Document of The World Bank Report No: ICR00001148 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-36290 IDA-36291) ON A CREDIT IN THE AMOUNT OF SDR 10.7 MILLION (US$ 14.0 MILLION EQUIVALENT) TO THE REPUBLIC OF CAPE VERDE FOR AN HIV/AIDS PROJECT DECEMBER 30, 2009 Human Development Sector Health, Nutrition and Population (AFTHE) Country Department 1 AFCF1 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective) Currency Unit = Cape Verde Escudo (CVE) February 2002: US$1.00 = 119.8 CVE October 2006: US$1.00 = 81 CVE June 2009: US$1.00 = 79.2 CVE ABBREVIATIONS AND ACRONYMS ABC Abstain ... Be faithful ... Use a condom ACTAfrica AIDS Campaign Team for Africa APL Adaptable Program Loan ADB African Development Bank AIDS Acquired Immuno-Deficiency Syndrome ANC Ante Natal Care APIS AIDS Indicators Study (Inquérito dos Indicadores da SIDA) ART Anti-Retroviral Therapy ARV Anti Retroviral AU Administrative Unit (of the CCS-SIDA Secretariat) BCC Behavioral Change Communications BSS Behavioral Surveillance Survey CAS Country Assistance Strategy CBO Community-Based Organization CCS-SIDA Coordination Committee to Fight AIDS (Comite de Coordenação do Combate a SIDA) CDC Center for Disease Control CSW Commercial Sex Workers DCA Development Credit Agreement DHS Demographic and Health Survey DOTS Directly Observed Treatment Short-term EMP Environmental Management Plan EU European Union EMPROFAC Cape Verde Parastatal Organization for Procurement of Pharmaceuticals and Medical Supplies (Empresa Nacional de Produtos Farmaceuticos) ES CCS-SIDA Executive Secretariat of the Coordination Committee to Fight AIDS FA Financing Agreement FM Financial Management GAMET Global Monitoring and Evaluation Team GFATM/GF Global Fund to Fight AIDS, TB and Malaria GNI Gross National Income GPRSP Growth and Poverty Reduction Strategy Paper HIV Human Immunodeficiency Virus HTA High Transmission Area IAPSO Inter-Agency Procurement Services Office ICRR Implementation Completion and Results Report IDA International Development Association IDSR Demographic and Reproductive Health Survey (Inquérito Demográfico e de Saúde Reproductiva) IEC Information, Education, and Communication IFR Interim Financial Report INE National Statistics Institute (Instituto Nacional de Estatistica) INFARMA National Drug Manufacturing Company IPPF International Planned Parenthood Federation ii ISR Implementation Status Results and Report KAP Knowledge, Attitudes and Practices KPI Key Performance Indicators MAP Multi-Country HIV/AIDS Program MDGs Millennium Development Goals M&E Monitoring and Evaluation MIS Management Information System MOH Ministry of Health MTCT Mother-to-Child Transmission MTP Medium-Term Plan MTR Mid-Term Review NGO Non-governmental Organization OI Opportunistic Infection OVC Orphans and other Vulnerable Children PAD Project Appraisal Document PCT Project Coordination Team PDO Project Development Objective PEPFAR President's Emergency Plan for HIV/AIDS Relief PHRD Policy and Human Resources Development Fund PIP Project Implementation Plan PLWHA People Living with HIV and AIDS PNLS National Program to Fight HIV/AIDS (Programa Nacional de Luta contra a SIDA) POM Project Operations Manual PPF Project Preparation Facility QAG Quality Assurance Group QER Quality Enhancement Review RH Reproductive Health SDR Special Drawing Rights SIL Specific Investment Loan STI Sexually Transmitted Infection TB Tuberculosis TT/TTL Task Team/Task Team Leader UNAIDS Joint United Nations Program on HIV/AIDS UNDP UN Development Program UNFPA United Nations Population Fund UNICEF United Nations Children's Fund USD US Dollar VCT Voluntary Counseling and Testing WHO World Health Organization Vice President : Obiageli K. Ezekwesili Country Director : Habib Fetini Sector Manager : Eva Jarawan Project Team Leader : Mirey Ovadiya ICR Team Leader : Johanne Angers iii CAPE VERDE HIV/AIDS PROJECT Table of Contents 1. Project Context, Development Objectives and Design ____________________________________________ 1 1.1 Context at Appraisal ______________________________________________________________________ 1 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) ____________________ 1 1.4 Main Beneficiaries and Benefits _____________________________________________________________ 2 1.5 Original Components _____________________________________________________________________ 2 1.6 Revised Components ______________________________________________________________________ 3 1.7 Other significant changes __________________________________________________________________ 4 2. Key Factors Affecting Implementation and Outcomes____________________________________________ 4 2.1 Project Preparation, Design and Quality at Entry _______________________________________________ 4 2.2 Implementation __________________________________________________________________________ 6 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization___________________________ 8 2.4 Safeguard and Fiduciary Compliance ________________________________________________________ 9 2.5 Post-completion Operation/Next Phase ______________________________________________________ 10 3.1 Relevance of Objectives, Design and Implementation ___________________________________________ 11 3.2 Achievement of Project Development Objectives _______________________________________________ 11 3.3 Efficiency ______________________________________________________________________________ 16 3.4 Justification of Overall Outcome Rating ______________________________________________________ 17 3.5 Overarching Themes, Other Outcomes and Impacts_____________________________________________ 18 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops __________________________ 19 4. Assessment of Risk to Development Outcome __________________________________________________ 19 5. Assessment of Bank and Borrower Performance _______________________________________________ 19 5.1 Bank Performance_______________________________________________________________________ 19 5.2 Borrower Performance ___________________________________________________________________ 21 6. Lessons Learned __________________________________________________________________________ 22 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners _________________________ 22 Annex 1: Project Costs and Financing_____________________________________________________________ 24 Annex 2: Outputs by Component_________________________________________________________________ 25 Annex 3: Economic and Financial Analysis ________________________________________________________ 32 Annex 4: Bank Lending and Implementation Support/Supervision Processes ____________________________ 34 iv Annex 5: Beneficiary Survey Results ______________________________________________________________ 36 Annex 6: Stakeholder Workshop Report and Results ________________________________________________ 36 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR ________________________________ 37 Annex 8: Comments of Co-financing partners and Other Partners/Stakeholders _________________________ 43 Annex 9: List of Supporting Documents ___________________________________________________________ 44 MAP v A. Basic Information Country: Cape Verde Project Name: HIV/AIDS Project Project ID: P074249; P101950 L/C/TF Number(s): CR 3629 CV; CR 36291 ICR Date: December 30, 2009 ICR Type: Core ICR Lending Instrument: SIL Borrower: GOVERNMENT OF CAPE VERDE Original Total SDR 10.7 M Disbursed Amount: SDR 10.6 M Commitment: Environmental Category: B Implementing Agency: Secretariado Executivo - Comite de Coordenação do Combate a SIDA (Executive Secretariat - Coordination Committee to Fight AIDS or SE-CCS/SIDA) Cofinanciers and Other External Partners: N/A B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 10/04/01 Effectiveness: 06/01/02 07/17/02 Appraisal: 01/25/02 Restructuring: 12/19/06 Approval: 03/28/02 Mid-term Review: 09/13/04 09/13/04 Closing: 12/31/06 06/30/09 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Satisfactory Satisfactory Moderately Moderately Quality of Supervision: Implementing Agency/Agencies: Satisfactory Satisfactory Moderately Moderately Overall Bank Performance: Overall Borrower Performance: Satisfactory Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Indicators QAG Assessments (if any) Rating Potential Problem Project at any time (Yes/No): No Quality at Entry (QEA): N/A Problem Project at any time (Yes/No): No Quality of Supervision (QSA): N/A Moderately DO rating before Closing/Inactive status: Satisfactory vi D. Sector and Theme Codes Original/ Original/ Additional/ Additional/ Planned Actual Planned Actual Sector Code (as % of total Bank financing) Health 72% 72% 16% 16% General Education 0% 0% 3% 3% Central Government 19% 19% 47% 47% Sub National Government 3% 3% 3% 3% Other Social Service 6% 6% 31% 31% Theme Code HIV/AIDS 50% 50% 33% 33% Participation and civic engagement 25% 25% 17% 17% Decentralization 0% 0% 17% 17% Other financial and private sector 0% 0% 17% 17% Social risk mitigation / Other social development 25% 25% 16% 16% E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto Madavo Country Director: Habib Fetini John Mclntire Sector Manager: Eva Jarawan Maryvonne Plessis-Fraissard Project Team Leader: Mirey Ovadiya Gylfi Palsson ICR Team Leader: Johanne Angers ICR Primary Author: Peter Bachrach F. Results Framework Analysis Project Development Objectives 1 The objectives of the project were to assist the Borrower in: (i) reducing the spread of HIV/AIDS in the Borrower's population; (ii) mitigating the health and socioeconomic impact of HIV/AIDS on persons infected with or affected by HIV/AIDS within the Borrower's territory, thus sustaining an economically productive population; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. Revised Project Development Objectives (as approved by original approving authority) The PDOs were not revised but the key performance indicators (KPI) were formally revised in the Additional Financing that was approved by the Board on December 19, 2006. 1 The objectives are taken from the Development Credit Agreement and Financing Agreement. While similar in substance, the Project Appraisal Document (PAD) describes the PDOs differently. vii (a) PDO Indicator(s) - Original Credit Original Target Formally Actual Value Achieved Values (from Revised Indicator Baseline Value at Completion or approval Target Target Years documents) Values By the end of the third year of the project (2005), prevent the increase (compared with Indicator 1 : the first year of the project) in seroprevalance of HIV in the general population. Value quantitative or Qualitative) 2.08% < 2.08% 0.8% Sentinel Surveillance Date achieved IDSR II (2005) Report (2002) Comments (incl. % The target was met. Among the general population between the ages of 15-24 years, achievement) HIV prevalence in 2005 was 0.1%. By 2005, reduce by 20% HIV prevalence among women attending ante-natal care clinics Indicator 2 : (compared with the first year of the project). Value quantitative 1.13% at ANC sentinel 0.9% 0.8% or Qualitative) posts Sentinel Surveillance Date achieved IDSR II (2005) Report (2002) The target was met. Sentinel surveillance data indicate the following HIV prevalence Comments (incl. % rates for women attending ante-natal clinics: 0.9% (2006); 0.7% (2007); and 0.5% achievement) (2008). By 2006, reduce from the baseline 45% to 20% the percentage of sexually active people Indicator 3 : reporting having non-regular sexual partners over the previous 12 months. Value quantitative 45% 20% Data not available or Qualitative) Date achieved IDSR (1998) Comments (incl. % This indicator was modified at the MTR when the notion of gender was introduced as in achievement) Indicator 3a. By December 2006, to reduce from the baseline of 69% for men and 39% for women to Indicator 3a: 50% for men and 20% for women, the percentage of sexually active people reporting having had non-regular sexual partners over the previous 12 months. Value quantitative 69% for men 50% for men 66% for men or Qualitative) 39% for women 20% for women 43% for women Date achieved IDSR (1998) IDSR (2005) APIS (2009) found the results for men and women were 54.4% and 41.5%, respectively Comments (incl. % in 2009. The modified indicators improved for women, but the targets were not achievement) met. By 2005, reduce by 25% the incidence of reported sexually transmitted (urethritis) Indicator 4 : infections in men age 15-49 years in the previous 12 months, compared with the first year of the project. Value quantitative Data not available Data not available Data not available or Qualitative) Date achieved Comments (incl. % This indicator was modified at the MTR as in Indicator 4a. viii Original Target Formally Actual Value Achieved Values (from Revised Indicator Baseline Value at Completion or approval Target Target Years documents) Values achievement) By 2005, reduce by 25% the point prevalence of sexually transmitted infections amongst Indicator 4a: the community as measured by syphilis prevalence amongst pregnant women, compared with the first year of the project (ANC sentinel posts). Value quantitative 1.7% (2004) 1.73% Reduce by 25% or Qualitative) 1.6% (2007) Date achieved ANC Sentinel posts (2002) ANC Sentinel Posts Comments (incl. % The modified indicator improved, but the target was not met. achievement) By 2005, increase the median age of first sex by one year among both females and males Indicator 5 : (compared with the first year of the project). Value quantitative Female 14.3; Female: 15.3; Female: 17; or Qualitative) Male: 15.6 Male: 16.6 Male: 17 Date achieved IDSR I (1998) IDSR II (2005) Comments (incl. % The targets were met and exceeded. achievement) By 2005, increase from the baselines of 43% (men) and 9% (women) to 60% (men) and Indicator 6 : 30% (women) the proportion of men and women aged 15-49 years who report using a condom in their last act of sexual intercourse with a non-regular partner Value quantitative Female 9.0%; Female 30.0%; Female 46.0%; or Qualitative) Male: 43.0% Male: 60.0% Male: 72.0% Date achieved IDSR I (1998) IDSR II (2005) Comments (incl. % The targets were met and exceeded. achievement) a) PDO Indicator(s) ­ Additional Financing Original Target Actual Value Achieved Formally Revised Indicator Baseline Value Values (from at Completion or Target Values approval documents) Target Years The proportion of the 15-49 age group who report using a condom in their last sexual act Indicator 7 : with a non-regular partner has increased from 46% to 50% for females and from 72% to 75% for males (as a measure of effective preventive interventions) Value quantitative Female 46%; Female: 50%; Female: 67.6%; or Qualitative) Male: 72% Male: 75% Male: 78.9% Date achieved IDSR II (2005) INE (2009) Comments (incl. % The targets were met and exceeded. achievement) Indicator 8 : The median age of first sexual relation is maintained among both females and males (15- 24 year olds) Value quantitative Female: 17; Female: 17; Female: 16; or Qualitative) Male: 17 Male: 17 Male: 15 Date achieved IDSR II (2005) APIS (2009) ix Original Target Actual Value Achieved Formally Revised Indicator Baseline Value Values (from at Completion or Target Values approval documents) Target Years The targets were not met. The increases of almost two years achieved by the original Comments (incl. % operation could not be maintained. At the same time, the significant increase in condom achievement) use (Indicator 7) may compensate for the decline in the age of first sexual relation. Indicator 9 : The percentage of commercial sex workers who report using condoms has increased by 20 percent Value quantitative 29 out of 39 (or 20% increase 66 out of 104 (or 64%) or Qualitative) 74%) Qualitative Survey Rapport Verdevem Date achieved on Population at (2009) risk (2006) The outcome of this indicator cannot be confirmed as positive or negative given the Comments (incl. % different methodologies of the two studies and especially the uncertainty of the sampling achievement) methodology. (b) Intermediate Outcome Indicator(s) ­ Original Credit Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years By the end of the first year of the project (2003), at least 70% of HIV/AIDS focal point Indicator 1: people in line Ministries have had some form of formal training on HIV/AIDS Value (quantitative 0 70% 78% or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2004) (2002) The target was met and exceeded. ES CCS-SIDA data indicate that by 2004, 35 focal Comments (incl. % point persons from 11 of 15 (73%) ministries, with an average of 3 focal points per achievement) ministry, had received training in various subjects pertaining to HIV/AIDS. By the end of the first year of the project (2003), at least 60% of the municipalities have Indicator 2 : HIV/AIDS committees that have received formal training on HIV/AIDS Value (quantitative 0 No less than 60% 100% or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2003) (2002) The target was met and exceeded. All Municipal Committees for the Fight against AIDS were established in the first year of the program and all members received training Comments (incl. % on prevention of HIV/AIDS, IEC for behavior change, management and drafting of HIV achievement) sub-projects, procurement, management and accounting, and monitoring and evaluation of HIV projects. A total of 111 members of committees, leaders of social services of municipalities and municipal facilitators received formal training. By the end of the third year of the project (2005), at least 3 national-level HIV/AIDS- Indicator 3 : related financial management training sessions organized under the auspices of the NGO platform Value (quantitative 0 3 4 x Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years or Qualitative) ES CCS-SIDA ES CCS-SIDA (2007- Date achieved (2002) 2009) The target was met. The NGO Platform, in partnership with the ES CCS-SIDA, held 4 Comments (incl. % training sessions in management of HIV projects, including accounting and financial achievement) management (NGOs, Volunteers, and CBOs). A total of 75 NGO members, including religious organizations, Women and Youth groups were trained. Indicator 4 : By 2003, all ministries have and are implementing their HIV/AIDS work plans. Value (quantitative 0% 100% 46% or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2004) ES CCS-SIDA (2003) (2002) The indicator improved, but the target was not met. In 2003, 6 of 13 (46%) Comments (incl. % ministries were implementing work plans; these included the priority ministries of health, achievement) education, defense, youth, and labor/social welfare. In 2004 and 