Document of The World Bank Report No: ICR00001129 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H1100) ON A GRANT IN THE AMOUNT OF SDR 4.7 MILLION (US$7.0 MILLION EQUIVALENT) TO THE REPUBLIC OF GUINEA-BISSAU FOR AN HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT July 28, 2009 AFCTS AFCW1 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective March 31, 2004) Currency Unit = Franc CFA (FCFA) FCFA1.00 = US$1.93 US$1.00 = SDR 0.67 FISCAL YEAR January 1 ­ December 31 ABBREVIATIONS AND ACRONYMS AfDB African Development Bank NAC National AIDS Council AGMS Social Marketing Agency of NAS National AIDS Secretariat Guinea-Bissau NGO Non Governmental Organization ART Anti Retro-Viral Treatment NTSA National Technical Secretariat on CBO Community Based Organization AIDS CSO Civil Society Organization OI Opportunistic Infection CECOME Central Medical Store OVC Orphans and Vulnerable Children GF Global Fund PAD Project Appraisal Document GFATM Global Fund to Fight HIV/AIDS, PDO Project Development Objective Tuberculosis and Malaria PLWHA People Leaving with HIV/AIDS IDA International Development PMU Project Management Unit Association PNDS National Health Development IEC Information, Education and Project Communication PSO Public Sector Organization ISS Interim Support Strategy SDR Special Drawing Right KPI Key Performance Indicators SNP Strategic National Plan M&E Monitoring and Evaluation STI Sexually Transmitted Infection MAP Multi-Country HIV/AIDS Program TTL Task Team Leader MTCT Mother to Child Transmission VCT Voluntary Counseling and Testing MTR Mid-Term Review Vice President: Obiageli Ezekwesili Country Director: Habib Fetini Sector Manager: Ian Bannon Project Team Leader: Dirk Nicolaas Prevoo ICR Team Leader: Liba Strengerowski-Feldblyum GUINEA BISSAU HIV/AIDS GLOBAL MITIGATION SUPPORT PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design....................................................1 2. Key Factors Affecting Implementation and Outcomes ...................................................4 3. Assessment of Outcomes.................................................................................................8 4. Assessment of Risk to Development Outcome .............................................................14 5. Assessment of Bank and Borrower Performance..........................................................15 6. Lessons Learned ............................................................................................................17 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ...............17 Annex 1. Project Costs and Financing...............................................................................19 Annex 2. Outputs by Component ......................................................................................20 Annex 3. Economic and Financial Analysis......................................................................21 Annex 4. Bank Lending and Implementation Support/Supervision Processes .................22 Annex 5. Beneficiary Survey Results................................................................................24 Annex 6. Stakeholder Workshop Report and Results .......................................................25 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..........................26 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders............................27 Annex 9. List of Supporting Documents...........................................................................28 MAP A. Basic Information HIV/AIDS GLOBAL Country: Guinea-Bissau Project Name: MITIGATION SUPPORT PROJECT Project ID: P073442 L/C/TF Number(s): IDA-H1100 ICR Date: 07/28/2009 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: GUINEA-BISSAU Original Total XDR 4.7M Disbursed Amount: XDR 4.7M Commitment: Revised Amount: XDR 4.7M Environmental Category: B Implementing Agencies: STNLS Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 12/04/2003 Effectiveness: 01/14/2005 Appraisal: 03/15/2004 Restructuring(s): 12/07/2007 Approval: 06/02/2004 Mid-term Review: 10/10/2006 10/10/2006 Closing: 12/31/2007 12/31/2008 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Unsatisfactory Risk to Development Outcome: High Bank Performance: Unsatisfactory Borrower Performance: Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Unsatisfactory Government: Unsatisfactory Quality of Supervision: Unsatisfactory Implementing Agency/Agencies: Unsatisfactory Overall Bank Overall Borrower Performance: Unsatisfactory Performance: Unsatisfactory i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Yes Quality at Entry None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Unsatisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health 20 20 Other social services 40 40 Sub-national government administration 40 40 Theme Code (as % of total Bank financing) HIV/AIDS 33 33 Participation and civic engagement 17 17 Personal and property rights 17 17 Population and reproductive health 16 16 Tuberculosis 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Habib M. Fetini John McIntire Sector Manager: Ian Bannon Mary A. Barton-Dock Project Team Leader: Dirk Nicolaas Prevoo Christian Fauliau ICR Team Leader: Liba C. Strengerowski-Feldblyum ICR Primary Author: Liba C. Strengerowski-Feldblyum F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The project will support the medium-term strategy of the Government to expand and accelerate the national response to HIV/AIDS by: (i) reducing the spread of HIV/AIDS infection; (ii) increasing access to treatment for STIs and HIV/AIDS; and (iii) decreasing ii the socio-economic impacts of HIV/AIDS at the individual, household, and community levels. Revised Project Development Objectives (as approved by original approving authority) The project will assist the Government in increasing access to HIV prevention, care, treatment and mitigation services. (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years The percentage of young women and men aged 15-24 reporting the use of a Indicator 1 : condom the last time they had sex with a non-marital, non-cohabiting sexual partner has increased to 65% (new indicator after restructuring 12/07) Value quantitative or 35 65 31 Qualitative) Date achieved 01/01/2004 12/31/2008 12/18/2008 Comments (incl. % Actual value achieved is the latest available number from 2006 CAP achievement) The percentage of identified commercial sex workers who report using a condom Indicator 2 : with their most recent client has increased to 25% (new indicator after restructuring 12/07) Value quantitative or <20 25 32 Qualitative) Date achieved 01/01/2004 12/31/2008 12/18/2008 Comments (incl. % achievement) 5,000 persons aged 15 and older have received counseling and testing for HIV Indicator 3 : and received their test results during the last 12 months (new indicator after restructuring 12/07) Value quantitative or 993 5000 13,996 Qualitative) Date achieved 01/01/2004 12/31/2008 12/28/2008 Comments (incl. % Actual value achieved is during quarter 1-3 of 2008 achievement) 5,000 pregnant women living with HIV have received antiretrovirals to reduce Indicator 4 : the risk of Mother to Child Transmission during the last 12 month (new indicator after restructuring 12/07) Value quantitative or 144 5000 258 iii Qualitative) Date achieved 01/01/2004 12/31/2008 12/18/2008 Comments (incl. % Actual value achieved in part due to problems with GFATM achievement) The percentage of youth (15-24) who can correctly identify at least two methods Indicator 5 : of HIV/AIDS transmission has increased to 60% (new indicator after restructuring 12/07) Value quantitative or 5 65 7 Qualitative) Date achieved 01/01/2004 12/31/2008 12/18/2008 Comments (incl. % Actual value achieved is latest data from 2006 CAP achievement) Reduce the spread of HIV/AIDS infection in Guinea Bissau: by the end of Y3 of Indicator 6 : the project, the rate of increase of seroprevalence of HIV amongst antenatal women aged 15-24 has declined in the population (original indicator) the rate of increase based on studies carried of seroprevalence Value out before project start- of HIV amongst quantitative or up, transmission rates antenatal women no data available Qualitative) were 2,400 new cases in aged 15-24 has the group aged 15-24 declined in the population Date achieved 03/03/2006 12/31/2007 06/29/2007 Comments This PDO indicator is targeted for amendment based on the Nairobi workshop (incl. % recommendations. No specific data exist in-country to measure progress towards achievement) this objective Increase access to STI/HIV/AIDS treatment: increase from 0% to 20% of Indicator 7 : PLWHA that receive medical assistance (OI and/ot ART) by PY3; 20% increase in men and women aged 15-49 seeking care for STI (original indicator) increase from 0% to 20% of PLWHA that receive medical OI: 9,712 (2005); Value attention (OI 6,957 (2006); 1,938 quantitative or ART:0 OI:7,199 and/or ART) by (Q1 2007) Qualitative) PY3; 20% increase ART: 65 (2005); in men and women 436 (2006); 496 aged 15-49 (Q1 2007) seeking care of STI Date achieved 01/03/2003 12/31/2007 06/29/2007 Comments (incl. % achievement) Indicator 8 : Reduce socio-economic impacts of HIV/AIDS, at the individual, household, and community levels and strengthen national capacity to respond to the epidemic iv (original indicator) Value quantitative or 0 no data available no data available Qualitative) Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % Target not defined at appraisal; indicator is too broadly defined to be meaningful. achievement) Will be revised at MTR (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Completion or documents) Target Values Target Years Indicator 1 : 1 million male and female condoms have been distributed during the last 12 months (new indicator after restructuring 12/07) Value (quantitative 209,876 1,000,000 2,028,160 or Qualitative) Date achieved 01/01/2004 12/31/2008 11/28/2008 Comments (incl. % quarter 1-3 in 2008 achievement) 10% of identified orphans and vulnerable children whose households received Indicator 2 : free basic external support in caring for the child during the last 12 months in the five pilot regions (new indicator after restructuring 12/07) Value (quantitative 0 10% 4,544 or Qualitative) Date achieved 01/01/2004 12/31/2008 12/08/2008 Comments (incl. % The percentage of identified orphans and vulnerable children receiving