39296 THE WORLD BANK INDEPENDENT EVALUATION GROUP An Independent Evaluation of the World Bank's Support of Regional Programs Case Study of the West Africa HIV/AIDS Project for the Abidjan-Lagos Transport Corridor Deepa Chakrapani and Catherine Gwin Director-General: Vinod Thomas Director: Ajay Chhibber Manager: Victoria Elliott Task Manager: Catherine Gwin This paper is available upon request from IEG. 2006 The World Bank Washington, D.C. ENHANCING DEVELOPMENT EFFECTIVENESS THROUGH EXCELLENCE AND INDEPENDENCE IN EVALUATION The Independent Evaluation Group (IEG) is an independent unit within the World Bank; it reports directly to the Bank's Board of Executive Directors. IEG assesses what works, and what does not; how a borrower plans to run and maintain a project; and the lasting contribution of the Bank to a country's overall development. The goals of evaluation are to learn from experience, to provide an objective basis for assessing the results of the Bank's work, and to provide accountability in the achievement of its objectives. It also improves Bank work by identifying and disseminating the lessons learned from experience and by framing recommendations drawn from evaluation findings. IEG Working Papers are an informal series to disseminate the findings of work in progress to encourage the exchange of ideas about development effectiveness through evaluation. The findings, interpretations, and conclusions expressed here are those of the author(s) and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank cannot guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply on the part of the World Bank any judgment of the legal status of any territory or the endorsement or acceptance of such boundaries. Contact: Independent Evaluation Group Knowledge Programs and Evaluation Capacity Development (IEGKE) e-mail: eline@worldbank.org Telephone: 202-458-4497 Facsimile: 202-522-3125 http:/www.worldbank.org/IEG Contents Acronyms.......................................................................................................................... iv Preface.................................................................................................................................v Evaluation Objectives and Methodology.................................................................v Evaluation Criteria..................................................................................................v Executive Summary........................................................................................................ vii 1. Introduction..................................................................................................................1 Regional Challenges................................................................................................1 Regional Program Summary Description................................................................2 2. Relevance: Overarching Regional/Sub-Regional Relevance of the Program ........4 Subsidiarity Principle ..............................................................................................4 Alignment with Country, Regional, and Bank Goals and Strategies.......................5 Regional Consensus.................................................................................................7 Design of the Regional Program .............................................................................7 Clarity and Monitorability of Objectives...............................................................10 3. Efficacy: Outcomes, Impacts, and Sustainability ...................................................12 Achievement of Objectives.....................................................................................12 Realized Distribution of Costs and Benefits ..........................................................22 Capacity Building ..................................................................................................23 Risks to Outcome and Impacts...............................................................................24 4. Efficiency: Organization, Management, and Financing of the Regional Program26 Efficient Use of Resources .....................................................................................26 Governance, Management and Legitimacy ...........................................................26 Finance ..................................................................................................................30 Donor Performance ...............................................................................................31 5. Monitoring and Evaluation.......................................................................................32 6. World Bank's Performance in Support of the Regional Program........................33 Comparative Advantage.........................................................................................33 Quality of Support & Oversight.............................................................................33 i Structures and Incentives.......................................................................................35 Linkages to Other Bank Country Operations ........................................................35 7. Participating Countries' Performance in Support of the Regional Program ......36 Country Participation............................................................................................36 8. Conclusion and Lessons Learned.............................................................................37 Lessons Learned.....................................................................................................37 Annex A: Background Information on the Regional Program ...................................39 Annex B: Governance and/or Management Arrangements ........................................40 Annex C: Financial Data (estimated).............................................................................43 Annex D: Goals, Objectives, Outcomes, Outputs, and Activities................................44 Annex E: Summary of Regional and Non-regional Issues...........................................47 Annex F: Persons Consulted...........................................................................................48 Annex G: Documents Reviewed .....................................................................................50 Annex H: Project Strengths and Weaknesses as identified by Government Officials and Stakeholders in Benin and Ghana.....................................................................51 Annex I: Summary of Concrete Results listed by Stakeholders in Border Towns....52 Annex J: Summary of Factors Affecting Successful Project Implementation...........54 Annex K: Summary of Selected Activities in Border Towns.......................................56 (as reported to IEG mission team in September 2005).................................................56 Annex L: Lack of Comparable Data from Border Towns...........................................59 Boxes Box 1.1: Highlights of the Project's Baseline Study ...........................................................2 Box 2.1: Outcome Indicators: Clear, Quantitative but not Monitorable............................10 Box 4.1: Clear, but Elaborate Governance and Management Arrangements....................27 Tables Table 1.1: High HIV/AIDS Prevalence Rate among Target Population Groups ................1 Table 3.1: Significant Progress in Increasing Awareness of HIV/AIDS...........................13 Table 3.2: Limited Progress on Access to Treatment, Care and Support..........................15 ii Table 3.3: Harmonized Strategies Developed, but yet to be Implemented Fully..............19 Table 3.4: Slow Progress on Improving Transportation Flows.........................................20 iii Acronyms ARV Anti-Retroviral Drugs BCC Behavior Change Communication BTO Back to Office Reports CAS Country Assistance Strategy CSO Civil Society Organization ECOWAS Economic Community of West African States GAMET HIV/AIDS Monitoring and Evaluation Team IDA International Development Association IEC InformationExchangeCommunication IEG Independent Evaluation Group MAP Multi-Country HIV/AIDS Program M&E Monitoring and Evaluation PMU Project Management Unit PAD Project Appraisal Document PSR Project Status Report STI Sexually Transmitted Infections TWG Transitional Working Group UNAIDS Joint United Nations Program on HIV/AIDS USAID United States Agency for International Development VCT Voluntary Counseling and Testing iv Preface EVALUATION OBJECTIVES AND METHODOLOGY This review of the regional HIV/AIDS project for the Abidjan Lagos Transport Corridor is one of 22 reviews undertaken as part of an independent evaluation by the Independent Evaluation Group (IEG) of the effectiveness of World Bank support for multi-country regional programs over the past ten years (1995-2004). Sixteen of the reviews are desk reviews; the other six reviews, including this assessment are in-depth field studies. All reviews draw on core program documentation as well as program progress reports, existing self- and/or independent program evaluations, related Bank country assistance strategies (CAS) and sector strategies, and interviews with key Bank staff. This study reviewed: (i) the IDA funded Multi-country HIV/AIDS Program (MAP) documents for Phase II; and (ii) relevant project documents such as Project Appraisal Document (PAD), the Midterm Review, Implementation Status Reports (ISR), related aide-memoirs and back to office reports on key Bank missions as well as internal Bank memoranda on the minutes of key stakeholder and governing body meetings. Please see Annex G for a list of reviewed documents. A two-member IEG team conducted a mission in September 2005 and interviewed key government and civil society stakeholders, and Bank country office staff. The most recent report on project performance is the project commissioned midterm review completed in January 2006. The midterm review was carried out by the project's Secretariat (and therefore not an external or independent evaluation). It reports on progress against project objectives and highlights various project activities, but falls short of addressing three important strategic issues: (a) options for project sustainability, (b) the costs and benefits of contracting out management functions and the implications thereof for future project management, and (c) the way forward for improving the project's performance indicators, in light of the shortcomings highlighted. EVALUATION CRITERIA This review uses the following criteria to assess the relevance, efficacy, and efficiency of World Bank's support. In addition, the review also evaluates the Bank's and countries' performances as well as the effectiveness of the program's monitoring and evaluation. Relevance · Subsidiarity: To want extent is the program being addressed at the lowest level effective, and either complements, substitutes for, or competes with Bank country or global programs? · Alignment: To what extent does the program arise out of a regional consensus, formal or informal, concerning the main regional challenges in the sector and the need for collective v action? To what extent is it consistent with the strategies and priorities of the region/sub- region, countries, and the Bank? · Design of the regional program: To what extent is program design technically sound, and to what extent does it take account of different levels of development and interests of participating countries, foster the confidence and trust among participants necessary for program implementation, and have clear and monitorable objectives? Efficacy · Achievement of objectives: To what extent has the program achieved, or is it likely to achieve, its stated objectives, including its intended distribution of benefits and costs among participating countries? · Capacity building: To what extent has the program contributed to building capacities at the regional and/or participating country levels? · Risk to outcomes and impact: To what extent are the outcomes and impacts of the program likely to be resilient to risk over time? Efficiency · Efficient use of resources: To what extent has the program realized, or is it expected to realize, benefits by using a reasonable level of time and money? · Governance, management, and legitimacy: To what extent have the governance and management arrangements clearly defined key roles and responsibilities; fostered effective exercise of voice by program participants and coordination among donors; contributed to or impeded the implementation of the program and achievement of its objectives; and entailed adequate monitoring of program performance and evaluation of results? · Financing: To what extent have financing arrangements affected positively or negatively the strategic direction, outcomes, and sustainability of the program? World Bank's Performance · Comparative advantage and coordination: To what extent has the Bank exercised its comparative advantage in relation to other parties in the project and worked to harmonize its support with other donors? · Quality of support and oversight: To what extent has the Bank provided adequate strategic and technical support to the program, established relevant linkages between the program and other Bank country operations, and exercised sufficient risk management and oversight of its engagement? · Structures and Incentives: To what extent have Bank policies, processes, and procedures contributed to, or impeded, the success of the program? Country Participation · Commitments and/or capacities of participating countries: How have the commitments and/or capacities of participating countries contributed to or impeded the success of the program? · Program coordination within countries: To what extent have there been adequate linkages between the regional program's county level activities and related national activities? vi Executive Summary Background 1. The West Africa HIV/AIDS Project for the Abidjan-Lagos Corridor targets the major East-West highway that connects the five coastal countries of West Africa--Benin, Cote d'Ivoire, Ghana, Nigeria, and Togo--and serves as a transit route for both increasing trade and the spread of HIV/AIDS across national borders. UNAIDS analytical work had showed that HIV/AIDS transmission rates were generally high along transportation routes in Africa and delays for truckers at border crossings prolonged opportunities for risky behavior. The interconnection between these two trans-boundary dynamics of communicable disease and trade was the impetus for the corridor project. Program Summary Description 2. The project, which is a four-year pilot operation started in 2004, is financed by a $16.6 million IDA grant to the government of Benin on behalf of all five participating countries. Its main objectives are to: · Improve access to HIV/AIDS prevention, treatment, care and social support services for target populations · Enhance regional capacity and cooperation to deal with HIV/AIDS · Improve the flow of commercial and passenger traffic along the corridor 3. To achieve these objectives the project supports a comprehensive package of activities for HIV/AIDS prevention, treatment, care and support, which entails information and communication, STD testing and treatment, safe disposal of medical waste, and local and national level capacity building. These efforts target truck drivers, commercial sex workers, migrant populations and the resident populations in the border towns along the highway. In addition, the project supports activities aimed at streamlining and accelerating border control measures. 4. These two sets of project activities are managed by a free-standing project secretariat located in Benin; and are implemented through national project coordinators and community-level NGOs and cross-border committees of border control officials. A Governing Board comprising representatives from health ministries or HIV/AIDS commissions and transport ministries from each participating country provides overall strategic direction and oversight, with input from an inter-country advisory committee of public sector, private sector, and civil society representatives. Rationale for the regional program 5. The project was conceived as a complement to national HIV/AIDS programs and trade and transport agreements the countries had adopted under the aegis of the Economic Community of West African States (ECOWAS) on the rationale that country' interests in the management of these trans-boundary issues could not be met by any one of the five countries acting alone. As emphasized by one high-level Ghanaian official, "Any AIDS vii effort on our part at [the border towns of] Aflao and Elubo would be compromised if there is no action by our neighbors in Togo and the Ivory Coast." In addition, the project envisaged some economies of scale from such joint activities as awareness campaigns, social marketing of condoms, and development and distribution of common border crossing documentation, though this was not a primary rationale for the project. 6. The relevance of a regional HIV/AIDS project to address hard to reach populations along an extended inter-state transport route was substantial. There was broad consensus among political leaders on the need for the program. Ministers of Health or heads of national aids commissions and Ministers of Transportation of all countries served on the program's governing body, and they agreed on harmonized strategies for HIV/AIDS treatment protocols. Their commitment was also encouraged by the provision of grant financing from the World Bank. Quality of Design & Implementation 7. Overall, the project's objectives were clearly defined and the multi-country, multi-sectoral package of activities was well linked to those aims. Four features of the project's institutional arrangements were also viewed by stakeholders as particularly constructive in building trust among the countries and contributing to reasonably effective implementation. · The participating countries understood and accepted their roles and responsibilities in the governance and management structures · Sufficiently high level country participation facilitated needed policy and procedural harmonization · The project management unit (secretariat) communicated well with the national and local level government officials and other stakeholders in the countries · Committees or other bodies promoted cross-country consultations and operations on the health and transport issues at the regional and local (border town) level. 