2005, 8 of 13 (62%) and 9 of 13 (69%) of ministries were implementing work plans. By 2004, all Government and parastatal managed primary, secondary and high schools Indicator 5 : are using curricula that incorporate HIV/AIDS in a skills-based learning approach. Value (quantitative 0% 100% Data not available or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2002) The target was partially met. In 2004, 621 teachers were trained in UNFPA's life skills Comments (incl. % course; as of 2009, instructional materials have been adopted, school administrators and achievement) teacher training schools trained, and 1597 teachers representing 423 primary and secondary schools have integrated the HIV/AIDS content as part of the curriculum. By the end of the second year of the project (2004), develop and disseminate national Indicator 6: policy on social support networks for HIV/AIDS at national level. Value (quantitative 0 1 Data not available or Qualitative) Date achieved Comments (incl. % The indicator was not measured. achievement) By 2003, 80% and by 2004, 100% of non-MOH national public sector agencies have and Indicator 7: are implementing HIV/AIDS plans. Value (quantitative 2003: 80% 2003: 26% (10 out of 38) 0% or Qualitative) 2004: 100% 2004: 61% (23 out of 38) ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2002) The indicator improved, but the target was not met. Though the overall targets were Comments (incl. % not met, two-thirds of the non-MOH public sector agencies implementing plans were in achievement) the priority areas of health information, education, and youth. Indicator 8 : By the end of the first year of the project (2003), all ministries have HIV/AIDS teams xi Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years trained as information, education, and communication (IEC) agents for their respective ministries. Value (quantitative 0 Ministries 15 Ministries 6 Ministries (40%) or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2003) (2002) The indicator improved, but the target was not met. ES CCS-SIDA data indicate the Comments (incl. % following achievements for Ministries: 11 of 15 ministries (2004-2006); 13 of 15 achievement) ministries (2007-2009). These ministries included the priority ministries of health, education, defense, youth, and labor/social welfare. By 2005, increase from 0 to 50%, and by 2006, reach a target of 80% of HIV positive Indicator 9 : pregnant women receiving preventive treatment for mother-to-child transmission (PMTCT) of HIV Value (quantitative 2005: 50% 2005:80% 0 or Qualitative) 2006: 80% 2006: 100% ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2002) Comments (incl. % The target was met and exceeded. Also recorded are data for 2007: 98% and 2008: achievement) 92%. By 2004, all municipalities have and are implementing their respective HIV/AIDS plans Indicator 10 : formulated with stakeholder participation Value (quantitative 2004: 17 of 17 0 of 17 2004: 17 of 17 or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2002) Comments (incl. % The target was met. Data recorded in 2008 indicate that the 5 new municipalities (22 in achievement) all) were also implementing HIV/AIDS plans in a participatory manner. By 2005, municipality policies for social networks of people affected by HIV/AIDS are Indicator 11 : being implemented in all municipalities. Value (quantitative 0 of 17 17 of 17 2005: 17 or Qualitative) ES CCS-SIDA Date achieved 2005 ES CCS-SIDA (2008) (2002) The target was met. The number of municipalities was expanded from 17 to 22, and the Comments (incl. % project (with the help of recruited facilitators) supported 7 social networks offered by the achievement) municipalities. By 2005, increase from 0 to 60% the proportion of municipalities in which VCT services Indicator 12 : are being provided. Value (quantitative 2005: 41% 0 60% or Qualitative) 2006: 100% ES CCS-SIDA Date achieved 2005 ES CCS-SIDA (2009) (2002) Comments (incl. % By 2005, the indicator improved; by 2006, the target was met. In 2005, 7 of 17 (41%) achievement) of municipalities were providing VCT; by 2006 17 of 17 municipalities were offering xii Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years VCT services. Currently, VCT services are offered in all 22 districts through 26 health centers and 5 maternal health centers. By 2004, all municipalities receiving project funding are submitting acceptable Indicator 13 : accounting and expenditure reports Value (quantitative 0 100% 2004: 100% or Qualitative) ES CCS-SIDA Date achieved 2004 ES CCS-SIDA (2009) (2002) Comments (incl. % The target was met. achievement) Indicator 14 : By 2004, all schools in the community are implementing HIV/AIDS sensitive curricula Value (quantitative 0% Data not available or Qualitative) Date achieved Comments (incl. % This indicator was not monitored as it is subsumed under Indicator 5 above. achievement) By 2004, increase from 0 to 50%, and by 2006 reach a target of 80% of reported people Indicator 15 : living with HIV/AIDS who are receiving some form of home or community-based support. 2004: 17% (5 out of 30) Value (quantitative 2004: 50% 0% 2006: 24% (120 out of or Qualitative) 2006: 80% 503) ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2002) Comments (incl. % The indicator improved, but the target was not met. achievement) Total value of project contracts entered into with communities, NGOs, CBOs, Indicator 16 : associations of people living with HIV/AIDS, and private sector agencies is no less than 30% of all project contracts entered into over the previous twelve months. Value (quantitative Equal to or greater than Equal to or greater than 0% 30% 30% for 2002-2005 or Qualitative) ES CCS-SIDA (2002- Date achieved CCS-SIDA (2002) 2006) The target was met for all years in which the project had sufficient funds to award sub- Comments (incl. % projects. The indicator itself raises issues concerning the appropriate level of sub-project achievement) funding for communities, NGOs, CBOs, etc. Indicator 17 : A progress report is produced every 6 months Value (quantitative 0 2 per year 4 per year or Qualitative) Date achieved CCS-SIDA (2002) ES CCS-SIDA (2009) Comments (incl. % The target was met and exceeded. achievement) xiii Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years Project annual action plans and budgets for the next year are produced within the last Indicator 18 : three months of the current financial year 1 per year produced Value (quantitative with the last three 0 Data not available or Qualitative) months of current fiscal year Date achieved CCS-SIDA (2002) Comments (incl. % This indicator was not monitored as it is subsumed under Indicators 4, 7, and 10 achievement) above. (b) Intermediate Outcome Indicator(s) ­ Additional Financing Original Target Formally Actual Value Achieved Indicator Baseline Value Values (from approval Revised Target at Completion or Target documents) Values Years Percentage of pregnant women using ante-natal services benefiting from VCT increases Indicator 19 : from 13% to 40% Value (quantitative 13% 40% 93.7% or Qualitative) Date achieved IDSR II (2005) MOH (2008) The target was met and exceeded. The proportion of pregnant women using ante-natal Comments (incl. % services benefiting from VCT during ANC visits increased as follows: 55.4% (2006); achievement) 71.5% (2007); and 93.7% (2008). No health structure providing anti-retroviral treatment has been out of stock of anti- Indicator 20 : retroviral drugs over the previous 12 months. Value (quantitative 0 0 0 or Qualitative) Date achieved MOH (2005) MOH (2009) The target was met. ARV stockouts were verified at Central Stores as follows: (i) from June-July 2008 for Lamivudina syrup, but patients were not affected as existing stock in Comments (incl. % health facilities covered the time required for an emergency purchase; and (ii) from achievement) December 2008-February 2009 for Estavudina+ Lamivudina), but only patients in Praia were affected and health facilities were able to use two kinds of drugs instead of a single drug during the stock-out period. Percentage of private enterprises (30 or more employees) investing in activities Indicator 21 : supporting the National HIV/AIDS Strategic Plan 2006-10 reaches 10% Value (quantitative 0 10% 22% (19 of 85) or Qualitative) ES CCS-SIDA Date achieved ES CCS-SIDA (2009) (2006) Comments (incl. % The target was met and exceeded. achievement) xiv G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 04/27/02 Satisfactory Satisfactory 0.0 2 09/30/02 Satisfactory Satisfactory 0.7 3 04/03/03 Satisfactory Satisfactory 0.3 4 10/22/03 Satisfactory Satisfactory 1.4 5 04/23/04 Satisfactory Satisfactory 2.2 6 11/03/04 Highly Satisfactory Highly Satisfactory 3.1 7 05/02/05 Highly Satisfactory Highly Satisfactory 1.5 8 11/08/05 Highly Satisfactory Satisfactory 0.6 9 05/16/06 Highly Satisfactory Satisfactory 0.7 10 11/01/06 Highly Satisfactory Satisfactory 0.2 11 05/02/07 Highly Satisfactory Satisfactory 0.0 12 06/19/07 Satisfactory Satisfactory 1.1 13 12/27/07 Satisfactory Satisfactory 0.7 14 03/17/08 Satisfactory Satisfactory 0.9 15 09/03/08 Satisfactory Satisfactory 0.9 16 03/20/09 Satisfactory Satisfactory 0.9 Moderately Moderately 17 06/30/09 2 0.5 Satisfactory Satisfactory H. Restructuring Board ISR Ratings at Amount Restructuring Approved Restructuring Disbursed at Reason for Restructuring & Key Changes Date(s) PDO Restructuring in Made DO IP Change USD millions Board approved on December 19, 2006, an additional Credit No. 3629-1-CV of SDR 12/19/2006 n.a. HS S 10.9 3.4 million (US$ 5.0 million equivalent), which included changes in the results framework but not in the PDO. If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Moderately Satisfactory Against Formally Revised PDO/Targets Moderately Satisfactory Overall (weighted) rating Moderately Satisfactory 2 The last ISR downgraded the DO and IP ratings from S to MS due to (1) the unavailability of data for two of the outcome indicators at project closing--those were subsequently made available in August 2009; and (2) the insufficient and untimely counterpart funding , which was downgraded from S to MU. xv I. Disbursement Profile xvi 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Following the identification of the first case of HIV in 1986, the Ministry of Health established a National AIDS Control Program (PNLS) and implemented a series of medium-term plans (MTP). With assistance during MTP II (1994­98), particularly from French Cooperation and the European Union, the Ministry of Health (MOH) strengthened HIV surveillance and improved information collection and analysis. Donor support for these interventions ceased in 1998, resulting in an interruption in sentinel surveillance data collection from 1998 to 2000 and the reduction of PNLS staff to a single person. 2. Consequently, information about the characteristics and evolution of the epidemic was limited, but the authorities were concerned by the increasing number of cases: (i) health facility data (2000) estimated the number of HIV cases at 3,000-4,000 and the number of AIDS cases at 75 (1.8 AIDS cases per 10,000 population), or more than double the reported 32 cases in 1996; and (ii) sentinel surveillance data (1997) estimated the prevalence of HIV in the general population at 1.5-2.5%. Further, two-thirds of those infected were estimated to be aged 30-49 years with some 20% of all infected people aged 25- 29. The main transmission mechanism was heterosexual sex, although mother-to-child transmission (MTCT) was believed to contribute new cases, and rising drug abuse by injection was cited anecdotally. 3. Government authorities were further concerned by the potential impact of the epidemic on the country's economic growth and social progress, which had been significant. Beginning in the late 1980s, Cape Verde's growth averaged some 2.5% per capita per year, and the country had joined the ranks of lower middle income countries, with a GNI per capita of US$ 1,310 in 2001. Poverty had declined; the human development index was increasing (from 0.59 in 1990 to 0.67 in 2003); life expectancy at birth (69 years) was the third highest in Africa; and adult literacy rates were high (about 76% in 2002). 4. Though the 1997 Country Assistance Strategy (CAS) did not mention HIV/AIDS, Government authorities submitted a request for support from the World Bank in late 2000. The request anticipated: (i) the CAS Progress Report (June 2001), which identified HIV/AIDS as an area for Bank support; and (ii) the subsequent CAS (2002), which emphasized HIV/AIDS in the Bank's program of assistance through a multisectoral approach, within the framework of the multi-country HIV/AIDS program for Africa (MAP-Phase II). The project was thus consistent with both the CAS Progress Report and the subsequent CAS. 5. In line with the MAP eligibility criteria, the Government: (i) established (July 2001) the "Comite de Coordinaçào do Combate a SIDA" (CCS-SIDA) in the office of the Prime Minister; (ii) formulated (2001) and adopted (January 2002) a national multisectoral HIV/AIDS strategy for the period 2002-06, with the participation of central and municipal government, NGOs, and UNAIDS and other international donors; and (iii) agreed to use exceptional implementation arrangements to fund multiple implementing agencies. 6. Bank support for the country's efforts to fight HIV/AIDS was justified by insufficient donor attention to the issue and the resulting inadequate resources to address the epidemic. It was expected that the Bank's financial support to the National HIV/AIDS Strategic Plan together with its ability to ensure appropriate fiduciary architecture and to attract donor interest would catalyze a coherent, multisectoral, and well-funded response to HIV/AIDS in Cape Verde. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 7. The objectives of the project were to assist the Borrower in: (i) reducing the spread of HIV/AIDS in the Borrower's population; (ii) mitigating the health and socioeconomic impact of HIV/AIDS on persons infected with or affected by HIV/AIDS within the Borrower's territory, thus sustaining an economically 1 productive population; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. 3 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 8. The original PDO were not formally revised during implementation of the project, but the Project Key Performance Indicators (PDO and intermediate outcome indicators) were formally revised in December 2006 at the time of the approval of additional financing for the project. The project was not part of the umbrella MAP restructuring (in 2007)4 because the approved additional financing had already dropped the indicator on seroprevalence of HIV in the general population in 2006. 9. Data on the original and revised PDO and intermediate outcome indicators are presented in Section F of the Data Sheet and discussed in more detail in Section 3.2 and Annex 2. 1.4 Main Beneficiaries and Benefits 10. The initial project was expected to benefit the entire population, combining a comprehensive Information, Education, and Communication (IEC) effort with smaller scale interventions targeting a range of particularly vulnerable and specific at-risk groups for intensified services, including: (i) youths (in particular teenage girls); (ii) women and in particular pregnant women; (iii) water and road transport workers; (iv) commercial sex workers; (v) people addicted to drugs; (vi) the military and other uniformed forces; and (vii) impoverished orphans. As confirmed by the IDSR II (2005), improved sentinel surveillance data and the sero-prevalence study estimated overall HIV prevalence at 0.8%, and the additional financing proposal opted to fund a smaller, better targeted number of activities focusing on consolidating the initial results and finding ways to assist: (i) people living with HIV/AIDS; (ii) HIV/AIDS affected households; and (iii) specific at-risk groups, including commercial sex workers, street children, and drug addicts. 11. By financing sub projects through multiple channels, including ministerial, municipal, and civil society groups, the project was expected to: (i) reduce the number of new HIV/AIDS cases; (ii) improve the diagnosis, treatment and care for people living with HIV/AIDS; (iii) extend the productive life of people living with AIDS; (iv) improve the ability of communities, households and individuals to prevent or cope with impact of HIV/AIDS; and (v) improve the economic prospects of orphans and poor HIV- stricken families. 1.5 Original Components 12. Project Component 1: Capacity-Building (US$ 0.86 million) was intended to finance capacity- building activities for the public sector and civil society to implement HIV/AIDS prevention, care, and support activities in the country. Sectoral entities, municipalities, civil society organizations, and the Coordination Committee to Fight AIDS (CCS-SIDA) were all expected to benefit from capacity building in selected technical areas as well as in administrative and financial management. 13. Project Component 2: Public Sector Initiatives (US$ 4.31 million) was intended to support HIV/AIDS initiatives comprising public sector HIV/AIDS activities coordinated at national level by ministries and parastatal agencies; and at decentralized levels by municipalities. 3 There were some inconsistencies in the presentation of the indicators in the original credit within the PAD (between Section A.2 and Annex 1) and between the PAD and the legal minutes of the negotiations (the indicators were not included in the original DCA). The PDO and intermediate outcome indicators presented under Section F of the Data Sheet are taken from: (i) original credit: PAD, Annex 1; (ii) additional financing: Project Paper, Appendix B. 4 The umbrella restructuring eliminated the use of HIV prevalence rates as an outcome indicator after determining it to be an inadequate measure for HIV/AIDS projects performance. 2 2a) National initiatives. The Ministry of Health, Employment and Solidarity, which already had a unit (PNLS) with responsibilities for HIV/AIDS, was to continue to carry out health sector related HIV/AIDS activities, in addition to setting policy and strategy, and providing technical health related HIV/AIDS support to other ministries and municipalities. As part of the multisectoral approach to HIV/AIDS, each ministry was, at a minimum, expected to: (i) have a focal person or team for HIV/AIDS; (ii) establish a mechanism (at central and community levels) for informing and educating its employees and a social support network; (iii) prepare or update an HIV/AIDS strategy and action plan to include measures for preventing and mitigating the effect of HIV/AIDS in the work place; and (iv) propose HIV/AIDS interventions aimed at reaching clients of the ministries and agencies. Some of these activities were expected to be contracted out to civil society organizations or the private sector. 