groups were inadequate. (iii) Given the gender differences, targets for some indicators (especially behavior) should be set differently for women and men when possible. (iv) Indicators for the third PDO (capacity building) were inadequate. Especially, there are no indicators to assess the improvement in institutional development and capacity strengthening for UAC and communities. (v) The link between the project M&E and the national strategic framework M&E could have been better defined and elaborated. (vi) In the M&E framework, there seems to be the assumption that the expected outcomes are solely attributable to project inputs and outputs. However, there should have been the acknowledgment of the problems of attribution; as UACP is only one part of the national response to HIV/AIDS, and many other non-UACP activities also contribute to the achievement of the PDOs. The M&E design is rated substantial. M&E Implementation: Similar to most MAP projects, M&E implementation was a challenge for UACP, especially during the first half of the project. While M&E arrangements were well thought out in the design as discussed above, it took some time for them to operationalize. For example, the MIS only became functional two years into the project, and it was not until after the MTR that UACP was able to recruit the M&E Specialist. However, once the arrangements were in place, very good progress was made in M&E, especially after the MTR. Thanks to simplified reporting formats, streamlined and strengthened MIS, and M&E capacity building for stakeholders, UACP was able to significantly improve data collection, the information flow, and the timeliness and completeness of reporting by most implementers. This enabled quarterly reports to be produced on time. A culture of information-based decision making and planning was introduced (see below).. Baseline data were supplemented by higher quality information from population-based surveys (e.g. UDHS 2001) during project implementation. After MTR, the project also fine-tuned its key indicators and targets with the availability of better data from the UDHS and LQAS 10 surveys. This was a commendable effort to make the indicators easier to monitor and targets more realistic, although the revision did not go through formal approval procedures. . A highlight of M&E under UACP is the implementation of the LQAS survey. Although this relatively low-cost and simple household survey instrument was not included in the original M&E design, the country and the task team, with the technical support of from the Global HIV/AIDS Monitoring and Evaluation Team, successfully introduced this methodology into Uganda with two rounds of LQAS surveys ­ one before the MTR and one before the end of project. This favorably reflects on the project's readiness and flexibility to adopt new M&E techniques during implementation. In fact, UACP was the first HNP project in the Bank to apply this survey instrument, which generates information on the coverage of key HIV interventions at the sub-district level. Feedbacks from implementers were extremely positive: they felt greatly empowered through their direct participation in the survey and their use of the findings for planning. This was considered to be a M&E best practice and was shared in various international fora. Interestingly, Ugandan implementers were able to internalize this methodology and conducted the subsequent rounds by themselves and at a significantly lower cost. They also extended the application of LQAS to other areas such as child health, investigating Schistosoma mansoni prevalence, social services mapping, etc. However, there are a couple of M&E implementation issues. First, the revision of indicators and targets after the MTR should have been adopted through formal approval procedures. Second, the link between UACP M&E and the UAC M&E system was not strong. Due to this disconnect, it was mostly the M&E capacity of the PCT that was strengthened rather than that of UAC. After the project closing, the MIS of UACP was transferred to and harmonized with UAP M&E system. Implementation of M&E is rated substantial. M&E Utilization: The use of M&E for decision making was good, especially of the LQAS information. For the first time in Uganda, districts had solid information on their performance to inform decision making, which was reflected in all UACP districts' HIV/AIDS work plans. This is a good example of decentralized M&E to generate local information for local decision making. LQAS as well as other M&E data were also used by the stakeholders to make tactical changes to the project activities at mid-term review. The utilization of data is rated substantial. 2.4 Safeguard and Fiduciary Compliance (focusing on issues and their resolution, as applicable) Safeguards: The project was given a C rating for environmental safeguards and therefore no environmental assessment was required. On the other hand, an environment assessment (including heath) was conduced under the PRSC project and environmental safeguards were fully complied with in the context of PRSC. Financial management: As discussed above, in the first half of the project, there was a severe clash flow problem due to two reasons. First, under a decentralized arrangement, UACP involved a large number of grass-root level implementers with limited fiduciary capacity. This resulted in delays in submission of receipts of accountability by implementers to the PCT and affected the replenishment of the Special Account. Second, the size of Special Account was small. This was successfully resolved by: (i) an increase in the size of the Special Account; (ii) the use of four 11 accounting firms to support districts to prepare accountability reports; which tremendously improved the turn-around time and quality of accountability reports; (iii) simplified procedures for the disbursement of community grants in line with new IDA disbursement guidelines for community sub-projects under MAP; and (iv) the conversion to FMR-based disbursement. Otherwise, there was no major financial management issue. All the audit reports were submitted in compliance with IDA requirements and deemed to be unqualified. Procurement: As discussed above, the key challenge was poor procurement planning for the national HIV/AIDS response as a whole, resulting in many emergency procurements. Procurement capacity of CHAI implementers was particularly limited. This problem was addressed by: (i) close implementation support in procurement; (ii) revision and adherence to the project procurement plan; (iii) development and dissemination of a simple manual for procurement planning for communities; and (iv) simplification of the Project Procurement Guidelines for districts and communities. As the result, procurement by lower level implementers significantly improved in the second half of the project. The positive lessons from the CHAI procurement were used by the government in revising the Local Government Act to allow for community procurement. By the project end, all UACP procurements were completed. There were no major issues identified by ex-post procurement reviews. 2.5 Post-completion Operation/Next Phase (including transition arrangement to post-completion operation of investments financed by present operation, Operation & Maintenance arrangements, sustaining reforms and institutional capacity, and next phase/follow-up operation, if applicable) Toward the end of the project, steps were taken to transfer some capacity, especially in M&E, from PCT to UAC. Other than the use of Northern Uganda Social Action Fund (NUSAF) project to support community sub-projects in the north, GoU has not put in place systematic arrangements to continue support for HIV/AIDS activities by communities and some line- ministries. IDA recently conducted a scoping mission to Uganda to discuss with the government and partners on future options for IDA's continued support to the national HIV/AIDS response. As discussed above, over the last three years, there have been significant increases in external support for HIV/AIDS in Uganda. The challenge is to harmonize and consolidate those different funding sources to improve effectiveness and efficiency of HIV spending. IDA will support a study to review available external funding for HIV/AIDS and identify additional financial needs. Future IDA support and its modality will hinge upon the recommendations of the study. There is also a plan to consolidate all IDA CDD operations (include support for HIV/AIDS at the community level) into one project. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation (to current country and global priorities, and Bank assistance strategy) Relevance of PDOs: As of the time of ICR, the PDOs are still highly relevant because (i) HIV/AIDS remains a significant threat to health and development in Uganda, (ii) addressing HIV/AIDS is part of the 5th pillar in the country's current Poverty Eradication Action Plan (PEAP) of 2004, and (iii) HIV/AIDS is one of the priorities of the current Uganda Joint Assistance Strategy prepared by IDA and other development partners. Relevance of design: First, the recent significant injection of external HIV/AIDS funding from different sources calls for improved planning and coordination of the national response. This includes the need for harmonization and consolidation of different funding mechanisms and 12 inputs for HIV/AIDS to improve the efficiency of HIV/AIDS expenditures. In this context, a SWAP-like operation embedded in the National Strategic Plan for HIV/AIDS would be in a better position to help the government use resources more efficiently and effectively, regardless of the source. Second, the design lacked a technical and economic assessment of the NSF. Instead of accepting the NSF as a whole, the project should have conducted a technical and economic assessment of the plan to prioritize interventions and identify priority areas which the project should focus on. Third, the link between HIV/AIDS and other closely related health issues in the design is weak. This is a missed opportunity, as HIV/AIDS has strong links to other health issues such as sexual and reproductive health, and tuberculosis. Therefore, the relevance of the project design is only modest. Relevance of implementation: At the time of the ICR, project components and implementation arrangements are still substantially relevant. However, the number of multi-sectoral and civil society implementers should be limited to those with the largest potential impact on the epidemic based on their comparative advantages. On balance, relevance of objectives, design and implementation is substantial. 