8. But the project's design and implementation also had shortcomings which hampered its pace and, in some areas, its output. Implementation moved much more slowly than planned because working in a coordinated way in five countries and two languages was more complex than expected. Internal turf battles among agencies within countries, which were not foreseen in the project design, complicated coordination efforts between the national programs and the regional project. Also, the program provided little support to the capacity building in national agencies needed to enable the eventual absorption of the project activities into national programs. Program Achievements 9. After initial delays, a large number of activities have been undertaken to improve awareness and access to HIV/AIDS prevention, but there is little concrete evidence to date on their impact on behavior. Numerous activities have also been undertaken to enhance access to treatment, care, and support, but with few achievements to date. The project has introduced a common treatment record card that can be used be used by viii travelers at all points along the corridor, but these efforts have yet to be fully implemented. Similarly, common border control procedures have been devised to speed the flow of traffic across borders and inform truckers about them. But as yet there has been limited improvement in transit times and on reported outcomes. Interviews with stakeholders at the national level also indicate that the project could be doing more to foster greater cross country sharing of promising implementation experiences. 10. Based on the increased pace of implementation in the last year, stakeholders report that they expect the project to make major strides in achieving its set of objectives by the end of the project period. But full achievement of the objectives faces two major uncertainties: 1) what will happen to the sustainability of outputs and outcomes at the end of the four years of World Bank grant financing and 2) what measures will be taken to ensure the geographical extension of the project beyond the border towns to the full length of the corridor, necessary for there to be the intended reduction in HIV/AIDS prevalence in the sub-region. The five countries face the option of absorbing the project's activities into their national programs, maintaining a free-standing extended corridor effort, or bringing the Abidjan-Lagos effort under the aegis of ECOWAS. This last option would provide a forum for building high level political consensus for scaling up the effort within a broader regional effort focused on multiple transport corridors (an arrangement rejected at the outset by the five countries because of their preference to keep the initial pilot under their direct control). The costs, benefits, and feasibility of these options have not yet been explicitly addressed. Effectiveness of World Bank Performance 11. The Bank used its convening power and provision of grant financing to bring the five countries together in support a regional approach. The intensive Bank support, technical advice, and supervision helped the project secretariat to become fully operational. But it took 26 months to prepare the project, compared to a Bank-wide average processing time for country-level projects of 16 months. Though the Bank has been supporting national HIV/AIDS programs in all of the participating countries, this regional project is not managed by Bank country staff and not interconnected with national programs. Also, the Bank has not ensured adequate monitoring and evaluation by the project of outcomes and has not yet fostered the discussions necessary to establish arrangements for follow on financing beyond the duration of the pilot of four years. ix 1. Introduction REGIONAL CHALLENGES 1.1 The Abidjan Lagos corridor is the major east to west travel route between the five coastal countries of West Africa ­ Benin, Cote d'Ivoire, Ghana, Nigeria and Togo. These countries also belong to Economic Community of West African States (ECOWAS) and the ECOWAS policy on free movement of nationals of member countries has led to increased trade and travel along this route. Studies have noted the correlation between the movement of populations and the propagation of disease and illness, particularly Sexually Transmitted Infections (STI) including HIV/AIDS among groups such as truck drivers, commercial sex workers, migrants and the local populations of the border towns. 1.2 While the national HIV/AIDS prevalence rates in the five participating countries is not as high as that in Southern Africa, the limited data suggest that high prevalence rates prevail among populations that are being targeted under the project (see Table 1.1). Table 1.1: High HIV/AIDS Prevalence Rate among target Population Groups HIV/AIDS Prevalence Rate1 Benin Cote D'Ivoire Ghana Nigeria Togo All adults (2001) 3.6% 9.7% 3% 5.8% 6% Cotonou Abidjan Accra Lagos Lome Commercial Sex Workers 85.4% 63% 74% 30% 80% Truck Drivers 33% Source: PAD. 1.3 The project arose out of a series of analytical work undertaken in the mid-1990s under UNAIDS's West African Initiative that highlighted the (a) importance of corridors and high transmission rates of HIV/AIDS among the target groups, and (b) the difficulties in addressing these target groups through national programs. Along with data on the importance of the transport corridors in HIV/AIDS in general, there was also data on the economic importance, high density of traffic and hence high transmission risks along the Abidjan Lagos transport corridor. Thus, in a UNAIDS meeting in Accra 2000, the decision was made to first address the Abidjan Lagos Corridor. 1.4 A baseline study conducted by the project in mid-2004 of the target population between 13-35 years highlighted the low level of awareness of HIV/AIDS and prevention techniques, the inadequacy of treatment, care and support services, and inappropriate management of medical waste refer (Box 1.1 below). A more recent study completed in February 2005 highlighted the long border crossing times, ranging from three hours to nine hours depending on the border, for passengers and commercial vehicles traveling along the highway. It also reported that a third of the travelers lacked knowledge on procedures and formalities or were not able to find the exact location of the immigration and customs services. 1Data on prevalence rates for high risk groups are available for capital cities. These estimates relate to data from the early-1990s though they were collected for capital cities in different years and are therefore cannot be subject to cross country comparisons. 1 Box 1.1: Highlights of the Project's Base Line Study · 20 percent of the vulnerable target groups (truck drivers, commercial sex workers, uniformed service personnel and youth) did not believe that HIV/AIDS existed. · Less than 50 percent of all the target groups with the exception of commercial sex workers were aware of ways to prevent transmission of HIV/AIDS. · Levels of testing were less than 20 percent among truckers and haulers and the youth and only about 80 percent of those who tested themselves went to collect the results. Two thirds of commercial sex workers and 33 percent of uniformed personnel did go for testing and nearly all those tested went to collect the results. · Low levels of public facilities available for testing, treatment and care for HIV/AIDS. There were few private institutions and care and support services were almost non-existent. · Less than a third of the health centers undertook medical waste segregation and of those only 35 percent had appropriate disposal bins for medical waste. · There was no policy or regulation governing medical waste management at the community level or at health centers in any of the countries2. · Only 3 out of 416 health staff was trained in prevention of infections in general. Source: Midterm review, January 2006. 1.5 Bank staff noted that UNAIDS saw its mandate and resources to be insufficient to meet the needs of the project. UNAIDS is oriented primarily towards advocacy, research and knowledge dissemination. UNAIDS believed that the Bank's financial resources and complementary skills were necessary and encouraged Bank involvement. REGIONAL PROGRAM SUMMARY DESCRIPTION 1.6 Until 1997, the Bank gave lower priority to fighting a single disease, like HIV/AIDS, than to reforming weak health systems that were expected to improve all health outcomes in the long run. The Multi-Country HIV/AIDS Program (MAP), with its focus specifically on HIV//AIDS, represents the Bank's response to the exceptionality of HIV/AIDS as a health and development problem with a debilitating economic and social impact on developing countries. The MAP program for Africa amounts to $1 billion ($500 million in two phases) in Bank commitments and represents a long term Bank commitment (10-15 years) to the fight against HIV/AIDS. Phase II of the MAP permitted funding of regional (multi-country) projects, in addition to country level initiatives. This Abidjan Lagos project was prepared under the aegis of Phase II of the Africa MAP. 1.7 This project addresses the trans-boundary problem of the spread of HIV/AIDS along the Abidjan Lagos transport corridor. Its overall goal is to "increase access along 2Benin and Togo had national legislation that was restricted in its application and did not cover health centers or community level agencies. 2 the Abidjan Lagos transport corridor, to HIV/AIDS prevention, basic treatment, and support and care services by underserved high risk groups." Approved in November 2003, this $16.6 million IDA grant aims to achieve the following objectives: (a) Improve access to HIV/AIDS prevention services for target populations, (b) Improve access to HIV/AIDS treatment, care and social support services, (c) Enhance regional capacity and cooperation to deal with HIV/AIDS, and (d) Improve the flow of commercial and passenger traffic along the corridor.3 1.8 The project's prevention related activities include supporting an integrated Information-Exchange-Communication (IEC) and Behavior Change Communication policy along the corridor (BCC) and undertaking social marketing of condoms. Under treatment, the project focuses on three sets of activities: (a) enhancing VCT and STI treatment, particularly HIV/AIDS, (b) enhancing capacity of CSO/NGOs to provide care and support services, and (c) encouraging safe disposal of medical waste. The participating governments have strongly encouraged the project to focus on treatment aspects, including more recently on ARVs (details in chapter 3). 1.9 The project targets populations that are difficult to reach (through national programs) and those in contact with them. These include: (a) commercial vehicle drivers who spend long periods of time traveling across many countries, (b) commercial sex workers who often travel away from their communities for long periods of time, where they may not easily have access to the local HIV/AIDS programs, (c) migrant populations who are foreign to hosting countries and do not systematically benefit from the host country's social welfare systems, including HIV/AIDS services, and (d) resident population in border towns, which in some cases are remote and often have inadequate access to public services, including on HIV/AIDS. 1.10 The project became effective in March 2004, is mid-way through implementation and expects to close in July 2007. A midterm review is being planned for February 2006. 3 Interviews with the Bank staff suggests that they believed that easier movement and reduced transit time at borders could contribute to reductions in HIV/AIDS transmission rates by minimizing the amount of time spent at border crossings which can extend for as long as a month at each crossing. 3 2. Relevance: Overarching Regional/Sub-Regional Relevance of the Program 2.1 Summary: The relevance of this project is substantial. Informants' views confirm the project rationale stated in Bank project documents for adopting a multi-country approach: (a) reducing the spread of HIV/AIDS is a national necessity, (b) higher prevalence rates in the corridor border towns than the national average justifies a targeted initiative, and (c) high mobility of persons along the five-country corridor means that no one country acting alone can deal effectively with the problem. The program's multi- sector approach of combining transport objectives of reduced transit time at the borders with HIV/AIDS was an innovative feature. The program is well aligned with the goals and strategies of the sub-region, participating countries, and the Bank. The project is also well designed in most aspects. But it overestimated the time and resources that would be required to prepare and implement a multi-sector, multi-country operation. The project's performance indicators for outcomes as well as its system for data collection and monitoring need improvement SUBSIDIARITY PRINCIPLE 2.2 The subsidiarity principle states that a program should be organized and carried out at the lowest level effective, whether it is a regional, global, or Bank country operation. The multi-country geography of the transport corridor and high levels of mobility/migration across border towns makes HIV/AIDS a trans-boundary problem that necessitated a sub-regional approach. 2.3 The high mobility of the resident population in border towns and the high density of traffic particularly among high risk groups for HIV/AIDS such as truckers and migrants meant that none of the countries could have addressed HIV/AIDS at their own border towns without adequate complementary action from neighboring countries. An official in Ghana noted, "Any AIDS efforts on our part at Aflao and Elubo (border towns) would be compromised if there is no action by our neighbors (i.e. Togo and Cote D'Ivoire). And the corridor project is strategically important to Ghana because it has provided a framework for continued engagement with these countries on HIV/AIDS despite their volatile political climate." A multi-country approach was deemed necessary to reduce the transit time at borders, as it would require all countries along the corridor to agree on harmonized border control procedures. 2.4 The project did not include all 22 ECOWAS countries as they did not directly fall within the defined geographical space. Bank staff and stakeholders believed that the project would have not worked if the whole of ECOWAS had been involved as it would have then become too large a program. 2.5 The project envisaged some economies of scale in specific activities such as HIV/AIDS awareness campaigns and social marketing of condoms a result of stronger policy and program coordination although this was not a motivating factor for adopting a regional approach. 4 ALIGNMENT WITH COUNTRY, REGIONAL, AND BANK GOALS AND STRATEGIES 2.6 The Abidjan-Lagos Transport Corridor Project is consistent with the strategies and priorities in the region, the participating countries, and the Bank. 2.7 On regional priorities, government officials in Benin and Ghana noted that there had been little action on regional integration, although the issue has been on the agenda of the West African countries for a long time. Multi-country projects were believed to be a mechanism to promote regional integration. One official noted, "Regional integration begins with regional cooperation and regional action on specific issues...It is easier to promote regional action for a common issue like HIV/AIDS." 2.8 The "heads of state of Cote d'Ivoire, Ghana, Togo, Benin and Nigeria made a joint declaration to develop a multi-sector HIV/AIDS program along the Abidjan-Lagos transport corridor."4 While all countries acknowledge that HIV/AIDS messages need to be tailored to the needs of the local population, they also believe that there is a need to ensure that the quality and technical content of messages are consistent along the transport corridor. The project aims to support a common program of action along all border areas on the transport corridor. 2.9 Similarly, on transport, the project is facilitating implementation of regional policies on regional policies laid out by ECOWAS on free movement of goods and persons. Thus, the transport objectives for the project were directly derived out of high level political agreements that had been facilitated by ECOWAS. Government and non- government stakeholders noted that reduced transit time at the borders can help mitigate the social behaviors that increase transmission of HIV/AIDS among truckers, commercial sex workers and high-risk groups. There is general stakeholder agreement that (a) countries on both sides of the border need to agree on ways to harmonize border control procedures or at least reduce the time taken at borders, and (b) truckers and transporters need to be educated on documentation needed to cross the various borders. 2.10 On country priorities, the regional project aims to build on and complement national HIV/AIDS programs ongoing or underway in all participating countries. The project's institutional arrangements are such that representatives of national HIV/AIDS programs of the five countries are members of the governing body for the project and are responsible for directing project implementation. Thus, the project aims to ensure continued alignment with member country HIV/AIDS strategies, policies and programs during its implementation. These representatives, as members of the Transitional Working Group (TWG), were also actively involved in the preparation of the project thereby ensuring consistency of the preparation process with their own national HIV/AIDS requirements. 2.11 Government officials in Benin and Ghana, stakeholders in the border and capital cities viewed the project to be an important complement to national HIV/AIDS efforts. In all countries except Ghana, as the national programs were relatively new and had yet to 4Project Appraisal Document. Page 8. 5 reach the border towns, the project was seen as a necessary complement to national efforts. Several officials in Benin noted the high mobility of the population at border towns and the high HIV/AIDS prevalence rates in the border towns, relative to national average, especially among the target group for the project. One health ministry official in Benin said that the project "provides an assurance to the national program that there is now concrete action on high-risk populations." Even in Ghana, where the national response is more established, government officials felt that Ghana's national efforts in border towns would not effective "unless there is a complementary effort in the border towns in neighboring countries." 2.12 The corridor project focused its HIV/AIDS activities at targeted groups along the transport corridor, with particular attention to border crossing areas. It was expected that the other market towns along the route would be subsequently addressed. "On the other hand, national HIV/AIDS projects will cover all other national HIV/AIDS activities which are aimed at populations other than those targeted by the corridor project. The corridor project is therefore a vital complement to, rather than a substitute for, the national HIV/AIDS programs"5 2.13 In the Bank, at the corporate level, the project is aligned with the Bank's fight against HIV/AIDS, which is an explicit objective of the Millennium Development Goals. The project is consistent with the IDA strategy that calls for national efforts to be complemented by efforts at the regional and sub-regional levels.6 At the regional level, the project is consistent with the Bank's regional integration strategy for West Africa, the purpose of which is to create a `unified economic space' for trade and transportation as well as second order priorities that include health especially HIV/AIDS services.7 This regional strategy acknowledges work by USAID as well as the French in cross country disease control efforts in the region and aims to "scale up these efforts." At the country level, the Bank's Country Assistance Strategies (CAS) or CAS progress report for all five countries identify HIV/AIDS as an important area for Bank support to prevent any large scale transmission to the population at large. 