2b) Municipal initiatives. Given the importance of Cape Verde's municipalities for effecting change at the local level, the project supported activities to be carried out by municipalities, or contracted out by them to civil society organizations or the private sector. Under this component, municipalities were to support: (i) HIV/AIDS awareness of municipal authorities, teachers, school management teams and community leaders; (ii) training and support for municipal and community- based staff in HIV/AIDS prevention, support, and care, provision of voluntary counseling and testing (VCT) services; (iii) HIV/AIDS-related health services at municipal facilities for prevention (including HIV-related IEC and condom distribution to the municipal workforce), diagnosis, treatment5, and care (for the syndromic treatment of sexually transmitted infections (STI) and Directly Observed Therapies (DOTs); and (iv) promotion of community and civil society-led HIV/AIDS initiatives through their selection, contracting, financing and supervision. Many of the activities financed under this component were to support activities at community levels by civil society and the private sector, i.e. advocacy, training, promotion of community led HIV/AIDS initiatives, and DOTs. 14. Component 3: Civil Society and Private Sector Initiatives (US$ 2.62 million) was intended to support community-led HIV/AIDS activities directly carried out, or contracted out, by civil society organizations, such as NGOs, religious organizations and organizations of PLWHA. These activities were expected to include, for example: targeted support to orphans, guardians of poor orphans, and AIDS-stricken impoverished households; support to families affected by HIV/AIDS including revenue generating activities; community-based IEC; home-based care; promotion of the use of condoms at the community level; support of community-based HIV/AIDS networks in prevention, care, and support activities. 15. Component 4: Project Facilitation, Coordination, Monitoring and Evaluation (US$ 1.31 million) was intended to fund the operations of the Secretariat of CCS-SIDA in charge of facilitation, coordination, review of action plans and funding proposals, supervision, monitoring and evaluation ( to be outsourced), and support to CCS-SIDA for longer-term national planning and policy development. 1.6 Revised Components 16. The additional financing proposal retained the same four project components of the original project as well as activities consistent with the National HIV/AIDS Strategic Plan (2006-2010), but shifted its focus on high risk groups; proposed project results and outcomes were modified in accordance with the 5 ART was not originally included, but was later. 3 project's achievements at the time and expected future results before the revised closing date of December 31, 2008. 1.7 Other significant changes 17. Amendment of the Development Credit Agreement (DCA). The original DCA was amended four times to: (i) revise procurement procedures (April and July 2004)6; (ii) reallocate the project proceeds (September 2005); and (iii) extend the closing date (December 2006). The Additional Financing Agreement modified the project performance indicators and was amended three times to: (i) reallocate the proceeds of the project (May 2007 and November 2008); and (ii) extend the closing date a second time (December 2008). 18. Additional financing. A request for additional financing of US$5 million equivalent was approved by the Board on December 19, 2006 and became effective on April 17, 2007. The additional funds were requested to help finance: (i) scale up cost-effective interventions for high-risk groups successfully initiated under the original credit; and (ii) identify ways of ensuring the financial sustainability of efforts to fight HIV/AIDS, given limited public financing and the anticipated completion of the original IDA financing. 19. The additional financing was consistent with the Bank's conditions for Additional Financing as stated in BP 13.20 (June 2005). It was also consistent with Pillars 3 (human capital development) and 5 (social protection) of Cape Verde's Poverty Reduction Strategy (2004) and Pillar 3 of the Bank's CAS (2005-08), which calls for implementing social programs aimed at alleviating poverty and inequity. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 20. Project preparation. Project preparation was initiated in the spring of 2001. A PHRD grant was signed in June 2001 for US$475,000 (of which US$410,000 was spent) with the objectives of: (i) carrying out a number of studies (baseline study, social and gender assessment, NGO capacity assessment, etc.); and (ii) specifying institutional and operational mechanisms, including financial management assessment. To support the single person responsible at the time for all the activities of PNLS, consultants were recruited in the areas of IEC (to draft a strategy and training plan), epidemiology/public health (to re-launch the HIV/AIDS sentinel surveillance system), and HIV/AIDS care and support. 21. Subsequently, the project preparation also utilized a project preparation facility (PPF) in the amount of US$400,000 to: (i) restart the HIV/AIDS sentinel surveillance (including procurement of reagents to supply the sentinel posts); (ii) strengthen the implementation capabilities of CCS-SIDA and the Administrative Unit providing procurement and financial management assistance; (iii) pilot the implementation of the Project Operational Manual by making funds available to selected line ministries, municipalities, and NGO's; and (iv) organize workshops and study tours to improve capacity in sentinel surveillance, medical waste management and Bank operations. 22. Though most of the PHRD activities were carried out, the baseline study was not, with the result that both essential elements of the background analysis (which might have led to a more targeted intervention approach) and some baseline indicators for M&E were lacking. The PPF activities were implemented and provided essential elements for enhancing project implementation. 6 These amendments were intended to bring the project in line with the Bank's guidelines for the acquisition of HIV/AIDS Medicines and Related Supplies (February 2004) and with the new procurement procedures (May 2004). 4 23. During the project preparation process, the Bank repeatedly flagged the following issues: (i) the paucity of information concerning the epidemic and the need for baseline information on the sero- prevalence of HIV; (ii) insufficient development of the strategy for certain interventions (VCT, social marketing of condoms, and helping PLWHA to organize themselves) and logistical and supply mechanisms; and (iii) the need to strengthen the technical capabilities of the PNLS and train health staff in treatment and care of HIV/AIDS patients. Despite such concerns, Bank project preparation missions proceeded on schedule.7 24. At the same time, the Government proceeded on schedule to: (i) create the national coordinating body in July 2001; (ii) organize a broad consultative process to formulate the national strategy; and (iii) establish ministry focal points and Municipality HIV/AIDS committees. Concurrently, NGOs were developing HIV/AIDS action plans in anticipation of submitting proposals for project funding. 25. Similarly, project preparation for additional financing moved smoothly and swiftly in 2006, with appraisal in October, negotiations in November, and Board approval in December. 26. Project design. The project was designed, with some adaptation, according to the first generation of MAP's design and mechanisms for implementation, which was appropriate at the time given the country's limited knowledge of the epidemic. Though a detailed analysis of the epidemic was incomplete, agreement was reached on the project's components, which aimed to: (i) mainstream HIV/AIDS prevention, treatment, care, and support activities into all sectors of Government and into civil society; (ii) scale up successful interventions and coverage among the general population; and (iii) strengthen coping mechanisms, particularly for orphans, households headed by women, the very young, and the elderly. Project design discussions addressed and resolved a number of key challenges for the country given its geographical and economical particularities, including: (i) the complexity of introducing a multisectoral strategy, particularly where the Ministry of Health had played the predominant role for an extended period; (ii) the difficulties of coordinating and managing program interventions at national and sub-national levels, especially given the geographical dispersion of the population among ten islands; and (iii) the weak capacity of the civil society to implement activities in a new and difficult area. 27. The Bank's preparation team was headed by a transport specialist, who received assistance from public health specialists and advice from ACTAfrica and TTLs who had already prepared multi-sectoral HIV/AIDS projects. Project preparation followed two complementary tracks: (i) tailoring internationally accepted practices for HIV/AIDS response to the Cape Verdean situation for incorporation into the national strategy8; and (ii) systematically organizing consensus-building exercises through visits to ministries, municipalities, NGOs, etc. to ensure a broad understanding of the multi-sectoral approach to HIV/AIDS among all stakeholders. 28. The PAD for the original project correctly identified the major critical risks and proposed appropriate risk mitigation measures, which were generally applied and adequate when they were subsequently required to resolve problems with one exception. The PAD accurately identified the potential risk related to adequate financing during and financial sustainability after the end of the project 7 A draft PCD was prepared in the spring of 2001, shared informally with the Government and its partners in June 2001 and during an identification mission in July 2001; a pre-appraisal mission was conducted in October 2001; and the appraisal mission was carried out in February 2002. 8 Many of the "lessons learned" presented in the PAD were drawn from a note on "Early MAP Country Operations" prepared in March 2001 by ACTAfrica and were consistent with UNAIDS guidance in developing countries. 5 (and particularly Government's ability to provide timely and sufficient counterpart financing during implementation); in this case, however, no mitigating measure was proposed. 29. The Project Paper for the Additional Financing9 noted that while the changes in project components were not substantial, the proposed changes in project design consisted mainly of sharpening the current approach with an eye to target high risk groups. Specifically, the additional financing was intended to: (i) build on project-financed studies (of commercial sex workers, street children and drug addicts) and implement recommendations to better target project interventions; (ii) strengthen the expanding network of VCT sites established on the individual islands; and (iii) improve the operations and results of the M&E system. The Project Paper also emphasized the risk of adequate financing and the need for sufficient time to secure the required funding to sustain activities after project closing. 30. Quality at Entry. No Quality Enhancement Review was conducted. At the decision meeting (January 2002) the principal comments, which were subsequently addressed by the team, concerned: (i) strategic issues related to the national HIV/AIDS strategy; (ii) the size of the credit; and (iii) implementation issues related to the institutional arrangements (coordination, procurement of pharmaceuticals, etc.), procedures (for M&E, financial management and procurement mechanisms, and the operational manual), and conditionalities. Of particular pertinence to the project were the meeting's comments on: the fiduciary architecture of MAP which results in relatively high fixed costs that vary only marginally between small and large countries and which need to be taken into account in providing a rationale for the size of the credit; the importance of a reasonable financial commitment by the Government, even though the country's fiscal situation might dictate other options for meeting this financial commitment; and the need to focus on capacity building (including intensive Bank supervision), particularly during the first year of implementation, and on ensuring the Secretariat's role of facilitation and coordination rather than command and control. 2.2 Implementation 31. Disbursement overview. The original Development Credit Agreement (Cr 3629-CV) in the amount of SDR 7.3 million (US$9.0 million equivalent) was approved on March 28, 2002 and became effective on July 17, 2002. Government was expected to finance US$0.6 million equivalent bringing the total project cost to US$9.6 million equivalent. The Additional Financing Agreement (Cr 3629-1 CV) in the amount of SDR 3.4 million (US$5.0 million equivalent) was approved on December 19, 2006 and became effective on April 17, 200710. Government was expected to finance an additional US$0.5 million equivalent. 32. Though disbursement began slowly in 2002, expenditures had increased so rapidly by the time of the mid-term review (September 2004) that a major concern was the potential depletion of funds for HIV/AIDS without any other potential sources of support. In fact, from February 2005 through the April 2007, the project was only able to fund selected priorities (initiated ARV treatment implementation, M&E, and the institutional structure). Similarly, there were initial delays in disbursing the additional financing (related to finalizing the action plans and financial agreements with various stakeholders and implementers), but these were almost entirely committed (at least for the sub-projects) 9 The initial Bank intervention assumed a longer-term involvement and included provision for a follow-up MAP project (which was requested by the Government in 2005), but given the unexpected low prevalence, a project extension and additional financing were deemed to be sufficient. 10 The delay in effectiveness resulted from the effectiveness condition that a revised version of the Operating Manual reflecting agreed changes be approved by IDA. 6 by the end of 2007 and disbursed over the remaining eighteen months of the project. The disbursement profile is presented in Section I of the Data Sheet. 33. Implementation overview. Implementation began prior to project effectiveness with a number of important actions, including efforts: (i) by MOH to adopt a draft IEC strategy, prepare a procurement plan for reagents, pharmaceuticals, etc., and re-launch the HIV/AIDS sentinel surveillance system; and (ii) by the other ministries, municipalities, and NGOs to develop action plans for project funding. 34. After project effectiveness, the pace of implementation slowed,11 though the decision to use the Administrative Unit (AU) of the Transport Project as a source of technical expertise for procurement matters attenuated some of these effects. Bank missions expressed concerns (in April and September 2003) about the institutional arrangements12, Government's need to "recommit" to the implementation of the national strategy, the insufficient number of MOH staff working on HIV/AIDS, slow progress in addressing capacity weaknesses at all levels, and the complicated and time-consuming review by municipalities of proposals from civil society organizations. The missions also emphasized the need for promoting actions to empower PLWHA and to develop care and support programs for them. 35. By early 2004, overall project implementation had improved, the AU's functions had been transferred to the ES-CCS and key replacement staff hired. The MOH, in particular, had made progress in establishing surveillance, standard protocols and procedures (for STDs, IOs, VCT, and PMTCT), and procurement of ARVs.13 Thereafter, overall project implementation was consistently rated Satisfactory or better in ISRs with the exception of the last ISR in June 2009, when it was rated Moderately Satisfactory, based on reduced ratings for project management (from Satisfactory to Moderately Satisfactory) and especially counterpart financing (from Satisfactory to Moderately Unsatisfactory). Component implementation was rated Satisfactory or better throughout, with occasional Moderately Satisfactory ratings between March 2008 and June 2009 for Components 2a (national initiatives) and 4 (project facilitation). 36. The mid-term review was held as scheduled in September 2004 and noted that "in implementing the project, the Government has actively engaged and encouraged participation of every level of society: national and municipal public sectors, civil society and private sector ­ and society has responded robustly." The MTR recommended the recruitment of facilitators for the municipalities, but this only occurred later (in 2007) and proved to be useful both for implementing the additional financing and for strengthening longer term capacity at the municipal level. 37. Implementation of the project was marred by: (i) an inability to mobilize sufficient non-IDA funding for HIV/AIDS; and (ii) delays in and inadequate amounts of counterpart financing. Of the total US$1.1 million for counterpart financing, indicated in the original and additional financing credits, the project had received US$0.54 million (or 49%) by June 30, 2009. However, because counterpart funds were expected to finance only 10% of works, local goods, and operating costs, which altogether comprised a relatively small proportion of the credit, there were no disruptions in the financing of the principal activities. 11 There were some difficulties in recruiting an Executive Secretary, related partly to the proposed salary scale and partly to the interest and qualifications of the candidates. 12 The September 2003 supervision mission reviewed the implementation difficulties at all levels and proposed solutions but noted that the Government authorities did not entirely agree with either the Bank's analysis or its recommendations. 