3.2 Achievement of Project Development Objectives (including brief discussion of causal linkages between outputs and outcomes, with details on outputs in Annex 2) UACP supported the goals of the NSF, which is in turn also financed by many other different sources of funding (GoU, GFATM, bilaterals, etc.). All of these contribute to the same higher level objectives of prevention, care, support and mitigation. In this context, different inputs from different projects (or sources of funding) often contribute to the same outputs and outcomes. This makes attribution almost impossible. Therefore, instead of attempting to attribute a certain extent of the achievement of the PDOs to the UACP, the ICR will examine the contribution of the project to the achievement of the PDOs. In addition, the revision of indicators and targets at MTR, while represents an improvement, did not go through formal approval process as discussed above. For this reason, this ICR (i) relies on the original indicators and targets as the basis for assessment (as shown in the Results Framework Analysis or RFA) and (ii) uses the progress against the revised indicators and targets as additional evidence. PDO1 (Reduce the spread of HIV infection). According to the 2005 National HIV Sentinel Surveillance data,, the target of reducing the HIV prevalence among pregnant women to below 6% was met in rural areas (5%) but missed in urban areas (7%). According to the 2005 UHSBS data, this target was almost achieved (6.5% in pregnant women). However, HIV prevalence rate is not a good indicator for progress in reducing the spread of HIV infection. Incidence, while a better indicator for this purpose, is difficult to monitor8. Available estimates of adult incidence rates through modeling indicate: (i) a steep fall in incidence in the late 1980s and early 1990s, long before the start of the project; (ii) stabilization of incidence during most of the project implementation period; and (iii) a small increase in the last two years (Graph 1). 8 Incidence is monitored though cohort studies. On this basis, national incidence is estimated through modeling. 13 Intermediate outcome indicators related to behavior change are better indicators of prevention progress9. As demonstrated by UDHS and UHSBS data in the RFA, out of the project's three behavior indicators, two show progress for women between 2001 and 2005, namely (i) increasing condom use in last high-risk sex (from 28% to 47%) and (ii) reducing the proportion of sexually active youth (from 49% to 46%). However, these two indicators worsen for men (from 59% to 53%, and 39% to 42%, respectively). The third behavioral indicator (non-regular sex partners) indicate set backs for both genders, with the proportion of women reporting non-regular sex partners increasing from 11% to 15% and men from 21% to 37% over the same period. If one considers the progress against the revised indicators and targets at MTR which were monitored by the LQAS surveys, the data seem to confirm worsening trend in condom use in men (Table 1). However, the two rounds of LQAS surveys show that the revised target of reducing the proportion of youth aged 15-24 having sex with non regular partners to below 20% was fully achieved (16.8%) in the UACP districts (Table 1). They also show significant increases in HIV/AIDS related knowledge between 2003 and 2006 in UACP districts (See Table 2 of Annex 2 for more details). The goal of reducing reported STIs in men aged 15-49 was not achieved either against the original target (see the RFA) or the revised one (Table 1). On the other hand, there was a marked increase in the utilization of VCT and PMTCT services in UACP districts. Between 2003 and 2006, the proportion of adults who had used VCT service and received their test results increased from 23% to 32.3% for men, and from 24.5% to 38.3% for women. The proportion of mothers of young infants using PMTCT service also increased from 13.7% to 34.5%. These correspond with a significant scale up in VCT and PMTCT services in as shown in the RFA. In conclusion, it is a mixed picture in HIV/AIDS prevention with: (i) no significant increase in incidence; (ii) improving knowledge of HIV/AIDS;, (iii) improvement in two project behavior indicators for women; (iv) achievement of one revised behavior indicator and corresponding target for youth; (v) increases in VCT and PMTCT utilization; and (v) stagnation or declination in other safer sex behavior and practices, including condom use For these reasons, achievement of PDO1 is rated as modest. UACP contributed to this PDO through supporting: (i) condom procurement (160 million male condoms), quality control, promotion and distribution; (ii) procurement of STI drugs and diagnostics, HIV test kits, infection control supplies; (iii) scaling up VCT and PMTCT services; and (iv) IEC/BCC activities at national, district and communities levels. The latter include: (i) the development and implementation of a Multi-sectoral Behavior Change Communication Strategy in 24 districts; (ii) the development and dissemination of IEC/BCC materials; (iii) life skills program in 130 secondary schools; (iv) mass media campaigns (e.g. radio programs); (v) community BCC in CHAIs. (See Table 3 of Annex 2 for more details). 9UDHS and UHSBS data are comparable, but not with results of the LQAS due to different methodologies. LQAS was carried out in the UACP districts only and the results from different rounds are comparable. 14 Graph 1: Adult HIV incidence estimates in five Eastern and Southern African countries 5% Kenya Rw anda 4% South Africa Tanzania Uganda 3% 2% 1% 0% 0 2 4 6 8 0 2 4 6 8 0 2 4 6 8 0 198 198 198 198 198 199 199 199 199 199 200 200 200 200 200 201 Source: UNAIDS 2006 (provided by GAMET) PDO2 (Mitigate the health and socio-economic impact of HIV/AIDS at individual and household and community levels) Coverage of care, support and mitigation interventions for PLWHAs and OVCs has significantly increased in 30 UACP districts. According to the LQAS data, the proportion of PLWHA registered with service organizations benefiting from some form of support increased from a baseline of 30% in 2000 to 76% in 2003 and 86% in 2006. Between 2003 and 2006, there was a significant increase in the number of beneficiaries of care and support by the project - six-fold for PLWHA (from 5,504 to 33,309) and 23-fold for orphans (from 12,979 to 301,129) (Table 1). Over the same period, the percentage of school-age orphans (6-18 years) receiving educational support from the project increased from 14% to 22%. This increase was from 18.8% to 30.4 % for CHAI villages, and from 13.6% to 20.9% for non-CHAI villages in UACP districts (Table 2). Anti-retroviral Therapy (ART) was scaled-up significantly, covering 85,000 out of approximately 200,000 eligible patients10. However, the target for school attendance for orphans was not met (71% against a target of 80% established at MTR). The coverage of DOTS for the management of TB, a common opportunistic infection in PLWHA, improved significantly from 13% to 100% of the districts. The achievement of PDO 2 is therefore rated as substantial. UACP contributed to this PDO through supporting: (i) the launch of the public sector free ART program with the procurement of ARVs, CD4 count machines, and other laboratory equipment, (ii) drugs for TB and other opportunistic infections, (iii) care and support for 33,309 PLWHA, and (iv) care and support for more than 0.3 million OVC. (See Table 3 of Annex 2 for more details). 10 . ART was jumpstarted with UACP support and this coverage was subsequently achieved with contribution from other initiatives (e.g. GFATM and PEPFAR) as well. 15 PDO3 (Strengthen the capacity of communities, civil society and government to respond to the epidemic) UACP had a significant role in building up the capacity in HIV/AIDS policy development, planning, implementation and M&E for stakeholders in key sectors and at all levels. The project was highly successful in strengthening the capacity of communities and districts. After UACP funding ended, many of the district CSOs and CHAI groups, with their enhanced capacity, have become implementers under other partners' HIV/AIDS initiatives. The project thus helped build a strong capacity foundation from which other programs (e.g. GFATM, PEPFAR) are benefiting. UACP's contribution to building the capacity of line ministries and national CSOs is also substantial. On the other hand, the strengthening of UAC to fulfill its coordination mandates only happened in the second half of the project as discussed above. UACP contributed to this PDO through supporting capacity building and the operation of: (i) the HIV/AIDS Committee and the HIV/AIDS focal person in each of the 15 line ministries; (ii) the District HIV/AIDS Committees and District HIV/AIDS Focal Persons in 30 districts; (iii) 38 national and 233 district levels CSOs; and (vi) 3,627 community groups. It also supported the training of health professionals, local government personnel and Community Development Officers in various HIV/AIDS-related topics. Details of the achievements of this PDO at different levels are further elaborated in the discussion below on project achievements by components as well as in Table 3 of Annex 2. The achievement of this PDO is rated as substantial. Overall, the achievement of all three PDOs is rated as substantial. Table 1. Progress against some revised project indicators and targets: Indicator Baseline (MTR) Target 2006 (end-of- project) Prevention % of men aged 15-54 reporting STIs 19.7% urethritis 10% urethritis 14.9% urethritis 10.0% urethral 5% urethral 16.2 % urethral discharge discharge discharge % of 15-24 years old reporting sex with non-regular 30.2% Below 20% 16.8% partner in the past 12 months % of sexually active persons reporting condom use in 46.2% for men 60% for men 24.0% for men the