2.14 The Bank, at the time of design, noted that national programs had not developed the capacity to successfully address HIV/AIDS issues among the target groups identified above. The Bank also considered this project as an essential complement to national HIV/AIDS efforts underway or proposed under the Africa MAP. In Togo and Cote D'Ivoire, national programs are still under preparation. The Bank expected the project to fill gaps in national programs by targeting populations not easily accessible to national programs. 5Page 7. 6IDA Strategy Framework Paper ­ July 2003. 7See PAD page 4. 6 REGIONAL CONSENSUS 2.15 There is broad consensus on the need for a regional project and strong political as well as community level commitment to its implementation. 2.16 In the project's initial design phase, Bank staff noted that while there was consensus and cross-country interaction among technical staff working on HIV/AIDS in the countries, the level of consensus at the ministerial level was less apparent. This is evidenced by much delayed contribution of counterpart funds from Nigeria, slow announcement of the joint declaration of the heads of state, and delayed signing of the legal agreement. But HIV/AIDS was considered a global emergency that made participants look beyond national interests. Differences among policy makers were few and minor and there were no clear losers or vested interests that could be threatened and de-rail the project. Thus, over time the project was able to build the "policy level" consensus necessary for it to take off, albeit with some delays. 2.17 Stakeholders in Benin and Ghana viewed this as a necessary delay that helped to build consensus and foundation for the project. As noted by one member of the project team, "Political will has never been the problem. And yet it took time to build consensus due to differences in national policy." The multi-sector nature of the project added an additional element of complexity to building consensus between five countries, as it involved two separate Ministries (Health and Transport) for each country. 2.18 The political commitment from the five participating countries since project approval has been strong and in the view of one official in Ghana, has "increased over time". As evidence of the same, stakeholders noted: (a) timely payment of counterpart funds by all countries, (b) high level participation by all countries in governing board meetings and in consultations on the request of the executive secretary; (c) development and implementation of harmonized strategies for raising awareness and treatment protocols, (d) willingness of countries to explore harmonization of border control procedures, and (e) ability of the project to successfully maintain activities in Togo's border towns even during a period of political instability. This was particularly important as Togo lies in the middle of the corridor and its actions affect not only its own border towns but also those of its neighbors, Benin and Ghana. In this regard, several informants noted the strategic importance of locating the project secretariat in a politically stable country, Benin to minimize disruptions to project implementation. DESIGN OF THE REGIONAL PROGRAM 2.19 Overall, informants noted that the project design is unique, responsive to local needs, and a major reason for continued relevance and commitment to the project. In particular, government and local stakeholders identified the following elements of project design as key strengths. 2.20 Multi-sector approach: The project's multi-sector approach combining transport and health is innovative. The project recognized the importance of reduced transit time at border crossings to curbing social behaviors that result in higher transmission rates 7 among the target groups. Having a separate but related transport objective ensured buy-in and involvement of the Ministries of Transport in what was essentially a health issue. The inclusion of the transport objective also helped to promote the ECOWAS program of facilitating speedier trade and transportation among its member countries in two ways: (a) training of public (e.g. mayors, uniformed services) and private sector, and (b) building up of local infrastructure to facilitate trade and transportation. 2.21 Comprehensive technical package: The project's HIV/AIDS package was comprehensive; encompassing awareness, prevention, testing, treatment (including anti- retroviral drugs more recently), care and support and medical waste management. This comprehensive package along with the approach of combining treatment of HIV/AIDS with STI and other opportunistic infections in order to deal with the stigma associated with HIV/AIDS has won strong stakeholder endorsement. 2.22 Confidence in governance and management arrangements: Stakeholders lauded the project's governance and management arrangements for enabling country participants to significantly influence program design and implementation, as well as for providing the basis for an equal partnership between all participants (also see governance and management). As a result, stakeholders reported that after a rocky start, the project fostered trust and confidence among participants. Bank staff and stakeholders believe that this trust enabled participating countries to look beyond minor differences in the amount of support they received individually to the larger HIV/AIDS cause. For instance, the countries have accepted that the project benefits could accrue to nationals from non participating countries, such as the SAHEL states, traveling along the corridor. 2.23 Reliance on local community participation: The project has created community institutions and networks to undertake and oversee project implementation and uses private and public sector implementing agencies to secure local stakeholder involvement. It has also promoted the creation of beneficiary association to act as pressure groups to ensure continued program commitment and relevance. All of this has won strong stakeholder endorsement and is seen as important for retaining the necessary political consensus and the momentum for implementation (see legitimacy below). 2.24 Clarity in scope of activities: Stakeholders endorsed the clear delineation of scope, including the geographical focus initially on eight border towns and the target population groups (truckers, migrant populations, commercial sex workers, and local residents in border towns). This was deemed appropriate to the pilot nature of the project. The PAD proposes to expand the scope over time (a) to include other population centers and market towns along the corridor, and (b) to integrate the efforts along the towns on either side of a border. There is strong stakeholder support for geographical extension. Both extension and integration of border efforts are yet to materialize. 2.25 Flexibility in implementation: The project has demonstrated flexibility in responding to issues that have arisen during the course of implementation. For instance, the project was largely aimed at undertaking prevention related activities, but on suggestions from participant countries, included treatment and care and support activities in its scope. Further, although anti-retroviral (ARV) drugs were not included in the 8 original design, in response to the demands of participating governments, the project has included this element into its treatment and care objective. Similarly, the activities of implementing agencies were not well coordinated in the border towns. In the last six months, the project has charged an intermediary NGO in each country to monitor and coordinate the work of implementing agencies at the border towns. The intermediary NGOs have organized the implementing agencies in each town into thematic groups (such as awareness and prevention, treatment, care and support, and medical waste management) based on their activities. According to stakeholders, this has enhanced information sharing between implementing agencies and avoided duplication of efforts. 2.26 There were however a few design shortcomings. First the Bank underestimated the complexity of working with five countries and in two sectors and, therefore, the time and resources that would be required to prepare and implement the project. One example of this was the eighteen months that it took to build the necessary consensus on project activities and institutional structure. Bank staff noted that this part reflects the wide range of constituencies (national governments, NGOs, private sector and civil society in five countries and international organizations) that had to be engaged in this instance in order to ensure project success that generated significant preparation costs relative to the size of the grant. The design was also unrealistic about the time needed to build implementation capacity both of the Executive Secretariat and border level implementing agencies and community groups overseeing implementation, and complete planned activities, especially in view of the weak underlying capacity levels at the border towns. 2.27 The second shortcoming highlighted by some Bank staff and country stakeholders was the lack of adequate linkage with regional institutions, especially ECOWAS, after the decision in order to ensure sustainability of project activities beyond the four-year time period and scaling up of pilot efforts to other corridors should the pilot prove to be a success. Bank staff noted that ECOWAS has been invited to attend governing body meetings. In particular, in the last year, Bank staff has noted that the project has made greater efforts to work closely with regional institutions, in particular ECOWAS. Four representatives from ECOWAS participated in the project's midterm review completed in February 2006 and there is work on-going to establish a Memorandum of Understanding to formalize the partnership between ALCO and ECOWAS. 2.28 Third, several in-country stakeholders noted the exclusion of a key high risk group from the target population, the itinerant women traders. Itinerant trading is the second major economic activity for women and these women constitute an important chain in the distribution of goods in West Africa. As women and as highly mobile people, they have been identified as a highly vulnerable group for exploitation and HIV/AIDS transmission8. 8Institute of Statistical, Social and Economic Research, University of Ghana, Legon. 9 CLARITY AND MONITORABILITY OF OBJECTIVES 2.29 The project's goal is increased access to HIV/AIDS prevention, treatment, and care and support facilities along the Abidjan Lagos corridor. There are four clear program objectives that follow from this goal (refer paragraph 1.4 above), and that are supported by related outputs and activities. Annex D details the project's log frame. As required for regional initiatives financed under phase II of the MAP, there are also clear, quantitative outcome level performance indicators (refer Box 2.1). Box 2.1: Outcome Indicators: Clear, quantitative but of irrelevant coverage · On HIV/AIDS: At least 90% of the local population, commercial vehicle drivers, and commercial sex workers along the corridor can identify at least 2 ways to prevent HIV/AIDS. · On Sexually Transmitted Infections: (a) Reduce incidence of reported sexually transmitted (urethritis) infections in male commercial vehicle drivers working by 30%. (b) Reduce prevalence of gonorrhea in commercial sex workers by at least 50%. · On speedier movement of persons and goods: Reduce the average time for commercial vehicles to clear border formalities along the corridor at least 20%, and at the Nigeria-Benin border post by at least 50% compared with the first year of the project. 2.30 The project's outcome level measures are weak. The project includes testing and treatment of STI in order to overcome the stigma specifically associated with HIV/AIDS. Yet outcome indicators have several major shortcomings: · The targets focus on STI among commercial sex workers and truck drivers in general, but there are no targets on HIV/AIDS that form the bulk of the project component and 80 percent of the financing9. · The targets even for STI focus on rates of "prevalence" or the percent of population that are infected with HIV/AIDS. This has limited usefulness in measuring program impact as prevalence rates can rise or fall, depending on whether more people become infected than die. It does not take into consideration the HIV/AIDS incidence or the rate of new HIV/AIDS infections, which is the objective of HIV/AIDS programs10. · Targets on HIV/AIDS are limited to one aspect, namely awareness. There are no outcome indicators on HIV/AIDS prevention, treatment or care and support aspects11. · Similarly, there are no clear outcome indicators on speedier flow of passenger traffic, the indicators relate only to commercial traffic. 2.31 The project defined its performance indicators (both outcome and output) in relative terms ­ i.e. reduction in percentages from the start of the project. It would have 9Bank staff noted that prevalence rates may not be visible in a four year time frame. 10Committing to Results: Improving Effectiveness of HIV/AIDS Assistance. IEG 2005. Page 35, Box 3.4. 11Output level indicators emphasize behavior change (increase in condom usage, VCT services, and facilities in health centers), harmonization of policies and training of local residents. 10 been useful to conduct a baseline study during its long preparation period of two years to estimate absolute targets, for both the HIV/AIDS and transport objectives. The midterm review also acknowledges the inadequacy of the performance indicators but it does not make concrete suggestions on changes or provide a timetable of when and how the indicators will be revised. 2.32 The performance targets were not devised with the benefit of a baseline study. Despite Bank efforts, a baseline study was completed only in mid-2004, only after project effectiveness. One Ghanaian official noted that careful baselines studies undertaken prior to the project could have provided greater specificity to the project's interventions. This was particularly important as there is reportedly no comparable and reliable national level data on project objectives particularly in border towns. The implications of not having a baseline are: (a) project objectives are not adequately specific, (b) there is no benchmark against which to measure progress over the life of the project, and (c) it will be difficult for the project to attribute improvements to its activities, rather than to those of other donors or even to the national programs. 2.33 While most stakeholders contend that the project's indicators on health are realistic and likely to be achieved substantially, some expressed doubts about significant achievement of transportation targets in some borders crossings such as Aflao at the Togo-Ghana border. They noted that achievement of the target would require implementing and enforcing other actions agreed under the ECOWAS declaration, that are not under the project's control. Nevertheless, stakeholders believe that the project will likely meet its targets substantially. 2.34 At the time of project design, there was little capacity on the ground for regular and reliable data collection and reporting on implementation progress. The project addressed the issue by contracting a management consultant firm with the responsibility for some aspects of project implementation including M&E. But the Bank was overoptimistic of the time and effort it would take the management firm to implement a mechanism for project reporting. Thus, the indicators were often not monitorable in the local context (see also Chapter 5 on Monitoring and Evaluation). 11 3. Efficacy: Outcomes, Impacts, and Sustainability 3.1 Summary: At the time of this review, the project has been in operation for just over a year and a half (since March 2004) and is not expected to close till July 2007. Evidence to date shows that after initial implementation delays, a large number of process steps have been undertaken, but the success of the project will depend on its ability to achieve and demonstrate credible improvements against its outcome objectives. And as yet there is very little concrete evidence illustrative of the project's achievements against its intended objectives. Most informants expect the project to make major strides in achieving its full set of objectives provided it maintains its current momentum. But given the uncertainty of continued grant funding at the end of the project lifespan of four years, the success of the project depends on the extent to which it can ensure sustainability of its activities either by involving other donor partners and/or by ensuring that national HIV/AIDS programs absorb the project's activities. Hence the risks to outcomes, and therefore impact, remain high. ACHIEVEMENT OF OBJECTIVES 3.2 Although successive Bank supervision missions, the latest in September 2005, have rated progress against all objectives to be satisfactory, implementation has been slow and as yet, the project has yet to make demonstrable progress towards its outcome objectives. 3.3 All stakeholders and Bank staff acknowledge the slow pace of project implementation. But stakeholders contend that the necessary structures, people, and resources are now in place, and that implementation has picked up over the last six months. So they expect that the project will achieve its outcome objectives substantially, if not fully, in its 4-year timeframe. Annex I summarizes informants views on concrete results to date. But these do not always directly correspond to the outcome indicators set in Box 2.1 and are yet to be supported by concrete evidence. 3.4 The project has undertaken several activities related to both prevention and treatment and care services. These are summarized below in Box 3.1. But as yet, testing levels remain very low and there is no concrete evidence to support the anecdotal improvements cited by informants at the border towns such as increased awareness among target population, increases in condom demand and use, some reduction in stigma attached to HIV/AIDS, greater community support for people living with HIV/AIDS, and greater awareness among public officials and truckers on border crossing procedures and documentation. The project has also developed harmonized strategies on Information, Education and Communication (IEC), and on access to treatment and care along the corridor. Initial steps are also being taken to harmonize border crossing procedures. But at this time, it is not clear how these strategies formulated exclusively for the Corridor (a) will affect the eventual absorption of project activities into national programs and (b) will be sustained after 12 the life of the project. The effects and implications of such project specific strategies on the implementation of national programs are also not clear. 