13 During project preparation, MOH was somewhat reluctant to get involved with treatment. The PAD and the DCA opened the possibilities for treatment "if future Government policy deems it appropriate" (PAD, p. 11), and subsequent Bank missions encouraged and endorsed MOH's efforts to develop protocols, procure drugs, etc. 7 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 38. M&E design. Successive preparation missions proposed to delegate the M&E components as follows: (i) biological surveillance and epidemiological research (including the annual antenatal HIV prevalence survey) to PNLS assisted by the Epidemiology Unit of the Ministry of Health; (ii) behavioral surveillance to a consulting firm or NGO; and (iii) financial and program management monitoring to the AU (and subsequently to the CCS-SIDA), including responsibility for an integrated data base and reporting system for submitting M&E reports in an agreed format at agreed intervals.14 It was expected that an in-country consultant would be recruited to develop an M&E system during the project preparation phase, but when this did not occur, the Bank prepared the draft M&E manual (in June 2002) and proposed the recruitment under the project of a long-term M&E officer with short-term technical assistance. 39. M&E design for both the original credit and for the additional financing was weakened by: (i) the absence of Project Outcome Indicators for two of the three PDO (mitigation and capacity), though appropriate intermediate outcome indicators were selected to monitor all three PDO; (ii) the lack of baseline data for some indicators (reducing the spread of HIV/AIDS); and (ii) the imprecision in the formulation of certain indicators and/or the inability to obtain data to measure results. The original credit relied on the Demographic and Health Surveys (or IDSR) to measure several indicators, but the timing of these studies did not coincide well with project needs: (i) some baseline indicators used the results of the 1998 IDSR instead of the planned baseline survey; and (ii) most indicators were to be measured in 2005 (only three years after the start of the project) to ensure that the 2005 IDSR would provide adequate and timely data. 40. Implementation. Under the arrangements for monitoring, CCS-SIDA was responsible for defining M&E needs and for the strategic use of M&E data and reports to inform project and program management. A team of two persons worked on M&E throughout the project, with the assistance of a long-term M&E consultant and periodic visits by the Global Monitoring and Evaluation Team (GAMET). 41. Two computerized management information systems were installed to assist project activity monitoring, but the initial system never functioned satisfactorily and the subsequent system (TECPRO) was not generally used by the M&E unit, which relied on Word and Excel tables to prepare reports. These tables provided useful information on sub-projects (e.g., promoter, targeted people/number of beneficiaries, estimated cost, type of intervention (awareness, treatment, and such), etc. but were difficult to manipulate in a timely manner. Overall, insufficient human resources and an inability to develop standardized indicators has hindered the development of program monitoring; this was particularly the case at the municipality level where monitoring of sub-projects had some weaknesses. 42. An ambitious schedule of quantitative and qualitative studies for surveillance and research was carried out as follows: 14 Regional technical assistance was envisioned for all three components, with World Bank Washington assistance to coordinate operations research and ensure maximum MAP program learning and dissemination. 8 Table 1: Types of planned and executed studies Types of studies Instrument Planned Executed Biological surveillance Antenatal 2002-2008 2002-08 Sex workers and drug users DHS+ 2003 2003 Household behavioral surveillance DHS DHS 2004; 2008 2005 APIS AIDS module APIS 2006 2009 Behavioral surveillance Uniformed services (primarily male) BSS 2003; 2005 2003 Low-income market traders (primarily female) BSS 2003; 2005 2003 Sources: Aide memoire (April 2003) for planned; report dates for executed. Epidemiological surveillance was expanded from 2 to 22 sites and annual reports produced by MOH; behavioral surveillance studies targeted uniformed forces (armed forces, police, etc.), female market traders, and drug users (2004); and impact studies through APIS and INE were used to determine several of the results of the project (2009). Other research was carried out on: (i) sexuality among adolescents and teenage pregnancy; (ii) drug use by injectable drug users, sex workers, and adolescents; (iii) vulnerability among orphans and street children; and (iv) communication strategies in general and for social marketing of condoms in particular. 43. ISRs during the first five years of project implementation routinely rated M&E satisfactory; over the last eighteen months of the project, however, M&E was rated moderately satisfactory in three of the four ISRs, due principally to weaknesses in the management information systems and delays in obtaining the data on project outcomes. The additional financing required that special studies be conducted at the end of the project period; these were done but were only available after project closing. 44. Utilization. Data from the different surveillance studies (particularly the 2003 BSS and the 2005 IDSR) were used to modify the national strategy and to justify revised targets for additional project funding. Data from the project monitoring system provided the basis for quarterly reports to the project steering committee and to the Bank as well as for the annual reviews of HIV/AIDS in Cape Verde. 2.4 Safeguard and Fiduciary Compliance 45. Environment. The environment category of the Project at the time of appraisal was B, with inappropriate handling and disposal of medical waste and inadequate management of the respective disposal sites in urban or peri-urban areas cited as the major problems. Financed by the PPF, a detailed waste management plan was a condition for negotiations in February 2002 and finalized in March 2002.15 The plan focused on revising existing health sector guidelines on appropriate management of medical waste and on training of health care professionals and community workers delivering care to HIV/AIDS patients; implementation of the medical waste management plan began in earnest in 2003 and it was noted in the aide-memoire of the January 2004 supervision mission that "the progress achieved is worth sharing with other countries dealing with similar problems." 46. The mid-term review noted that: (i) the waste management plan is comprehensive and takes into account all needs (ex. both storage and disposal aspects), all types of waste ­ solid, liquid, human tissues/annexes; all geographical levels from hospitals to laboratories to the smallest health facilities at 15 The revised safeguard policy, requiring a separate environmental plan for category B projects and disclosure in country and in Infoshop, was introduced during the project's preparation. As a result, disclosure was not possible prior to project appraisal. 9 community level; and (ii) Cape Verde has established clear ownership of the waste management plan that has been locally developed. Throughout project implementation, the ISRs rated compliance with environmental and social safeguards as satisfactory or highly satisfactory, and the medical waste management framework is considered as a best practice for the sub-region.16 47. Procurement, Disbursement, and Financial Management. Procurement was carried out initially by the AU and then by a staff of (mostly) two persons. ISR ratings for procurement were uniformly satisfactory, though periodic reviews noted inadequacies in updating the procurement plan (due in part to the demand-driven nature of the project), the broad range and small quantities of goods to be procured, and the insufficient use of the operations manual as a reference for the appropriate procedures. 48. As noted earlier, project disbursement was constrained by the lack of available funds. As noted in Annex 1, project cost, combining original and additional financing, was estimated at US$15.1 million equivalent. On June 30, 2009, IDA disbursements totaled US$15.7 million and Government disburse- ments US$0.54 million, with the discrepancies due principally to large exchange rate fluctuations. 49. Project financial management (FM) was ensured by a small, stable staff of three persons. 17 While early reviews noted project compliance with the disbursement procedures set forth in the DCA and with international accounting standards, FM was downgraded from Highly Satisfactory to Moderately Unsatisfactory in September 2005 when the mid-term review's recommendations were not implemented, resulting in the continued failure to produce timely Interim Financial Reports (IFRs), delays in preparing the annual budget, and weak internal controls. Renewed adherence to a detailed action plan to strengthen FM and the subsequent full installation of a computerized accounting system (TOMPRO) restored the rating to Satisfactory by May 2006 where it remained for the duration of the project. Though the financial management rating remained as Satisfactory at project closing, several insufficiencies were noted, including: (i) weak accounting and financial management at municipality level, particularly with respect to submitting receipts; and (ii) non submission and or delay in submitting IFRs. The last IFR of November 10, 2009, was received after a 3 month delay and does not provide information on status of pending receipts with regards amounts transferred to municipalities, ministries, and civil societies. 2.5 Post-completion Operation/Next Phase 50. Politically and institutionally, the project has established a good basis for the post-completion continuation of the project's benefits: (i) appropriate legislation has been adopted (though not entirely implemented); (ii) the authorities were successfully mobilized and maintain a high interest in the fight against HIV/AIDS; and (iii) the project ultimately succeeded in reaching the entire population through the municipalities and the civil society organizations. Further, the early investment in capacity building enabled the structures put in place to adapt to the changing project implementation conditions, scaling up quickly in 2003-04, prioritizing actions when funds ran short in 2005-06, and then scaling-up again beginning in 2007. The inclusion of associations, including associations of PLWHA, as formal stakeholders was a significant step in the society's approach to the epidemic. 51. Technically, the project contributed to the adoption of policies, strategies, protocols, etc., which consolidated the national consensus in areas of prevention, treatment, and mitigation. In particular, the project should be cited for its adherence to a multisectoral approach, the focus on youth (whether in 16 The estimated budget for the implementation of the waste management plan was about US$ 2.6 million (or more than 25% of the initial credit); data on actual expenditures is lacking but it is doubtful that this amount was spent. CCS- SIDA was asked to provide additional information on the implementation of the waste management plan but have not yet responded to the request. 17 Secretariat staff of CCS-SIDA was for the most part remarkably stable over the life of the project with most key personnel present for virtually the entire project. 10 schools, or in their mandated army training tours, or in other forums), and the introduction of ARVs. All of these contributions have been embraced by both govenment authorities and civil society organizations. 52. While there was a hiatus in funding between the closing of the project and the availability of the Global Fund money, 18 the Global Fund grant (of US$5.3 million over the first two years) will cover approximately 90% of the gap between estimated total program costs and available financing. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 53. The relevance of all three of the project's objectives and components as well as its specific activities is rated Substantial for both the original credit and for the additional financing based on: (i) Cape Verde's epidemiological situation and program priorities during the two distinct phases of the fight against HIV/AIDS in the country; and (ii) the Bank's current overall policies and country strategy. 54. Based on available data and an assessment of the country's elevated risk related to its open economy and large number of migrants, the original credit (2002-06) implemented the recommended multisectoral approach through line ministries and in support of a large number of civil society sub projects to reach broad segments of the population concentrated in high-risk groups. After the 2005 IDSR results which: (i) staged the view of the epidemic to one with low prevalence; and (ii) influenced the revision of the National Strategy 2006-10, the additional financing (2007-09) applied a more targeted approach based on improved knowledge (both in the Bank and in Cape Verde) of the efficacy of specific interventions and the importance of focusing on high-risk groups. To this end, the additional financing: (i) shifted the focus from developing plans to executing them; (ii) emphasized interventions and services for high-risk groups while maintaining prevention efforts through IEC and condom promotion at all levels; and (iii) expanded the capacity for diagnosis and treatment. 55. The PDOs remained consistent with the country's international commitments (MDG's, the Three Ones, etc.) and national strategies as presented in the Growth and Poverty Reduction Strategy Paper (GPRSP). With respect to the World Bank's country strategies, the Project's Development Objectives (PDOs) contributed to: (i) the identification (in the CAS progress report of 2001) of HIV/AIDS as an area for Bank support; and (ii) the inclusion of HIV/AIDS within the MAP framework (in the subsequent CAS of 2002). A follow-on HIV/AIDS project was initially envisioned but replaced by additional financing consistent with the high case scenario of the 2005 CAS. 3.2 Achievement of Project Development Objectives 56. Based on outcome indicators measuring the reduction of the spread of HIV infection (substantial) and on other key performance indicators measuring mitigation of the health and socioeconomic impact of HIV/AIDS on persons infected with or affected by HIV/AIDS (modest) and on building a strong and sustainable national capacity to respond to the epidemic (substantial), the project's achievement of its development objectives is rated as Substantial. The rating is justified below with details available in the Data Sheet and in Annex 2 (presenting the results chain). Furthermore, each project objective (and ultimately the overall project achievement rating) was weighted in proportion to the actual disbursements of the original credit at the time of approval of the additional financing, according to Appendix B of the Implementation and Completion Results Report Guidelines (OPCS/IEG, August 2006 updated June 2007). 18 The final extension of the project closing date, from December 31, 2008 to June 30, 2009 was intended in part to provide bridge money to the Global Fund financing, but as of December 30, 2009, the Global Fund financing was not yet effective. 11 57. Given that IDA funds accounted for 85% of the national program resources for HIV/AIDS activities over the period 2002-2009, much of the progress during the project period can be attributed to project activities (Table 8). 58. Objective 1: Reducing the spread of HIV/AIDS in the Borrower's population. The project made a substantial contribution to the achievement of this PDO during both the period of the original credit and the period of the additional financing. The country was successful in reducing prevalence of HIV in the general population from 2.08% in 2002 to 0.8% in 2009; and among women attending anti- natal clinics from 0.8% in 2005 to 0.5% in 2008. These results were linked to changing behavior by: (i) raising the median age of first sex; (ii) increasing condom use with non-regular partners; (iii) reducing the proportion of sexually active people reporting having non-regular sexual partners; and (iv) reducing the prevalence of sexually transmitted infections. 59. Raised median age of first sexual relations (Indicators 5 and 8). The project initially aimed by 2005 to increase the median age by one year among both females and males and thereafter to maintain the median age at that level. The project results are presented in the following table. Table 2: Project results to raise the median age of first sex Objectives Results Indicator Baseline 2005 Final 2005 2009 Median age of first sexual relations among males M: 15.6 M: 16.6 M: 17.0 M: 17.0 M: 15.0 and females F: 14.3 F: 15.3 F: 17.0 F: 17.0 F: 16.0 Sources: IDSR I (1998-Baseline); IDSR II (2005); APIS (2009) The table shows that by 2005, the project had achieved the envisioned results, but that it was unable to maintain the results for males and females. Although the project was not able to sustain the initial gains and achieve the PDO, the project did contribute to an increase of almost two years in the median age of first sexual relations for females. 60. Increasing condom use (Indicators 6, 7, and 9). The project initially aimed by 2005 to increase the proportion of the 15-49 age group reporting use of a condom in their last sexual act with a non-regular partner to 60% for males and 30% for females and then subsequently by December 2008 to 75% for males and 50% for females. The project results are presented in the following table. Table 3: Project results to increase condom use with non regular partners Objectives Results Indicator Baseline 2005 Final 2005 2009 Proportion of the 15-49 age group who report M: 43% M: 60% M: 75% M: 72% M: 78.9% using a condom in their last sexual act with a non- F: 9% F: 30% F: 50% F: 46% F: 67.6% Sources: IDSR I (1998-Baseline); IDSR II (2005); INE (2009) The table shows that there was a significant increase in the use of condoms from 43% of men in 2005 to 78.9% in 2009 and from 9% of women in 2005 to 67.6% in 2009. Further, the INE study (2009) found that among the youngest men and women (aged 15-19 years) condom use was even higher: 83% for men and 71% for women. 61. The project aimed during the second phase to increase condom use among the 922 commercial sex workers identified in the country. However, given the small sample sizes of the baseline and follow-up surveys, the outcome of this indicator cannot be confirmed as positive or negative. 