last sexual act with a non-regular partner 3.3% for women 20% for women 3.8% for women Mitigation % of PLWHAs identified by CSOs that are receiving 75.9% 90% 86.3% some form of psychosocial support The number of PLWHAs identified through the 5,504 7,706 (40% 33,309 project that are receiving care (from the project) increase) % of orphans who attended school 5 days in the 69.7% 80 % 71.1% preceding week The number of orphaned children identified through 12,979 19,469 301,129 the project that are receiving educational support (50% increase) (>100% (from the project) increase) Source: LQAS and PCT 16 Table 2: Findings of the two LQAS surveys: Outcomes for OVC in CHAI and non-CHAI villages (2003 and 2006) Indicator 2003 2006 CHAI Non-CHAI CHAI Non-CHAI (%) (%) (%) (%) OVC in school 81.9 82.9 78.3 77.0 OVC attending school 5 days in last 64.7 70.3 73.6 70.7 week OVC receiving educational support 18.8 13.6 30.4 20.9 School fees 16.1 10.5 23.6 17.4 Uniforms 16.3 11.5 27.4 20.7 Scholastic material 17.2 12.6 28.3 22.5 OVC receiving psychosocial support 22.4 9.3 13.3 12.4 in last one month OVC receiving material support 11.5 5.2 11.0 8.8 Beddings 6.0 1.8 8.0 5.3 Clothing 9.8 2.7 6.5 3.9 Agricultural materials 3.8 2.6 1.2 2.8 Food support 4.1 2.1 7.6 7.0 Source: LQAS 2003 and 2006 (UAC) Achievements by Components Component 1: National level (US$ 36.2 million or 65% of total project cost11) All 15 line ministries were able to appoint HIV/AIDS focal persons, formed functional HIV/AIDS committees, and implemented HIV/AIDS work plans. Sector HIV/AIDS policies, strategic plans and mainstreaming guidelines were developed. However, in many cases, mainstreaming HIV/AIDS was mostly restricted to workplace programs, and "external" mainstreaming (e.g. reaching out to the populations served by the sector) was limited. Strong performers include the Ministry of Health, the Ministry of Education and Sports, and the Ministry of Gender, Labor and Social Development which have witnessed rapid scaling up of their programs in the last two years. Other than the strong performers, national line ministries' support to their counterparts at lower levels could have been better. In addition to the line ministries, 38 national-level NGOs were also supported to carry out HIV/AIDS interventions. Especially, the project helped with the establishment and strengthening the national networks of PLWHA and AIDS support organizations. UACP helped strengthen the Uganda AIDS Commission through: (i) supporting technical assistance in finance, planning, monitoring and evaluation; (ii) supporting development of the overarching policy on HIV/AIDS; (iii) revision of the NSF; and (iv) construction of the new UAC headquarters. These, together with creation of the Self Coordinating Entities and the coordination framework for district HIV/AIDS activities, enabled the Uganda AIDS Commission to enhance its coordination role. While institutional arrangements were put in place, UAC is still facing a major challenge in coordinating, harmonizing and monitoring various HIV/AIDS financing 11 Of this, US$ 27.19 million (36% of total project costs) were for the procurement HIV/AIDS commodities to be used at all levels and in all 56 districts. 17 mechanisms in country, making it difficult to effectively determine, plan and deploy inputs for HIV/AIDS. The achievement of this component is rated as modest. Component 2: District level (US$ 8.69 million or 15% of total project cost ) With UACP support, 30 districts were able to formulate and implement comprehensive multi- sectoral HIV/AIDS work plans in line with the decentralization policy. District level work plans included IEC/BCC, condom promotion and distribution, VCT and PMTCT, Directly Observed Treatment of Tuberculosis (DOTS), management of STI, treatment, care and support for PLWHA, capacity building activities as well as mobilizing and supervising CHAI initiatives. 233 district-level CSOs were also supported to carry out HIV/AIDS interventions. School-based BCC programs and CSO activities are reported to be among the most successful activities under the district component. The project supported district-level coordination, planning and implementation of HIV/AIDS activities through the establishment and operationalization of District HIV/AIDS Committees which has been strengthened since MTR. A recent study shows that UACP-supported districts have better institutional arrangements for planning and reporting of their HIV/AIDS programs. UACP funded training of over 1000 personnel from district local governments as well as district level CSOs in strategic planning; 184 Community Development Officers (CDOs) from the 30 districts to serve as trainers of trainers to train Community Development Assistants (CDAs) in the districts and backstop DAC and CSOs in monitoring all district community HIV/AIDS initiatives. UACP also funded the training of: (i) 564 sub-country level CDAs from 30 districts to strengthen the local government's capacity for mobilizing community; (ii) 450 district level government and non-government service providers from 30 districts in LQAS, (iii) 227 district health personnel from 4 districts in the use of the new HMIS that incorporates HIV/AIDS indicators; (iv) 78 district personnel from 30 districts in the use of database for HIV/AIDS data collection, management and reporting; (v) 1172 agricultural and fisheries extension workers in HIV/AIDS; and (vi) 1074 farmers through the Uganda Farmers Federation. Especially, the project supported the establishment of district and sub-district network of PLWHA and by doing so strengthened the participation of PLWHA. The achievement of this component is rated substantial Component 3: Community level (US$ 11.30 million or 20% of total project cost) 3,627 CHAI groups were supported by UACP with a total direct funding of US$ 9.78 million, providing: (i) educational support to 301,129 orphans; (ii) care and mitigation support to 33,309 persons living with HIV/AIDS; (iii) IEC/BCC interventions for more than 0.5 million people (Table 3). The majority of sub-projects were OVC-related. The LQAS surveys of 2003 and 2006 show better outcomes for orphans in CHAI villages than those in non-CHAI villages (Table 2). There were fewer projects in home-based care, community AIDS education, and condom distribution. However, this component built up a network of providers who went on to implement other HIV/AIDS initiatives funded by other development partners. CHAI has often been recognized by stakeholders as the most successful and popular component of the project which greatly contributed to the empowerment of communities. 18 Table 3. Community interventions Type of interventions Beneficiaries Subprojects No. No. % Education support (fees, uniforms other 301,129 2,355 81 materials) Material Support (beddings, cloths) 173,509 1,897 66 General mobilization/sensitization 272,659 952 33 Home based care 68,466 642 22 Community AIDS education 542,558 585 20 Agriculture/food production 15,567 252 9 Condom education/promotion 54,141 97 3 Source: Uganda HIV/AIDS Control Project. The achievement of this component is rated as high. 3.3 Efficiency (Net Present Value/Economic Rate of Return, cost effectiveness, e.g., unit rate norms, least cost, and comparisons; and Financial Rate of Return) Efficiency is modest for various reasons. First, in the NSF which UACP supported, there was little prioritization of interventions on the basis of cost-effectiveness12. As the result, there was an imbalance between prevention vs. care, treatment and support. Second, within prevention, there was little targeting of the drivers of the epidemic and geographical "hot spots". Third, the integration of HIV/AIDS activities was limited, especially among CHAI. For example, many community sub-projects tended to focus on narrow aspects of care or support while other interventions such as BCC and condom promotion could have been added without significant marginal costs. Fourth, the government's weak harmonization and coordination of various HIV/AIDS resources and inputs from different sources also made UACP less efficient. 3.4 Justification of Overall Outcome Rating (combining relevance, achievement of PDOs, and efficiency) Rating: moderately satisfactory With a substantial (or 3 out of a 4 point scale) rating for project relevance, substantial (3 out of 4) rating for project efficacy and modest (2 out of 4) rating for efficiency, the overall outcome rating is moderately satisfactory (8 out of 12 point scale). 3.5 Overarching Themes, Other Outcomes and Impacts (if any, where not previously covered or to amplify discussion above) a) Poverty Impacts, Gender Aspects, and Social Development HIV/AIDS is a well known cause of poverty. By limiting the spread HIV and mitigating its consequences, the project is expected to have helped to prevent or reduce HIV-related poverty. Unfortunately, the extent of the project's poverty reduction impacts cannot be quantified. However, the majority of the beneficiaries of the community-led interventions are OVCs, PLWHA, AIDS-afflicted households and the rural poor. There seems to be a gender balance 12 The new National Strategic Plan for HIV/AIDS 2007/8-2011-12 which is being finalized addresses this issue through a costing and prioritization exercise. 19 among the project beneficiaries. For example, 50.6% of all OVC supported by the UACP were female. (b) Institutional Change/Strengthening (particularly with reference to impacts on longer-term capacity and institutional development) As discussed above, institutional strengthening is substantial, especially at the lower levels. Districts and communities have been mobilized and greatly empowered to implement HIV/AIDS interventions. This is one of the high lights of the project. In fact, the strengthened community capacity under UACP informed the revision of the Local Government Act to better enable community participation in grass-root development. (c) Other Unintended Outcomes and Impacts (positive or negative) N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops (optional for Core ICR, required for ILI, details in annexes) An end-of-project stakeholder workshop was held with participants from different levels. Key findings on project achievements included: (i) the project played a critical role in operationalizing the multi-sectoral response; (ii) capacity for HIV/AIDS response was strengthened at all levels; and (iii) the community response stood out for being innovative and the most successful component of the project. The main challenge identified was to maintain some of these successes after the project closing as, other than UACP, there was no other funding mechanism which systematically financed the multi-sectoral and community activities. This in turn pointed to the need for a follow-on project. The workshop also discussed the cross cutting issues of the national HIV/AIDS response, namely the shortages of HIV/AIDS commodities due to poor procurement planning and supply chain management, as well as the fragmentation of HIV/AIDS funding mechanisms. 