care is achievement) unknown Indicator 3 : US$1 million provided to Civil Society Organizations for subprojects (new indicator after restructuring 12/07) Value (quantitative 0 US$1 million US$1.3 million or Qualitative) Date achieved 01/01/2004 12/31/2008 07/01/2008 Comments (incl. % achievement) Indicator 4 : US$500,000 provided through Public Sector Organizations (new indicator after restructuring 12/07) Value (quantitative 0 US$500,000 US$1.3 million or Qualitative) v Date achieved 01/01/2004 12/31/2008 01/01/2008 Comments (incl. % achievement) The community response is available: training of 50 traditional healers + 50 sage Indicator 5 : femmes in each region have received formal training STI/HIV/AIDS counseling by PY2; and 50 traditional sage femmes (original indicator) Value (quantitative 0 50 no data available or Qualitative) Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % not started achievement) Indicator 6 : In the five pilot regions, civil society and private sector capacity is built to implement HIV/AIDS prevention care and support (original indicator) Value (quantitative 0 5 5 or Qualitative) Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % achievement) Indicator 7 : Each of the six key ministries identified in the PEN have included HIV/AIDS mitigation into its national strategy and work plan (original indicator) Value (quantitative minimal 100% 133% or Qualitative) Date achieved 01/03/2005 12/31/2007 01/03/2005 Comments (incl. % Actual value achieved in 8 ministries in 2006 achievement) Indicator 8 : Numbers of men and women who are being counseled and tested for HIV (outside MTCT) (original indicator) Value 1,020 (2005); 3,861 (quantitative 993 No data available (2006); 2,427 (Q1 or Qualitative) 2007) Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % Original target values not defined at appraisal achievement) Indicator 9 : Condom use (15-19 year age group) - data are for 15-24 year old age group (original indicator) Value (quantitative 37% not defined at 37% (2004) and or Qualitative) appraisal 35% (2005) Date achieved 01/01/2004 12/31/2007 06/29/2007 Comments Actual value achieved: (i) source UN 37% (of which 55% always) (2006) - (ii) vi (incl. % source CAP ND for 2007 35% achievement) Indicator 10 : Number of operational VCT centers in five priority regions (original indicator) Value (quantitative 1 6 (one in each 2 (2005); 4 (2006); or Qualitative) region) 6 (q1 2007) Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % achievement) Indicator 11 : HIV seroprevalence rates by specific source (original indicator) bloodbank: 8.8%; antenatal care Value bloodbank:11.5%; providers: 4.6%; (quantitative antenatal care seekers: not defined estimate for or Qualitative)4.6% ; national rate national estimate:>4% between 2.1 and 6%, with median of 3.8% Date achieved 01/03/2005 12/31/2007 06/29/2007 Comments (incl. % (source UNAIDS) achievement) Indicator 12 : All secondary and tertiary health facilities of pilot regions have capacity to treat STI/HIV/AIDS care (original indicator) Value (quantitative 0 100% 96.15% or Qualitative) Date achieved 01/03/2005 12/31/2008 06/29/2007 Comments (incl. % Actual value achieved is in the five priority regions achievement) G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 09/28/2004 Satisfactory Satisfactory 0.00 2 06/29/2005 Satisfactory Satisfactory 0.99 3 12/24/2005 Moderately Satisfactory Moderately Unsatisfactory 1.54 4 04/07/2006 Satisfactory Moderately Satisfactory 1.89 5 09/25/2006 Satisfactory Moderately Satisfactory 3.05 6 03/09/2007 Moderately Satisfactory Moderately Unsatisfactory 4.25 7 11/28/2007 Unsatisfactory Unsatisfactory 5.68 vii 8 05/09/2008 Moderately Satisfactory Moderately Satisfactory 6.58 9 12/18/2008 Unsatisfactory Unsatisfactory 7.02 H. Restructuring (if any) ISR Ratings at Amount Restructuring Board Restructuring Disbursed at Reason for Restructuring & Date(s) Approved Restructuring PDO Change Key Changes Made DO IP in USD millions The restructuring was part of the umbrella restructuring and 12/07/2007 Y U U 5.70 amendment of the financial agreements for all MAP projects in the Africa Region. 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 Unsatisfactory Against Formally Revised PDO/Targets Unsatisfactory Overall (weighted) rating Unsatisfactory I. Disbursement Profile viii 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Guinea-Bissau became independent in 1974. The eruption of armed conflict in 1998-99 brought to an end the progress that had been made in economic development in the early 1990s. The conflict reduced real GDP by 28% and agricultural production by 17%. Part of the physical infrastructure, including the health sector, was severely damaged. As a result, health services, which are crucial for HIV/AIDS mitigation, were in disarray and will take a long time to recover given the poor state of the physical infrastructure and the precarious state of public finances. As to common knowledge, the displacement of people fuels HIV/AIDS transmission rates, which increased following the civil war also in Guinea-Bissau, especially among the under-30 age group. 2. The importance of the HIV/AIDS epidemic was clear to the Government, which developed a Strategic National Plan for the health sector (SNP) and a National Program to implement the SNP, with support from various technical and financial partners. In the SNP, the Government confirmed its commitment to a decentralized participatory approach, a multi-sectoral strategy, and a reliable and fully transparent financing system. The SNP formed the basis of the request for financial support to both the World Bank and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM). The HIV/AIDS Global Mitigation Support Project was designed to support Government implementation of its SNP. 3. In 2003, the Government requested access to IDA resources within the framework of the first phase of the Multi-Country HIV/AIDS Program (MAP) for the Africa Region. Guinea-Bissau was eligible for MAP funding and satisfied the four eligibility criteria as follows: (i) it had a coherent national strategy and had developed a comprehensive medium-term, multi-sectoral plan in a participatory manner with all concerned stakeholders; (ii) a National HIV/AIDS Council (NAC) was created on March 14, 2004 (a condition of effectiveness), chaired by the Prime Minister, and with equal representation from Government, civil society, and the private sector; (iii) Government agreed to implementation procedures that would help expedite and outsource project implementation; and (iv) Government agreed to use and fund multiple implementation agencies as reflected in its plans to channel funds directly to both public and private implementing agencies, Civil Society Organizations (CSOs), Non-Governmental Organizations (NGOs), associations of people living with HIV/AIDS (PLWHA), and to communities. 4. This Specific Investment Loan was consistent with the objectives of the Bank's regional HIV/AIDS strategy and consistent with the objectives of the 2004 Guinea-Bissau Interim Support Strategy (ISS). 5. At the time of Project preparation, some limited actions to prevent HIV/AIDS and mitigate its impact were being carried out by a few NGOs in Guinea-Bissau, but they were not coordinated and had limited financial support. There were also no comprehensive and reliable HIV statistics. Available data from the Ministry of Health show that from 1994 to 1996, there were between 600 to 900 new cases per year and 1,101 in 1999. The disease was continuing to spread mostly along the main transportation axes from Bissau to Bafatá, Gabú, and Cacheu. According to the 2001 WHO estimates, health centers were only capturing around 16% of estimated cases. It was projected that without intervention, 24 to 40 persons would be infected daily with HIV-1.1 1The majority of infections in Guinea-Bissau are HIV-1. 1 1.2 Original Project Development Objectives (PDO) and Key Indicators 6. The Project's initial PDO was to support the medium-term strategy of the Government to expand and accelerate the national response to HIV/AIDS by: (i) reducing the spread of HIV/AIDS infection; (ii) increasing access to treatment for sexually transmitted infections (STIs) and HIV/AIDS; (iii) decreasing the socio-economic impacts of HIV/AIDS at the individual, household, and community levels; and (iv) strengthening national capacity to respond to the HIV/AIDS epidemic. 7. The SNP had identified a large number of output, process, and outcome indicators. The project results framework selected some of these indicators as shown in Table 1. Table 1: Key Outcome Indicators Element of PDO Associated Outcome Indicator Reducing the spread of HIV/AIDS infection. By the end of Y3, the rate of increase of sero-prevalence of HIV among antenatal women aged 15-24 has declined in the population (compared to Y1). Increasing access to treatment for sexually Increase from 0% to 20% of PLWHA that receive medical transmitted infections (STIs) and HIV/AIDS. assistance (OI and/or ART) by Y3. 20% increase in men and women aged 15-49 reporting STI symptoms in the last 12 months, who sought care at a health facility, in the five pilot regions by PY3. Reduce socio-economic impacts of HIV/AIDS, at the %age of orphans receiving support increased from 3% to individual, household, and community levels. 20% by PY3. Strengthen national capacity to respond to the Increase from 0 % to 20 % of PLWHA that receive medical epidemic. assistance (OI and/or ART) by PY4. 1.3 Revised PDO and Key Indicators, and reasons/justification 8. A restructuring package was approved by the Board on July 3, 2007 and countersigned on December 7, 2008 with revised PDO and associated key performance indicators (KPIs). The restructuring was part of the umbrella restructuring and amendment of the financial agreements for all MAP projects in the Africa Region. The restructuring of this Project aimed to align it with MAP implementation experience. The original PDO as formulated could not be measured as no baseline data existed, but more importantly, MAP implementation experience had shown that it was unrealistic to expect, and thus target, a reduction in prevalence over the short span of the project. A more realistic and attainable objective for MAP projects would be to target prevention, care and mitigation. The PDO was modified along these lines, but components were not changed as a result of the restructuring. 