12 Table 4: Project results to increase condom use among commercial sex workers Objectives Results Indicator 2005 2009 2006 2009 Number of commercial sex workers who report 74.4% 94.4% 29 of 39 66 of 104 using condoms has increased 74% 64% Sources: Qualitative Survey on Population at risk (2006-Baseline); Rapport Verdevem (2009) The number of CSW reporting the use of condoms increased, but the proportion of CSW reporting the use of condoms did not. 62. Reduced proportion of sexually active people reporting having non-regular sexual partners over the previous 12 months (Indicator 3). The original indicator was modified as follows at the MTR: By "December 2006, reduce from the baseline of 69% for men and 39% for women to 50% for men and 20% for women, the percentage of sexually active people reporting having had non-regular sexual partners over the previous 12 months." IDSR II (2005) provided the following result: 66% for men and 43% for women, indicating that the result was not met. According to APIS, the actual values for men and women were 54.4% and 41.5%, respectively in 2009. 63. Reducing the prevalence of sexually transmitted infections (Indicator 4). The project initially aimed by 2005 to reduce by 25% the incidence of reported STIs (urethritis) in men age 15-49 years; the indicator was never reported on and was replaced by the objective to reduce by 25% the prevalence of STIs among the community as measured by syphilis prevalence amongst pregnant women. The project results are presented in the following table. Table 5: Project results to reduce the prevalence of STIs (syphilis among pregnant Objectives Results Indicator 2002 2005 2004 2007 Prevalence of STIs among the community as 1.73% 1.31% 1.65% 1.60% measured by syphilis prevalence among pregnant Sources: Baseline: ANC Sentinel (2002-Baseline); ANC Sentinel (2004, 2007) Overall, the project did not achieve the 25% reduction but made progress in reducing the prevalence of STIs (as measured by syphilis among pregnant women attending ANC). 64. Reducing the spread of HIV/AIDS (Indicators 1 and 2). The following table presents data from the ANC sentinel sites and the sero-prevalence study over the period 2002-2008: Table 6: HIV prevalence results Objectives Results Indicator Baseline 2005 2002 2003 2004 2005 2006 2007 2008 By 2005, prevent the increase (compared with 2.08% Tot: 0.8% the first year of the project) in seroprevalance of M: 1.1% HIV in the general population F: 0.4% By 2005, reduce by 20% HIV prevalence among 1.13% 0.90% 0,84% - 0,69% - 0,31% - 0.80% 0,90% 0,70% 0,50% women attending ante-natal care clinics 1,42% 1,08% 0,57% (compared with the first year of the project). Baseline: ANC Sentinel; 2002-04: ANC Sentinel; 2005: IDSR II; 2006-08: ANC Sentinel While acknowledging the limitation of both indicators, evidence from sentinel surveillance suggests that HIV prevalence (for the general population and among pregnant women aged 15-24 years old attending ANC) shows a decline. 65. In addition to these outcomes, the project achieved a number of other important results related to reducing the spread of HIV: 13 The proportion of HIV positive pregnant women receiving preventive treatment for mother-to- child transmission (MTCT) of HIV surpassed initial targets and increased from 0 to 80% by 2005 and to 100% by 2006. Voluntary counseling and testing services were expanded to all the municipalities and the number of persons tested has doubled since 2005. Significantly, among pregnant women attending antenatal services, 10% were tested in 2005, 94% are now tested, and the test is considered virtually routine. Though less impressive, results in Table 17 showed improvement in other areas of prevention as well (e.g., sensitization of vulnerable groups, blood transfusion, etc.) 66. Objective 2: Mitigating the health and socioeconomic impact of HIV/AIDS on persons infected with or affected by HIV/AIDS. Though no outcome indicators were linked to this PDO, other measures of achievement show that the project made modest progress in achieving this PDO during the original credit and substantial progress with the additional financing. The overall rating for achievement of this objective, using the ICRR guidelines, is modest. 67. Providing home or community-based support to PLWHA (Indicators 11 and 15). Social networks for people affected by HIV/AIDS were by 2005 being implemented in all 17 municipalities. Though the proportion of PLWHA benefiting from home or community-based support did not meet the targets for 2004 and 2006, this was in part due to the increased number of PLWHA who were being monitored19 as part of the support system, as shown in the table below: Table 7: Proportion of reported PLWHA receiving home or community-based support Objectives Results Indicator 2004 2006 2004 2005 2006 2007 2008 Cumulative number of HIV cases 1 489 1 712 2 011 2 330 2 606 Cumulative number of registered PLWHA 30 318 503 746 1 018 Number of persons receiving support 10 38 120 142 230 Proportion of reported PLWHA receiving some 50% 80% 33% 12% 24% 19% 23% form of home or community-based support Source: SE CCS-SIDA data Overall, the number of PLWHA benefiting from home or community-based support increased from 10 in 2004 to 120 in 2006 and then virtually doubled by 2008. 68. ARV treatment (Indicator 20). As shown in Table 7, the number of PLWHA being monitored has increased from 30 in 2005 to 1018 at the end of 2008; the number being treated with ARVs has increased from 148 in 2005 to 462 (or 75% of those estimated to require treatment) were being treated with ARVs. While there were periods during which stockouts of ARVs occurred in the supply chain, the health authorities were able to provide adequate alternative solutions while emergency measures were instituted to acquire the recommended drugs. 69. In addition to these results, the project also provided support for more than 500 orphans or more than 10% of the orphan population estimated at 5,000 by the Solidarity Foundation. 70. Objective 3: Building a strong and sustainable national capacity to respond to the HIV/AIDS epidemic. Though no outcome indicators were linked to this PDO either, the project made substantial contributions to this PDO during both the period of the original credit and the period of the additional 19 In Table 18, the denominator used by the project to measure those targeted by the home visits is the number of PLWHA identified at the "treatment poles" but not meeting the criteria for ART. 14 financing. Consequently, the overall rating for this PDO is substantial as evidenced by the results with regards the following intermediate indicators: Training targets for ministries (Indicator 1), municipalities (Indicator 2), and NGOs (Indicator 3) were met and surpassed. The target for training all ministry HIV/AIDS teams in IEC (Indicator 8) was partially met, with teams were trained in the priority ministries of health, education, defense, youth, and labor/social welfare. Though about a year late in implementing their HIV/AIDS actions plans, roughly two-thirds of Ministries (Indicator 4) and non-ministry national public sector agencies (Indicator 7) were doing so by 2004. All of the 17 municipalities were implementing an action plan by 2004 (Indicator 10) and submitting acceptable financial reports (Indicator 13). NGOs and community associations were financed at the funding levels targeted by the project (Indicator 16) and submitted acceptable financial reports. The proportion of private sector entities investing in HIV/AIDS activities exceeded the project's target (Indicator 21). The project submitted a progress report every six months (Indicator 17). 71. In addition to these results, it should be noted in summary that the project succeeded in expanding the national capability from a small unit within the Ministry of Health to a range of public and private sector entities at national, municipal, and local levels and that these entities have in turn ultimately succeeded in reaching the entire population. 72. Overall achievement result. Because the project was restructured and the indicators revised in 2006, the ICR guidelines require that the project outcome be assessed against both the original and the revised project outcomes with separate outcome ratings weighted in proportion to the share of actual credit disbursements made in the periods before (when 69% of the total credit was disbursed) and after formal approval of the revision. Table 10 shows achievement (efficacy) ratings for each of the PDO according to the guidelines, with an overall achievement rating of substantial. The worksheet detailing the calculations leading to these results is available from the Project Files. 73. The project's importance for these results is shown by: (i) the Global Fund proposal indicating that the project's share of total country financing for HIV/AIDS activities over the period 2002-09 was about 85%; and (ii) an ACTafrica survey (July 2008) estimating project contributions to certain key results: 15 Table 8: Contribution of the project to prevention, treatment and support, and mitigation Total Project Activities number support % HIV prevention IEC/BCC No. of IEC/BCC events organized 15 000 12 673 84% No. of persons reached by the IEC/BCC events 165 000 144 384 88% No. of employees reached by workplace HIV prevention events 12 000 4 500 38% Condom distribution No. of male condoms distributed 9 000 000 7 696 764 86% VCT No. of VCT centers 28 22 79% No. of persons receiving the results of HIV tests 43 000 42 396 99% No. of women enrolled in PMTCT programs 167 167 100% No. of patients treated for STIs 15 098 10 500 70% Treatment and support No. of sites offering ART 22 22 100% Cumulative no. of patients receiving ART 335 335 100% No. of PLWHA receiving treatment for OIs 256 256 100% Impact mitigation No. of vulnerable persons receiving external support 350 261 75% No. of vulnerable children receiving support 650 493 76% No. of orphans receiving educational subsidies and support 130 68 52% No. of income generating activities supported 120 68 57% Source: Results of the ACTAfrica Questionnaire, July 2008. 3.3 Efficiency 74. Project efficiency was rated as Modest based on considerations of: (i) the allocation of funds to the sub-projects; (ii) the project management unit's efforts to enhance implementation efficiency by expanding capacity over the life of the project; and (iii) the results achieved relative to the costs, particularly during the second phase of the project. 75. Analysis of the allocation of funds to the sub-projects shows a shift of resources from the period of the original credit to the period of the additional financing: Table 9: Sub project allocations by intervention and beneficiary group Intervention / Beneficiary group 2002-06 2007-09 Interventions Capacity building, social mobilization, and IEC 66% 28% Diagnosis and treatment 27% 72% Beneficiary group Women, youths, and the general population 74% 26% Infected/Affected persons 16% 72% Source: SE CCS-SIDA data From financing sub-projects emphasizing broad population groups (women, youths and the general population) in the early years, the project shifted to financing sub-projects targeting high-risk and vulnerable groups, and specific interventions in support of those infected and affected by the epidemic in the later years. Table 17 in Annex 2 demonstrates conclusively that while the number of general preventive activities declined over the period 2007-09, both IEC/BCC activities for vulnerable groups and activities targeted to condom distribution, treatment of STIs, and VCT (for all groups but especially for high-risk populations) increased substantially. 16 76. Analysis of the sub-project allocations and overall project results show that project management was able to simultaneously address a range of institutional, financial, and technical considerations. Institutionally, the project focused in the early years on building skills among potential public and private implementing agencies to develop capacity for expanding services later.20 For instance, the project: (i) used the existing Administrative Unit to complement and then train CCS-SIDA personnel, whose skills were then transferred to 8 facilitators recruited to assist the 22 municipalities; (ii) tested approaches and relied on the NGO Platform as an umbrella organization to help other NGOs requiring particular assistance in sub-project preparation and implementation; (iii) financed the key non-health ministries (Youth, Education, and Defense) before financing others; and (iv) assisted the Ministry of Health in establishing protocols, treatment procedures, and practices for ARV treatment before expanding treatment to all of the municipalities. 21 77. Financially, the rapid disbursement of project funds and the results of the 2005 IDSR forced the project to further prioritize and sequence activities based on the experience gained. As a result of limited funding in 2005-06, the project limited expenditures to: (i) the institutional structure, (ii) the ARV pilot, and (iii) support for selective funding of M&E. At the same time, however, the project was able to sustain intersectoral coordination, increase interest and commitment with civil society, and lay the groundwork for transferring greater responsibility for sub-project approval. 78. Technically, the project was able to balance the competing demands of financing sub-projects, producing concrete results with difficult to access populations, and allocating sufficient resources to ensure the highly visible treatment and mitigation efforts. 3.4 Justification of Overall Outcome Rating 79. Based on consideration of the various ratings criteria and indicators and disbursement prior to and after the approval of the Additional Financing, the following table presents the overall outcome rating for the project as Moderately Satisfactory. Table 10: Summary ratings by objective Criteria / Indicators Relevance Efficacy Efficiency Outcome Moderately Reducing the spread of HIV/AIDS Substantial Substantial Modest satisfactory Mitigating the impact of HIV/AIDS on persons Modest Modest Modest Moderately infected with or affected by HIV/AIDS unsatisfactory Building a strong and sustainable national capacity Substantial Substantial Substantial Satisfactory Moderately Overall Project Outcome Rating Substantial Substantial Modest satisfactory OVERALL RATING MODERATELY SATISFACTORY 20 See in particular, Operations Evaluation Department, Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (2005), especially Table 4.1, p. 45. 21 An evaluation of the first year of the ARV pilot was conducted in December 2005; based on the positive results of the evaluation, the ARV intervention was considered to be a priority. 17 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 80. While the PAD noted the importance of poverty and gender disparities for the spread of HIV/AIDS and the need to address vulnerability factors, project implementation did not focus explicitly on these themes nor did project supervision systematically address them. The project did, however, contribute to: adoption of legislation to reduce stigma and discrimination, though interviews in Cape Verde suggest that very little has been done to implement the legislation;22 development of associations of PLWHA and support for persons affected by HIV/AIDS, with more than 10% of total project expenditures spent on psycho-social support for PLWHA and for persons affected by HIV/AIDS; and identification of Cape Verde's population of orphans and vulnerable children (which was estimated at about 1500 in 2005-06) and support (medical, educational, and psycho-social) for this population. 81. More broadly, there is a consensus that the project had a significant impact on: (i) transforming the discussion of HIV from a taboo subject to a national issue and that the resulting information of the population has been crucial (even if changes in behavior have not been commensurate with increasing knowledge of the disease); and (ii) establishing the responsibilities of the municipalities and the local communities in the fight against HIV/AIDS. (b) Institutional Change/Strengthening 82. As a multisectoral operation, the project was not intended to address major institutional or long-term reforms within any one sector. The project did, however, strengthen certain key institutional changes by: (i) making the national HIV/AIDS program multisectoral and mainstreaming HIV/AIDS activities into the action plan of every Government agency; (ii) ensuring a participatory national HIV/AIDS program with private sector (for-profit and not-for-profit) participation and community empowerment; (iii) expanding the national capability from a small unit within the Ministry of Health to a range of public and private sector entities at national, municipal, and local levels, and by this, reaching the entire population; and (iv) strengthening the capacity of national and municipal structures (particularly through the recruitment of facilitators for the municipalities and of the NGO platform to assist other groups and associations) as well as the Executive Secretariat of the CCS-SIDA for national coordination. Given these achievements supported by the project, institutional change is rated substantial. (c) Other Unintended Outcomes and Impacts (positive or negative) 83. Three positive unintended results of the project should be cited. First, several of the approaches used by the project were "copied" for other interventions by the Government: (i) the multisectoral approach was subsequently employed for use in combating other diseases (malaria and TB); and (ii) the IEC campaign for HIV/AIDS was adapted to address the country's drug problem. Second, the project's support for NGOs expanded their range of expertise (previously limited mostly to agriculture and rural development) into the area of health. Third, because of the difficulties encountered in procuring ARVs and other consumables in small quantities, the national drug manufacturing company (INPHARMA) has begun examining the feasibility of producing ARVs in Cape Verde for countries in the sub-region; the requisite studies leading to WHO certification was already underway. 22 The DHS (2005) found that only 16% of those interviewed indicated the requisite tolerance for PLWHA. 18 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 84. Beneficiary assessments were not organized either prior to or at the end of the project. Similarly, stakeholder workshops were not organized. 