4. Assessment of Risk to Development Outcome The risk to development outcome is significant for the following reasons: Institutional: The PCT was the key provider of coordination and implementation support for UACP implementers. After project closing, some of the PCT capacity was absorbed by the UAC. However, it is obvious that implementers will not be able to get the same level of support as under UACP. Financial support for the multi-sectoral and community response: For most line-ministries, HIV/AIDS has not been mainstreamed in their sector annual budgets. Some key line ministries (e.g. Health, Education) have access to funding by other donors after project closing. Other than that, there is no mechanism to systematically sustain the multi-sectoral response. The situation is similar for the community component. This shows the need to develop longer-term funding mechanisms for the multi-sectoral and community response. Prevention: As shown by recent data, the risk of prevention complacency and reversal of good behavior is significant. This can be exacerbated by inappropriate prevention strategies (e.g. abstinence only) and the failure to target the drivers of the epidemic with effective preventive interventions. Treatment sustainability: Most of the current external support is time-bound and earmarked for treatment and care. While treatment is a long-term agenda, there is no mechanism to ensure financial sustainability for treatment. This unresolved issue is critical, given the need to: (i) continue treatment for those already on ART; (ii) expand ART to other eligible patients; and (iii) 20 address the eventual emergence of HIV strains resistant to first-line drugs which will drive up the cost of ART. To help the country better address the risk to development outcomes, the Bank conducted a scoping mission in April 2007 to identify areas which IDA can provide support as the next steps. 5. Assessment of Bank and Borrower Performance (relating to design, implementation and outcome issues) 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase) The project was efficiently prepared in record time. Overall, the financial, technical and institutional aspects of design were appropriate. As discussed in 2.1, the project objectives were responsive to the government's NSF. Structured along the lines of a standard MAP, the design also used Uganda's extensive experience in fighting HIV/AIDS, the lessons from previous IDA operations, as well as from other sectors (especially social funds). Despite the time constraint, the team ensured adequate consultations, and detailed preparation for the start-up period. Design could have been strengthened by: (i) a technical and economic assessment of the NSF; (ii) a more realistic risk assessment and mitigation; (iii) a focused multi-sectoral approach; and (iv) inclusion of capacity building indicators in the result framework. A quality at entry assessment was conducted by QAQ with which graded Bank performance as satisfactory. The assessment focused on institutional aspects, M&E, risks and implementation. However, it did not discuss issues such as prioritization of interventions, technical efficacy and efficiency of the project design. The Bank performance in ensuring quality at entry is rated moderately satisfactory (b) Quality of Supervision (including of fiduciary and safeguards policies) Regular supervision was conducted with quality implementation support, especially in public health, community response, M&E, institutional arrangements and the fiduciary areas. Especially, the Bank involved sector specialists (education, CDD, gender) in supervision, who were instrumental in conducting dialogue and providing support to their respective ministry counterparts. The transfer of the task team leadership to the country-based staff facilitated interactions with and support to implementers on a continuous basis in the second half of the project. An on-time and thorough MTR was conducted which greatly enhanced implementation in the second half of the project. With the introduction of the LQAS methodology, the task team significantly strengthened the "learning by doing" approach. During implementation, the Bank fostered good partnerships with other DPs. This improved their understanding and buy-in of the project. Good dialogue was maintained with the GoU throughout the project. The Bank managed to leverage its IDA funding to help address various cross-cutting issues. For example, through the financing of the first batch of ARVs, the Bank successfully encouraged the government to develop a national ARV strategy. The Bank team was proactive in helping the client to address bottlenecks in procurement and financial management as discussed above. An area in supervision which could have been strengthened was that more dialogue and technical assistance would have helped the project better to address the targeting agenda in prevention. The Bank's performance in ensuring quality supervision is rated satisfactory. 21 (c) Justification of Rating for Overall Bank Performance With satisfactory preparation and supervision, the overall Bank performance is satisfactory. 5.2 Borrower Performance a) Government Performance The Government prepared for this project well, most notably with the development of the NSF, one of the first comprehensive national HIV/AIDS strategic plans in Africa, which served as the project's foundation. This was one of the factors enabling the project preparation to be completed in record time. All the covenants and agreements were complied with. Counterpart funding, though delayed at various points of the project's life, was eventually fulfilled as as planned. However, there are areas in which Government performance could have been improved. (i) The Project Steering Committee, established to provide general oversight to project implementation, did not meet regularly and was unable to provide adequate guidance to the project. (ii) The mismanagement of the GFATM grants, though not related to the project as discussed above, reflected unfavorably on the government's efforts in the fight against HIV/AIDS. (iii) The GoU should have acted more aggressively to address the "abstinence only" controversy. The Government's performance is rated moderately satisfactory. (b) Implementing Agency or Agencies Performance UAC: UAC capacity was limited at the beginning. After the first year, it became stronger and was able to carry out its coordination functions. However, it is still facing major challenge in coordinating various funding sources for HIV/AIDS. On the other hand, the PCT was very capable and formed the backbone for the project coordination. In many cases, it played the role of the UAC in supporting the project implementers at all levels. The PCT was theoretically considered to be part of the UAC, but given its limited lifespan (it was disbanded after project closing) and independent mode of operation, its satisfactory performance cannot be counted toward UAC's performance. For the above reasons, UAC performance is rated as moderately satisfactory. Line ministries: As discussed above, the performance of line ministries is moderately satisfactory. Districts, Communities and CSOs: As discussed above, the performance of districts, community and CSOs is satisfactory. Overall, the performance of implementing agencies is moderately satisfactory. (c) Justification of Rating for Overall Borrower Performance Considering (a) and (b), the overall Borrower's performance is moderately satisfactory. 6. Lessons Learned (both project-specific and of wide general application) The multi-sectoral approach: First, there is a need for a more focused multi-sectoral approach which prioritizes sectors with the largest potential impact on the epidemic such as health, education, transport, labor, gender and defense on the basis of their comparative advantages. Second, mainstreaming in the multi-sectoral approach should go beyond workplace interventions 22 for staff in the line ministries to include interventions for the populations which the sectors serve. Third, technical assistance to key line ministries is important in building capacity, and this includes the involvement of sector specialists to provide support to line ministries. Fourth, district departments that received regular and consistent support from the central line ministries have a better chance of success, which underlines the importance of central support to lower-level sectoral implementers. Community response: Communities can be successfully mobilized to implement HIV/AIDS interventions. CHAI has put them into the driver's seat in the grass-root development agenda13.However, the demand-driven community response tends to focus on certain areas deemed by communities as priorities such as support for OVCs and PLWHA while not adequately addressing topics such as the targeting of high-risk groups, BCC and condom promotion. To improve the effectiveness of the community response, efforts should be made to: (i) provide communities with adequate guidance on "what works" in HIV/AIDS; (ii) encourage the integration among various community-level HIV/AIDS interventions; (iii) provide user- friendly BCC instructions/materials to guide community HIV/AIDS discussions; and (iv) strengthen the link between community and HIV/AIDS service providers. In addition, where CSOs are used to mobilize, provide support and supervise communities, community sub-projects are more successful. Prevention: The risk of scaling up care and treatment agenda at the expense of prevention is real.. Financial sustainability of the ART efforts is unlikely if Uganda is unable to reduce the number of new infections. Targeted preventive interventions for high-risk groups and IEC/BCC for the general population are not mutually exclusive. There is still a need to focus on the drivers of the epidemic in a generalized epidemic setting like Uganda. HIV/AIDS commodities: It is critical to ensure a non-disrupted supply of HIV/AIDS commodities (condoms, drugs, test kits etc.) through good procurement planning and supply chain management. This is especially important for district-level implementation. M&E: The success of the LQAS demonstrates the importance of the principle "local information for local decision making". It also greatly facilitates the "learning by doing" approach. Coordination of various HIV/AIDS funding sources: While Uganda has very advanced health SWAP, the national HIV/AIDS response is less well coordinated. Little is known about the fund flows or who is funding what for HIV/AIDS. There is a need to put in place functional mechanisms for coordination, alignment and harmonization of the major funding streams for HIV/AIDS. Transparency and accountability: As discussed above, unlike the GFATM grants, there was no corruption/governance issue identified under UACP. This can be attributed to: (i) the use of the independent Technical Resource Network; (ii) the project's emphasis on transparency and accountability of budget allocation and expenditures14; (iii) clear eligibility criteria for 13 Many CHAIs became CBOs or expanded their activity scope beyond HIV/AIDS. 14 For example, budget allocations for the districts are made known to all stakeholders, including members of the parliament, district authorities and community members. 23 implementers; (iv) the contracting of accounting firms to help the districts with financial management issues; and (v) fiduciary capacity building for CSOs. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: The Government reviewed the ICR and was satisfied with the ratings. (Dr. Peter Nsubuga, Project Director) (b) Cofinanciers (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society) 24 Annex 1. Project Costs and Financing (a) Project Cost by Component (in US$ million equivalent) Components Appraisal Estimate Actual/Latest Estimate Percentage of (US$ million) (US$ million) Appraisal Nationally Coordinated Activities 5.00 9.01 180% Nationally Coordinated Activities (large ticket procurements) 20.00 27.19 136% District Activities 10.00 8.69 87% Community-led HIV/AIDS Activities 10.00 11.30 113% Unallocated 5.00 0.00 Total Baseline Cost 50.00 56.19 112% Physical Contingencies 0.00 Price Contingencies 0.00 Total Project Costs 50.00 56.19 112% Total Financing Required 50.00 56.19 112% (b) Financing Actual/Latest Source of Funds Type of Appraisal Estimate %age of Financing (US$ millions) Estimate (US$ millions) Appraisal Borrower 2.50 2.83 113% International Development 47.50 53.36 112% Association (c) Project Financing by Category (in US$ million equivalent) Category Appraisal Estimate Actual/Latest Percentage Estimate of Appraisal IDA GoU IDA GoU IDA GoU Civil Work 2.7 0.3 0.55 0.03 20% 10% Goods 20.9 1.1 20.13 0.73 96% 66% Consultant services & training 4.0 0.0 8.41 0.21 210% Community-based initiatives 9.5 0.5 10.73 0.56 113% 112% Operating expenses 5.4 0.6 13.54 1.30 244% 217% Unallocated 5.0 0.0 Total Cost 47.5 2.5 53.36 2.83 112% 113% 25 (d) Project Cost by Procurement Arrangement (Actual/Latest Estimate) (in US$ million equivalent) Category Procurement Method15 N.B.F Total Cost ICB NCB Others16 Civil Work 0.58 0.00 0.00 0.00 0.58 (0.55) (0.00) (0.00) (0.00) (0.55) Goods 16.02 2.68 2.16 0.00 20.86 (16.02) (2.10) (2.01) (0.00) (20.13) Services & Training 0.00 0.00 8.62 0.00 8.62 (0.00) (0.00) 8.41) (0.00) (8.41) CHAIs 0.00 0.00 11.29 0.00 11.29 (0.00) (0.00) (10.73) (0.00) (10.73) Incremental operating costs 0.00 0.00 14.48 0.00 14.48 (0.00) 0.00 (13.54) (0.00) (13.54) Total 16.6 2.68 36.55 0.00 56.19 (16.57) (2.1) (34.69) (0.00) (53.36) 15 Figures in parenthesis are the amounts to be financed by the Bank Loan. All costs include contingencies. 16 Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units. 26 Annex 2. Outputs by Component Table 1. Project original and revised indicators PAD MTR Revised Baseline Indicator (2001) Target 2006 Indicator Baseline (2003) Target 2006 Actual Estimate 2006 Project Development Objective 1: Reduce the Spread of HIV Infection By 2006, 60 % of secondary schools 0% 60 % By 2006, HIV/AIDS issues for HIV/AIDS not HIV/AIDS HIV/AIDS issues for apply the secondary school inclusion in the secondary school included in the issues for inclusion in the secondary curriculum that incorporates curriculum identified secondary school inclusion in school curriculum HIV/AIDS information curriculum the secondary identified school curriculum identified By 2006, increase from 13 % to 13 % 100% No revision 100% 100% the proportion of districts implementing TB DOTS By 2006, increase from 6 % to 50 % 6 % 50 % No revision 100% the proportion of hospitals providing prevention of mother to child transmission services By 2006, increase from 0 % to 50 % 0 % 50 % By 2006,increase by 50 % the 12,979 (June 2003) 19,469 301,129 (Mar 2006) the number of identified orphaned number of orphaned children children (by sex) that are receiving identified through the project that social support from the project are receiving educational support from the project By 2006, train 60 % of agriculture N/A 60 % 1,172 district agricultural and fishery extension workers on extension workers (963 HIV/AIDS males and 209 women) 27 Increase by 40 % the number of 5,504 (June 2003) 7,706 33,309 (Mar 2006) PLWHAs identified through the project that are receiving care from the project Project Development Objective 2: Mitigation of Health and Social Economic Impact of HIV/AIDS at the Individual Household and Community level By 2006, all relevant line ministries 5 13 By 2006, all relevant line 5 13 15 (13) have incorporated HIV/AIDS ministries (13) have incorporated prevention or mitigation activities in HIV/AIDS prevention or their regular work-plans and are mitigation activities in their implementing them regular work-plans and are implementing them By 2006, increase from 0 to 45 the 0 45 By 2006, 30 (all) UACP supported 0 30 30 number of districts that are districts will be implementing implementing integrated HIV/AIDS integrated (multisectoral) work-plans HIV/AIDS workplans By 2006, increase from 0 to 80 % the 0% 80% By 2006, 80 % of district hospitals 0% 80 % Out of 23 reporting proportion of district hospitals report no stock-outs of essential districts, 16 (31%) had no reporting no stock-outs of essential drugs for managing sexually stock-outs drugs for managing sexually transmitted infections in the last 3 transmitted infections in the last 6 months months By 2006, increase from 20 to 80 % 20% 80% By 2006, 80 % of counties have 20 % 80 % 95 % the proportion of districts that have HIV/AIDS voluntary counseling HIV/AIDS voluntary counseling and and testing centers testing centers The amount of project funding No revision N/A > 25 % 20% disbursed under community-led HIV/AIDS initiatives (CHAI) will account for at least 25 % of all N/A 25% project funds disbursed in the previous 12 months. By 2006, ARVs procured by 0 3,000 3,000 UACP will be accessed by more than 2700 adults and 300 children 28 By 2006, increase proportion of 75.9 % (LQAS 90% 86.3 % (LQAS 2006, 12 PLWHAs identified by CSOs that 2003,12 districts) districts) are receiving some form of psychosocial support to 90 % Project Development Objective 3: Strengthen the Capacity of Communities, Civil Society and Government to respond to the epidemic By 2006, reduce from 49 to under 40 49% Under 40% By 2006, reduce the proportion of 28.3 % (LQAS < 20 % 16.8 % (LQAS 2006, 12 % the proportion of 15-19 years old 15-24 years old who report sex 2003, 12 districts) districts) boys and girls that are sexually active with non-regular partner in past 12 months from to less than 20 % By 2006, reduce from 14 to 10 % the 14% 10% Indicator dropped proportion of sexually active people reporting non-regular sexual partners By 2006, reduce from 15 to 5 % the 15% 5 % By 2006, reduce the proportion of 19.7 % urethritis 10% urethritis 14.9% urethritis and rate of reported sexually (urethritis) reported STIs in men aged 15-54 and 10.0 % urethral 5% urethral 16. % urethral discharge infection in men aged 15-49 in the years in last 12 months - urethritis discharge (LQAS discharge (LQAS 2006, 12 districts) last 12 months to 10 %, and urethral discharge to 2003, 12 districts) 5 % By 2006, reduce by 30% the drop-out N/A Reduce by 30% By 2006, increase the proportion 69.7% (LQAS 80 % 71.1% (LQAS 2006, 12 rate of orphaned children in primary of orphans who attend school for 5 2003, 12 districts) districts) school days in the preceding week to 80 % 29 By 2006, increase from 30 to 50 % 30 % 50 % By 2006, increase the proportion 46% for men and 60% for men 24.0% for men and 3.8% the proportion of men/women aged of sexually active persons who 3.3% for women for women (LQAS 2006, 15-49 who report using a condom in report using a condom the last (LQAS 2003, 12 20% for women12 districts) their last act of sexual intercourse sexual act with a non-regular districts) with a non-regular partner partner to 20 % for females (15- 49yrs) and to 60 % for men (15- 54yrs) By 2006, reduce HIV/AIDS 8.5% 6 % By 2006, reduce HIV prevalence 8.5% Below 6%) Sentinel surveillance: prevalence from 9 to below 6 % below 6 % among women of child 5% for rural, 7% for urban among women attending prenatal bearing age as measured in ANC UHSBS: 6.5% care services By 2006, increase by 50 % the 1,339 (June 2003) 14,128 (Sep 2006) number of youth receiving AIDS education 30 Table 2: Findings of the two LQAS surveys, 2003 and 2006 Indicator 2003 2006 % 95 % CI % 95 % CI Knowledge % of young people who correctly 50.8 2.70 64.8 2.70 identified at least two ways of preventing the sexual transmission of HIV % of women who correctly identified 48.1 2.69 61.0 2.77 at least two ways of preventing the sexual transmission