9. The new PDO, with more reasonable goals, focusing more on prevention, was reformulated as follows: "The objective of the Project is to assist the recipient in increasing access to HIV prevention, care and treatment, and mitigation services." The following KPIs were added to the financing agreement (Schedule 6) and replaced the indicators in the Project Appraisal Document (PAD): PDO Indicators: The percentage of young women and men aged 15-24 reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting sexual partner has increased to 65%. The %age of identified commercial sex workers who report using a condom with their most recent client has increased to 25%. 5,000 persons aged 15 and older have received counseling and testing for HIV and received their test results during the last 12 months. 5,000 pregnant women living with HIV have received anti-retrovirals to reduce the risk of Mother to Child Transmission (MTCT) during the last 12 months. 2 The percentage of youth (15-24) who can correctly identify at least two methods of HIV/AIDS transmission has increased to 60%. Intermediate indicator: 1 million male and female condoms have been distributed during the last 12 months. 10% of identified orphans and vulnerable children whose households received free basic external support in caring for the child during the last 12 months in the five pilot regions. US$1million provided to CSOs for subprojects. US$500,000 provided through Public Sector Organizations (PSO). 10. Some of these new indicators carried on some of the activities from the pre-restructuring phase, mainly: condom use and distribution, support for civil society initiatives, support to orphans and vulnerable children, and counseling and testing. A number of KPIs were dropped, including: support to find alternative income sources for PLWHA and affected families, STI/HIV/AIDS treatment capacity in all health facilities, training of traditional healers and sage femmes in each region, condom use, number of operational VCT centers, and HIV seroprevalence by source. 1.4 Main Beneficiaries 11. The Project was intended to benefit the following groups: (i) women, by giving full prophylactic treatment to pregnant women, and by providing counseling and testing on MTCT; (ii) young people and PLWHA, by raising awareness on unprotected sex, on transmission and viable treatment of the disease, on the risks of multiple partners and offering counseling; (iii) hospital workers, by raising awareness of the risk posed by insufficient or no sterilization of medical equipment; (iv) orphans and other vulnerable children, through engagement of civil society, NGOs and orphans associations; and (v) groups which engage in high-risk HIV related behaviors, such as sex workers, truck drivers and migrant workers. Community Based Organizations (CBOs) and civil society associations--namely, religious organizations, PLWHA associations, and orphans associations--would also benefit. 1.5 Original Components 12. The Project would be implemented through three components, described below. 13. Component 1: Community and Civil Society Initiatives, and Capacity Building (US$2.5 million), focused on social mobilization and community-level responses to HIV/AIDS. Funds were to be set up to expand and strengthen HIV/AIDS activities of CBOs and civil society associations themselves, or to contract NGOs or private sector entities. Groups that received funding were to be encouraged to focus, but not necessarily limit, their activities on the most vulnerable groups, including: PLWHA, hospital workers, orphans, youth, commercial sex workers, and truck drivers. Among these, priority was given to orphans and PLWHA. 14. Component 2: Government Multi-Sector Response (US$2.2 million), comprised a fund to scale up and strengthen prevention, care, support and mitigation of the social and economic impact of HIV/AIDS through programs/activities of the public sector. Component 2 had the following subcomponents: 15. Subcomponent 1: Support to Ministry of Health (US$1.3 million), supported the Ministry of Health in combating the epidemic by partially financing the Ministry's HIV/AIDS work plan, including prevention activities, medical treatments, counseling, supply of drugs, and monitoring the progress of the epidemic. Funding sources from other partners would complement Project activities to ensure national coverage. 3 16. Subcomponent 2: Support to other Ministries and Government Agencies (US$0.9 million), focused on mainstreaming HIV/AIDS awareness and prevention in the regular activities and work plans of key ministries (Education, Finance, Defense, Justice, Agriculture, and Transportation). 17. Component 3: Institutional Development for Program Management (US$2.3 million), supported the National AIDS Council (NAC), whose broad responsibilities focused mainly on advocacy and exerting leadership on the multi-sectoral response to HIV/AIDS. The Project also supported the National AIDS Secretariat (NAS), including its regional components and focal points, to fulfill its national HIV/AIDS coordination mandate, as well as technical support, financial management, and monitoring and evaluation. 1.6 Revised Components 18. Project components were not changed. 1.7 Other Significant Changes 19. Changes in implementation arrangements were formalized through amendments to the Development Grant Agreement. A first amendment was approved in August 2006. A new disbursement category for sub-projects was introduced to provide support to CSOs, with a reallocation of SDR 700,000 into this new category. This category was to have been included in the original Project design, but was omitted. 20. In addition, the Project originally envisaged that there would be five operational surveillance centers, one in each of the five regions covered by the project (Bissau, Bafatá, Oio, Cacheu and Gabú), but at the time of the mid-term review (MTR) the Bank realized that: (i) funding was insufficient to have the desired impact in all five regions; and (ii) there was significant overlap with the activities of GFATM in two regions (Oio and Gabú). It was therefore agreed to focus interventions on Bissau, Bafatá and Cacheu. In Oio and Gabú, the Project would focus only on supporting activities related to the first component. 21. A restructuring package was approved by the Board in July 2007, and took effect when it was counter signed in December 2007. The restructuring included a revision of the PDO and KPIs (formalized as Schedule 6 to the Agreement), extended the closing date from December 31, 2007 to 31 December 2008, and reallocated funds. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 22. The quality at entry is rated unsatisfactory. Although Project design drew on other country experiences (Uganda, Brazil, Senegal), and took into account lessons from other Bank HIV/AIDS projects in Africa, and recommendations of studies in key areas (use of rural radios, support to orphans), it failed to adequately address a number of key issues which seriously affected Project outcome and impact: The Project's objectives were too ambitious given the extremely weak implementation capacity in the country and the lack of available information to measure Project impact. This was one of the key comments received at the decision meeting from the Operations Advisor for HIV/AIDS, but there is no evidence that this concern was addressed in Project design. Discussions of the SNP at the Government level were limited to the Ministry of Health, and did not involve other Government stakeholders. As a result, the SNP lacked Government ownership and remained a document written specifically for the donor community by consultants. The decree establishing the SNP implementation structure was not discussed in the Council of Ministers and adopted by the Prime Minister, but instead based on a decree signed by the then 4 Minister of Health, greatly diminishing the buy-in of the Prime Minister's Office and other Ministers. GFATM funding was not adequately taken into account in Project design and the coordinating mechanism between the two projects (Bank and GFATM) was not addressed. The PAD did not make clear which activities were to be funded by GFATM and which by the Bank. This lack of coordination became a major contributing factor to implementation problems. The PAD did not make it clear that a number of activities were assumed to be carried out by other Projects. In particular, the safeguard measures were inadequately evaluated and depended on the multi-donor supported National Health Development Project (PNDS) for the required investments in health infrastructure and incinerators. The delayed implementation of these investments greatly impacted the project. Despite the long list of indicators in the PAD, there was no monitoring and evaluation (M&E) system included in Project design, making it impossible to measure KPIs. During preparation, there was a suggestion to use Dakar-based firms to handle financial management and procurement, as there were no firms in Guinea-Bissau that would meet Bank standards. This option was rejected by the task team as too costly and these functions were thus assigned to NAS, despite the fact that staff with these skills were very scarce in the country. Similarly, the Bank agreed with Government that all NAS staff should be Guinea-Bissau nationals, even though there was a severe shortage of experienced people in-country and the salaries offered were too low to attract nationals living overseas (the Coordinator earned about US$30,000 per year). Project implementation arrangements were very top heavy, in particular for the first component, which required the establishment of regional teams with high operating costs. No detailed and reliable cost estimates were prepared for the Project in the form of cost tables or other tools. The Project Costs Annex in the PAD only shows total amounts by the three Project components with no details or disaggregation. 