4. Assessment of Risk to Development Outcome Rating: Moderate 85. Politically, administratively, and programmatically, the risks would seem to be negligible to low. Government commitment to fighting HIV/AIDS is clear at central and municipality levels, and the institutional measures and strategic documentation provide a sound framework for continued progress. The growing program responsibilities for municipalities and the increasing participation of civil society have strengthened implementation capacities at decentralized levels, not only for combating HIV/AIDS but also for other initiatives. Administratively, the complementary responsibilities of CCS-SIDA and the Ministry of Health have contributed to an effective implementation of the national strategy. 86. There are, however, important concerns about the financial future and sustainability of the measures established between 2001 and 2009. These concerns were noted during preparation and at the mid-term review; they were cited as a continuing risk and a major reason for seeking additional funds in 2006; and they have been a preoccupation of supervision missions since 2007. The slowness with which counterpart funding has been made available and the reduction in CCS-SIDA staff on the closing date of the project are also worrisome, but as a middle income country, Cape Verde does have the means to provide adequate resources for the national response to the epidemic. Further, the approval of the country's Global Fund application (though not effective at the time of project closing) will provide an additional period for transitioning to a sustainable funding level. However, given the uncertainties about: (i) the timing of and conditions for using the expected GF financing; and (ii) the medium-term prospects for financing the national program, the risk to development outcome is considered moderate. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 87. The Bank successfully pursued a project preparation strategy based on: (i) drawing lessons learned from earlier MAPs with relevance for the Cape Verdean situation23; and (ii) developing a broad consensus among all stakeholders to ensure that the enthusiasm generated during project preparation would not dissipate during implementation. The Bank largely succeeded (both for the initial credit and for the additional financing) in establishing the conditions for smooth implementation by: (i) building on existing strengths (e.g., the national strategy, the complementary roles of CCS-SIDA and the Ministry of Health, the skills of the Administrative Unit and subsequently the Executive Secretariat) for project implementation, etc.); and (ii) sustaining the dynamism for rapid implementation of the project components (e.g., through capacity building, expansion of sub-project initiatives to municipalities and NGOs and other civil society organizations). 23 The PAD cited Uganda and Senegal in particular and emphasized, among other factors, the importance of: (i) political commitment; (ii) vulnerability factors as key drivers of the epidemic; and (iii) community participation as a process of empowerment. 19 88. Processing of both credits was completed in a timely manner. Preparation of the initial credit was helped by frequent technical visits from individual members of the preparation team in addition to the scheduled missions; preparation of the additional financing was straightforward. In both instances, other partners were consulted regularly and differences among them were handled with skill by the Task Teams. 89. While project preparation for both the original credit and the additional financing succeeded in establishing many of the principal elements for project implementation (e.g., administrative structures, capabilities for procurement, accounting, etc.), it was less successful in organizing the modalities for measuring project results. Among the shortcomings were: (i) the lack of initial baseline data information for some indicators; (ii) the absence of outcome indicators for two of the three PDOs (though intermediate outcome indicators were assigned); and (iii) the unavailability and/or lack of analysis of data for certain key indicators all contributed to a somewhat difficult appreciation of the project's progress.24 (b) Quality of Supervision Rating: Moderately Satisfactory 90. Given the large number of implementers and initiatives, the need for intensive supervision was identified early on in the preparation process, and a number of donor agencies based in Cape Verde expressed a willingness to assist in future supervisions. While this collaboration was not fully realized, the Bank did respect its commitment to intensive supervision through the mid-term review before returning to the usual rhythm of supervision thereafter.25 The mid-term review was organized as planned (in September 2004); and the ICRR process was initiated during the final supervision mission. Periodic assessments were also carried out by procurement and financial management specialists. 91. Among the strengths of Bank supervision were: (i) the continuity of the Task Team (with essentially two TTLs over the life of the project26); (ii) its extensive support (with assistance from GAMET) for strengthening monitoring and evaluation; and (iii) its frankness in informing the Government of how the project was being rated within the Bank.27 In addition, the Task Teams responded in a timely manner to requests for changes in the DCA and for non objections and other approvals. It should also be noted that the Bank played proactive and important roles: (i) during the first phase of the project by encouraging and assisting the Government in the adoption of protocols and the procurement of supplies for ARV treatment; and (ii) during the second phase of the project by promoting the empowerment of the municipalities and NGOs in the delivery of services. 92. The most important weaknesses were noted during the second phase, when, despite repeated efforts, the supervision missions were unable to resolve key implementation problems related to: (i) project financing, with respect to both counterpart financing (where an Satisfactory rating was maintained throughout project implementation until downgraded to Moderately Unsatisfactory during the last supervision mission); (ii) the collection of the necessary data on project outcomes (particularly toward the end of the project); and (iii) the use the M&E data to present a clear description of the project's progress (where the use of more output data might have provided Bank management with a better evidentiary basis for commenting on and making informed decisions about what was actually occurring on the ground. 24 In addition to the usual covenants for counterpart funding and project audit and financial reporting, the only other covenant in the DCA dealt with M&E, but this covenant was not systematically addressed in the ISRs. 25 There was one notable hiatus in project supervision between late 2005 and late 2006. 26 A third TTL managed the project but only to prepare the additional financing, not to supervise implementation. 27 The aide memoires constitute a rare instance (in this author's experience) of where ISR ratings are noted in the aide memoire and explained to the Government. 20 (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory 93. The Task Team's design of the initial and follow-on projects, its encouragement of specific Government initiatives (to decentralize sub project funding, to introduce ARVs, etc.), its flexibility in responding to changes in the project implementation environment, and its continuing frank dialogue with the Government were all satisfactory. Due to some shortcomings in M&E design and in supervision in the later stages of project implementation, Bank performance justifies a Moderately Satisfactory rating. 5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory 94. As previously indicated, Government contributed to many positive aspects of the fight against HIV/AIDS, including: (i) clear political and institutional commitment; (ii) progress in establishing an enabling environment based on the Three Ones (a comprehensive strategy, a single coordinating body with participation by all stakeholders, and a common M&E framework); (iii) development of and reliance on the implementation capabilities of governmental, non governmental, and community-level organizations; and (iv) technical progress in monitoring the development of the epidemic. However, as a result of its inability to provide adequate and timely counterpart financing and to leverage Bank funding to establish a sustainable basis for financing the fight against HIV/AIDS, the Government's performance is rated as moderately satisfactory. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 95. Though financial management and M&E were occasionally rated less than satisfactory in the ISRs, implementation progress in general and project management in particular were never rated less than satisfactory until the final ISR.28 This assessment is justified by project management's: (i) achievement (and often overachievement) of planned outputs; (ii) timely accomplishment of major project milestones (the mid-term review, and the Borrower's ICR); (iii) adaptation to changed circumstances (whether to decrease disbursement and safeguard project priorities in 2005-06 or to increase disbursement after receiving the additional funding 2007); and (iv) ability to quickly resolve implementation issues and to respond to requests for information and/or to produce specific analyses of project data. 96. Of particular note are project management's: (i) adherence to the principles of multi sectoriality and participation; (ii) institutional relationships with the Administrative Unit (of the Transport Project) and the Ministry of Health, both of which could have been problematic but which were extremely positive for the project; and (iii) contribution to capacity building in the transfer of responsibilities and capabilities to the municipalities and to civil society organizations. 97. However, within the Executive Secretariat, some weaknesses in procurement, financial management, and M&E were noted at various times. And among the other implementing agencies 28 Financial management was downgraded from S to MU after the mid-term review when the recommendation to improve accounting procedures at the municipality level was not implemented; the rating was subsequently raised to S for the rest of the project. M&E was downgraded to MS toward the end of the project based in part on the inability to develop the requisite outcome information. It should be noted that project management was somewhat strained toward the end of the project with the departure of the long-time executive director, the need to disburse remaining project funds, and the demands of responding to the Global Fund's application procedures. 21 (ministries, municipalities, NGOs, civil society organizations, etc.), there were also periodic difficulties in submitting adequate plans, disbursing and accounting for funds, and reporting on results achieved. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory 98. The Moderately Satisfactory performance of the Government and the Moderately Satisfactory performance of the Implementing Agency yield an overall rating of Moderately Satisfactory. 6. Lessons Learned 99. The PAD's thorough analysis of the lessons learned from the early MAPs was confirmed during project implementation; the project's attempts to apply these lessons during project implementation were neither straightforward nor easy. Examples of some of the difficulties from the Cape Verde project may be important for other projects. 100. A multisectoral strategy requires does not mean that the funding should not be targeted. As IEG has noted, the Bank should focus support for implementation on those sectors where activities have the greatest potential impact on the epidemic and with some comparative advantage in implementation-- such as the Ministry of Health, and those ministries related to the military, education, and transport. This project shows that, even if a project has started with the objective of covering all line ministries (as in the first-generation MAPs, it has in fact put more focus on certain ministries such as the Ministry of Health that received 64% of the overall funding allocated to line ministries, including education and youth (14%) (Annex 2). This makes sense as these are the ministries with the largest number of employees and most vulnerable (e.g teachers and medical personel posted in remote areas). 101. Implementation of a multisectoral strategy requires that roles and responsibilities (along with the accompanying human and financial resources) be defined and respected by the various public and private actors. While the project succeeded in building capacity through traditional means (training, TA, etc.), its greater success may have been in focusing (as noted in the PAD) on facilitation and coordination rather than command and control. By empowering public authorities and private agencies at all levels, the project enabled these actors to buy in and contribute significantly to the achievement of the project's objectives, particularly in the areas of awareness raising and prevention. 102. It is a challenge to ensure political commitment to target vulnerable populations. The key to maintaining political commitment at all levels are not necessarily compatible with improving the targeting of vulnerability factors. The transition from (i) information and sensitization of the general population to (ii) support for more focused groups (women, youths, orphans, etc.) to (iii) actions aimed at the specific drivers of the epidemic (commercial sex workers, drug users, mobile populations, etc.) or persons living with HIV/AIDS has implications for local mayors (who may be less interested politically in certain groups) and for civil society organizations (who may lack the skills for working with these targeted groups). 103. For monitoring and evaluation to be useful over the long-haul, certain critical elements must be in place form the beginning. The need for robust M&E is well-known but it is critical that certain elements be correctly established from the beginning. While systems can always be improved, the lack of baseline data for selected indicators and timely follow-up complicates results-oriented project supervision by the countries and by the Bank's internal management (through the ISRs). Most projects cannot fully recover from such an initial handicap during implementation and are consequently penalized at the time of the ICR. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: The Borrower has prepared a comprehensive final evaluation report in Portuguese, which did not contain a summary. The task team and the Borrower 22 agreed on the data at the time of the ICR mission and on those contain in the Borrower's report, which used the same source of information. Hence, additional issues reflected in the Borrower's final report and related to the Borrower's concerns with respect to the constraints on project implementation (Part D) and the report's conclusions (Part E) are presented in Annex 7 in English. The Borrower's final evaluation report is available from the Project Files. (b) Co-financing: Not applicable (c) Other partners and stakeholders: Not applicable 23 Annex 1: Project Costs and Financing (a) Project Cost by Component Appraisal Appraisal Estimate Actual/Latest Estimate Percentage of Components Additional Estimate (USD Original credit Appraisal financing (USD millions) * (USD millions) millions) 1. Capacity building 0.86 1.00 2.35 126% 2a. National incentives 2.64 1.70 5.08 117% 2b. Municipal incentives 2.17 0.65 0.62 22% 3. Civil society / Private 2.62 1.00 3.62 100% sector initiatives 4. Project facilitation, 1.31 1.15 4.57 186% coordination, and M&E Estimated Total 9.60 5.50 Project Cost Total Original Credit and 15.10 16.24 Additional Financing Sources: 1) Annex 2 of PAD, 2) Appendix C of Additional Financing Project Paper, and 3) Client Connection (November 2009). * Increases in total project financing reflect exchange rate fluctuation in the SDR to dollar exchange rate over the project life. (b) Financing Appraisal Actual/Latest Type of Co Percentage Source of Funds Estimate Estimate * financing of Appraisal (USD millions) (USD millions) International Development Association (IDA) 14.00 15.70 112% Borrower 1.10 0.54 49% Local Communities Total Project Cost 15.10 16.24 108% * Increases in total project financing reflect exchange rate fluctuation in the SDR to dollar exchange rate over the project life. 24 Annex 2: Outputs by Component The project involved: (i) reducing the spread of HIV infection in the country; (ii) mitigating HIV/AIDS health and socioeconomic impact at the individual, household and community levels; and (iii) establishing a strong, sustainable national response to the epidemic. During both phases of project implementation, the project relied on mainstreaming program activities into line ministries and agencies at national/municipality levels and harnessing the capacity of communities and NGOs/CSOs to provide services. However, from 2002-06 the initial credit reflected the traditional MAP approach, while from 2007-09, the additional financing adopted a more targeted approach. Reducing the spread of HIV/AIDS. As shown in the following table, the project's health results were generally positive for the output and intermediate objectives. Table 11: Health Results / Intermediate outcomes and outputs Indicators 2002 2003 2004 2005 2006 2007 2008 2009 Outputs Increase from 0% to 60% the proportion of municipalities in 3 of 17 3 of 17 6 of 17 7 of 17 17 of 22 of 22 of 22 of which voluntary counseling and testing services are being 18% 18% 35% 41% 17 22 22 22 provided 100% 100% 100% 100% By 2006, increase from 0 to 100% of HIV positive pregnant 12 of 15 51 of 50 of 53 of 27 of women receiving preventive treatment mother to child 80% 51 51 57 27 transmission (MTCT) of HIV 100% 98% 93% 100% Intermediate outcomes (6 mos.) Percentage of pregnant women using ante-natal services 12.9% 55.4% 71.5% 93.7% benefiting from voluntary counseling and testing (VCT) By 2005, no health structure providing anti-retroviral Ruptures of ARV stocks were verified at central medical treatment has been out of stock of anti-retroviral drugs over stores for: (i) June-July 2008 (Lamivudina syrup) but not the last 12 months. for those in need because sufficient stocks were available at the facility level to cover the period needed for an emergency purchase; and (ii) December 2008-Feburary 2009 (Estavudina +Lamivudina) and only in Praia where patients took two different pills rather than a single one during the period. Sources: IDSR I (1998), IDSR II (2005); Data from MTR, CCS-SIDA, MOH and Direction de la Pharmacie The project achieved its projected outputs and increased significantly the percentage