of HIV % of men who correctly identified at 59.8 2.63 72.6 2.54 least two ways of preventing the sexual transmission of HIV % of women who correctly identify 52.1 2.68 59.1 2.79 common symptoms of STIs in women % of men who know at least two of the 45.6 2.67 59.4 2.79 benefits of VCT % of women who know at least two of 37.9 2.55 54.3 2.83 the benefits of VCT % of women with children aged 0-11 78.5 2.27 85.7 3.53 months who know that HIV/AIDS can be transmitted from mother to child % of women with children aged 0-11 49.7 9.21 79.1 4.12 months who know that HIV transmission from the mother to child can be reduced Behavior % of young people reporting having 66.3 2.57 49.7 3.33 had sex in the past 12 months % of young people reporting the use of 56.7 4.59 11.6 1.94 a condom during sexual intercourse with a non-regular sexual partner % of women who had sex with a non- 9.0 1.48 10.9 1.73 marital, non-cohabiting partner %of men who had sex with a non- 23.9 2.37 24.0 2.39 marital, non-cohabiting partner % of women who have ever used a 30.1 2.39 36.0 2.74 condom % of men who have ever used a 49.5 2.69 57.2 2.74 condom % of women who used a condom 3.3 0.95 3.8 0.99 during sex with a non-marital, non- cohabiting partner in the last 12 months % of men who used a condom during 46.2 5.69 11.3 1.72 sex with a non-marital, non-cohabiting partner in the last 12 months VCT utilization 31 % of women who have ever voluntarily 24.5 2.23 38.3 2.74 requested an HIV test, received the test and received the results, by age group % of men who have ever voluntarily 22.7 2.29 32.3 2.55 requested an HIV test, received the test and received the results, by age group % of women with children aged 0-11 13.7 1.83 34.5 2.55 months who were counseled for VCT/PMTCT services Mitigation % of school going-age (6-18 years) 14.2 1.95 22.1 2.365 orphans who have received educational support in the last one year (primary education) % of PLWHAs registered with service 75.9 2.72 86.3 1.98 organizations who received psychosocial support services in the last 3 months % of PLWHAs registered with service 13.4 2.17 41.8 2.84 organizations who received material support in the last 3 months Source: LQAS 2003 and 2006 (UAC) 32 Table 3: Outputs by components Component 1 Component 2 Component 3 Nationally Coordinated Initiatives District Initiatives Community-led Initiatives PDO 1: IEC/BCC Reduce the - A Multi-sectoral BCC Strategy was - The Multi-sectoral BCC Strategy was - 4,881 persons (3 from each CHAI spread of developed implemented in 24 districts group) were trained in IEC/BCC HIV - A HIV/AIDS information flip chart was - School-based and student-led -32,585 youths received HIV/AIDS developed, translated into local languages HIV/AIDS programs were implemented education through CHAIs. and distributed of for 30 districts, 13 line in all secondary schools in project - 542,558 persons received HIV/AIDS ministries, 6 national CSOs and 150 districts. education through CHAIs. secondary schools. - Life skills programs were supported in - A peer-led BCC discussion guide for in 130 secondary schools (4-6 schools per and out-of-schools youths was developed district) in 28 districts. 750 secondary and implemented in school BCC teachers were trained in life skills in programs in 30 districts. secondary schools. - A Community BCC guidelines was - Drama groups were trained in BCC. developed and disseminated to 3,786 - 30 districts were supported to develop community groups (including NUSAF- and implement radio programs in funded ones). HIV/AIDS. - Three PIASCY handbooks for teachers - UACP supported the training of trainers in primary schools were developed and in BCC at the districts level (at least three distributed. per districts). - UACP provided technical inputs for the development of the PIASCY handbooks for secondary schools and supported their production for use in 30 districts. - A consultancy to develop the HIV/AIDS content for the secondary school curriculum. Condom procurement, promotion and distribution - 160 million of Engabu condoms were - 4690 condoms demonstration kits were - Condom promotion for 73,170 persons procured for free distribution. produced and distributed in 21 districts. through CHAIs (the target was to reach - A condom-testing machine was - All 30 districts were supported to train 45,799 persons). 31 procured to enable the Uganda Drug frontline service providers in condom Authority to conduct post-shipment promotion and use. quality control for condoms. - Between January 2002 and 31st August - UACP supported a MOH program to re- 2006, 143,348,943 free male condoms introduce Engabu condoms after they were distributed (MOH data, not were temporarily withdrawn following including condoms distributed through the finding of a defective batch. social marking) Management of STIs - The project procured: (i) 400,000 RPR - 519 health workers from 25 districts test kits for the diagnosis of syphilis, (ii) were trained in syndromic management 1,000,000 adult doses of benzathine of STIs penicillin (3-week treatment course); and - 459,445 syphilis tests were carried out (iii) 2,000,000 adult doses of doxycyline in 30 UACP-funded districts between (2-week treatment course) for all 56 August 2002 and August 2005 (HMIS) districts - Nine (33%) out of 27 of the district hospitals reported no stock-outs of essential drugs for STIs management in the past 6 months in December 2005. VCT and PMTCT 268,000 Determine and 30,000 Unigold - By 30th June 2006, training in HIV test kits were procured and HIV/AIDS counseling and rapid HIV distributed to all 56 districts testing was conducted for: + 1,293 counseling aides + 700 counseling assistants + 50 counselors + 363 counselors for VCT service delivery + 151 district laboratory personnel (in rapid HIV testing) - 12 VCT centers were refurbished. - 2,140 VCT outreach sessions were reported by 29 districts - 829,828 first line HIV tests were carried 32 out in VCT centers in project districts from January 2004 to August 2006. PDO2: Treatment, care and support PLWHA Mitigate the First batch of ARV drugs (for 3,000 - In 30 UACP districts, 123,456 patients - 2,200 home caregivers were trained. health and patients for two years) was procured by were treated for TB from 2002 to 2004. - 33,050 PLWHAs received home care socio- UACP to launch the public sector free - Through the district local governments, - 31,342 PLWHAs received material economic ART program. By 31st August 2006, over UACP supported district CSOs to provide support impact of 30,000 PLWHAs were on ARVs with the care and support to PLWHAs HIV/AIDS support from other initiatives (GFATM, at the PEPFAR) individual, - UACP supported the MOH to procure household CD4 count machines, chemistry and and haematological analysers for the 13 community regional referral hospitals. levels - UACP supported the MOH to procure drugs for TB and other opportunistic infections. Care and support for OVC UACP supported the initiation of orphan - 301,129 OVC received educational registration in four districts. support in school fees, uniforms or scholastic materials. - 9,573 benefited from home visits - 3,027 was supported in household food production through the supply of agriculture inputs (seeds, ploughs, cattles, etc.) - 60,306 OVC received other material support (e.g. getting household items, beddings, or benefiting from shelter and day centers ) - 4, 658 received HIV/AIDS education PDO3: - 15 line ministries were supported to - 30 project districts and 233 district - By September 31st 2006, 10,878 Strengthen implement workplace programs. All have CSOs were supported to implement members of the Community Project 33 the national active HIV/AIDS focal persons and HIV/AIDS programs. Among the latter, Committees were trained in participatory capacity to functioning HIV/AIDS committees. 135 district CSOs were used to provide planning, implementation, community respond to - UACP supported 5 sectors to develop technical backstop to community based monitoring, procurement, book the HIV/AIDS policies, develop or review subprojects in implementation and keeping and report writing. epidemic their strategic plans and to produce reporting. - Other members of the 3,629 community guidelines for mainstreaming (Education, - Over 1,000 personnel from district local groups also developed those skills Agriculture, Works, Gender and Public governments and district CSOs in through a "learning by doing" approach Service) HIV/AIDS strategic planning. As the - UACP supported UAC to: (i) develop result, all project districts were able to and disseminate District Coordination develop comprehensive district guidelines to all 56 districts; (ii) mid-term HIV/AIDS strategic plans for and end review of the last NSF ; (iii) implementation and resource develop the next 5-year National mobilization. Strategic Plan, (iv) construction of the - 184 Community Development Officers new UAC headquarters. (CDOs) from the 30 districts received - UACP supported the Ministry of training of trainers, who then (i) trained Agriculture, Animal Industry and Community Development Assistants Fisheries to (i) train 30 trainers of trainers (CDAs) and (ii) assisted DAC and CSOs from 30 districts in HIV/AIDS, (ii) in monitoring all district community reproduce and disseminate documents for HIV/AIDS initiatives (not just CHAIs). HIV/AIDS mainstreaming. - 564 CDAs from 30 districts were - UACP funded the procurement of trained to mobilize and support laboratory equipment for Mulago hospital communities. This training was part of and the Uganda Virus Research Institute the strategy to strengthen and sustain to enhance their HIV/AIDS research implementation of the community led capacity. HIV/AIDS approach once the project phases out. - 450 service providers (both government and non-government) from 30 districts were trained in LQAS. All 30 districts conducted LQAS surveys and used the findings for district HIV/AIDS planning. - 227 district health personnel from 4 districts were trained in the new Health 34 Management Information System. - 78 district personnel from 30 districts were trained in M&E for HIV/AIDS - 1,172 agricultural and fisheries extension workers and 1,074 farmers received training in HIV/AIDS through the local governments and the Uganda