23. Overall Project risk was rated as substantial. The PAD identified two risks as high: (i) NAS management and implementation capacity would be inadequate for the task; and (ii) insufficient data would be available to measure project impact (some key data may not be easily collectable or collected too late to be of use in project evaluation). Although these were indeed critical risks that affected Project implementation, the proposed mitigation measures were weak or not followed through. In the case of NAS capacity, the risk mitigation measures refer to a transparent recruitment process without acknowledging the possibility that not enough qualified staff would apply, and refers to an institutional assessment to be carried out in 12 months after effectiveness, but there is no evidence that such an assessment took place. In the case of data availability, the risk mitigation measure proposed a data assessment as part of establishing the M&E system, and notes the need to put in place appropriate data collection systems. There is no evidence that a systematic data assessment was carried out, but in addition the proposed mitigation measure did not adequately address the risk that the data would be difficult to collect or not available in a timely manner. The lack of a baseline and an inadequate and delayed M&E system impacted Project performance. 24. Four risks were rated as substantial: (i) quality and commitment of political leadership, including NAC, would be weaker than required; (ii) a weak health sector would hamper strategic HIV/AIDS-related care issues; (iii) donor interest and financing would not increase; and (iv) there could be insufficient CBOs and NGOs available in the regions to fully carry out the program. Mitigation measures were weak and proved inadequate. Advocacy campaigns are not an appropriate substitute or palliative for lack of political commitment, or leadership capacity in the national coordinating body (NAC). Weaknesses in the 5 health sector could not be addressed through the Project's HIV/AIDS interventions alone. Donor support generally requires Government leadership and commitment, which in this case was weak, and the lack of a well-functioning M&E system likely reduced donor confidence that donor funds would be well used and targeted. 25. All identified risks affected Project implementation to varying degrees--with the exception of the availability of CBOs and NGOs--and the mitigation measures proved inadequate and not well thought out or fully evaluated. In addition, an unforeseen critical risk was the unstable political environment, with frequent Government changes that greatly undermined the ability of the Project to achieve its results. Overall, the risk assessment should have been more detailed, considered alternatives, and made specific reference to the fact that a new multi-sectoral project operating in a weak post-conflict environment would force formidable challenges. 26. The Project was not subject to a review by the Quality Assurance Group for either quality at entry or quality of supervision. 2.2 Implementation 27. Effectiveness was delayed by 6 months after Board due to several factors. The first was delays in contracting NAS staff, which were in the end not contracted until close to effectiveness. Thus, there was a lack of continuity of NAS staff between preparation and implementation, adding to misunderstandings and implementation delays. In addition, the then Minister of Health did not want to release one of her key directors to work at the NAS, because it would severely affect the capacity of the Ministry. The officer selected for M&E received a competing offer from another project and withdrew his candidacy. As a result, the staffing of NAS, which functioned as the Project Management Unit (PMU), was inadequate. 28. The second reason was the delay in preparing the first year work program, which was in part linked to the delay in hiring NAS staff and weak Government capacity. Following approval of the PPF, the PNDS PMU agreed to handle procurement and financial management, until NAS staff was on-board. 29. The main issues affecting the Project during implementation were: Insufficient capacity to plan and implement. None of the NAS staff had ever managed a program before and most were mid-level former civil servants from the Ministry of Health. In addition, none had been involved in project preparation and there was inadequate briefing at Project start-up. Project staff and the Bank team did not communicate well, not only because of the general communication difficulties in Guinea-Bissau, but also because the first and second TTL did not speak Portuguese and not all NAS staff and Government officials understood French or English well. Inadequate collaboration between UN agencies (with the exception of WHO) and NAS, despite the agreement by UNDP to provide technical support and build capacity in NAS. UNDP, as implementing agency for the GFATM Grant, appeared to have limited interest in supporting capacity building in NAS as UNDP itself was itself seeking to implement GFATM programs in Guinea- Bissau. It was only toward the end of the project, when it became clear that NAS would be the new implementing agency for the second phase of the GFATM HIV/AIDS Grant that the UN agencies started to support NAS. Limited initial support across the Government for the program which was seen as a Ministry of Health project. Although there was an experienced Procurement Officer in the PMU, procurement remained the weakest link, primarily due to the passive procurement execution (the procurement officer was also working for PNDS and gave priority to this work) and weak capacity in the PMU to write terms of reference. In addition, there was insufficient support from the Bank in procurement supervision and 6 in particular for the review of procurement plans and performance. Also, the composition of the Bank's team during supervision missions was weak: according to information in the ISRs, the Social Development Specialist only participated in one mission, the Public Health Specialist participated only in three missions, and no Safeguard Specialist was part of the team. Serious delays in implementing the waste management plan. 30. Strong points during project implementation were: Ability to reach all intended beneficiary groups such as women, orphans, vulnerable children, PLWHA, young people, truck drivers and sex workers. Voluntary counseling and testing, and the community component, which were both spearheaded by highly motivated NAS staff. Strong collaboration between the TTL for the GFATM Grant from Geneva and the Bank team with yearly joint supervision missions. 31. A Mid Term Review (MTR) took place in October 2006. During the MTR it was agreed that the Project needed to be restructured as the achievement of the PDO could not be measured and several KPIs therefore needed to be reformulated. It was also agreed to extend the closing date from December 31, 2007 until December 31, 2008, and to reallocate grant proceeds. An action plan was drawn up to improve Project implementation performance. 32. The restructuring package was approved by the Board July 3, 2007. It was part of the umbrella restructuring and amendment of the financial agreements for MAP projects. As Government had not formally adopted the second SNP nor its revised institutional structure, the Bank team asked Government to formally adopt the Plan and to formalize this in a Prime Ministerial decree, as a condition for signing the amendments to the Financing Agreement. These conditions were met by November 2007, and as a result of the Cabinet-level discussions there was much greater involvement of the Prime Minister in HIV/AIDS awareness activities and greater overall Government buy-in. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 33. Design. The Project did not include an M&E system in its design and there was therefore no M&E system at the start of the Project. The M&E system was expected to be developed during implementation. A consultant was hired to design an integrated M&E system that would apply to all HIV/AIDS activities in the country. Unfortunately, the consultant could not complete her work due to health problems. UNICEF and UNAIDS offered to provide support to complete the establishment of the M&E system, but this support did not materialize in a timely manner. 34. Implementation. Despite the fact that the consultant mentioned above could not complete the manual, she was instrumental in training the M&E officer in data collection and reporting. Implementation was difficult and NAS was not able to effectively produce reports. In March 2007, there were still delays in finalizing the M&E system, which was negatively impacting Project performance. Overall M&E, especially data collection and reporting remained inadequate and a major constraint. 35. Utilization. Limited M&E capacity in NAS, and the unavailability of a management information system for more than two years, made monitoring difficult, compounded by the fact that many indicators had no baseline. 2.4 Safeguard and Fiduciary Compliance 36. The Project was an environmental category B. The most important environmental issue identified was medical waste disposal. An incinerator was supposed to be built in the National Hospital through PNDS with AfDB financing, but by the end of 2007 construction had not yet started. In lieu of this, and 7 only in the last year of the Project, three mini-incinerators using WHO-approved guidelines were built at the National Laboratory and at two health centers (Bandim and Belém), funded by the Project. Prior to the construction of these incinerators, each testing and Counseling Center disposed of hazardous waste by digging a hole in the ground where the hazardous waste was dumped and incinerated with fuel, a common practice in Guinea-Bissau. 37. Financial Management suffered in the beginning, owing to the lack of trained staff, while passive procurement execution and weak capacity slowed implementation. More reliable financial information became available following the transfer of financial management responsibilities from PNDS to the Project, the associated adoption of the new financial management system, and the timely submission of quarterly reports. The internal control system put in place was adequate, and audit reports were submitted on time. There were no qualified audits. 2.5 Post-completion Operation/Next Phase 38. Due to the limited IDA country envelope and the availability of GFATM resources, the Bank did not prepare a follow-on project. The GFATM Grant (US$13.1 million) was signed on November 12, 2008, with NAS as principal recipient. The Grant aims to: (i) decrease trends of HIV infection in the general population; (ii) improve living conditions of PLWHA; (iii) provide complete and reliable strategic information on the trends of the epidemic for decision making and resource allocation; and (iv) involve all HIV/AIDS partners in the country in the fight against the epidemic. The new Grant will support some activities initiated under the Bank's Project, such as the associations of PLWHA, but not others, such as Regional AIDS Centers. 