of pregnant women using VCT; in fact, health facility personnel indicated that this is now considered to be part of the overall battery of pre natal tests provided for all pregnant women. While there were periods during which stockouts of ARVs occurred, the health authorities were able to provide alternative solutions while emergency orders were being acquired. As indicated in the main text and indicated in the table below, the project in all likelihood contributed maintaining the low rate of HIV prevalence in Cape Verde. Table 12: Health Results / HIV prevalence Indicator 2002 2003 2004 2005 2006 2007 2008 By 2005, the HIV prevalence among women attending ante- 0,84% - 0,69% - 0,31% - Tot: 0.8% 0,9% 0,7% 0,5% natal care clinics has not increased (compared with the first 1,42% 1,08% 0,57% M: 1.1% year of the project). F: 0.4% Sources: ANC Sentinel data: 2002-04 and 2006-08; 2005: Sero-prevalence study Mitigating the socio-economic impact of HIV/AIDS. Though no specific indicators were proposed to measure the mitigation of the socio-economic impact of HIV/AIDS, the allocation of resources over the two phases of the project indicate the attention that was paid to persons infected and affected by the epidemic. During the period 2002-06, 16% of the sub project funds were allocated to 25 PLWHA, their families, and OEV; from 2007-09, 72% of the sub project funds were allocated to these same groups, with the funds used for diagnosis, treatment, and psycho-social support. Establishing a strong and sustainable national capacity. Though no specific indicators measured this result, several findings suggest that a national capacity to respond to the epidemic was established. Anecdotally, discussions with the principal actors responsible for mainstreaming activities describe a profound change since 2002 in: (i) the country's willingness to discuss and respond to the threat of HIV/AIDS; (ii) the various institutional measures to establish structures at all levels of society and to protect PLWHA; and (iii) the participation in sub-projects of all ministries and municipalities as well as some 70 CSO's and private sector enterprises, which attests to the widespread interest in implementing programs to combat HIV/AIDS. Institutional measures at different levels of society. As shown in the table below, with a few qualifications, the project was able to mainstream HIV/AIDS activities. Table 13: Mainstreaming Results Intermediate outcomes / Outputs 2002 2003 2004 2005 2006 2007 2008 2009 Ministries and Non-ministry agencies By 2003, all ministries have HIV/AIDS teams trained as 2 of 15 6 of 15 11 of 15 11 of 15 11 of 15 11 of 15 13 of 15 13 of 15 Information, Education and Communication (IEC) agents for 13% 40% 73% 73% 73% 73% 87% 87% their respective ministries By 2005, all line ministries have and are implementing 1 of 13 9 of 13 5 of 13 4 of 13 0 of 13 5 of 13 13 of 13 13 of 13 HIV/AIDS Action Plans 8% 69% 46% 31% 0% 38% 100% 100% By 2003, 80% and by 2004, 100% of non-ministry public 0 of 38 10 of 38 23 of 38 2 of 38 0 of 38 2 of 38 3 of 38 2 of 38 sector agencies have and are implementing HIV/AIDS 0% 26% 61% 5% 0% 5% 8% 5% projects in accordance with sectoral plans By 2004, all Government and parastatal managed primary, 621 Curric. secondary and high schools are using curricula that teachers being incorporate HIV/AIDS in a skills-based learning approach trained finalized Municipalities All municipalities have and are implementing their respective 3 of 17 15 of 17 11 of 17 3 of 17 2 of 17 22 of 22 22 of 22 22 of 22 HIV/AIDS Action Plans formulated with stakeholder 18% 88% 65% 18% 12% 100% 100% 100% participation By 2004, all municipalities receiving project funding are 17/17 17/17 17/17 22/22 22/22 22/22 submitting acceptable accounting and expenditure reports (100%) (100%) (100%) (100%) (100%) (100%) Civil society The total value of project contracts entered into with 60% 50% 36% 18% 0% 60% 10% 96% communities, non-government organizations (NGOs), community-based organizations (CBOs), associations of people living with HIV/AIDS, and private sector agencies is no less than 30% of all project contracts entered into over the previous twelve months (excluding the Ministry of Health) The total value of project disbursements by civil society 54% 69% 70% organizations (CSO) is no less than 30% of all project disbursements by the public sector, excluding those with the Ministry of Health, over the previous twelve months. Private sector Percentage of private companies (30 or more employees) 2 of 85 15 of 85 19 of 85 investing in activities supporting the National HIV/AIDS 2% 18% 22% Strategic Plan 2006-10 has reached 10% Sources: CCS-SIDA: Données sous-projets CCS-SIDA, DAF, MTR. Though the project met or surpassed its objectives with respect to mainstreaming activities into municipalities, civil society organizations, and the private sector, the results varied somewhat among these three entities. As shown in the table and documented by the sub-project results in this annex, with respect to line ministries and non-ministry public sector agencies: 26 Ministries quickly established IEC agents, but preparation and financing of action plans was limited until 2007; in 2008, the project set allocations by ministry to implement action plans, accounting for the fact that 100% of ministries were able to implement their respective plans. Ultimately, all 13 line ministries and a number of other national agencies received funding, but the Ministry of Health was the principal recipient (receiving 64% of all sub-project funding); the ministries of education and youth were the other major recipients (receiving 14%). With the exception of 2003, only a few non-ministry public sector agencies actually participated in the program. The effort to incorporate HIV/AIDS in a skills-based learning approach advanced very slowly, and only in 2009 was the curriculum finalized. Similarly, municipalities and civil society organized themselves quickly in 2003-04 to receive sub-project funding, and large numbers of sub-projects and great amounts were subsequently allocated based on demand; in 2005-06, very few sub-projects received funding; and in 2007-09, the demand driven approach was complemented with fixed allocations to each of the municipalities. A total of 95 municipal and 488 community sub-projects were funded by the project. Participation in sub-projects. Data collected by CCS-SIDA on the numbers and amounts of sub- projects approved annually demonstrate the development of national capacity by location, type of intervention, and beneficiary group. Overall, as shown in the following table, some 800 sub-projects were approved with CSOs receiving almost two-thirds of the approved projects: Table 14: Annual number and amounts of approved sub-projects (in '000 CVE) Sous projets 2002 2003 2004 2005 2006 2007 2008 2009 Total % Number approved 45 263 230 28 7 108 104 12 797 Ministry of Health 0 13 50 11 0 1 1 0 76 9.5% Other ministries 2 22 19 4 0 4 13 0 64 8.0% Other public agencies 0 17 48 2 0 2 3 2 74 9.3% Municipalities 5 23 17 4 2 22 22 0 95 11.9% Civil society / Private sector 38 188 96 7 5 79 65 10 488 61.2% Amount approved 24. 7 238. 8 495. 3 31. 9 10. 8 224. 0 291. 2 4. 9 1 321. 6 Ministry of Health 0. 0 16. 3 185. 3 19. 1 0. 0 133. 3 159. 9 0. 0 513. 9 38.9% Other ministries 3. 2 25. 2 42. 5 4. 9 0. 0 15. 2 69. 2 0. 0 160. 3 12.1% Other public agencies 0. 0 28. 5 95. 8 2. 3 0. 0 3. 2 2. 9 0. 2 132. 7 10.0% Municipalities 6. 6 51. 1 41. 0 3. 2 3. 1 18. 2 45. 8 0. 0 169. 0 12.8% Civil society / Private sector 14. 9 117. 7 130. 7 2. 4 7. 7 54. 3 13. 4 4. 7 345. 6 26.2% Source: Executive Secretariat, CCS-SIDA. Financially, the Ministry of Health was the biggest beneficiary and received almost 40% of the sub- project funds approved. As indicated in the text, sub-project approval occurred in two large waves, interrupted by almost two years of limited financial resources. More detailed information by ministry, municipality, and civil society may be found in this annex. Overall, as shown in the following table, more than 80% of the sub-projects were aimed at youths and the general population during both phases of the project, but the share of allocated resources declined from 74% in the first phase to 26% in the second phase as the average amount of the sub- project allocation decreased from 1.3 million to 0.4 million CVE. 27 (in Table 15: Annual number and amounts of approved sub-projects / Beneficiary groups '000 CVE) Sub-projects 2002 2003 2004 2005 2006 2007 2008 2009 Total % Number 45 263 230 28 7 108 69 12 762 Professors 0 6 9 1 0 1 0 1 18 2.4% Health workers 0 6 28 10 0 0 1 1 46 6.0% Youths 28 128 76 10 0 56 40 7 345 45.3% Women 1 3 1 0 0 2 1 0 8 1.0% High risk groups 1 6 7 0 0 0 1 1 16 2.1% Others/General population 15 111 95 5 0 30 19 1 276 36.2% HIV+ 0 1 8 1 7 16 4 0 37 4.9% OEV 0 0 6 1 0 3 3 1 14 1.8% Affected families 0 2 0 0 0 0 0 0 2 0.3% Amount 24. 7 238. 8 495. 3 31. 9 10. 8 224. 0 16. 3 4. 9 1 046. 7 Professors 0. 0 4. 1 15. 4 0. 8 0. 0 0. 9 0. 0 0. 1 21. 3 2.0% Health workers 0. 0 2. 5 25. 1 4. 3 0. 0 0. 0 0. 5 0. 5 32. 9 3.1% Youths 13. 3 64. 3 95. 7 5. 8 0. 0 18. 4 4. 7 0. 7 202. 9 19.4% Women 0. 3 1. 5 0. 9 0. 0 0. 0 0. 6 0. 1 0. 0 3. 3 0.3% High risk groups 1. 9 4. 7 15. 8 0. 0 0. 0 0. 0 0. 7 0. 7 23. 9 2.3% Others/General population 9. 2 155. 9 244. 6 5. 2 0. 0 31. 9 5. 3 2. 8 454. 9 43.5% HIV+ 0. 0 3. 6 79. 8 14. 8 10. 8 170. 2 3. 4 0. 0 282. 5 27.0% OEV 0. 0 0. 0 18. 0 1. 0 0. 0 2. 0 1. 6 0. 2 22. 8 2.2% Affected families 0. 0 2. 3 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 2. 3 0.2% Source: Executive Secretariat, CCS-SIDA. Overall, as shown in the following table, almost 90% of all sub-projects and 60% of sub-project allocations focused on capacity building, social mobilization and IEC. While the proportion of sub- projects emphasizing capacity-building, social mobilization, and IEC did not change from the first to the second phase (86% and 87% respectively), the proportion of allocated funds dropped from 66% to 28%. (in Table 16: Annual number and amounts of approved sub-projects / Interventions '000 CVE) Sub-projects 2002 2003 2004 2005 2006 2007 2008 2009 Total % Number 45 263 230 28 7 108 69 12 762 Studies 0 6 10 1 0 0 0 0 17 2.2% Capacity building/Training 3 62 61 5 0 27 3 2 163 21.4% Social mobilization 25 93 44 3 0 1 0 0 166 21.8% IEC 17 94 77 11 0 62 62 8 331 43.4% Condom distribution 0 0 1 0 0 0 0 0 1 0.1% Diagnosis (STI, HIV, OI) 0 0 9 2 0 0 0 0 11 1.4% VTC 0 3 2 2 0 0 0 1 8 1.0% Treatment of OI 0 0 0 0 0 0 0 0 0 0.0% ARV 0 1 14 4 0 1 0 0 20 2.6% Psycho-social support 0 4 12 0 7 17 4 1 45 5.9% Amount 24. 7 238. 8 495. 3 31. 9 10. 8 224. 0 16. 3 4. 9 1 046. 7 Studies 0. 0 15. 6 24. 6 1. 0 0. 0 0. 0 0. 0 0. 0 41. 2 3.9% Capacity building/Training 4. 1 116. 8 127. 6 2. 4 0. 0 34. 1 1. 4 0. 6 287. 0 27.4% Social mobilization 6. 7 38. 9 35. 5 2. 7 0. 0 1. 4 0. 0 0. 0 85. 2 8.1% IEC 13. 9 57. 9 114. 5 7. 1 0. 0 15. 7 11. 6 3. 5 224. 1 21.4% Condom distribution 0. 0 0. 0 15. 6 0. 0 0. 0 0. 0 0. 0 0. 0 15. 6 1.5% Diagnosis (STI, HIV, OI) 0. 0 0. 0 65. 9 0. 2 0. 0 0. 0 0. 0 0. 0 66. 1 6.3% VTC 0. 0 2. 9 0. 2 1. 9 0. 0 0. 0 0. 0 0. 2 5. 3 0.5% Treatment of OI 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0. 0 0.0% ARV 0. 0 0. 6 74. 8 16. 5 0. 0 133. 3 0. 0 0. 0 225. 2 21.5% Psycho-social support 0. 0 6. 2 36. 5 0. 0 10. 8 39. 6 3. 4 0. 7 97. 1 9.3% Source: Executive Secretariat, CCS-SIDA. 28 Table 17: Summary table of project results Indicators 2002 2003 2004 2005 2006 2007 2008 2009 Total Prevention Sensibilization / General population Nb of sessions held 96 922 1 955 720 70 444 617 84 4 908 Nb of participants attending the sessions 2 419 6 658 6 658 3 410 1 050 13 350 17 668 2 539 53 752 Nb of men attending 1 119 2 500 2 500 1 410 430 7 518 10 425 1 229 27 131 Nb of women attending 1 300 4 158 4 158 2 000 620 5 832 7 243 1 310 26 621 Nb of condoms distributed 1 106 752 1 219 742 1 358 647 1 288 944 1 316 101 1 526 964 2 586 709 1 242 926 11 646 785 Nb distributed free of charge 1 106 752 1 219 742 1 350 147 1 279 344 1 305 101 1 484 963 2 564 038 1 242 710 11 552 797 Nb sold 8 500 9 600 11 000 42 001 22 671 216 93 988 Sensibilization / Vulnerable groups Commercial sex workers 5 20 45 42 112 Mobile populations 150 100 75 100 97 196 718 Prisoners 650 55 62 250 150 80 1 247 Intravenous drug users 25 7 4 36 Treatment of STIs Nb of health facilities treating STIs 32 32 32 Nb of persons treated for STIs 2250 1 853 nd nd 1 895 3 206 5488 Nb of men 425 677 Nb of women 1 470 2 529 Security of blood transfusion Nb of health facilities providing services 2 2 2 3 5 5 5 6 Nb of blood donations tested 1296 1580 1658 1983 2230 2323 2304 Nb of blood donations positive for VIH 2 5 11 5 6 6 5 Nb of blood donations positive for Hep B 34 56 68 86 76 77 64 Nb of blood donations positive for syphilis 7 18 11 10 5 6 5 VTC / General population Nb of municipalities with services (cumulative) 0 3 6 15 17 23 23 Nb of tests - Total 3 069 3542 8 106 8 159 13 467 14 500 16 016 50 843 Nb of tests - Men 3 097 4 424 Nb of tests - Women 9 292 11 592 Nb of positive tests - Total 151 169 260 223 299 319 276 1 697 Nb of positive tests - Men 79 84 109 105 104 123 116 Nb of positive tests - Women 72 83 151 112 194 195 159 % of positive tests 4.92% 4.77% 3.21% 2.73% 2.22% 2.20% 1.90% juin 3.34% 29 Indicators 2002 2003 2004 2005 2006 2007 2008 2009 Total VTC / Targeted populations Pregnant women Nb of pregnant women expected 10 412 10 659 13 567 13 771 14 030 12 371 12 695 13 069 Nb of pregnant women using ANC services 10 650 10 303 10 679 11 010 10 999 10 705 10 411 5 800 Nb of pregnant women tested 0 0 0 1 156 6 097 7 661 9 755 % of pregnant women using ANC and tested 10.5% 55.4% 71.6% 93.7% Nb of pregnant women identified VIH+ 15 43 58 29 25 Nb of pregnant women with PTV 12 43 34 29 25 Nb of infants born with HIV+ mothers (18 mos.) 20 Commercial sex workers Nb of CSW identified (n=922; Epid. 2004) 32 40 32 Nb of condoms distributed to CSW 2 440 3 080 3 020 Nb of CSW consulting for STIs 37 Nb of CSW diagnosed and treated for STIs 24 Nb of CSW doing VTC 0 0 69 Nb of CSW testing VIH+ 0 0 6 Drug users Nb of drug users identified 25 30 30 Nb of drug users doing VTC 151 169 260 25 30 35 Nb of drug users testing VIH+ 3 2 11 4 1 0 Treatment and care Evolution of the epidemic Nb of cases of HIV Nb of cases of HIV - Annual 151 169 260 223 299 319 276 Nb of cases of HIV - Cumulative 1 060 1 229 1 489 1 712 2 011 2 330 2 606 Nb of cases of SIDA - Annual 98 90 123 122 97 80 87 Nb of cases - Men 62 47 66 69 36 35 42 Nb of cases - Women 36 43 57 53 61 43 44 Treatment (ARV, OI, Prevention TB) Nb PLWHA being treated for IOs 5 95 151 224 305 Nb PLWHA being treated for TB 5 Nb of PLWHA being monitored 30 318 503 746 1 018 1 029 Nb of PLWHA being treated with ARV 0 0 5 148 242 348 462 462 Mitigation Support for PLWHA Nb of PLWHA support groups 2 2 8 67 4 Nb of PLWHA participating in groups 12 12 39 171 16 Nb of PLWHA-Male participating 22 103 4 Nb of PLWHA-Female participating 17 68 12 30 Indicators 2002 2003 2004 2005 2006 2007 2008 2009 Total Nb of PLWHA benefiting from: Home visits 82 459 35 Nutritional support 0 0 10 38 120 142 230 95 Psychological support 10 38 120 118 228 54 Revenue generating activities 0 0 0 5 15 20 64 19 Medical support Housing support 0 0 0 0 0 6 20 10 Other support 0 3 0 25 54 120 Support for OVC Nb of orphans receiving school support 40 79 199 518 349 42 Nb of orphans receiving school support - Boys 15 34 102 287 178 22 Nb of orphans receiving school support - Girls 25 45 97 231 171 20 Source: Executive Secretariat / CCS-SIDA; results for 2009 are partial. 31 Annex 3: Economic and Financial Analysis Economic impact of the Cape Verde MAP HIV/AIDS Project No specific economic analysis was carried out during preparation of either phase of the Cape Verde MAP. Instead, both PADs referred to the economic analysis contained in Annex 5 of the Multi- Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR), which included a cost- benefit analysis of HIV/AIDS interventions and an assessment of the overall impact of HIV/AIDS on the economy. The main findings of the assessment as summarized in the PAD were as follows: HIV/AIDS has a negative effect on productivity levels, domestic savings and overall economic growth. HILV/AIDS increases health costs and runs the risks of crowding out other key public health programs, such as immunization, maternal and child health, malaria and parasitic diseases. Care and treatment of AIDS patients imposes high costs on families and reduces their earning capacity. Family coping strategies may result in children abandoning school or the family cutting other health or social expenditures to unacceptable levels. Though difficult to quantify and impossible to attribute solely to the MAP, a number of potentially positive economic impacts of the project have been highlighted in the text for individuals and households, for private sector firms and the Government, and for the economy as a whole. These are summarized by level in the following paragraphs. Individual and household levels. From the perspective of slowing the spread of HIV, the project focused on the appropriate elements of the population (particularly among youths, who are the most potentially productive segment of the population) with the appropriate interventions for slowing the spread of HIV (condom distribution, VCT, etc.). Then, when the IDSR indicated that this was happening, the project shifted resources to the diagnosis and treatment of PLWHA and to the mitigation of the effects on the affected families. Prevention: The argument for the potentially positive economic impact of the Cape Verde MAP on prevention is based on the findings that: the median age of first sex has increased for young women, though it has decreased for young men; comprehensive knowledge has increased significantly (2005 IDSR), and the use of condoms with non regular partners has increased significantly (particularly for females); and sexually active Cape Verdiens are increasingly seeking testing for HIV, both among the general population and especially among pregnant women. Treatment: The Cape Verde MAP did not attempt to estimate the potential number of deaths that could be or were averted by introducing ART, but the positive impact of treatment seems clear based on the findings that: Cape Verde has dramatically increased as more than a thousand cases are being monitored and some 460 are receiving ARVs; management of PLWHA has improved with: (i) enrollment rates based on average CD4 and WHO stage on enrollment comparable to those in other countries; and (ii) relatively low loss to follow up; and 32 the project provided the means for helping households cope with the direct and indirect costs of illness, by providing medical and psycho-social assistance, nutritional support, and educational support for OVC. Unfortunately, no assessment of the beneficiaries of MAP funded sub projects was carried out to suggest how these sub-projects might have contributed to the overall quality of their lives, but it seems clear that the project has contributed in at least small ways to mitigating the epidemic's direct and indirect costs at the household level. Firms. The growth in the number of firms (from 2 of 85 to 19 of 85 in just three years) attests to the importance attached to the fight against HIV/AIDS by the private sector. Government level. The project addressed non-health government agencies as well as the Ministry of Health. Non-health agencies: Though not explicitly measured, the effects of the project on the ministries of youth and education as well as on the uniformed services was probably substantial, especially in terms of prevention, through sensitization and IEC, the distribution of condoms, and the increase in voluntary counseling and testing. Immediate benefits among other non-health agencies and for the municipalities are less likely to have been substantial, particularly after the second phase shifted the emphasis from IEC activities to treatment and impact mitigation activities. Health agencies: The PAD's concern that the cost of HIV/AIDS might crowd out other key public health programs did not occur for the simple reason that the MAP did not attract the amounts of additional financing which were expected. An analysis of HIV expenditures as a proportion of total health expenditures was not carried out. Economy. The effects of the project's impact on the economy as a whole have not been closely examined; it is probably too soon, and there are certainly other confounding factors. But with presumed declining incidence, increasing numbers of patients treated, and improved efforts to mitigate the effects of the disease, the project did contribute to those elements which would be expected to have an effect on productivity and the economy as a whole. Financial sustainability of the Cape Verde HIV/AIDS Project From a strictly financial perspective, the sustainability of some of the project's benefits will be greatly improved by the arrival of the Global Fund. The prospects of sustaining the public sector and civil society activities funded under the project are mixed with some associations being self sufficient, other organizations attracting new sources of financing, and some institutions may be adversely affected if they do not identify alternative sources of funding. Of immediate concern at project closing was the Global Fund's anticipated contribution from the Government. 