3.5 Improve access to HIV/AIDS prevention: The project expected to support two sets of activities to achieve this objective: (a) implementation of an integrated HIV/AIDS IEC and BCC policy along the transport corridor, and (b) support for social marketing of condoms in the eight border towns. There has been significant number of project activities undertaken against this objective (see Table 3.1). The project has reported data on inputs and outputs of the various activities undertaken. As yet, there is no concrete evidence on outcomes such as behavior changes among the high-risk target groups such as increased use of condoms. Table 3.1: Large Number of Activities to Improve Awareness and Access to HIV/AIDS Prevention, but Little Concrete Evidence on Outcomes Objective Outcomes Activities and Outputs Increased At the national level · HIV/AIDS services available in previously access to · Harmonized IEC/BCC underserved areas. prevention strategy and material · Large number of IEC materials distributed were developed. · 1100 peer educators trained on peer-to-peer At the border towns and focus group discussions. · Anecdotal evidence of: · Peer educators organized 1816 public (a) increased demand for awareness campaigns and 7593 focus group and use of condoms, activities that engaged 732 youths, 138 (b) greater awareness commercial sex workers, 182 truckers and among residents and the 38 uniformed services personnel. target group of HIV/AIDS, · 20 mass media programs broadcast through and the national medial of all five countries. (c) reduction in stigma · Mass awareness campaigns ­ love life associated with and about caravan (described below) people living with · Organized HIV/AIDS days HIV/AIDS. · Increased availability (140 locations), distribution and sale of male and female condoms. Source: Annex I of the report, Midterm Review. 3.6 Among its various IEC/BCC activities, the project: · Developed an integrated IEC/BCC strategy for the corridor that includes an extensive assessment of tools and potential actors (CSO/NGO) groups and is in the process of implementing it. · Undertook an awareness campaign in partnership with Coca Cola--Abidjan- Lagos HIV/AIDS caravan--launched in Nov. 200412. The partnership was innovative in that it: (a) represented a successful collaboration with the private sector, and (b) resulted in widespread mass media coverage (estimated to have 12The Caravan traveled the length of the corridor presenting awareness related activities and information. It was supported by public figures/celebrities and involved local communities. It reached Abidjan on 7th December 2004 and stopped at 8 border towns and capitals of the 5 corridor countries. 13 reached 1 million people). A second caravan is planned for Nov. 2005. But here again there is no evidence of resulting outcomes. · Reports of all border towns distributing IEC material13, conducting a variety of awareness activities such as mass media campaigns (documentaries, film shows, and radio broadcasts), undertaking advocacy group meetings, and small group chats (refer Annex K14). One border town even reported completing planned IEC activities ahead of schedule. But the data from border towns even on inputs such as number of advocacy meetings and group chats, and outputs such as people reached by awareness and mass media campaigns, are not comparable. Both methodology and verification are issues. The number of people reached through such efforts appears to be based on individual estimates. · Obtained land (or got land donated) at border towns for constructing information kiosks. IEC brochures and information signs at or close to the border areas were installed. These signs direct travelers at border posts and inform travelers on where to go for further HIV/AIDS assistance. · Reported that all eight Border committees celebrated World AIDS day in 2004. 3.7 On social marketing of condoms, the mid term review reports the distribution or sale of about 2.9 million male and female condoms in 2005 alone, and a total of 4.2 million over the period 2001-2005. The condoms were purchased by the project and were in addition to those available through national program(s)15. In all condoms were made available at non-traditional outlets (such as bars, hotels, restaurants, and information kiosks that are open 24 hours). But as yet, there is little concrete data on the demand for and/or usage of condoms16. 3.8 Evidence of concrete outcome is available only in Ghana, where a 2005 national survey highlighted 95 percent awareness of HIV/AIDS among the larger population including those at border towns. The survey shows a reduction in national HIV/AIDS prevalence from 3.9 percent in 2001 to 3.1 percent in 2005. The reduction in prevalence rates does not relate directly to border towns. And though officials expected a similar trend at the border given the presence of the corridor 13Border towns distributed about 300,000 posters, stickers, buttons, T-shirts and other IEC materials. 14Data provided to the IEG team during a field visit on September 2005 at the border towns. IEG does not guarantee veracity of the data ­ these are self-reported figures that have been cumulated to the extent possible. In some towns, data reported does not appear to be comparable and so ranges have been provided. 15A critical issue in the past has been procurement of an adequate and regular supply of condoms. The project recently secured UNFPA as its main suppler. UNFPA agreed to provide the necessary supplies and use its own inventory if needed to ensure minimal disruptions. 16Using an assumption that an average couple would use 150 condoms per year and the number of condoms sold and distributed each year, the mid term review estimates that condom usage or the number of couples protected rose from 4,892 in 2001 to 6,482 in 2003 to 19,452 in 2005. But this data does not reflect any assessment of behavior pattern on condom use and therefore is not reliable. 14 project, they noted that it would be difficult to attribute any reduction in prevalence to the project given the mass media campaigns and other activities undertaken by national program(s). 3.9 There is no clear survey data in other countries. Bank supervision reports, the midterm review and informants in border towns noted high degree of awareness among residents and high risk target populations on HIV/AIDS as a result of project activities, but there is as yet no concrete evidence to support the same. 3.10 Improved access to HIV/AIDS treatment, care and social support services for targeted populations: Activities to be undertaken to achieve this objective were threefold: (a) strengthen public and private health care facilities to enable them to provide Voluntary Counseling and Testing (VCT) and treatment of STI, particularly HIV/AIDS, (b) support CSO/NGOs to enable them to undertake support and care services, and (c) support disposal of medical waste related to the project. Progress on implementing this component has been slow, with few visible outcomes to-date (see Table 3.2). Table 3.2: Activities to Enhance Access to Treatment, Care and Support getting underway, with few achievements to-date Objective Outcomes Outputs and Activities Increased At the national level At the national level access to · Harmonized treatment · Development of standard health card for treatment regimes and procedures for target groups to enable access to drugs services access to HIV/AIDS and treatment in five countries. treatment, including ARVs. At the border towns At the border towns · Five towns introduced VCT centers, two · Evidence of small increase more centers being rehabilitated. in number of people testing. · 100 health personnel were trained in STI · Increase in number referred syndromic management, 79 on medical for treatment, when tested care and support, and 145 in VCT positive. services. · Small increase in care and · Nutritional support to 356 OVCs and support services for HIV+ education support to 135. people, and OVC where · Facilities for medical waste mgmt. there was none. introduced in five border towns. · 100% of health centers segregate waste; 95% use appropriate disposal containers. Source: Annex I of the report. 3.11 Strengthening of public and private health facilities for VCT and STI testing: VCT services are relatively new and five towns now have VCT services17. In some instances, the services are provided in separate health centers accessible from the main highway and yet secluded; in other cases they are located within an existing health center or hospital. As part of a harmonized strategy on access to 17In Elubo, at the remote Ghana-Cote d'Ivoire border, people are referred to the District Hospital. Testing centers are being constructed in Kodvijakope, Togo and Aflao, Ghana. 15 treatment along the corridor, the project developed standard health cards for truckers to enable them to access drugs and treatment in any of the five corridor countries. 3.12 Though five treatment facilities have been provided with basic drugs and are operational, there are several unresolved issues as evidenced by the following: · Testing levels remain low. The project counseled more than 16,000 people in border towns where testing services are available. Of the 2531 tested, about 357 people or 14 percent of those tested were HIV positive18. It is not clear if the people tested represented members of the target population; this breakdown of population tested by target population groups was reported only in one border town (Aflao). Further, as people cross borders for testing, the numbers cannot be directly compared to national averages. Relative to the size of border towns, the number of people tested represent less than 1 percent of people living in border towns are getting tested. In addition to local residents, there are large numbers of transit passengers who may use testing services. Thus, though informants noted that at all border towns there had been an increase in numbers of people getting tested, this is from a very low base and still does not represent a significant portion of the target population. · Shortage of capacity in medical facilities until recently: Data from a small number of border towns suggest that (a) only 42 percent of those who sought VCT services were tested19, (b) only 44 percent of those diagnosed with STIs were treated (Annex K). The Bank's April 2005 supervision report notes that some towns provided a rapid test for HIV but not the follow up confirmatory tests. There were no procurement issues were raised at the time of this report and Bank staff noted that there has never been a shortage of drugs, leading to the conclusion of capacity constraints at the testing centers. The midterm review notes that 100 health personnel were trained in STI syndromic management and 145 in VCT services. But as yet, it is not clear what the outcome of such training has been in terms of either the number of people tested or the quality of services. · None of the facilities has access to anti-retroviral drugs at present. The project hopes to provide treatment and drugs by referring patients to clinics and hospitals served by national programs. Project staff noted working with national programs to ensure that the ARVs are available and accessible at hospitals in the vicinity of border areas that are/will be served by national HIV/AIDS programs. The project is also working with Clinton Foundation to secure a reliable source for ARVs as treatment requires a continuous, uninterrupted supply. It is expected that the project will provide 300 and 500 patients with free ARVs. · The implications of the project's activities on cost recovery need to be made clear. The project has supported and asked health centers to follow national cost 18 19Only three border towns presented information on number of people demanding testing services. 16 recovery procedures, but cautioned that prices not be made so high as to exclude target high-risk groups. The new harmonized strategy on access to treatment and care for the corridor reimburses some countries such as Ghana that charge a fee providing HIV/AIDS drugs to project beneficiaries, should they need them while in Ghana. (In other countries like Benin, drugs for HIV/AIDS are free of charge). Such arrangements may facilitate project implementation in the short run, but may not be sustainable beyond the project's life or facilitate absorption of project activities into national programs. Given relative ease of movement of people across borders, there may be other adverse implications for national HIV/AIDS programs in each country. · The role of the project in financing physical infrastructure at treatment facilities was in dispute. The Bank emphasized upgrading existing infrastructure for cost-efficiency while project authorities preferred to procure new infrastructure. The Bank has now agreed to finance small public works and assured no abrupt end towards such financing. · There is a need to demonstrate outcomes(such as behavior change) and not just in terms of inputs (availability of testing services) and outputs (levels of testing). There is snow some emerging evidence to suggest that in Malawi, for instance, that increased voluntary counseling and testing has not resulted in behavior change.20 Neither those who tested positive nor those who tested negative and learned the results exhibited any change in behavior, suggesting that in Malawi, at least, voluntary counseling and testing is an important public good but not an effective prevention mechanism. 3.13 Overall, transmission of HIV/AIDS along travel corridors is inherently trans- boundary and requires a coordinated, cross country effort on prevention and behavior change among mobile and high risk populations. But treatment issues are inherently country specific ­ drug regimens, cost recovery, and access policies. The sustainability of undertaking a differentiated (though harmonized) treatment strategy for a particular geographical space like the Abidjan Lagos transport corridor is uncertain. And one alternative would have been for the project to link up with the national HIV/AIDS programs from the outset so that treatment and care services are provided by the national programs and not by this regional project. The regional project could work with national programs to enable the latter to strengthen treatment centers and facilities at or in the vicinity of the border. The Bank recently has, for each of its eight towns, identified reference hospitals that are in some cases already being covered by national MAP programs. And it is now working with other donors and the national MAP to ensure that the hospitals have adequate equipment and supply of drugs, including ARVs. 20The demand for and impact of learning HIV results. Rebecca Thornton, Harvard University. Paper presented to the annual meetings of the Population Association of America, held in Los Angeles, California. March 29-April 1, 2006. 17 3.14 The project has provided care and support services to people living with HIV/AIDS and to Orphans and Vulnerable Children (OVC) in all border towns except Noe and Elubo at the Cote d'Ivoire­Ghana border. As Annex K illustrates, data on care and support services presented to the IEG mission team was inconsistent. For instance, the number of support groups in place range from 10 in Seme, Nigeria to 134 in Kadjviakope, Togo. And anywhere from 18-100 people living with HIV/AIDS have been reached in each border town through house visits. The recent midterm review notes that the project has provided nutritional support to 356 OVCs and education support to 135 OVCs. And the midterm review reports training of 79 health personnel on medical care and support. Thus, while care and support activities are now underway at the border towns, the number of people covered is still small and it is too early to determine their effectives and impact. 3.15 On medical waste management, procurement of medical equipment was delayed and but now all border towns have procured and installed bins for collection of medical waste. In three of the six borders, there are now waste disposal facilities in health centers. But processing and final disposal of medical waste is just beginning. The project is currently financing the construction 8 incinerators and septic tanks. The midterm review notes training of almost 300 persons including nurses, community leaders, and local ministry officials. This was undertaken along with more than 150 different workshops, awareness and clean-up campaigns. 3.16 But there is limited evidence on outcomes such as behavior changes of medical personnel (such as improvements in disposal of medical waste) or results (reduction in new infections arising from mishandled medical waste). A project- commissioned assessment completed in December 2005 noted "level of awareness has remarkable improved" and greater awareness of the need to segregate and manage medical waste. But there are no supporting data. The mid term review also citing the same report notes that all health centers in border towns segregate medical waste and 95 percent of centers have and use appropriate medical waste management containers. The project has prepared a plan for harmonized treatment of medical waste along the corridor for discussions. 3.17 Enhanced regional capacity and cooperation to deal with HIV/AIDS. At the national level, the project aimed to promote an integrated IEC/BCC strategy and harmonized policy for access to treatment and care services, including use of ARVs along the corridor. The project has had some success in this effort (Table 3.3). A harmonized IEC/BCC strategy is now being implemented. And a harmonized strategy for national access, treatment policies and continuum of care for the Abidjan Lagos Corridor was completed in Feb 2005, though its recommendations especially on the most appropriate method of providing VCT services, ARV, and prevention of mother to child transmission of HIV/AIDS are yet to be implemented by all five countries. But it is not clear if these harmonized strategies designed specifically for the Abidjan Lagos Corridor can be sustained beyond the life of the project and/or extended to cover other corridors. Further, it is also not clear what the implications of such agreements (based on geographical space) are for eventual absorption of project activities into national programs. 18 Table 3.3: Harmonized strategies developed for the corridor, but yet to be fully implemented and their sustainability is unclear Objectives Outcomes Outputs and Activities Enhanced Development of a harmonized Greater information sharing regional capacity IEC/BCC strategy for the corridor. between border towns. Development of a harmonized Joint meetings/activities at strategy for access to treatment and border towns on either side, Joint care along the corridor. Awareness Days. Source: Annex I of the report and Midterm Review. 3.18 At the local level, the project aimed to promote increased knowledge sharing and coordinated activities among the border towns on each side of the corridor. Local officials at the border towns confirm that there are regular meetings among border committee members and joint activities by the two committees on either side of the border. But this is still short of the project's expectation of eventually merging border town committees ­ i.e. from one committee on each side of the border to a single committee for each border area comprising members of both border towns. 