39. The effectiveness and impact of the follow-on GFATM Grant will depend on whether it builds on the lessons learned from the Bank's Project and avoids its mistakes. With the restructuring of NAS, the country is better placed to implement the Government's HIV/AIDS strategy, but institutional gains in fragile states such as Guinea-Bissau tend to be fragile, and must be supported with effective, well-targeted and sustained financial and technical resources. Arrangements were made to ensure an adequate and smooth transition with GFATM, but due to the lengthy recruitment procedures to hire new NAS staff (over a year), the handover could not be properly effected. The new Grant will also have to contend with a very weak health sector, and widespread needs across the sector, especially in terms of capacity at the regional level, lack of reagents, little testing of pregnant women, and vertical control of MTCT. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 40. The relevance of the Project's objectives, design and implementation is rated moderately unsatisfactory. The Project was consistent with both the objectives of the Bank's regional HIV/AIDS strategy and with those of the 2004 Guinea-Bissau ISS. Additionally, the project supported the Government's medium-term strategy to expand and accelerate the national response to HIV/AIDS. Addressing the HIV/AIDS epidemic continues to be a priority in the country (estimated current prevalence rate of 3-7%), and is in line with global priorities to fight the disease. Although the Project was highly relevant at the time it was designed, design and implementation could have been improved in many important respects, but particularly in taking account of the fact that this was a complex operation in a very fragile state with extremely weak capacity. 3.2 Achievement of Project Development Objectives 41. Achievement of the PDO is rated unsatisfactory. Key indicators, both before and after the December 2007 restructuring, are presented in the datasheet. At the time of the restructuring, SDR 3.87 million had been disbursed, representing 82% of total disbursements. Since available data for many of the pre-restructuring indicators is weak or absent, progress under the Project prior to restructuring is 8 presented below by component and activities, rather than by KPI (the achievements by KPI for the post- restructuring phase are presented later). 42. Component 1, Community and Civil Society Initiatives and Capacity Building (i) Work with orphans and vulnerable children (partially achieved): The work with priority groups such as orphans and other vulnerable children, was successful due to partnerships created with NGOs (Casa Emmanuel, Aldeia SOS, CARITAS, AMIC, and Associação Nova Vida), which helped in the social integration of orphans and other vulnerable children. These NGOs worked directly with orphans, children that suffered sexual abuse, children of HIV-positive mothers and PLWHA, by providing emotional, nutritional and medical support. The Project succeeded in providing these children access to education and food aid, giving them a sense of belonging and normalcy, and helped reduce social stigma. There is, however, no data to assess or measure impact, without which it is not possible to rate this activity as achieved. (ii) Community activities (inconclusive): Despite starting with delays a total of 148 associations and NGOs submitted their legal documents, of which 99 were selected to receive training on how to prepare sub-project proposals, and 71 proposals of up to US$20,000 were approved by the Regional HIV/AIDS Councils (e.g., Youth Council, INDE--HIV-positive, and Casa Emmanuel--orphans). Although the Project succeeded in channeling increased support through civil society, their impact and effectiveness, especially in terms of behaviors of the general public, is unknown since at the end the Project did not have sufficient funds to measure behavioral impact, despite the fact that this had been planned as a priority activity. An important achievement was the emergence of a number of PLWHA associations and creation of a network of these associations. Three national groups emerged as a result of the Project. (iii) Behavior change of sex workers (partially achieved): Following a baseline survey, efforts to change behavior among sex workers started, with delays, in 2007. Subsequent to the Project's activities, the percentage of commercial sex workers who reported using a condom with their most recent clients was 32%, up from under 20% reported in the baseline and above the 25% target. (iv) Training (partially achieved): Toward the end of the project, PLWHA and sex workers received training from the NGO ADIM enabling them to successfully apply for micro-credits. ADIM also provided training to develop skills for various income-generation activities such as sewing, gathering fire wood, and selling chickens, thus opening up opportunities for beneficiaries to switch to alternative livelihood sources. 43. Overall the objectives of this component were only partially achieved and performance is rated moderately satisfactory. Although data is incomplete, through its work with orphans and vulnerable children as well as community activities, the component helped reduce the socio-economic impact of HIV/AIDS at individual, household and community levels. The Project also laid the foundation to further continue HIV/AIDS prevention activities and fostered national awareness on the importance of the response to HIV/AIDS through the mobilization of community and religious leaders, particularly at the regional levels. A major achievement was the support provided to the network of three associations of PLWHA, and the adoption of anti-discrimination legislation. 44. Component 2, Government Multi-Sector Response: this component was divided into two sub- components, one targeting the health sector and one targeting key ministries. 45. Sub- Component 1: The health sector sub-component aimed to strengthen the Integrated Health Network for the provision of voluntary counseling and testing and HIV/AIDS related services along the major transportation axes where prevalence rates are highest; increase the supply of drugs and materials; strengthen clinical laboratory capacity to enable diagnosis and monitoring of HIV therapy, including 9 those for CD4; monitoring and diagnosis of opportunistic infections; support epidemiological surveillance prevention, diagnosis, and treatment of STIs; prevent MTCT; manage opportunistic infections (OIs), focusing on prevention and treatment; and, lastly, support for management, monitoring and evaluation of component activities as well as the overall progress of the epidemic. Seven major activities were undertaken: (i) Voluntary counseling and testing (achieved): Voluntary counseling and testing and HIV/AIDS related services were extended. Major activities were: training in counseling and voluntary testing for health sector professionals, community associations and NGOs; and psycho-social support to PLWHA and their families. Support was also provided along the major transportation axes. During 2005-08, over 59,000 persons 15 years or older went through counseling and testing. Psychological care was provided also in one center, which was a substantial achievement in a country such as Guinea-Bissau that lacks psychological professional capacity. (ii) Supply of drugs (not achieved): The supply of drugs did not materially increase as a result of the Project and there continue to be insufficient materials and equipment (e.g., CD4 to determine at which moment the infected person should take retrovirals). A 2006 study on the changes in prevalence and incidence of HIV-1, HIV-2 and dual infections in urban areas of Bissau showed that anti-retroviral treatment (ARVT) was not available in the country, although ART drugs were funded by GFATM. Weak management of drugs and rupture of stocks of reagents and laboratory products, remained a concern throughout the project; this rupture was caused by slow procurement (through the national drugs store CECOME), but also due to shipment problems and low interest by suppliers. The drug supply chain was very weak, lacking good software to manage stock distribution. (iii) Epidemiological surveillance (partially achieved): Support to epidemiological surveillance was provided through training aimed at strengthening clinical laboratory capacity in areas such as: rapid tests (110 out of 100 planned); bacteriology and blood safety (50 out of 100 planned); biochemical exams (14 out of 20 planned); and treatment of STIs in PLWHA (140 out of 125 planned). Also, a baseline was carried out. (iv) Treatment (inconclusive): Access to STI treatment and ART was held-up at the start of the Project due to lack of test materials. The demand for STI/HIV/AIDS treatment increased, but due to poor basic data it is not possible to assess if it met the Project target, from 0 to 20%. It is also not possible to determine if the rate of increase of seroprevalence of HIV among antenatal women aged 15-24 declined. However, the percentage of pregnant women that were receiving full prophylactic treatment increased from 4.6% in 2004 to 11% in 2007. (v) Progress of the epidemic (inconclusive): Due to lack of data, it is impossible to measure the spread of HIV/AIDS infection in Guinea-Bissau. What is clear is that it remains much higher than in neighboring countries. (vi) Biosafety and waste disposal management (not achieved): Due to delays in implementing the PNDS waste management plan, the three incinerators, at the National Laboratory and at two health centers, were only constructed just before project close. Medical waste disposal therefore did not meet safeguard standards during most of the life of the Project. 46. Overall objectives of this sub-component were not fully achieved or inconclusive, and it is therefore rated as unsatisfactory. While data is scarce on which to judge the success of activities supported under this component, the data that is available combined with the low disbursement levels (approximately 26% of those originally planned) support the rating. Further, as stated above, many important outcomes that are key to the future sustainability of project efforts and the ongoing fight against the epidemic, such as supply of drugs, biosafety and measurement of the epidemic, were not successful. 