Farmers Federation respectively. Source: Uganda HIV/AIDS Control Project Table 4. Numbers of Community Projects Cumulative number as of December 30, 2006 No. mobilized 12,275 No. submitted 12,036 No. reviewed by DAC 8,777 No. approved by DAC 7,555 No. verified by PCT 5,105 No. funded by UACP 3,629 No. funded by UACP and 3,927 NUSAF Source: Uganda HIV/AIDS Control Project 35 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) 31 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/Specialty Lending Shiyan Chao Senior Health Economist ECSHD Mission Leader Peter Okwero Sr. Health Sepcialist AFTH1 Mission Participant Norbert Mugwagwa Lead Operations Officer AFTH1 Community Dev. Alexandre Abrantes Lead Public Health Specialist HD Health Rogati Kayani Procurement Specialist AFTQK Procurement Joseph K. Mubiru Financial Management AFTQK Financial Management John Nyaga Sr. Financial Management AFTFM Financial Management Spec. Sandra Rosenhouse Senior Health Specialist LCS LCR Health Sara Nsibirwa- Information Specialist AFMUG Information Nsubuga Victoria W. Taaka Team Assistant AFMUG Office Support Anabela Abreu Consultant AFTH1 Human Development Jonathan C. Brown Operations Adviser AFTQK Operational Pascal Tegwa Procurement Officer AFTQK Procurement Supervision/ICR Peter Okwero Sr. Health Specialist AFTH1 Mission Leader Mary C.K. Senior Social Development Lead discussion with the Bitekerezo Specialist AFTS2 Ministry of Gender, Labor & Social Dev. Emanuele Capobianco Young Professional YPP Review Multi-sectoral Victoria L. Fofanah Program Assistant ECSPS Provide backup Emmanuel G. Malangalila Sr Health Specialist AFTH1 Review plans Julie McLaughlin Lead Health Specialist AFTH1 Provide overall backup support Suleiman Namara Social Protection Specialist AFTH1 Lead discussion on the Community led component Son Nam Nguyen Sr Health Specialist AFTH1 Health Akim Okuni E T Consultant AFTH1 Monitoring & Evaluation Richard Olowo Sr Procurement Specialist AFTPC Procurement Peace K. Tukamuhabwa Program Assistant AFMUG Provide Admin work Patrick Piker Umah Sr Financial Management Review the status of Tete Specialist AFTFM financial management 32 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands No. of staff weeks (including travel and consultant costs) Lending FY01 64.10 302.60 FY02 16.12 38.50 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 Total: 80.22 341.10 Supervision/ICR FY01 0.00 FY02 26.40 99.30 FY03 47.91 133.50 FY04 64.50 187.10 FY05 32.06 84.17 FY06 28.08 53.60 FY07 25.30 80.90 Total: 224.25 638.57 33 Annex 5. Beneficiary Survey Results (if any) 34 Annex 6. Stakeholder Workshop Report and Results (if any) 35 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Below is the Executive Summary of the Borrower's ICR. The full report is available from the Uganda AIDS Commission. Introduction. The Government of Uganda requested access to IDA resources within the framework of the first phase of the Multi-Country HIV/AIDS Program (MAP) for the Africa Region to sustain present HIV/AIDS activities started under Sexually Transmitted Infections Project (STIP) but also step up the National response by addressing gaps and challenges; ensuring multi-sectoral planning and implementation; and continuing to build capacity as a key cornerstone in confronting the epidemic as well as taking the initiatives down to the community level. UACP became effective on the 14th May 2001 though actual implementation commenced in July 2001 and it is scheduled to close on the 31st December 2006. The Uganda HIV/AIDS Control Project (UACP) was designed to support the goals of the National Strategic Framework for HIV/AIDS 2000/01 to 2005/06. It was a 53 USD million International Development Association loan from the World Bank and Government of Uganda provided USD 2.59 million as counterpart funds. Project Objectives. The Uganda HIV/AIDS Control Project (UACP) objectives were derived from the goals of the Government of Uganda's National Strategic Framework (NSF) for HIV/AIDS 2001-2006, which aimed to: a) Reduce the spread of HIV infection; b) Mitigate the health and socioeconomic impact of HIV/AIDS at individual, household and community levels; and c) Strengthen the national capacity to respond to the epidemic. The NSF proposed to attain these goals by financing a multi-sectoral response including, line ministries, districts, civil society, private sector and communities. After the midterm review, the project focused on six program areas: Behavioural Change Communication (BCC); Capacity Building; Supervision, Monitoring and Evaluation including Lot Quality Assurance Sampling (LQAS); Quality Services Delivery including STI management, VCT and condoms use; Treatment, Care and Support of Persons Living with HIV/AIDS (PLWHAs); and Care and Support for orphans. Project Scope. The project initiated and sustained a national and decentralised multi-sectoral response to the HIV/AIDS scourge through support to the public sector and Civil Society Organisations (CSOs) and through direct support to Community-led HIV/AIDS Initiatives (CHAIs). The contribution of UACP to the achievement of the three goals of the NSF was mainly through service delivery and capacity building for implementation at the National, District and Community levels. UACP pioneered the widest ever community led HIV/AIDS initiative in Uganda that has guaranteed the delivery of services at the grass roots providing support to very many needy orphans and PLWHAs. The project supported the following 15 line ministries to mainstream HIV/AIDS activities as part of their core business: Health; Uganda AIDS Commission; Education and Sports; Gender, Labour and Social Development; Local Government; Agriculture, Animal Industry and Fisheries; Public Service; Internal Affairs (Police and Prisons); Justice and Constitutional Affairs; Foreign Affairs; Defence (UPDF); Finance and Economic Development; Lands, Water and Environment; Office of the President and Office of the Auditor General. The line ministries have HIV/AIDS focal persons appointed, functional HIV/AIDS committees, operational HIV/AIDS workplans in place and were supported to develop HIV/AIDS policies and guidelines and to carry out HIV/AIDS workplace programmes. The project has also been an important support to both national and district level Civil Society Organizations (CSOs), the latter being supported through the local governments on demand for their services. To date, 36 national level and 233 district level CSOs have received funding from the project. UACP supported HIV/AIDS activities in the following 30 districts: Apac, Arua, Bushenyi, Hoima, Iganga, Jinja, Kabale, Kabarole, Kaberamaido, Kalangala, Kampala, Kamuli, 36 Kamwenge, Kayunga, Kitgum, Kyenjojo, Lira, Masaka, Masindi, Mayuge, Mbale, Mbarara, Moyo, Mukono, Nakapiripirit, Rakai, Sironko, Soroti, Tororo and Wakiso. In these 30 districts, by September 30th, 2006, the project had funded 3,629 HIV/AIDS community subprojects. Project inputs and outputs. Between 2001 and 2006, UACP has been an important source of funds for procurement of HIV/AIDS commodities and logistics such as: · STI drugs and reagents (US$ 2.454 million); · TB drugs (US$ 1.911 million); · Infection control sundries (US$ 0.351 million); · 160 million male latex condoms (US$ 3.550 million); · Selected opportunistic infection drugs (US$ 0.190 million); · Test kits for VCT, syphilis and surveillance (US$ 0.400); · 54 motor vehicles (US$ 0.770 million); · 5 motorboats (US$ 0.361 million); · 168 motorcycles (US$ 0.305 million); · ARV drugs (US$ 2.743 million); · 2 Viral load analysers (US$ 450,000); · 13 sets of equipment comprising of Clinical Chemistry Analysers, Flow Cytometers and Haematology Analysers plus reagents (US$ 3.474 million; · 122 portable generators (US$ 209,769); · 123 LCD projectors (US$ 554,683); · 90 Computers (US$ 243,192); · 58 Printers (US$ 34,760); · 122 Video decks (US$ 37,464); and · 7 Television screens (US$ 2,388). The project was also very responsive to funding innovative approaches in the implementation as evidenced by the launching of the public sector free ARVs scheme and procurement of CD4 count machines for use by the public sector thereby increasing the accessibility of Antiretroviral treatment (ART) to the poorer segments of the population. UACP initiated in-country post- shipment testing of condoms through procurement of the condom testing machine (US$ 0.190 million) thus greatly reducing the costs of overseas post- shipment testing. The project also supported the pioneering of the idea of a multisectoral behavioural change communication strategy and that of a community education HIV/AIDS flip chart. UACP piloted the first ever district level determination of HIV/AIDS behavioural markers using the Local Quality and Assurance Surveys (LQAS) and applied the results to the district HIV/AIDS programming. The project has set the platform for an enhanced multisectoral response to the HIV/AIDS scourge through support to sector and district strategic planning and HIV/AIDS mainstreaming guidelines development. UACP funded the construction of the Uganda AIDS Commission (UAC) secretariat offices (US$ 0.550 million). Project outcomes. To determine the impact of the project on outcome indicators within Districts, Local Quality Assurance and Supervision (LQAS) surveys were carried out in 2003 for 19 districts and in 2004 for the rest of the 11 districts. The indicator values of this baseline were compared for 12 of the first 19 districts in a repeat LQAS in 2006 for determination of trends in UACP funded districts and the results by the three objectives are described below: (i) Reduction in the spread of HIV. In the project area, between 2003 and 2006, there is evidence for increasing knowledge about the prevention and transmission of HIV and STIs. However, condom use among the population appears to be on the decline. In particular, condom use has 37 decreased most probably due to the lack of supply of the Engabu condom over the past 3 years that provided the bulk of the free condoms The impact indicator for reduction in the spread of HIV infection was the percentage of pregnant women that test positive for HIV during unlinked anonymous sentinel surveillance at selected antenatal clinics. Trends in this