3.19 Improve flow of commercial and passenger traffic along the corridor: The assumption made is that speedier flow of goods and persons will reduce transit time at borders and affect social behaviors of target groups like truckers and commercial sex workers in the border towns. The project has analyzed the main impediments to smooth circulation of traffic (using a PHRD grant) to provide strategic direction for its transport facilitation activities. But the proposed National Observatories to collect and analyze data on traffic flows have just been set up in six of the eight border towns. The data from the analysis found that contrary to expectations, the time taken at the Nigeria-Ghana border was more than that taken the Benin-Togo border. 3.20 It has also trained public officials in border towns responsible for smooth traffic flow such as police, and immigration and custom officers. It has produced and distributed leaflets with information on ECOWAS procedures and rules to truckers and transport companies. An ECOWAS information unit was to be twinned with the information kiosk on HIV/AIDS but it is not clear who would be responsible for maintaining these units and they have yet to be established. Table 3.4: Slow Progress on Activities to Improve Transportation Flows Objectives Outcomes Outputs and Activities Improved · Improvement in time At the national level flow of taken to cross borders · Initial discussions underway to harmonize traffic in two of eight border border control procedures along the corridor. crossings. Deterioration · Creation of the International Association of in time taken in other Truckers of the Abidjan Lagos Corridor towns. At the border towns · Anecdotal evidence of · Establishment of Inter-border Facilitation increased awareness Committee to expedite border control among travelers and procedures. truckers on border · Donation of land for basic infrastructure control procedures. needed to expedite border control procedures. 19 · IEC/BCC material (120,000 leaflets, 36,000 posters, 16 bill boards, 24 directional signs) to improve awareness of ECOWAS travel documentation needs. · Training for 20 uniformed personnel at the eight towns to serve as peer educators. · Establishment of observatories to analyze traffic flow patterns. Source: Annex I of the report and Midterm Review. 3.21 The project has undertaken several activities, but as yet there has only been limited improvement in transit time at the borders and on reported outcomes of various activities i.e. increased awareness among truckers or public officials on border control procedures. A recently completed survey (December 2005) shows dramatic improvements on border crossing times in one town and a more modest improvement in another town over the last year (since the baseline). Time taken to cross the Aflao border decreased from 3 hours 20 minutes in 2004 to 39 minutes in 2005. In Seme, the time taken reduced from 39 minutes to 27 minutes during the same period. In other towns, however, the survey has shown an increase in the time taken to cross the borders; the reasons for which have yet to be explored. This is more or less in line with anecdotal evidence provided to the IEG mission wherein only one stakeholder group, the International Association of Truckers of Abidjan Lagos Corridor, reported impressionistic evidence of improvements by their member as a result of greater awareness of border control procedures among uniformed personnel and truckers. 3.22 Stakeholder expectations are high from the newly created Inter Border Facilitation Committee at each border which includes members of all the uniform personnel on both countries of the border. The Committee is responsible for developing harmonized border control procedures and finding ways to expedite movement of persons and goods. The committees are new and it is too early to comment on their activities. 3.23 Linkages to national programs: The link between the regional project and national HIV/AIDS programs has been facilitated by the project's institutional arrangements (as discussed below), but it varies across the participating countries. 3.24 In Benin, the linkage to national programs is relatively strong due in part to the location of the project Secretariat in Benin, and in part due to fortuitous timing. The national HIV/AIDS efforts started at about the same time as the corridor project. As one health sector official noted, "There is complete consistency between the government's approach and approach and thematic areas the corridor project focuses on. For example, on prevention, the corridor project has helped develop harmonized policies along the corridor that sets a minimum standard for prevention work. Benin wants to decentralize its health services and the corridor project has forced the national government to establish treatment centers at the border. Without the project, 20 this process may not have moved as fast. It catalyzed decentralization of health services on HIV/AIDS." 3.25 In Togo and Cote d'Ivoire, where national programs have been affected by high level of political uncertainty, there is as yet little by way of national programs in the border areas for the project to link up to. 3.26 In Ghana, where the national program is more established, government officials noted that delays in preparation of the harmonized strategy on access to treatment and care stemmed from the need for the corridor project to ensure that its activities are consistent with Ghana's national plan on several dimensions of treatment such as (a) training of health workers, (b) procurement and devolution ARVs to the districts, and (c) improvement of medical waste facilities in health centers. The following comments of one health sector official are illustrative: "In areas like treatment and care and medical waste, there have been issues on coordination. For example, the corridor project sent consultants to survey hospital staff on disposal of medical waste. In Ghana such a survey had already been undertaken and consultation with us could have helped ensure better synergy. On treatment and care, especially on ARVs, there is a decentralization policy in effect. The corridor project has pushed us to make these drugs available in border towns. But we already have a planned and phased approach that we will follow. Also on ARVs, after some initial discussions, we all agreed that the drug regimen was the same in all the participating countries but Ghana charges nominally for ARVs, unlike Benin and some other countries and so it took time for us to agree on a scheme wherein the project would reimburse the Ghanaian government for giving free ARVs to patients who are part of the project, should they need to refill medications. Usually, these medicines are given for a long period of time and can be refilled in other places. But it took us some time to resolve this issue." 3.27 Over the last six months, coordination has improved according to the same health sector official: "In other areas we have built on synergies. For instance, on VCT manuals and prevention, Ghana has already invested in creating some material and we wanted the Corridor project to use the same, which they now are doing. We are also helping them train service providers in the border towns on STIs. This training will be done by Ghana Health Service trainers to ensure consistency of the training with national training guidelines and programs." 3.28 In some cases, internal country conflicts or division of labor issues have complicated coordination between the regional project and national programs. For example, in Benin, unlike other countries, as the National Aids Commission is responsible for the national HIV/AIDS project (under the Africa MAP), the Ministry of Health has taken the lead on this regional project. Likewise, in Ghana, though the NAC represents the country on this regional project, coordination with national activities requires collaboration with Ministry of Health and Ghana Health Service. 21 3.29 The Bank staff acknowledges the need to improve coordination with national programs as well as better communication and knowledge sharing of project related information with national programs. Following the September 2005 supervision mission and the midterm review, the Bank proposes to identify for each country, a focal person at a technical level within the Ministries of Health or agency involved with implementation of the national program, to ensure that there is adequate coordination and information sharing between the regional project and the national HIV/AIDS programs. 3.30 Cross Country Learning: Interviews with stakeholders at the national levels and Bank staff reveal that the project could have placed a more deliberate emphasis on cross country learning. Where there has been some cross fertilization of ideas on issues such as ARV pricing and availability, this reflects the channeling of regional level discussions into national level programs through individuals from participating countries who are also members of the governing body. For example, governing body members of all five countries are aware of national strategies on HIV/AIDS prevention and treatment in other participating states. The provision of free ARVs to some target groups in Benin has raised a discussion on ARV charges in countries like Nigeria. But by and large, while cross-country learning was always considered to be an implicit benefit of working sub-regionally, there appears to be no deliberate effort to determine what steps or actions are needed to ensure such learning. REALIZED DISTRIBUTION OF COSTS AND BENEFITS 3.31 The project intended to achieve an equal distribution of grant funds and equal counterpart payments by all participants. By design, the project ensured that each participating country had a clear role in project governance and management, and a power position therein. One view from informants is that perhaps Benin gained more than others in that it hosts the Secretariat, but these informants acknowledged that it corresponded with Benin's proactive role during project design, including acting as the Secretariat under an interim arrangement. Staffing of the Secretariat also aims to promote an optimal balance between nationals of all five participating countries. 3.32 The pace of implementation across countries has varied. One issue highlighted by some stakeholders (and raised by the midterm review) is the equal distribution of the grant money to all five countries, when in two countries (Nigeria and Cote D'Ivoire) the project is active in only one border town in comparison to two border towns in other countries (Benin, Ghana and Togo). Yet as these two countries were the last to open the Bank accounts, the pace of implementation and disbursement is slow. Less than 20 percent of project funds have been disbursed to Nigeria and Cote D'Ivoire. Benin and Togo have a 40 percent disbursement level and Ghana 25 percent. 3.33 Further, the proximity of border towns to capital cities and ease of access has affected pace of implementation. Elubo and Noe are the laggards among border towns as they are the most remote (eight hours from Accra and three hours from Abidjan). Similarly, due to political uncertainty in Togo, treatment, care and support 22 activities in Sanvee Condji at the Benin-Togo border are less advanced than in other border towns and patients are referred for testing to the neighboring town in Benin. CAPACITY BUILDING 3.34 To overcome the lack of adequate implementation capacity at the regional, national and local levels, the project is building capacity of the various institutional structures it has established. There has however been little capacity building in the national ministries involved (AIDS commissions, ministries of health and transport) that is necessary to ensure: (a) adequate coordination of the regional project and national AIDS programs, and (b) to prepare for eventual absorption of project activities into national programs. 3.35 The project was responsible for establishing, training and staffing the project Secretariat. It also catalyzed the governing body to establish the Secretariat as a sub- regional institution, the Abidjan Lagos Corridor Organization (ALCO) in August 2003. This signals the intention of participating countries to provide an institutional basis for funding HIV/AIDS along transport corridors. But funding for ALCO after the project is expected to come from country contributions, and supplemented by external financing. Hence its sustainability is uncertain (see risks to outcome below). 3.36 The creation of community institutions to oversee project implementation activities and the use of private and public sector implementing agencies has been largely successful in securing local involvement as well as in drawing attention to the need for capacity building at the grass root level. Moreover, the project has led to some unintended capacity building through the creation of two new cross-country associations that are working to promote the project's objectives: (a) the national truckers union in each of the five countries have joined to create an international union of truckers for the Abidjan Lagos corridor, that acts as a pressure group in support of the project's transport objective, and (b) religious leaders in the five countries have formed a network to promote HIV/AIDS awareness, treatment and care, and hope to become an implementing agency for the project. 3.37 The project aimed to promote knowledge sharing between ministries of health and transportation within and across participating countries. And there is scope to enhance cross-country learning. But there is no other capacity building effort in the ministries of health and transport (that are expected to take over project activities) either to manage program activities or of mechanisms to promote inter- country coordination. 3.38 The project has provided for training under each of its components: it trained a cohort of medical personnel in HIV/AIDS care and treatment, thirty-seven border committee representatives (refer 4.6 below), as well as truckers, transporters, and local public sector customs, police and immigration officials. The Bank's April 2005 supervision mission found the training satisfactory in most instances and believes that the benefits of training local NGOs and government officials in border towns 23 would extend beyond the life of the project. But there is no concrete evidence in support of these claims. RISKS TO OUTCOME AND IMPACTS 3.39 During design, the project's assessment of risks was fairly comprehensive. But there was no attempt to address the impact on the project should one or more countries not perform to expectations and the mitigation measures that would need to be used. This risk did materialize in the form of political turmoil in Togo and more recently in Cote d'Ivoire. The Bank had to seek the approval of the Bank's Board of Directors to ensure that Togo, which was in accrual status to the Bank, could participate in the project. This was particularly important as Togo lies in the middle of the corridor. And thus, while the Bank was able to manage the risk, it was not planned for. The political turmoil in Cote D'Ivoire delayed implementation of activities at the Noe border town. In other instances, the project has relied on peer pressure to ensure adequate implementation. 3.40 Ultimately, the impact of this project on HIV/AIDS prevalence in the five countries will be visible in the long-run and not in the project life span of four years. The project assessed sustainability of outcomes to the extent a pilot program could during design. The PAD notes that sustainability would depend on maintaining and extending interventions along the whole corridor beyond the border towns. From a financial stand point, it was clear even at design, that participating governments would not be able to fully finance the project activities or cover all target groups in the medium term and would require continued donor funding. The establishment of the Secretariat as a separate legal entity, the Abidjan Lagos Corridor Organization, reflected this reality and signaled the intention of participating countries to provide an institutional basis for future financing. The Bank did not rule out that the project may demonstrate economies of scale or other benefits from coordinated programming that could argue for a large regional program. Nevertheless, the expectation was that as national capacities were enhanced, national programs would assume some of the project's activities. This expectation remains among officials in Ghana. But officials in Benin noted that they do not believe that their national program would have advanced sufficiently to take over project activities by 2007. 3.41 The project is just midway and at present the risks to outcomes and impacts are high. Government officials in Ghana and Benin, as well as Bank staff confirm that neither the Bank nor the countries aimed to lock themselves in to a regional program. But they acknowledge that it is now more difficult for countries to move away from a regional approach to greater reliance on national systems. Some Bank staff fear that countries may not abandon the regional approach whether or not it remains necessary or efficient. They fear that the creation of ALCO could have the unintended consequence of dragging down national capacities to act in specific areas and on inter-country coordination. 3.42 But at this point such extension of activities beyond the border towns to the whole corridor, as envisaged during design, is uncertain. IDA also no longer 24 provides ear-marked grant funding for HIV/AIDS or for regional initiatives. And hence, decisions on sustainability will have important implications for the project's institutional and funding arrangements. Countries have at least three options: (a) absorb some of the project activities into strengthened national programs over time, (b) maintain a single sub-regional corridor project by mobilizing additional funds from the Bank, regional institutions like NEPAD and ECOWAS, or other donors, and/or (c) scale up the pilot to a larger sub-regional program covering a number of different corridors under the aegis of a broad regional institution such as ECOWAS. 3.43 The midterm review does not explore these options, not does it highlight options for extending project activities across the corridor, the level of commitment of countries to finance project activities, or the interests of other donors in financing project activities in future. While Bank staff note high degree of political will and commitment on project implementation on the ground, there is no concrete evidence as yet that countries are willing to absorb project costs after the pilot period. 