10 47. Subcomponent 2: Aimed, inter alia, to provide capacity building to mainstream HIV/AIDS- related activities (IEC campaigns, including promotion of condom use for staff and client awareness, to ensure sustainable behavior changes among staff and clients) into the regular work plans of four key ministries; facilitate the provision of HIV/AIDS social support networks for all staff; and carry out impact studies to investigate the qualitative and quantitative consequences of the epidemic on specified sectors and analysis of possible and appropriate responses. Two major activities were undertaken. (i) IEC (partially achieved): Awareness campaigns were developed with delays due to the late preparation of the procurement plan. Billboards were installed in a few key locations but were unclear and too complicated to effectively reach the population. More successful was the use of radios, where 774 programs were transmitted in local languages through contractual arrangements with radios, but they were not diversified enough to ensure a greater knowledge of methods of HIV infection beyond intercourse. (ii) Condom distribution (partially achieved): This activity was carried out together with other partners. Many NGOs targeted young people as this was the group with the highest likelihood for behavioral change. As the final survey was not carried out, it is unclear whether the target of increasing condom use from 35 to 65% was met. It is unlikely, however, that this target was met due to the difficulties in obtaining condoms evidenced in most areas. An expatriate team was providing support through PNDS for the development of social marketing capacity, but this contract was cancelled when the Project became effective. The NGO AGMS (Social Marketing Agency of Guinea-Bissau), which was created as a social marketing organization, carried out some activities under the Project but because of uncertainty about its status, which was also flagged by the Bank's procurement specialist, these could not be renewed. Despite this, AGMS successfully distributed over a million condoms to youths with Bank support. The Transport Ministry developed effective interventions such as gas stations providing free condoms for truck drivers and migrant workers. The Sailor's Union also distributed condoms for free. 48. Overall the objectives of this sub-component were only partially achieved and there is no evidence on impact. In addition, only 27% was disbursed of the amount envisaged at appraisal. The sub- component is therefore rated moderately unsatisfactory. Awareness campaigns should have been a priority from start and the availability of condoms was an issue. 49. Component 3, Institutional Development for Program Management, aimed to strengthen the capacity of NAS through the: (i) establishment of an effective and operational secretariat and networks at national, regional, and district levels to enable the design, implementation, monitoring and evaluation of strategic HIV/AIDS control interventions; (ii) establishment, operation and maintenance of performing financial management and procurement systems; and (iii) establishment, operation and maintenance of a performing M&E system. (i) Effective Secretariat (not achieved): NAC had the mandate for project oversight, while NAS was responsible for project implementation at the national level and for the regional structures to facilitate regional implementation. NAS, however, was not effective--its management and implementation capacities were inadequate, it did not provide the expected leadership for the multi-sectoral response to HIV/AIDS, and overall coordination was weak. The lack of pro-activity of NAS was a major factor in implementation delays. As a result of these deficiencies, it was agreed to restructure NAS and to bring in new staff for the final year of the project, both to improve performance and to ease the transition into a new project. However, this did not happen due to delays in recruitment of new staff. (ii) Financial management and procurement systems (not achieved): Although a financial management system was installed and functioning, and was rated S or MS throughout the life of the Project, the last ISR rates it as unsatisfactory, noting weak financial management that made it impossible to carry out the final impact evaluation study (which was a priority activity) and prevent a funding gap related to drug 11 purchases through CECOME. Although not always reflected in the ISR ratings, procurement was problematic throughout the Project, often being delayed mainly due to the fact that the procurement specialist prioritized PNDS. (iii) M&E system (partially achieved): M&E implementation was a challenge. Extensive delays in establishing a performing M&E system and continued poor procurement performance affected implementation. This delay in establishing a functional M&E system impeded the provision of accessible and timely information on progress of inputs, process, outputs and outcomes mainly in the beginning of the Project. Capacity was built with technical assistance support and data was available before the MTR. 50. Overall the objectives of this sub-component were not achieved, especially the critical component of ensuring an effective secretariat, and the sub-component is therefore rated unsatisfactory. NAS was not fully effective, M&E was delayed and not fully satisfactory, and financial management and procurement were weak. 51. Achievements by KPI for the post-restructuring phase are assessed below: Outcome indicators: (i) Condom utilization among the general population (not achieved): The percentage of young women and men aged 15-24 reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting sexual partner was 31%, less than half of the targeted 65%. (ii) Condom utilization among sex workers (achieved): The percentage of identified commercial sex workers who report using a condom with their most recent client increased to 32%, 7 percentage points above the target of 25%. (iii) Counseling (achieved): 13,996 persons aged 15 and older have received counseling and testing for HIV, and received their test results during the last 12 months, compared to a target of 5,000 persons. (iv) MTCT treatment (not achieved): Only 258 pregnant women living with HIV have received anti-retrovirals to reduce the risk of MTCT during the last 12 month, compared to a target of 5,000. (v) Identification of HIV/AIDS transmission (not achieved): The percentage of youth (15-24) who can correctly identify at least two methods of HIV/AIDS transmission was only 7%, well short of the 60% targeted. Intermediate outcome Indicators: (vi) Condom distribution (achieved): 2,028,160 male and female condoms were distributed during the last 12 months of the Project. (viii) Support to orphans and vulnerable children (inconclusive): Although 4,544 orphans and vulnerable children were identified, due to the absence of a baseline, it is not possible to determine if 10 % of those households actually received free basic external support for child care during the last 12 months in the five pilot regions. (ix) Funding grant allocation to Civil Societies (inconclusive): US$1.3 million was provided to CSOs for subprojects compared to a target of US$1.0 million. However, as indicated earlier, the Project did not carry out an assessment of the impact of these activities. Thus, while it is clear that additional resources were channeled through CSOs, there is no information to evaluate the effectiveness of the CSO programs or to draw lessons for future interventions. 12 (x) Public sector contribution (achieved): US$1.3 million provided through Public Sector Organizations compared to a target of US$0.5 million, but there is no information to assess impact or effectiveness. 52. Post-restructuring results are considered unsatisfactory. Although substantial achievements were recorded in terms of condom utilization among sex workers, condom distribution, counseling, and funding through CSOs and public sector agencies, there were major failings in terms of condom utilization by the general population, MTCT treatment, and identification of HIV/AIDS transmission. Moreover, there is no information to assess impact on support to orphans and vulnerable children, or the funds distributed through CSOs and public agencies. These last two components, which fell substantially below their targets (para. 54) were considered key for the sustainability of the program. Moreover, there is no information to assess impact on support to orphans and vulnerable children, or the funds distributed through CSOs and public agencies. 3.3 Efficiency Rating: Unsatisfactory 53. Project efficiency is rated as unsatisfactory. Weak governance and lack of accountability for results led to inefficiencies in the use of resources. The Project's resources were not managed efficiently and in line with Project objectives, and as a result the delivery of services was not efficient. Control over resources and budget follow-up on the part of Project management were lax and the monitoring of activities was weak. Symptomatic of these weaknesses is the fact that Components 1 and 2 were significantly underfunded (only 64% and 54% respectively of appraisal cost estimates), while disbursements under Component 3, which covered institutional develop for Project management, was almost double the appraisal estimate. This de facto reallocation did not appear to respond to a strategic realignment but rather to weak management and oversight. 