indicator when the years 2002 and 2005 are compared show that there was a slight decrease in some (5) and a slight increase in others (5) in the districts supported by UACP. (ii) Mitigate the health and socio-economic impact of HIV/AIDS at individual, household and community levels. Generally, service organizations providing care and support for PLWHAs are registering better coverage of most of the indicators in 2006 when compared to 2003.The percentage of PLWHAs registered with service organizations that received medical care in the last one month of all PLWHAs who required medical care remained high with a finding of 92.6 percent in 2006 compared to 96.4 percent in 2003. The percentage of PLWHAs registered with service organizations who received psychosocial support services in the last 3 months increased significantly from 75.9 percent in 2003 to 86.3 percent in 2006. The percentage of PLWHAs registered with service organizations who reported consistent use of condoms in the last 12 months increased significantly from 44.5 percent in 2003 to 54.5 percent in 2006. The percentage of PLWHAs registered with service organizations who received material support in the last 3 months increased significantly from 13.4 percent to 41.8 percent. There has been a subtle increase in all indicators for care and support for orphans and vulnerable children although the coverage is still under 25 percent. The percentage of school going-age (6- 18 years) orphans who have received educational support in the last one year has increased significantly from 14.2 percent in 2003 to 22.1 percent in 2006 while those who attended for at least 5 days in the last week did not decrease significantly from 71.6 percent to 71.1 percent. The percentage of orphans who have received psychosocial support the last one-month did change significantly but increased slightly from 10.8 percent in 2003 to 12.6 percent in 2006. The percentage of orphans who received material support in the last 3 months increased significantly though slightly from 5.3 percent in 2003 to 9.1 percent in 2006 and the percentage of orphans who received food support in the last one month also increased significantly from 2.4 percent to 7.1 percent. The percentage of orphans who know where to go when their rights are violated was not assessed in 2003 but in 2006 and the findings 98.2 percent were aware as to where to go. (iii) Strengthen the national capacity to respond to the epidemic. By September 31st 2006, there were 30 districts were executing multisectoral HIV/AIDS operational plans supported by UACP and within the 30 districts, 3,627 CHAI groups had been supported by UACP thereby providing educational support to 301,129 orphans and home based care to 33,309 persons living with HIV/AIDS while 15 line ministries had been supported to implement workplace programs and 38 National level and 233 District level CSOs were supported to carry out HIV/AIDS interventions. All 30 districts supported by UACP have had LQAS surveys in the past 5 years and the information obtained during the survey was used for district HIV/AIDS programme planning. UACP supported 5 sectors to develop HIV/AIDS policies, develop or review their strategic plans and to produce guidelines for mainstreaming (Education, Agriculture, Works, Gender and Public Service). UACP funded training of over 1000 personnel from district local governments as well as district level CSOs in strategic planning; 184 Community Development Officers (CDOs) from the 30 districts to serve as trainers of trainers to train Community Development Assistants (CDAs) in the districts and backstop DAC and CSOs in monitoring all district community HIV/AIDS initiatives including CHAIs UACP is also funded training of 564 CDAs from 30 districts to strengthen the Lower Local Government capacity for mobilising community based initiatives 38 using PRA techniques and providing technical support to Community based initiatives; 450 district level government and non-government service providers from 30 districts in LQAS. The training was practical in that it involved carrying out the LQAS survey immediately after orientation and subsequently tabular analysis of the data and report presentation. The benchmark data obtained was used for planning and will be used for monitoring the District HIV/AIDS program. In addition, UACP funded: Training of 227 district health personnel from 4 districts in the use of the new HMIS that incorporates more HIV/AIDS indicators; 78 district personnel from 30 districts in the use of database for HIV/AIDS data collection, management and reporting; Training on HIV/AIDS of 1172 agricultural and fisheries extension workers through the district local governments in 30 districts as well as 1074 farmers through the Uganda Farmers Federation. Ratings. The outcome of the HIV/AIDS Control Project is rated as satisfactory overall, based on moderately satisfactory outcomes in the project area in prevention, satisfactory outcomes on mitigation and satisfactory outcomes in capacity building. The project was able to absorb over 99% of the funds within the planned project period despite an increase project value of US$ 5.5 million resulting from appreciation of the Special Drawing Rights. Lessons · The multisectoral response requires strong coordination mechanisms among implementing and development partners. · Project planning and reporting mechanisms need to be well defined so as to fit into the existing planning needs of the supported sectors. · Capacity building is crucial for all levels when supporting a multisectoral response. · HIV/AIDS mainstreaming is a crucial strategy in the efforts to sustain the sector's role in HIV prevention and control. · The participatory approach used in the strategic planning process promoted ownership of the strategic plan, built capacity and improved skills in strategic planning. · Districts sometimes tend to look at Civil Society Organizations (CSOs) as competitors and vice versa in the HIV/AIDS response other than partners. · LQAS surveys provided useful benchmark information for district level HIV/AIDS planning and monitoring. · There is a strong sense of ownership of community subproject initiatives among members of the best performing groups as evidenced by their devotion and willingness to sacrifice their meagre resources (manual labour, time and finances) to the groups' causes. · The CHAIs interventions are extremely appropriate in addressing the urgent needs of the communities in HIV/AIDS prevention and mitigation. · CHAI subprojects have made substantial contribution in producing the desired outcomes and meeting overall objectives of HIV/AIDS prevention and mitigation. · It is feasible to replicate the CHAI model including design and implementation because CHAI strategy has put communities at the centre of action. · Some of the CHAIs sub-projects interventions and activities in HIV/AIDS mitigation and prevention can be broadly and deeply scaled up. · HIV/AIDS resources can be channelled directly to communities. · CHAI is efficient in that most of the resources go towards interventions and learning by doing enables quick capacity building for communities to address needs. 39 Annex 8. Comments of Co-financiers and Other Partners/Stakeholders 40 Annex 9. List of Supporting Documents 1. European Commission (2006). Sector-Based Assessment of AIDS Spending in Uganda. 2. Masindi District Local Government (2006). Masindi District HIV/AIDS Strategic Plan 2006/7-2010/11: Turning Commitment into Affirmative Action. 3. Ministry of Education and Sports (2003a). Presidential Initiative on AIDS Strategy for Communication to Youth. 'STAY SAFE'. Supported by UACP. 4. Ministry of Education and Sports (2003b). Presidential Initiative on AIDS Strategy for Communication to Youth. Teachers' Manual. Supported by UACP. 5. Ministry of Education and Sports (2006). Mainstreaming HIV/AIDS and Life skills in the secondary school curriculum. Teacher Training Module. 6. Ministry of Health (2003a). STD/HIV/AIDS Surveillance Report. 7. Ministry of Health (2003b). KABP and Sero-Survey on HIV/AIDS and STDs among Commercial Sex Workers (CSWs) in Kampala City, Uganda. 8. Ministry of Health (2003c). Knowledge, Attitudes, Behaviors and Practices Survey on STIs and HIV/AIDS among the fishing community in Mukono District, Uganda. 9. Ministry of Health (2006). Uganda HIV/AIDS Sero-Behavioural Study (UHSBS) 2004- 2005. 10. Uganda AIDS Commission/UACP (2004). LQAS Monitoring Report. Assessment of HIV/AIDS related Knowledge, Practices and Coverage in 19 Districts of Uganda, October ­November 2003. Uganda AIDS Commission (UAC)/Uganda HIV/AIDS Control Project. 11. Uganda AIDS Commission/UACP (2005). LQAS Monitoring Report. Assessment of HIV/AIDS related Knowledge, Practices and Coverage in 11 Districts of Uganda, September to October 2004. Uganda AIDS Commission (UAC)/Uganda HIV/AIDS Control Project. 12. Uganda AIDS Commission/UACP (2006). LQAS Monitoring Report. Evaluation of the impact of interventions on HIV/AIDS Related Knowledge, Practices and Coverage in 12 Districts of Uganda (Draft). 13. Uganda AIDS Commission (2006a). Uganda HIV/AIDS Control Project 2001-2006: End of Project Report. 14. Uganda AIDS Commission (2006b). Performance Evaluation of the National Strategic Framework for HIV/AIDS 2000/1-2005/6 (draft). 15. Uganda Bureau of Statistics (2001): Uganda Demographic and Health Survey 2000- 2001. 16. Uganda HIV/AIDS Control Project: Mid Term Review Report. 17. Uganda HIV/AIDS Control Project: Project Management Reports. 18. World Bank (2000). Uganda HIV/AIDS Control Project: Project Appraisal Document. 19. World Bank (2000-2007). Uganda HIV/AIDS Control Project: Aide-memoires 20. World Bank (2000-2006). Uganda HIV/AIDS Control Project: Implementation Status and Results (ISR) reports. 21. World Bank (2001a). Uganda HIV/AIDS Control Project: Development Credit Agreement. 22. World Bank (2001b). Uganda HIV/AIDS Control Project: Quality at Entry Assessment Report. 23. World Bank (2003). Uganda Sexually Transmitted Infections Project (STIP): Implementation Completion Report. 24. World Bank Operations Evaluation Department (2005). Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance. An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control. 41