25 4. Efficiency: Organization, Management, and Financing of the Regional Program 4.1 Overall Summary: Some of the project's institutional arrangements helped to garner legitimacy, has project implementation has been delayed due to underestimation of time involved in (a) dealing simultaneously with not only multiple countries but also two sectors, (b) building capacity at the local levels in small towns, and (c) building up capacity of the Secretariat to oversee and direct project activities. EFFICIENT USE OF RESOURCES 4.2 It took two and a half years for the project to be prepared and approved, considerably longer than for other AIDS projects at the country level (refer 6.2)21. The project became effective in March 2004, but it took more than a year for the project to get activities underway on the ground. It took a year for the project to recruit an Executive Secretary and set up the Secretariat, hire a management consultant firm, organize community groups, recruit local implementing agencies, and get activities underway on the ground. Though the risk of slow implementation was highlighted at the time of appraisal, in its 2004 progress report, the Executive Secretariat notes that "only 11 percent of the funds of the project have been disbursed as of December 2004 and 51 percent of the activities planned for in 2004 had been implemented." Procurement and disbursement lags led to delays in implementation (refer 3.1). 4.3 An April 2005 Bank supervision mission noted the following main constraints to efficient implementation: (i) difficulties in harmonizing multi country strategies, (ii) late payment of country counterparts funds in the first year, (iii) slow process of achieving lands at borders, (iv) political unrest in Togo and Cote d'Ivoire, and (v) turnover of governing board members (3 changes in 2004). 4.4 Stakeholders and Bank staff acknowledge the slow pace of implementation but believe that the pace has improved over the last six months. The midterm review notes that the disbursement as of December 31, 2005 stood at $7.71 million (or 44 percent) of total project costs. Nevertheless, the use of time and resources was not optimal. GOVERNANCE, MANAGEMENT AND LEGITIMACY 4.5 The Abidjan Lagos Transport Corridor project is financed by a Bank/IDA grant made to Benin on behalf of all five participating countries. There is no other donor financing and the project's ultimate governance rests with the Board of Directors of the World Bank. In that sense, it did not need a formal governance arrangement. 4.6 In view of the regional nature of the project, a Transitional Working Group (TWG) was formed at a stakeholders' workshop in Cotonou, Benin in July 2001. The TWG set out the project's institutional structure and was later reconstituted as the 21The project Concept Document dates to 2001 and the project was approved only in November 2003. 26 governing board for the project22. The program has put in place an elaborate institutional framework for both governance and management (Box 4.1) detailed in Annex B and chart B.1. The structure and allocation of responsibilities were endorsed at the highest political level by each country and is contained in a joint presidential declaration issued April 30, 2002. Box 4.1: Clear but Elaborate Governance and Management Arrangements Governance arrangements: · A governing body comprising representatives from health ministries/AIDS commissions and transport ministries from each of the participating countries · An inter country advisory committee comprising public and private sector representatives to guide the governing body. Management arrangements: · An executive secretariat (ALCO) is responsible for project implementation, supported by a management consultant firm. At the border towns, the Secretariat is supported by: (a) A national intermediary agency for each country (none for Cote d'Ivoire given the political situation) that coordinates activities in the country's border town(s). The four agencies meet across country once a year. (b) Eight border town committees--one in each town on either side of the border. The committee is chaired by a top political official and comprises community leaders and key beneficiary groups (including traders, commercial sex workers, truckers, residents and people living with HIV/AIDS). It is responsible for oversight and coordination of interventions in the border town. All eight border committees have met together once. (c) An inter-country facilitation committee in each border crossing (4 in all) to lead the effort on speeding the flow of traffic across the borders. The committee is chaired by top level uniform border officials or political leadership (mayor) of the towns along with stakeholder groups. (d) Public and private implementing partners (NGOs, agencies) that submit project proposals and are funded by the Secretariat to carry out activities in border towns. 4.7 The governance arrangements appear to working reasonably well. Informants confirmed that participating governments were actively involved in designing the institutional structure and were hence committed to it. The project went to considerable effort to ensure that institutional structure (a) reflected client needs, and (b) was optimal for project implementation. Each country has an equal role in the governance of the 22The project, in close collaboration with the governing body and civil society representatives of the five countries, prepared an Operations Manual. The manual defines procedures and eligibility criteria for review and approval of proposals from implementing agencies and guidelines for preparation, implementation, and supervision of the same. It includes the contractual arrangements between the Secretariat and implementing agencies, and procurement and financial management requirements. 27 project. The level of representation on the Governing Board for the project is at a sufficiently high level to exert influence and facilitate decision-making in national governments (in both transport and HIV/AIDS). The membership of the governing body is not too large and comprises 10 members. The active participation of members precluded the need for a technical oversight committee (also refer legitimacy below). 4.8 The governing body is active and operational. It meets annually, directs and oversees the Secretariat and has full decision-making power over the activities of the Secretariat. At the same time, it consults and is guided by Bank staff on implementation progress based on Bank supervision missions. It also applies the Bank's operational policies on financial management, procurement, disbursement and audit. The governing body has added legitimacy and serves as a forum for regional cooperation/coordination in the project. One criticism of the governing body is the frequent changes and/or short tenure of its members ­ there have already been three changes in the members appointed by participant countries to the governing board since the project became effective. 4.9 The Inter-Country Advisory Committee (ICC) that has been established to serve as the technical advisor for the governing body and includes private and public stakeholders was expected to meet before every annual general body meeting of the governing body. Informants note that the ICC is not working as well as expected due to lack of adequate and regular (periodic) information from the Secretariat (particularly to non-government participants) on work plans and progress therein. 4.10 There is room to enhance project management. The project is managed by a free-standing Executive Secretariat that has now been incorporated as a separate sub- regional institution ­ Abidjan Lagos Corridor Organization (ALCO). Although the Bank underestimated the time it would take to build the capacity of the Secretariat, the Executive Secretariat is now fully operational and supported by a management agency to which specific functions such as M&E, procurement and financial management have been contracted out. The Secretariat has qualified health and transport specialists. The contracting out of specific project management tasks was in line with best practice at the time of project design. But the midterm review has not explored the costs and benefits of the approach and its effectiveness to-date. 4.11 Interviews indicate that the Executive Secretary is good in ensuring adequate communication with the governing board and implementing agencies, and in bridging the language gap between participating Anglophone and Francophone countries. National and border town stakeholders laud the competence and responsiveness of the Secretariat, and personal accessibility of the Executive Secretary. 4.12 There is room to strengthen regular information sharing and communication by the Secretariat with national and local stakeholders in participating countries (such as non-governmental members of the ICC), especially on work plans and progress therein. Some donor informants such as DfID and UNAIDS who were involved during project design noted that they had not been kept abreast on project implementation. In part, this reflects the weaknesses in M&E (see Chapter 5). Other areas highlighted for 28 improvement regularly in Bank supervision reports and memos are procurement and financial management. 4.13 At the local level, all the border committees are operational and actively involved in project implementation. They meet on a regular basis, particularly the focal unit of four or five members within each committee that is responsible for most of its activities. Only in one instance Aflao, committee members noted difficulties in getting members to be proactive, as participation is voluntary. One constraint highlighted at all border towns is the frequent change in uniform personnel (immigration, customs and police) who are often key members of the Border Committees. Informants also endorsed the project's use of experienced local NGOs to act as intermediary agencies in the border towns. 4.14 At the start of this project, the Bank-promoted option of locating the project secretariat under ECOWAS, an existing regional institution or its new health sector arm, WAHO was not accepted by all participant countries (as ECOWAS/WAHO were viewed as being too bureaucratic and not subject to effective national control). A second option of creating an association under the West African Initiative (WAI) umbrella was also rejected due to legal complications. While most interviewees were not aware of the formal legal status of ALCO, they support the use 4.15 Subsequently, ALCO had only minimal interaction with ECOWAS and WAHO. Although bilateral and multilateral donor agencies have been invited to participate as observers on at governing board meetings, ECOWAS/WAHO have not. The Executive Secretary noted that ECOWAS has cited the corridor project as an example to illustrate to its other members how a regional approach would work in addressing HIV/AIDS along transport corridors. 4.16 Linkage with other regional institutions: There is wide support from stakeholders for the use of a free-standing, problem/issue specific sub-regional organization as distinct from a Project Management Unit or agency housed in a broader purpose regional organization. But many informants suggested that the project build greater linkages with regional institutions for two reasons: (a) to provide the broad policy level framework and consensus and (b) to enhance prospects for sustainability. Some stakeholders noted that though freestanding entities may facilitate flexibility and project implementation, the large regional institutions such as ECOWAS provide the necessary political framework and buy-in under which regional activities can be undertaken. For instance, this project successfully capitalized on the existence of a regional agreement on unrestricted movement of goods and people that was promoted by ECOWAS. And ALCO is now attempting to facilitate the implementation of this regional agreement. The absence of such an agreement on health and in particular HIV/AIDS meant that the project had to spend significant amounts of time and effort to harmonize IEC and treatment and care strategies along the corridor. Second, some informants argued that large regional institutions provide a mechanism for scaling up regional activities to other countries or geographic locations, and have the ability to raise funds for sustaining project activities. This is an issue that the mid-term review needs to consider prior to continued funding. 29 4.17 The project has ensured that the legitimate interests of participating governments as well as a broad range of public and private stakeholders, at national and local levels, were considered. Informants in Benin, Togo and Ghana at all levels highlighted the following as key strengths of the project: (a) the voice of participating countries in policy and oversight, and (b) ownership and commitment at the grass roots level created by active involvement of beneficiaries and community leaders. (Annex J summarizes stakeholder views). 4.18 There was significant country participation in determining the institutional and financing modalities for the project. The early inclusion of national authorities in project design helped added legitimacy for the project from the authorizing environment in the participating countries. During project design, stakeholders including civil society and public sector, from all five countries participated in a series of workshops. 4.19 The project's institutional structure has established several fora by which legitimate interests of all private sector stakeholders at all levels, including people living with HIV/AIDS are considered in implementation. The oversight groups (Inter Country Advisory Committee and eight border committees) do not have direct decision-making power. But the ICC reports to the governing body and the border committees to the Secretariat. The influence on decision making is indirect. Nevertheless, the inclusion of such wide stakeholder groups in project oversight has strengthened stakeholder and community level participation in the project and added ownership, transparency and accountability to the project. 4.20 A further element of legitimacy is the regular and transparent communication of project activities to the public at large through a project website. Some informants and Bank staff noted that the use of the website needs to be updated more regularly. FINANCE 4.21 The IDA grant of $16.6 million was made to Benin on behalf of five countries. The grant terms were an important motivator for all the participant countries. The IDA grant was also large enough to preclude other donor finance and this ensured greater predictability of resources over the life of the project. All countries pay in counterpart funding of a small and equal sum. Initially, there were delays in payment of counterpart funds (due to differences in exchange rates) but this was resolved and countries paid their counterpart funds on time in 2005. 4.22 The fact that the financing was in the form of a grant (rather than a credit) enabled Benin to take the resources on behalf of the project and to put administrative arrangements in place within a short period of time. This allowed the project to get started even before an executive secretary was hired and a management agency put in place. The Director of Finance in Benin stated unequivocally that had the funding been in the form of a credit not a grant, Benin would not have been willing to play this role. Rather separate credits would have had to be given to each country. He noted that should an extension of the project be supported by lending rather than a grant, the financing structure would have to change. 30 4.23 Participating countries can no longer rely on ear-marked IDA grant funding either for HIV/AIDS or for regional projects. Therefore, continued grant funding for this project would have to come from: (a) allocations from the national budget, (b) allocations from any IDA funding the countries may receive, or (c) other sources of concessional finance. DONOR PERFORMANCE 4.24 There are no other donors directly involved in financing this project but the Bank over the course of the project design and implementation, has worked with UNAIDS and other UNFPA for ensuring a regular supply of condoms and pharmaceuticals. And the Bank did involve major donors in the project concept and design discussions, some of whom are invited as observers to the meetings of the governing body. 4.25 One donor with similar HIV/AIDS efforts in participating countries and along important transport corridors is USAID's West Africa Regional Program (WARP), which sponsors the Action for West Africa Region-HIV/AIDS (AWARE)23. The corridor project has a signed a Memorandum of Understanding with USAID to ensure adequate division of labor. The MOU stipulates that the corridor project would focus on the coastal East-West Abidjan Lagos Corridor, and USAID would focus on inland North-South Corridors. Interviews confirmed that WARP is replicating corridor project­like efforts on the Sahal Corridor connecting Senegal, Mali, Niger, Nigeria, and Burkina Faso. 4.26 Interviews with other donor agencies suggest that the project has performed well in working with donors to avoid duplication and sharing information regularly in Benin, but has been less effective in doing the same in Ghana. CIDA-Benin and Global Fund in Benin confirmed close interaction and communication that the project Secretariat. The Global Fund representative noted: "The coordination (with the corridor project) is good. We have all made efforts not to duplicate but to complement each other." But donors such as DfID (Ghana) and UNAIDS in Ghana noted that though they had been actively involved during project design, they had not been kept abreast of project activities during implementation, even though the latter is an observer on the governing board. Information sharing among donors thus is uneven and can be further strengthened. 23AWARE is based in Ghana and operates in 18 West African countries. AWARE focuses on: (a) dissemination of promising and best practices in STI/HIV/AIDS, (b) advocacy for policy change, (c) capacity building of regional institutions and networks, and (d) development of health sector reforms. 31 5. Monitoring and Evaluation 5.1 Monitoring and Evaluation (M&E) remain the single biggest weaknesses of this project. As noted in Chapter 3, a baseline study to determine absolute targets was not undertaken until in mid-2004, only after project effectiveness. The Bank task team realizing the importance of M&E made two early attempts to use PHRD grant funding to undertake baseline studies. But Bank staff noted that in both instances, the bidding process was unable to generate any suitable proposal. 5.2 Recognizing that the underlying capacity in the border towns was extremely weak, the project relied heavily on a management firm to develop and implement an M&E plan. The Bank was unrealistic in its expectation of the time that it would take the management agency to set up capacity for regular data collection and reporting on implementation progress. As a result, none of the Implementation Status Reports has been able to specify progress against the specified outcome indicators. 5.3 In December 2004, the Bank asked that the M&E specialist conduct recurrent field visits and be proactive in interactions with border committees. And the health and transport specialists were asked to include additional performance indicators and enhance use of behavioral and biological surveillance techniques. Since then, there has been some progress. The M&E specialist has organized regular field trips and presented an M&E plan in early 2005 to the Bank, which is now being implemented. 