3.4 Justification of Overall Outcome Rating Rating: Unsatisfactory 54. Although the Project was clearly relevant, this ICR concurs with the last ISR which rated the PDO and overall implementation progress as unsatisfactory. Although some indicators were exceeded, as noted in the last ISR two key indicators that were considered key for the sustainability of the program fell substantially short of Project targets--the number of pregnant women living with HIV who received treatment to reduce the risk of MTCT was only 5% of the post-restructuring target; and the percentage of youth who can correctly identify at least two methods of HIV/AIDS transmission was only one tenth of the target. In addition to falling well short of these two key targets, the Project was unsatisfactory in terms of efficiency, had serious weaknesses in financial management and safeguards, did not manage a smooth transition with the follow-on GFATM Grant, generated little data to evaluate performance, and failed to carry out the assessment of behavioral change which was planned for the end of the Project and was appropriately considered a priority. Overarching Themes, other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 55. HIV/AIDS increases the cycle of poverty, as less family members are generating income and are socially productive. The prevention and treatment of the disease and STIs, is expected to have helped to prevent or reduce HIV-related poverty, by enabling community members to continue to contribute to society. The Project empowered local communities to help in the AIDS response, and awareness activities carried out increased likely acceptance of PLWHA, by reducing the cultural taboo and stigma, and thus 13 may have contributed somewhat to social cohesion in the country. Through partnerships created with NGOs, the Project assisted in the social reintegration of orphans and other vulnerable children, and provided them with emotional, nutritional and medical support. 56. An important achievement of the Project was to help raise social AIDS awareness, especially at the regional level. For instance, remote villages revealed a surprising knowledge of HIV/AIDS which were discussed in a variety local languages, laying the grounds for community behavioral change (e.g., voluntary testing). Although many key aspects of the Project were not successful or there is no data with which to evaluate impact, the Project has, in effect, laid a foundation for HIV/AIDS work in Guinea- Bissau which, if appropriately followed up, can begin to make a difference in mitigating the impact of the epidemic. 57. The Project made a special effort to focus on women. Targeting and involving women through the provision of drugs and materials such as condoms, and treatment for OIs as well as anti-retroviral drugs for the prevention of MTCT, was critical. Although difficult to assess, it appears that these efforts to target women have helped in social mobilization and sensitization efforts. (b) Institutional Change/Strengthening 58. The community response component has given voice and visibility to a large number of CSOs. It has built the capacity for advocacy and activism among PLWHA, as they were able to expand their national network and reach out to larger numbers of people. In addition, the Project contributed to strengthening a number of local communities through training and awareness campaigns. Local institutions supported under the Project were mobilized to promote activities for the benefit of their members. The voluntary testing program and the capacity building provided to NGOs carrying these out have led to the establishment of national standards, including acceptance of the need to ensure client confidentiality. As extensive training has been provided and detailed manuals exist, which have been validated by all technical partners, it is highly likely that the voluntary testing program and capacity built will be sustained after Project closing. (c) Other Unintended Outcomes and Impacts (positive or negative) N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A 4. Assessment of Risk to Development Outcome Rating: High 14 59. The main risk would be the discontinuation of external support for HIV/AIDS as the country has insufficient resources and capacity to address the epidemic. Resources available through the GFATM will mitigate this risk in the short to medium term, but their impact will depend critically on drawing the right lessons and avoiding some of the critical mistakes which appear to have hampered the Project. As a result of the recent restructuring, NAS is better equipped to perform its coordination functions, but in countries such as Guinea-Bissau these institutional gains can be very fragile and temporary, unless continuously supported with external resources and technical capacity. A critical risk, which will continue to affect follow-on activities and which lies beyond the scope of HIV/AIDS interventions, is the general weakness of the country's health sector. Without parallel and effective efforts to strengthen health policies, institutional capacity, skills and motivations of health staff, it will be difficult to sustain progress in the battle against HIV/AIDS. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Unsatisfactory 60. Structured along the lines of the standard HIV/AIDS project, the design used lessons learned from previous Bank operations. Inadequate attention, however, was paid to the specific capacity issues prevailing in Guinea-Bissau. Although there may have been some pressure at the time to launch MAP projects in the Region and perhaps over-optimism as to what could be achieved through a standard MAP approach, there is no evidence that the country's extremely low capacity, the precarious state of its health sector, and the country's serious lack of skills in all areas, were factored into Project design, even when this was explicitly raised at the Decision Meeting. In addition, dialogue with the Government remained at the level of the Ministry of Health and NGOs active in the health sector. Project design could have been strengthened by: (i) more modest objectives and components, better tailored to the country's extremely weak capacity; (ii) a better understanding of the local HIV/AIDS situation; (iii) a more realistic risk assessment and mitigation strategy; (iv) establishment up-front of an M&E system; (v) greater involvement of other stakeholders, especially throughout the Government; and (vi) an evaluation of the costs of the proposed implementation structure relative to available funds and Project objectives. (b) Quality of Supervision Rating: Unsatisfactory. 61. The task team made considerable efforts to compensate for the country's extremely weak capacity, initial lack of ownership and Government commitment, and a flawed Project design. It also made commendable efforts to coordinate with external partners, especially UN agencies and GFATM, even though these partners were not always receptive or fully collaborative. Supervision frequency was appropriate, with an average of two supervision missions per year (nine over the life of the Project), but task team composition was frequently not adequate--according to the ISRs, the Social Development Specialist only participated in one mission, the Public Health Specialist participated only in three missions, and no Safeguards Specialist was part of the team. The task team does not appear to have succeeded in building a solid partnership with the Borrower. The Borrower's ICR refers to lack of follow- up on the part of the task team as one of the weakest points of Project implementation, as well as the fact that the task team composition was incomplete during some supervision missions. 62. In addition, the internal management set-up of the Project can be questioned. The second TTL was not a health or HIV/AIDS expert and the Project was thus mapped to an environment unit (AFTEN). Although this represented an Africa Region strategy at the time, designed to emphasize that HIV/AIDS is multisectoral and that interventions should be mainstreamed across Bank operations rather than `belong' 15 to one sector (such as health), it would not appear to be an effective way to implement a complex multisectoral operation in a fragile country with extremely weak capacity. As discussed in this report, the Project faced many problems that were the result of a very weak health sector and thus greater coordination with and support from health sector colleagues would have been desirable. In addition, during the last year or so of Project implementation, the TTL remained the same but the Project was mapped to the fragile states and social development unit (AFTCS). Having two completely unrelated units being involved in the supervision of this project (AFTCS and AFTEN), was not conducive to strong managerial and technical supervision oversight of a project operating in a very weak environment. 63. The team and management missed an important opportunity during the MTR and subsequent restructuring, especially on two counts. First, it should have been clear at the time of the restructuring that something more than just changing the PDO was needed, especially given the limited time and resources remaining after restructuring. This could have been the time to substantially restructure the whole Project, most likely by refocusing it on a narrower set of objectives that could be reasonably accomplished in the remaining time. Instead, only the PDO was changed. Second, at this stage the team could have also sought urgent and dedicated technical support and assistance, especially from AFTHV, on the restructuring itself but also on M&E, general supervision, and impact assessments. 64. Financial management supervision was adequate, and in general the recommendations made by the Financial Management Specialist were followed, with timely submission of quarterly reports. However, financial management by the implementing agency was very weak, and as noted in para. 49 (ii), the Project was unable to carry out the final impact evaluation and ended with a cost over-run on procurement of drugs. There was insufficient support from the Bank in procurement supervision and review, particularly of procurement plans and procurement performance. (c) Justification of Rating for Overall Bank Performance Rating: Unsatisfactory. 65. The Bank's overall performance is rated as unsatisfactory, based on the assessment presented in section 5.1 above. 5.2 Borrower Performance (a) Government Performance Rating: Unsatisfactory. 66. Quality and commitment of the country's political leadership, including the National Aids Council, was initially weak, including the lack of coordination between the Prime Minister's Office and the Health Ministry. Also there was little progress in developing the enabling environment (politico- institutional, technical, financial, administrative) and productive relationships with donors and partners. In addition, the weak capacity of the PMU, and the limited cooperation between collaborating institutions, caused delays in implementation. (b) Implementing Agency or Agencies Performance Rating: Unsatisfactory. 