33 Annex 4: Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Specialty Lending (a) Original Credit Gylfi Palsson Task Team Leader Kees Kostermans Sr. Public Health Specialist Ahmadou Moustapha Ndiaye and Sr. Financial Management Specialists Prosper Biabo Bourama Diaite Sr. Procurement Specialist John Stephen Osika Sr. Health Specialist Pascal Dooh-Bill Institutional Specialist Anne-Marie Bodo Pharmaceutical Specialist David Wilson M&E Specialist Nadine Poupart Sr. Human Resources Economist Adriana Jaramillo Education Specialist Hélène Grandvoinnet Public Sector Specialist Carlos Fonseca Transport Specialist (b) Additional Credit Maurizia Tovo Task Team Leader Johanne Angers Operations Officer Stéphane Legros Public Health Specialist Bourama Diaite Sr. Procurement Specialist Osval Romao Financial Management Specialist Supervision/ICR Responsibility/ Names Title Unit Specialty Mirey Ovadiya Sr. Operations Officer AFTH2 Task Team Leader Stéphane Legros Public Health Specialist WBIHN Public Health Osval Romao Financial Management Specialist AFTFM Financial Management Cheick Traore Sr. Procurement Specialist AFTPC Procurement Johanne Angers Sr. Operations Officer AFTHE TTL for ICR Peter Bachrach Consultant AFTHE ICR main author (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY02 FY03 34 Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) FY04 FY05 FY06 FY07 FY08 Total: 29 174.68 Note: Breakdown by fiscal year is not available. Supervision/ICR FY02 0.00 FY03 9 86.66 FY04 28 149.25 FY05 16 123.95 FY06 8 38.12 FY07 6 25.94 FY08 15 77.42 FY09 16 0.00 FY10 8 35.0 Total: 106 536.34 35 Annex 5: Beneficiary Survey Results Not applicable Annex 6: Stakeholder Workshop Report and Results Not applicable 36 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR República de Cabo Verde Programa Multisectorial de Luta Contra a SIDA 2002-2009 "Final Report on the HIV/AIDS Project" 37 PRAIA ­ JUNHO 2009 República de Cabo Verde Programa Multisectorial de Luta Contra a SIDA 2002-2009 Extract from the Government of Cape Verde Report on the Project (Translation of Parts D and E of the Government's report) D ­ Main Constraints Implementation of the project was marked by various phases and a variety of difficulties, which were perhaps normal in the context of a fairly complex solution, from both an organizational and philosophical standpoint. First, the multisectoral nature of the project, involving a host of different organizations and institutions, should be noted. Second, the choice of a decentralized execution approach entailed participation and management by the Municipal Committees represented on all the councils in the country. Given that the organizational and work approaches were new, the philosophy behind these approaches was not always grasped at the desired speed, nor was this philosophy fully assimilated. Taking all observations into account, the following are the main constraints identified with project execution: Lack of experience on the part of many organizations with the design, preparation, and management of subprojects; Organizational weaknesses within a significant number of execution agencies, particularly community-based entities; Slow response times by some public execution agencies in the areas of submission of subprojects, financial absorption capacity, and submission of supporting documents; A host of accounting difficulties and delays, particularly with supporting documents for expenditures and the provision of data related to programmatic activities; Unstable organizational structures within Municipal Committees, with staff turnover resulting from electoral cycles. The investment made in personnel training is lost, along with knowledge of procedures and practices learned during project implementation; 38 The random nature of the disbursement system, which did not follow a fixed schedule for projects of this nature, proved inappropriate and had a negative impact on the development of activities by many subprojects and on the replenishment of a number of accounts; The delay in the reallocation of resources led to major bottlenecks and delays in disbursement by the Executive Secretariat to execution agencies and, as a result, to the extension of subprojects beyond the initially projected timeframes; The procurement system, run through UNICEF in Copenhagen, was not easy to manage. As a result, systematic delays were experienced with filling orders for reagents and ARV medication, leading the country to resort to emergency purchases from time to time; and Another problem stemmed from the fact that funding of projects of this nature, based on a revolving fund, with no safe guarantees being provided with respect to advances provided at the outset, can lead to problems. Consequently, owing to the fact that no guarantees were required in exchange for funds advanced, some of the funds provided are currently considered unrecoverable, while other funds, amounting to close to US$105,00, are tied up in legal proceedings. E ­ Conclusions The project contributed significantly to controlling the epidemic in Cape Verde, with the total number of cases remaining at under one percent. ARV treatment represented a significant step forward, leading to substantial improvements in the treatment plan used up to that point, and offered hope and quality of life to patients. The introduction of ARV treatment led to greater participation in HIV screening activities, with the number of tests increasing from 8,000 in 2005 to 16,000 in 2008. For the foregoing reasons, it can be concluded that: The project facilitated effective control of the epidemic; The main critical points such as vertical transmission and blood transmission are under control; Sexual transmission is fairly well controlled, with more targeted activities being required among the over 35 age group; The project guaranteed mitigation of the impact of HIV/AIDS on infected and affected persons; and The project provided a structured framework for combating AIDS in the country, which should remain in place with a view to the current and future control of the epidemic in Cape Verde. 39 Comments from the Government of December 29, 2009 to the Draft ICRR Indicator 3a: It was not prudent to commit to reduce, in 4 years, almost 20% of a change as it relates to behavioral issues. This is a non-realistic target since behavioral aspects take time to occur. Indicator 8: According to data from the APIS 2009, the median age at first intercourse is: Boys: 15 years Girls: 16 years There is an apparent decrease of the median age of first intercourse for boys from 17 to 15 years and for girls from 17.2 to 16 years. However, it noted that about 56% of those surveyed said they had not yet initiated sexual activity, which suggests that most young Cape Verdeans initiate sexual activity at a later age than the median ages show. Beyond the numbers, this indicator should be interpreted in a qualitative manner. Indicator 4: This indicator has been altered during the mid-term review. The content was revised as follows: "All ministries have and are implementing their Action Plans" The mid-term review concluded that: "this indicator fully achieved its target at mid-term as all the line ministries are implementing HIV/ AIDS work plans." This is an indicator that is cumulative. Indicator 15: 29 This indicator was revised during the mid-term review, and can be further described in the aide-memoire of the mid-term review. In 2004 when HAART was introduced, 30 PLWHAs, of which 5, were advised to start treatment with antiretroviral drugs. Of the 5 who began treatment (all adults) received psychological support, nutritional and home visits. Also in 2004, 40 orphans received support from the project ( 25 girls and 15 boys) as follows: · Psychological · Food aid · School supplies In 2006, 503 PLWHAs were confirmed, of which 242 were on HAART and received support as follows: . 120 (all who were in stages III and IV) received psychological and nutritional support; . 15 ICT activities and AGR; . 54 with other type of supports Also in 2006, 199 orphans received support similar to those already mentioned (psychological, nutritional, etc.). 29 Note from ICRR team: the same data are presented in Table 17 of Annex 2. The mid-term review aide-memoire is available in the Project files. 40 Pag. 12 (paragraph 58. Raised median age of first sexual relations) Although targets were not achieved, it should be noted however that about 56% of those surveyed in the same age group, had not initiated sexual activity, which suggests that most young Cape Verdeans begin sexual activity at a later age than the median age. Pag. 14 (paragraph 66. Objective 2: Mitigating the health and socioeconomic impact of HIV / AIDS on persons infected with or affected by HIV / AIDS) Though no outcome indicators were linked to this PDO, the project made modest progress in achieving it. Paragraph 67. Providing home or community-based support to PLWHA (Indicators 11 and 15). This objective should be assessed in light with the following aspects: 1) The country has a concentrated epidemic and not generalized to the population; 2) The number of reported cases of PLWHA includes people infected with HIV without AIDS, people with AIDS and under treatment, HIV-positive people under treatment, HIV-positive people who work, people who work under HAART, HIV-positive children, pregnant women under treatment for prevention against vertical transmission, etc.. 3) All cases at stages III and IV of the disease are first treated in hospitals, there are then sent back to the community where they are followed by local health facilities. 4) The relationship between the numerator and denominator represented in the table does not reflect what the revised indicator intends to measure, then we suggest a review of the classification of objective 2. 5) All cases in stages III and IV of the disease received medical, psychological and social supports. Pag. 15 3.3 Efficiency Analysis of the allocation of funds to the sub-projects shows a shift of resources from the period of the original credit to the period of the additional financing: At mid-term review, a consensus was reached in raising awareness and social mobilization as the project had already achieved the objective of mobilizing the Cape Verdean society to the problem of HIV / AIDS, and from that time it was necessary to refocus the strategy for more targeted interventions. Hence, interventions were focused on the most vulnerable groups, which resulted in the approval of more projects and the allocation of more resources towards those groups. Pag. 17 Justification of Overall Outcome Rating Paragraph 104. Based on consideration of the various ratings, criteria, indicators, and disbursement prior to and after the approval of the Additional Financing, the following table presents the overall outcome rating for the project as Moderately Satisfactory. It is necessary to review the classification of objective 2, taking into account the reasons set out in paragraphs 66 and 67 of the ICR. 30 30 Note from ICRR team: Using the rating procedures required by OPCS, and especially IEG, three ratings of Modest for objective 2 require an overall outcome rating of Moderately Unsastisfactory. 41 Pag. 18 Assessment of Risk to Development Outcome Rating: Moderate Cape Verde has secured funding for AIDS for the next 5 years through the Global Fund with negotiations that are almost finalized. This funding will support the development of the main activities that have been implemented under this project, which was closed on June 30, 2009, including prevention activities among high-risk groups, treatment, psychosocial support to adults and children orphaned and vulnerable, screening of all pregnant women at their first ante-natal visit, etc.. To this must be added the complementary support from the Government of Brazil and the United Nations agencies as demonstrated with the development of activities on prevention, training, etc.. 42 Annex 8: Comments of Co-financing partners and Other Partners/Stakeholders Not applicable 43 Annex 9: List of Supporting Documents World Bank Dr Innocent Ntaganira, Technical Support Mission to Relaunch Epidemiological Surveillance of HIV at the Sentinel Sites. (January and May 2002) Dr. Djibril Doucouré, Medical Waste Management Plan. (March 2002) Silvani Arruda, Recommendations for the Planning IEC/BCC Actions. (May 2002) Monitoring and Evaluation (M&E) Manual. (June 2002) Project Appraisal Document (Report No: 23443-CV). (March 2002) Project Paper on Proposed Additional Financing (Report No: 37423-CV). (November 2006) Worksheet detailing calculations on outcome ratings based on actual credit disbursements at the time of additional financing (December 2009) Government Policies and Strategies National HIV/AIDS Strategy 2002-2006. (January 2002) National HIV/AIDS Strategy 2006-2010. (June 2006) Introduction of ARVs in Cape Verde. (May 2004) Operating guidelines and procedures Blood Transfusion Security Policy Blood Transfusion Sentinel Site Operations Protocol for Sentinel Site Operations VCT Standards and Guidelines for Voluntary Counseling and Anonymous, the Rules of Operation of Voluntary Counseling Centers, PMTCT Regulation of Marketing of Breastmilk Substitutes (funded by UNICEF) and the Handbook the Advisor. Ministry of Health, Qualitative study for the development of a communication strategy for PMTCT (with co-funding from UNICEF) Regulation of Marketing of Breastmilk Substitutes (funded by UNICEF) and the Handbook the Advisor Treatment ARV Treatment Protocol. Revision of the National Drug Code (for ARV) Acquiring the necessary tests and medications. Policy Document Integrated Care Integrated Protocol for Opportunistic Infections 44 Protocol of the syndromic approach to STI (funding UNFPA) Project management CCS-SIDA, Implementation Manual. (June 2002, rev. October 2005) CCS-SIDA, Administrative, Accounting, and Financial Management Manual (May 2002). Monitoring and Evaluation Surveillance Annual reports of HIV sero prevalence (2002, 2003, 2004, 2006, 2007, and 2008) with coverage from the sentinel sites of Beach, Santa Catarina, and S. Production of the Epidemiological Bulletin Report Notification HIV / AIDS by 2008 Studies and evaluations IDSR (1998) IDSR (2005) The National Survey of sero prevalence and socio-behavioral therapy National survey on risk behaviors, knowledge, perceptions and attitudes towards STIs / HIV / AIDS, access to STI / HIV / AIDS, etc. Ministry of Health and GTZ, Study on the social marketing of condoms. Programa Multisectorial de Luta Contra a Sida (2002-2009). Relatório final do Projecto multissectorial de luta contra a SIDA. Praia, Junho 2009. Youths Study of in and out of school youths (10 to 24 years) with specific reference to actions on the issue of teenage pregnancy. Ministry of Education, Qualitative study on the sexuality of young people. Orphans Solidarity of Cape Verde, Study on orphans in Cape Verde. (2005) Other vulnerable groups Action Plan for intervention with Vulnerable Groups Behavioral Surveillance Survey (BSS) of the uniformed forces and the market sellers. (2004) Ze Moniz Association, Study on the behavior of young people with the problems of consumption of psychoactive substances and information HIV / AIDS. Community Institute, Study on the behavior to prevent HIV / AIDS among the population of Cape Verdean immigrants in Portugal. A qualitative study on the size of two populations at high risk for HIV/AIDS: Drug users/Intravenous drug users and commercial sex workers. (2005) A survey of street children and qualitative study. Study on Drug Use and its relationship with HIV in jails and treatment centers. (2007) Reports of annual meetings to review HIV / AIDS activities in Cape Verde. CCS-SIDA, Final Report of the Multi Sectoral AIDS Project (June 2009). Final Monitoring and Evaluation Report of the HIV/AIDS Project (June 2009). 45 46