5.4 In April 2005, the Bank noted that the M&E specialist should align the baseline data with the performance indicators set out for the project. The Bank also suggested that the project put in place a results framework, systematic data collection processes and a table listing components and activities, number of contracts awarded, the amounts spent and the results thereof including evidence of any behavioral change. As of September 2005, though there have been efforts to systematically collect and present data on project activities, the reporting remains mainly on inputs, processes and outputs (see Annex K). As yet there is no uniformity or consistency in the reporting mechanisms. Self-reported data from border towns and the intermediary NGOs specifically need some attention for their methodology and the data needs verification. 5.5 The Bank included an M&E specialist for the midterm review. The review highlights several shortcomings including lack of appropriate indicators, weak data collection systems at national and local levels, and lack of harmonized M&E systems for the five countries. It also identifies several areas in need of improvement: · Strengthening cooperation with the national AIDS Committees on M&E · Hiring an epidemiologist to overcome difficulties in gathering epidemiological data · Reviewing the performance indicators for the project. 5.6 In addition, the need for greater monitoring of the activities of about sixty NGOs and eight border committees is also critical. 32 6. World Bank's Performance in Support of the Regional Program 6.1 Summary: The Bank used its convening power and provision of grant financing to bring the five countries together in support a regional approach. The intensive Bank support, technical advice, and supervision has helped the Secretariat to become fully operational, but this has taken significant amounts of time and money. Though the Bank has active or proposed MAP programs in all participating countries, there is inadequate coordination between these country programs and this regional project. As noted above, the project is not adequately monitoring its achievements and has not made arrangements for follow on financing beyond the duration of the four year pilot. COMPARATIVE ADVANTAGE 6.2 The Bank is not the only donor active on HIV/AIDS issues in the region. But it did have several comparative advantages over other donors that inspired its initiative and support of this project: · The Bank used its considerable convening power in the Region to successfully build on an existing regional platform, ECOWAS, to promote and mobilize three Francophone and two Anglophone to support a regional approach for HIV/AIDS. · The Bank was able to capitalize on its experience with national HIV/AIDS programs in the Region and elsewhere that were funded by MAP ­ 1. · The Bank's experience multi-sector experience enabled it to bring together the transport and HIV/AIDS issues in a way that responded to client concerns. · The availability of IDA grant funding for regional HIV/AIDS initiatives under MAP II provided the Bank with a ready made financing tool. · The IDA grant was large enough to preclude the need for multiple donor grants, which enhanced the predictability of resources for the project. · The Bank was able to directly target high risk groups, unlike some other donors. QUALITY OF SUPPORT & OVERSIGHT 6.3 The Bank spent a substantial amount of time and resources on project preparation and supervision. There is a general perception among Bank staff and stakeholders that though this was disproportionate to the volume of the grant, the Bank's continued support was critical for nurturing what was considered an innovative approach, and a pilot project. At the same time, the project has to be seen as one of high cost for the Bank in terms of money and time. The project took 2.5 years to prepare. This was considerably longer than the average time for Africa MAP projects of 16. 2 months between project 33 identification and effectiveness24. As one staff put it, "The Bank has thrown everything its got at this pilot project to make it a success." 6.4 The Bank had budgeted $250,000 for intensive supervision in the first year of the project alone. This amount, which is large relative to the size of the grant, was justified on the grounds of the pilot nature of the project and the complexities involved. The supervision budget was reduced to $150,000 in FY 2005. And the Bank, as planned, has undertaken regular and intensive supervision missionsmost recently in September 2005with support from health sector staff and field visits to border towns. Bank staff participated in governing body and ICC meetings and visited other project activities such as the training sessions on transport facilitation. The presence of field based staff facilitated regular interaction with the Secretariat. 6.5 Bank supervision performance has been rated as excellent by the members of the governing body, Secretariat and border level committees and implementing agencies. Specifically, informants commended the Bank for: (a) the supportiveness of the team leaders including smooth transition of task team leaders, (b) administrative and logistical support (e.g.: processing non-objections within a week), and (c) critical and results- oriented supervision missions. As one informant noted, "We have a great relationship with Bank staff ­ they have been very responsive, there was a smooth transition during the change in task team leaders and we have had two very open-minded team leaders. Everyone wanted this project to succeed, so Bank went all the way to get it done. And this project has led to a highly positive image for the Bank in our countries." 6.6 Bank staff also commended the Bank's legal support staff in aiding the necessary financing arrangements. The grant to Benin on behalf of five countries was a departure from usual Bank practice and the legal department worked closely with the Bank project team to draft letters of agreement with other participating countries. The negotiation of the Grant agreement by the Bank task team with Benin alone though resulted in delays in getting the other countries to sign the letters of agreement. 6.7 One criticism both by Government officials and border level implementing agencies are on Bank procedures (especially on procurement) that were considered to be too cumbersome for local level actors. 6.8 The project was categorized as `high risk' from the onsetit was the first time a regional approach had been taken in the subject area in the region. The Bank rightly identified several risks to achievement of objectives: (a) the waning commitment and weak cooperation of national bodies, (b) that awareness does not lead to behavior change, (c) that awareness and prevention activities are not linked, (d) lack of NGO/CSO capacity to implement project activities, (e) poor cooperation from local communities and stakeholders, and (f) weakened support to Executive Secretariat from national programs. 6.9 Some of these risks have arisen. For instance, cooperation between the Executive Secretariat and national agencies needs improvement. And while the Bank has called for 24Committing to results: Improving the Effectiveness of HIV/AIDS Assistance. Box 4.2, page 49.IEG. 34 greater information sharing, it is not clear what concrete action will be taken and by whom. The risk of weak country commitment did surface in delays in payment of counterpart funds but was mitigated through peer pressure from the governing body. 6.10 The Bank, in its risk analysis in the appraisal document, did not separately identify the risk that (a) the capacity of the Executive Secretariat may not be sufficient to coordinate and oversee the diverse set of activities and the multitude of implementing agencies, and (b) the solution of outsourcing several management and oversight functions to a management consultant firm may not work ­ i.e. the consultant firm would also suffer from a similar lack of capacity. Bank staff noted that management arrangements were similar to emerging best practice at the time of other MAP projects. Nevertheless, although these risks were addressed as they became apparent they resulted in implementation delays. STRUCTURES AND INCENTIVES 6.11 The project has been designed largely by the transport sector although 80 percent of the components are recognized and categorized as health sector related. And it is being managed by transport sector staff ­ sector manager and sector directors. The Bank staff working on the project also reports to the recently created Country Director for Regional Integration Department in the Africa region, which is viewed by the Bank staff as a positive development. Nevertheless, it makes reporting relationships more complicated. 6.12 Interviews with Bank health and transport sector staff in Benin and Ghana suggest that there is no clear incentive for Bank country directors and country team staff to actively participate in multi-country projects. In their view, this explains the reason for the less than satisfactory Bank performance on linkage between the project team and other Bank supported country operations such as the Ghana MAP. This has important impacts not only for the Corridor project, but also its lessons as a pilot. LINKAGES TO OTHER BANK COUNTRY OPERATIONS 6.13 The links between this regional corridor project and other national HIV/AIDS projects, especially the Africa MAP programs, are minimal. Interviews with the project team suggest that while country directors and staff in the field were aware of the project, believed to be an important contribution, and had been involved initially in the concept phase, there was no active engagement or involvement of country staff during project implementation. In their view, greater country team involvement could have (a) enhanced the Bank's advice on policy matters, (b) ensured that cross country learning was more systematically built into the project, (c) helped the project to capitalize on synergies with other Bank operations and (d) enhanced the project's understanding of the medical epidemiology and behavioral and biological surveillance research and techniques. 6.14 The most recent Bank supervision mission calls for closer cooperation between the regional project task team with the health sector staff in the participating countries, working on national HIV/AIDS issues and the Bank-supported MAP program. 35 7. Participating Countries' Performance in Support of the Regional Program COUNTRY PARTICIPATION 7.1 Overall, the participating countries have demonstrated strong commitment to the regional project as evidenced by several factors, most important of which is the ability of the project to successfully maintain its activities in the border towns in Togo even during a brief period of political instability in the country. This was important given the location of Togo in the middle of the corridor. 7.2 Of the five participating countries, there is general acknowledgement that Benin clearly took the lead in actively aiding project preparation, by (a) taking the grant on behalf of all the donors, (b) making counterpart funds on behalf of other participants in advance, (c) making an exception to national policies and allowing all project related donor and counterpart funds to be maintained at a commercial bank to speed implementation, (d) acting as the Interim Secretariat in the initial stages, and (e) providing logistical support including office space to the Secretariat. 7.3 There is room to enhance program coordination between the participating countries. In some cases, internal country conflicts or division of labor issues within units in the country have complicated coordination between the national programs and regional project. For example, in Benin as unlike in other countries, whereas the National AIDS Commission is responsible for the national HIV/AIDS program, it is the Ministry of Health that has been taking the lead on this regional project. Similarly, in Ghana, though the National Aids Commission represents the Ghana on the regional project, coordination with national HIV/AIDS programs require collaboration with the Ministry of Health and the Ghana Health Service. 36 8. Conclusion and Lessons Learned 8.1 Overall, the transport corridor project demonstrates value-added of a multi- country approach to a problem that is both clearly viewed as a national priority by all participating countries and by its nature demands cross country coordination. It also demonstrates the importance of several design and process features for effective implementation at a multi-country level, especially: · An institutional framework with clear roles and responsibilities for all participating countries and sufficiently high level country participation to facilitate needed policy or procedural harmonization, · Continuous communication and transparency on the part of the project management unit (secretariat) within and between countries, · Solid consensus on the program's design as well as on agreed or common activities at the country level, and · Pertinent cross country operational and consultative mechanisms. 8.2 The project has benefited from good practice in Bank project preparation and supervision work. At the same time, the project has to be seen as one of high cost for the Bank in terms of money and time. 8.3 There are two major uncertainties: a) what happens at the end of grant financing, and b) what measures will be taken to ensure the geographical extension of the project that is necessary for it to reduce HIV/AIDS prevalence rate in the sub-region. LESSONS LEARNED 8.4 Some key lessons emerging from this review are: · It takes time to prepare a regional program because of the need to: (a) obtain consensus among countries on objectives, activities, and institutional arrangements, (b) build implementation capacity at both the regional and country level, and (c) establish modalities for collaboration among participating countries. Both the time and resources required to lay this foundation for successful program implementation need to be reflected in the costing and timeframe of a regional program. · The sustainability of a regional program initiated with grant financing is a major issue that needs to be addressed from the outset. Such a program needs to produce concrete benefits on the ground, that meet major interests of participating countries, to sustain cross-country cooperation and program consensus · The governance arrangement for a regional program needs to entail sufficiently high level government participation to ensure necessary policy and program coordination across and within participating countries, and to enhance the benefits of cross country 37 cooperation. Where a regional program is free-standing rather than housed within an existing regional institution, its governing body needs to be constituted to achieve this participation. · The roles of the regional project and related national programs need to be clarified and linked. · Where a regional project relies on a free-standing regional body for implementation, it is necessary that the project determine an appropriate framework for: (a) enabling high level political consensus necessary for project implementation, and (b) ensuring sustainability of project activities for the necessary period and if appropriate, building commitment and support for scaling up project activities. These may be functions that can be carried out by an existing regional institution, in which case the roles and responsibilities of the free standing regional body vis-à-vis the existing regional institution need to be clarified at the outset. · Where a regional program involves activities at the country level, there must be adequate capacity built not only within the responsible regional institution but also within institutions at the national level and, where pertinent to the program implementation, at the local level. · The Bank should create or provide mechanisms for regional country directors to be involved in and take ownership for regional projects that operate in their countries. 38 Annex A: Background Information on the Regional Program A1: Basic Information on the Program 1. Program (or project) number P074850 2. Program Dates Approval Date (estimated and September 2003 actual) Completion Date (estimated July 2007 and actual) 3. Sector or thematic areas Multi Sector ­ HIV/AIDS and Transport 4. Regional or sub regional) Sub-regional 5. Regional partnership or Project project Does it comprise country No projects? If yes, do the country projects: · Conform to a template · Address the same problem(s) · Regularly interact with each other (e.g., through information sharing, research, M&E)? 6. Rationale for the regional program: · Strategic focus: regional Geography ­ along a transport route. Common problems re high commons, trans-boundary risks of transmission, inaccessible populations and high-risk problems, regional groups. integration, or other cooperative actions? · Intended direct impact Sub-regional (regional/sub-regional and/or participating countries) 39 Annex B: Governance and/or Management Arrangements Management Entities for Project Implementation 1. What are the management ALCO Secretariat ­ see chart below and arrangements for project roles and responsibilities below implementation? List the project implementing and management units and describe roles and responsibilities of: · Task Manager and/or Task Team Justin Koffi Leader EXECUTIVE SECRETARIAT OF THE PROJECT c/o National HIVIAIDS Control Program, Republic of Benin Address: P.O. Box 04-0378, Cotonou, Republic of Benin Contact Person: Justin KOFFI Tel: (229)315488 and 317848. justinkoffi@hotmail.com · Oversight Manager Siele Silue and Stephen Brushett o in the Bank and/or o outside the Bank Regional Governance and/or Coordinating Body(ies) 2. Name, location, and internet address Governing Body of the regional governance and/or coordinating body(ies) for the project. 3. For each of these governance and/or coordinating bodies, what is the: · Size 10 · Membership/composition Ministers of Transport and Ministers of Health or National AIDS Commissions · Membership criteria Nominated by countries · Functions/responsibilities See below · Meeting frequency Annual Regional and/or Country-level Implementing Agency(ies) 4. Name, location, and internet address GTZ ­ management consultant. of implementing agency(ies) for the project. 