67. NAS faced a number of issues and challenges. The problem with staffing issues hampered implementation and affected the quality of interventions. In addition, the lack of pro-activity on the part of the National Secretariat continued to cause serious delays in implementation, reflecting the lack of strategic direction and of strong leadership. Mechanisms to ensure accountability and sustainability remained particularly weak throughout project implementation, particularly the limited efforts invested in improving effectiveness and sustainability by NAS. 16 (c) Justification of Rating for Overall Borrower Performance Rating: Unsatisfactory 68. Overall, Borrower performance is rated unsatisfactory based on the discussion in section 5.2. 6. Lessons Learned 69. In fragile and post-conflict countries, as was the case in Guinea-Bissau, project objectives and design need to be as simple and modest as possible. Project design must take full account of extremely weak institutional capacity, the strong likelihood of political instability and staff/ministerial turnover, the difficulties of ensuring full government ownership in the face of many competing demands and priorities, and the need for a strong supervision effort, especially during the first 1-2 years of the project, to support weak government structures and counterparts. Clear prioritization of activities, detailed implementation plans, sequencing of activities and decisions, and a limited set of objectives and activities should be essential requirements for projects to be implemented in fragile settings. These details should be fully discussed and reviewed before submission to the Board, and task teams should be encouraged to prepare detailed supervision plans for the first 12 months of project implementation. 70. Creating a new institution is a complex and time-consuming undertaking, but especially in a fragile state. As was the case of NAC and NAS in Guinea-Bissau, the difficulties are compounded when the new institutions are required to work cross-sectorally, ensure buy-in from government structures and the population at large, and include diverse representation (i.e., government, private sector, civil society). Although establishment of NAC was a condition of effectiveness, project implementation was affected by significant delays in contracting NAS staff, which should not have been surprising given the country's low capacity and human capital. The fact that recruiting staff with appropriate skills for a new public sector agency is a fragile state is likely to be difficult and lengthy; it should be factored into project design, and steps taken to front-load capacity building and technical support during the project's early phase. Sequencing and prioritization of project activities that can start early and that require relatively less capacity also need to be part of project design. 71. A multi-sectoral HIV/AIDS project, especially in an environment of weak capacity, should target sectors and population segments with the largest potential impact. Although awareness raising and sensitization of the population are welcome, given limited resources and institutional capacity, a better strategy would be to focus mitigation and communication efforts on population groups that are most vulnerable and that play a greater role in spreading HIV/AIDS. 72. An adequate baseline and functioning M&E system are essential in projects that are piloting new approaches, such as the first round of MAP interventions. Although development of the M&E system was planned during implementation, it suffered delays, remains weak and is still lacking an appropriate baseline. While some of the problems were unforeseen (health of the consultant, weak and delayed support from UN partners), corrective actions and alternatives need to be considered and prioritized. In the case of Guinea-Bissau, the lack of an adequate management information system hindered the strategic response to the even limited monitoring data that could be generated. Projects that are designed to learn-by-doing must have sufficient information to gather emerging lessons and adjust as the project proceeds. Without reasonable certainty that a good M&E system and baseline will be in place early during project implementation, it is questionable whether a learn-by-doing project should be approved in the first place, even if there is a need to respond quickly to a serious emergency, such as HIV/AIDS in Africa at the the time that MAP projects were approved. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 17 See Annex 7 (b) Cofinanciers N/A (c) Other partners and stakeholders N/A 18 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Actual/Latest Components Estimate (USD Estimate (USD Percentage of million) million) Appraisal (%) Community and Civil Society Initiatives, and Capacity 2.50 1.61 64.41 Building Government Multi-Sector Response Sub-component 2.1 1.30 0.34 26.18 Subcomponent 2.3 0.90 0.25 27.50 Institutional Development for Program Management 2.30 4.57 198.77 Total Baseline Cost 7.00 6.77 96.71 Physical Contingencies 0.20 0.00 0 Price Contingencies 0.30 0.00 0 Total Project Costs 7.50 Front-end fee PPF 0.76 0.32 41.54 Front-end fee IBRD Total Financing Required 7.00 6.77 96.71 (b) Financing Appraisal Actual/Latest Percentage of Source of Funds Type of Estimate Cofinancing Estimate Appraisal (USD million) (USD million) (%) Borrower IDA GRANT FOR HIV/AIDS 7.00 6.77 96.71 Other Donors - - - 19 Annex 2. Outputs by Component The ICR Mission was unable to obtain detailed data and information on project outcomes, and very little by way of analysis or studies. The only data set that was provided to the Mission did not include actual data, but estimates derived from a Spectrum model. Even this data was incomplete, very difficult to read and analyze. No Government or Project officials were available to assist the mission interpret the data or seek additional information. The only data the Mission was able to collect on output by components is provided in the ICR data sheet and is therefore not repeated in this Annex. The absence of data has greatly complicated the preparation of this ICR. 20 Annex 3. Economic and Financial Analysis N/A 21 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibilit Names Title Unit y/ Specialty Lending Christian Fauliau Task Team Leader AFTS4 Dirk Nicolaas Prevoo Operations Officer AFTS4 Laurent Mehdi Brito Procurement Specialist AFTPC Eduardo Brito Sr. Counsel LEGAF Fily Sissoko Sr. Financial Management Specialist AFTQK Marie-Jeanne Ndiaye Program Assistant AFTS4 Supervision/ICR Dirk Nicolaas Prevoo Senior Operations Officer/TTL AFTEN Demba Balde Senior Social Development Specialist AFTCS Eduardo Brito Sr Counsel LEGAF Bourama Diaite Senior Procurement Specialist AFTPC Joseph-Antoine Language Program Ellong Assistant AFTCS Stephane Henri Legros Public Health Specialist WBIHD Luz Meza-Bartrina Sr Counsel LEGAF Suzanne F. Morris Senior Finance Officer LOAFC Marie-Jeanne Ndiaye Program Assistant IEGSE Osval Rocha Andrade Financial Management Romao Specialist AFTFM Virginie A. Language Program Vaselopulos Assistant AFTEN (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands No. of staff weeks (including travel and consultant costs) Lending FY02 11 50.73 22 FY03 22 115.01 FY04 22 94.33 Total: 55 260.07 Supervision/ICR FY05 29 152.75 FY06 21 93.91 FY07 22 105.12 FY08 10 47.88 FY09 10 70.64 Total: 92 470.30 23 Annex 5. Beneficiary Survey Results No survey was carried out. 24 Annex 6. Stakeholder Workshop Report and Results No Stakeholder Workshop was carried out. 25 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR The Borrower pointed out in their ICR some strong and weak projects points, lessons learned, recommendations and conclusions as follows: Strong points of the Project: (i) existence of a National Strategic Plan in the fight against HIV/AIDS; and (ii) creation of the CNLS and the STNL. Difficulties: (i) institutional instability; (ii) lack of counterpart funding; and (iii) lack of motivation among the health sector workers. Weak points in the implementation and execution of the project: (i) frequent changes in Government; (ii) lack of availability of TTL for supervision missions and lack of follow-up on part of the TTL; (iii) change of TTL had a negative impact on the Project; and (iv) lack of authorization from TTL to proceed with training for different sectors of the SNLS. Lessons learned: Objectives, strategies and activities have to be more realistic and concentrate on priorities; There was no ownership on part of the Government of the project document and leading to not respecting the commitments engaged with the financier; and There is no guarantee that there will be sustainability of the achieved results. Relationship: Improvement of relationship with the World Bank team; Need of continuity of the interventions in the fight against HIV/AIDS to guarantee sustainability of the achieved results and have a better geographic coverage; and Improvement in ownership and integration on part of the Government in the management of funds. Recommendations: It would be desirable that a new elected Government could complete its mandate, which would allow to improve the involvement of the CNLS; Better ownership of documents that will bring better results; and Better coordination among partners and stakeholders and the CNLS. Conclusions: The results achieved were in general satisfactory, although some indicators were not achieved; and Development of the management capacity related to Project activities and experiences made it possible to lay the basic foundations for a better management of global resources. 26 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 27 Annex 9. List of Supporting Documents 1. World Bank: Project Appraisal Document on a proposed Learning a proposed Grant, May 2004. 2. World Bank: Development Grant Agreement, HIV/AIDS Global Mitigation Support Project 3. World Bank: Project Status Reports (PSRs) and Implementation Status and Results Reports (ISRs) 2004-2008 4. HIV/AIDS Global Mitigation Support Project Aide-Memoires of Supervision Missions and Mid-Term Review Aide-Memoire 5. HIV/AIDS Global Mitigation Support Project Mid-Term Review Issues Paper 6. Guinea Bissau ­ Improving Africa Region HIV/AIDS Portfolio, Restructuring/Amendments 28