5. Function of implementing agency(ies) The Institutional arrangements for the project are as follows: · The project would be guided by a Governing Body comprising the ministers of the five countries responsible for National HIV/AIDS programs and the transport sector. They represent a "conference of the ministers" nominated by the highest political offices 40 of the member countries. The President of the governing body is Nigerian while the vice- president is Ghanaian. The governing body is directs and oversees project implementation. It is responsible for overseeing (a) the preparation and execution of the multi-country HIV/AIDS transport corridor strategy and plan of action; (b) reviewing progress on implementation jointly with the key donors and stakeholders; and (c) implementation of overall sub-regional coordination, policy review and adoption. It will endorse the annual work plans developed and presented through the Executive Secretariat. · The governing body would be guided by an inter-country advisory committee that will include members from five countries (representing equally the public sector and civil society organizations). The ICAC Chairman would be Togolese. The committee will provide technical and policy advice, on project implementation. The composition includes key ministries, representatives of the national HIV/AIDS programs, civil society organizations including NGOs (associations of PLWHA or consortia of the NGOs), and the private-for-profit sector. · The program will be managed by an Executive Secretariat, located in Benin and the will be headed by a national of Cote d'Ivoire. The Executive Secretariat will be responsible for: (a) overall coordination and management; (b) preparation of quarterly progress reports; (c) coordinating the appraisal and approval of subprojects; and (d) project monitoring and evaluation. The Executive Secretary, who will lead the Executive Secretariat, will report to the President of the governing body. The Executive Secretary will be responsible for the daily management and project coordination - implemented through both public and private sector implementing partners. The Secretariat will be a small institution staffed with mainly core staff, which may include, among others, an office assistant and a professional translator to cater for the two official languages (French and English) used among corridor member countries. · Given the constraints of time and capacity, some Secretariat functions, including financial management and procurement review, were contracted out to a Management Consultant (firm). The Management Firm was responsible for: (a) financial management and disbursement; (b) procurement management; (c) monitoring and evaluation; and (d) participation in appraisal of community subprojects. It will be expected to have staff with strong financial management, procurement, and monitoring and evaluation, including skills in epidemiological monitoring and evaluation or the capability to manage any of such services which may be contracted out. · Intermediary NGOs: There is a national intermediary agency for each country (none as yet for Cote d'Ivoire given the political situation) that coordinates activities in the country's border town(s) and these five agencies meet across country once a year. · Border HIV/AIDS committees, with membership from both local civil society and local public sector representatives, will be responsible for coordinating local initiatives that are to be financed by the project. Such initiatives will be transformed into proposals 41 that are forwarded to the Executive Secretariat of the project for approval and financing25. In due course it is expected that these committees may evolve into cross-border committees to ensure the liaison of interventions of both sides of a given frontier. · Project activities are implemented through both public and private sector implementing partners. Civil Society Organizations (CSOs) will: (i) mobilize and empower communities along the corridor to address HIV/AIDS; and (ii) provide HIV/AIDS related services to various community groups along the corridor. (b) Public- sector implementing partners will target national agencies responsible for health, transport, police, immigration and customs along the border and local governments at border towns/districts. Governing Body Executive Secretariat Inter Country Advisory Committee Intermediary NGO for country 1 Management Consultant Border HIV/AIDS Committee for town 1 Border HIV/AIDS Committee for town 2 Public sector implementin Civil society Public sector Civil society g agencies agencies implementing agencies agencies 25Small proposals, the magnitude of which will be specified in the operational manual, may be approved by the Border HIV/AIDS committees and will be sent to the Executive Secretariat for financing. 42 Annex C: Financial Data (estimated) FY04 FY05 FY06 FY07 Total Total Disbursement * Planned 3.8 5.9 5.1 3.1 17.9 * Actual 1.39 6.32 - - 7.71 IDA Grant * Planned 3.5 5.5 4.8 2.8 16.6 * Actual 0.97 6.01 - - 6.98 Government Counterpart * Planned 0.30 0.3 0.4 0.3 1.30 * Actual 0.3 0.3 0.13 - 0.73 Source: Midterm Review. 43 Annex D: Goals, Objectives, Outcomes, Outputs, and Activities Mission Objectives Intended Outcomes Outputs Inputs/Activities Contribute Increase · Improve access to HIV/ AIDS · Increased awareness among local 1. Social marketing of condoms in the 8 to the access along prevention services for targeted population on HIV/AIDS prevention. geographic border communities and reduction the Abidjan- populations. along the entire corridor. of the Lagos Indicators: 2. Train HIV/AIDS activists. spread of transport Indicators: 1. Increase by 50%, compared with the 3. Information booths, training and HIV/AIDS corridor to By end 2006: first year of the project, the number of voluntary counseling centers at all and to the HIV/AIDS 1. At least 90% of local population people who use voluntary counseling and borders. mitigation prevention, residing along the corridor can testing centers along the corridor. of the basic identify at least 2 ways in which to 2. Increase by at least 50%, compared with adverse treatment, prevent HIV/AIDS. the first year of the project, the proportion Indicators: social and and support 2. At least 90% of the commercial of commercial vehicle drivers who report 1. By end-2006, train at least 500 economic and care vehicle drivers working along the using a condom in their last act of sexual residents of border towns along corridor impact o f services by transport corridor can identify at intercourse with a non-regular partner in as community HIV/AIDS IEC activists. HIV/AIDS high risk least 2 ways in which to prevent last 12 months. 2. Each border crossing along the corridor along the groups HIV/AIDS. 3. At least 80% of commercial sex workers annually organizes a rally to mark World W African particularly, 3. At least 90% of commercial sex along corridor report using condoms with AIDS Day with participation of residents, transport transport workers along the corridor can clients of the previous week. commercial truck drivers and CSOs from corridor. sector identify at least two ways to 4. Increase by 50%, compared with the both sides of border. workers, prevent HIV/AIDS. first year of the project, the number of 3. Each border crossing has at least one migrant condoms distributed through social voluntary counseling and testing center on population, marketing along the corridor. either side of the border. commercial · Improve access to HIV/AIDS · Strengthen public and private (where · Adequately equip, train and staff the sex workers, treatment, care and social applicable) health care facilities health care facilities. and local support services for targeted identified along the corridor to provide · Provide grants to CSOs (incl. NGOs populations populations. services in the areas of VCT, treatment and the private sector) to undertake living along of STIs (with promotion of the community based initiatives in the corridor, Indicators: syndromic approach) and HIV/AIDS HIV/AIDS care and support. especially at By end 2006: opportunistic infections. · Support the disposal of medical waste border 1. Reduce by 30%, compared with related to the project. towns. the first year of project, the 44 incidence of reported sexually Indicators: Indicators: transmitted (urethritis) infections None. 1. By end 2005, at least 40% of total among male commercial vehicle disbursements to sub-projects will be drivers working along the corridor. through CSOs. 2. Reduce by at least 50% 2. By end 2006, increase by at least 50%, compared with the first year of the compared with the first year of the project, prevalence of gonorrhoea project, the number of trained HIV/AIDS among commercial sex workers counselors working in voluntary along the corridor. HIV/AIDS counseling and testing centers along corridor. · Improved flow of commercial · Reduced time for border crossings · Education of transporters, truckers and passenger traffic along the and border officials on ECOWAS and corridor. The number of informal checks along the ways to increase efficiency of border Indicators: corridor reduced by at least 50%, crossings. This would be through 1. Average time for commercial compared with the first year of the project. training and information kiosks set up vehicles to clear border formalities at the borders. along the corridor is reduced by at · Completion on a study on the analysis least 20% compared with the first of the impediments to smooth flow of year of the project. traffic and implementing its 2. Average time for commercial recommendations. vehicles to clear border formalities at Nigeria-Benin border post is reduced by at least 50% compared with the first year of the project. · Enhanced regional capacity · An integrated HIV/AIDS strategy for · Develop strong HIV/AIDS inter- and cooperation to deal with IEC/awareness policy and treatment country coordination and partnerships HIV/AIDS issues. and care services along transport among governments and other project corridor. stakeholders of the 5 participating countries. Indicators: 1. By end 2004, all countries have adopted a common AIDS strategy for corridor. 45 List Components The project has the following three components: (i) HIVIAIDS prevention services for the targeted population (2.2 million) · Implementation of an integrated HIV/AIDS Information, Exchange and Communication (IEC) policy along the transport corridor; and · Social marketing of condoms in the 8 geographic border communities and along the entire corridor. (ii) HIVIAIDS treatment, care and support services for the targeted population (7.9 million) (a) Strengthening of public and private (where applicable) health care facilities identified along the corridor to provide services in the areas of VCT, treatment of STIs (with promotion of the syndromic approach) and HIV/AIDS opportunistic infections; (b) Provision of grants to Civil Society Organizations (including NGOs and the private sector) to undertake community based initiatives in HIV/AIDS care and support; and (c) Support the disposal of medical waste related to the project. (iii) Project coordination, capacity building and policy development. Both public sector and civil society organizations are key implementers of the project (6.5 million). (a) Development of strong HIV/AIDS inter-country coordination and partnerships among the governments and other project stakeholders of the five participating countries; (b) Implementation of policies for smooth movement of commercial traffic along the corridor; and (c) Capacity building among implementing partners. 46 Annex E: Summary of Regional and Non-regional Issues Regional Non-regional Institutional arrangements were legitimate ­ Implementation delays ­ procurement, included voice and participation of all countries disbursement. and equal distribution of benefits. Right size of governing body ­ at the right level of influence Rationale for regional approach is strong. Weak M&E in border towns Distribution of roles and responsibilities is Better information sharing by the Secretariat. equal and fair. Strong political will or common cause that Strong community involvement in makes regional cooperation imperative. implementation and oversight. Consensus must be balanced with action. Unique and novel AIDS intervention ­ multi- sector and comprehensive HIV/AIDS package. Need for better coordination/communication with national authorities in Ghana. ICC needs to function better. Sustainability ­ creation of a regional institutional basis for further financing Link to other regional institutions Need better incentives for CDs and staff in country offices to work on regional projects. 47 Annex F: Persons Consulted List of Bank Staff Consulted Bank Task Manager Siele Silue TM at approval Stephen Brushett Co-task manager - MAP Progress Review, Health Specialist Sheila Dutta IEG, TM for HIV/AIDS Evaluation Martha Ainsworth Task Team ­ Ghana Health Evelyn Avittor List of Interviewees during Field Visit to Benin, Togo and Ghana A. Project Secretariat Justin Koffi, Executive Secretary Ines Adingni, Team Leader, GTZ (management firm) B. Government Officials Benin AA Caisse Autonome D'Amortissement: Semiou Bakary, Directeur General Rachel Adjibi Gogan, Adinistrateur des Banques Chef Service Mobilisation de Medeiros-Dine Saodator, Directeur Gen Adjoint Benin National AIDs Commission Seclonde Comian Hoispice, CNLS (equivalent of the Aids Commission) Benin Ministry of Health Dr. Zannou Marcel, PNLS (Ministry of Health Dr Olivier Capo Chichi, PPLS ­ Coordinator of the National MAP Program Benin Ministry of Tarnsport Mrs Omichessan, Director Togo Ministry of Health Dr. Adom Wiyoou Kpao Leon, Director Programme National de Lutte Contre le SIDA/IST/PNKS/IST (also chairs ICC) Ghana AIDS Commission Prof. Sakyi Awuku Amoa, Director-General Dr. Sylvia J. Anie, Director Ghana Health Service Dr. Nii Akwei Addo, Program Manager ­ National MAP Program 48 ***, Director Ghana Ministry of Health Ghana Ministry of Transport Dr Richard Anane, Minister of Transport along with several directors C. Religious Groups: N.M. Zinsou-Lawson, Rev. Pasteur Martine-Grace English Methodiste Du Togo Felix Anani Adouayom, Rev. Pasteur English Methodiste Du Togo D. Donors Agbla Felix, Deputy National Coordinator, Canadian International Dev. Agency (CIDA) Dr. Olivier Bienvenu, CIDA Jim Malster, Representant Resident au Benin, Population Services International James Browder, Senior Regional HIV/AIDS Advisor - USAID West Africa Dr. Sosthene Bucyana, Specialiste en HIH/SIDA/IST - USAID Alain Akpadji, Coordinator, UNDP ­ Global Fund, Benin E. Border Towns: The team met with a wide range of stakeholders including local government officials, implementing NGOs, traditional, religious and community leaders, and beneficiary groups in each town. What follows is an illustrative list of stakeholders (in border towns): E.I.B. Okechukwu, President, Action Family Foundation, Benin Doris E. Dugble, Managing Director, Doriop Enterprise, Benin Prof. Fola Tayo, Health Systems Management Consultants. Ltd. Ghana Mabel Tsibu-Nyarko, Technical Manager, Ghana Social Marketing Fund Edim Itakpo, Hope Worldwide Chamberlain Nwachinaemere, CEO, Traders Against HIV/AIDS, Nigeria Agoli-Agbo Pierre, President, FSETRB (NGO) Alh Aderinto Abdul Hakeem, Seme-Border Committee Against HIV/AIDS Camarade Hlomador K. Dodji Mathias, Kpade Codjo Eugene Maire, Mayor, Commune de Grand Popo F. Other Stakeholders: MM. Agoli Agbo, International Association of Transporters for the Abidjan Lagos Corridor. Dr. Justin A. Ofulue, Exec. Secretary, The Professonal Institute of Corporate Drivers Dr Théophile Hounhouédo, President of Network of HIV/AIDS NGOs in Benin - ROBS 49 Annex G: Documents Reviewed 1. Project Supervision Reports­ April 2005, Nov 2004 and April 2004. 2. Aide Memoires from all Supervision Missions and Cover Letters 3. Aide Memoire for the HIV/Aids Project for Abidjan Lagos transport Corridor - Pre- Implementation Mission (June 22-27, 2003). 4. PAD ­ $500 million for HIV/AIDS project for Abidjan Lagos Corridor. 5. ALCO Action Plan 2005 ­ prepared in Jan 2005. 6. Back to Office Report on the Advisory Inter-Countries Committee annual meeting (January 17-18, 2005) and Governing Body annual meeting (January 21-22, 2005) in Lomé (Togo). 7. Africa Transport ­ SSATP Technical note #35. May 2003. 8. Back to Office Report on the HIV/Aids Project for Abidjan Lagos Corridor ­ Preparation Mission (October 13-15, 2003). 9. Back to Office Report on the HIV/AIDS Project for the Abidjan-Lagos Transport Corridor Pre- implementation Mission and Governing Body Meeting in Accra (August 1-8, 2003). 9. HIV/Aids Project for Abidjan Lagos Corridor ­ QER Panel Review Report. Jan 2002. 10. Back to Office Report on the HIV/Aids Project for Abidjan Lagos Corridor ­ Pre Appraisal Mission (Apr 28-May 23, 2002). 11. HIV/Aids Project for Abidjan Lagos Corridor ­ Minutes of the Meeting of the Transitional Working Group (Oct 9-10, 2001). 12. Second Multi-Country HIV/AIDS Program (MAP 2) for Africa, AFR Regional Office, World Bank. January 2002. 50 Annex H: Project Strengths and Weaknesses as identified by Government Officials and Stakeholders in Benin and Ghana Strengths Weaknesses BENIN High degree of country and political Language barriers. Complexity of dealing with commitment. French and English and other local languages in the border towns. Holistic package ­ treatment and prevention. Turnover of staff: Governing Board/uniformed personnel at the borders Multi-sector approach. Need to enhance support staff in Secretariat. Installed in country of peace. Need to use project on main towns in corridor ­ Lome, Cotonou, Accra, and Lagos. Spirit of collaboration with national programs. Can promote greater international cooperation on issues such as research on vaccines, and production and procurement of ARVs. Institutional Framework: Funds should be flexible so we can target same * Role/voice of participating countries in to the level of activity. For instance, instead of governance: at policy and oversight level. transferring the whole care/support may cost * Credibility of the chair and member of the more than prevention. Governing Board such as Prof. Babatunde. * Active involvement of community in implementation and oversight at the local level. * Local capacity building of NGOs * Relevance of the IBFC. Competence of the Secretariat and support staff Effectiveness of Bank support: financing, supporting during design and implementation. Focus on truckers as a special target group. GHANA Institutional Framework: Better communication of the Secretariat with * Role or voice of participating countries in national counterparts in both health and governance at the policy and oversight level. transport. Ensuring consistency with national * Active involvement of community in AIDS program is a challenge at times. More implementation and oversight at the local level. regular flow of information. * Inter-Border Facilitation Committee Epidemiologically, the multi-sector and Does not link to other sub-regional institutions country approach is sound. such as WAHO. Depends on political goodwill to maintain consensus. High degree of political commitment Need for strong data to support claims on change in behaviors. M&E can be improved. Demonstration effect: countries can cooperate The high turnover of staff at the border areas for a common cause if the objectives and scope may be a limitation that requires management as well as actions to be taken are clear and by extra investment on adequate documentation agreed upon. to ease the transition. More deliberate efforts needed to ensure cross- country learning at the technical staff level. 51 Annex I: Summary of Concrete Results listed by Stakeholders in Border Towns Stakeholders Prevention Treatment, Care and Medical Waste Transit time Support Management at Border Seme, Nigeria Greater awareness Care and support for No visible (Benin-Nigeria on HIV/AIDS. orphans of HIV/AIDS impact yet. Border) victims. Increase in condom Increased access to and use. use of VCT services. Krake Plage, Benin Greater awareness Increased access to and Medical staff No visible (Benin-Nigeria of HIV/AIDS. use of VCT services. knows how to impact yet. Border) dispose waste. Reduced stigma on Change in behavior of discussing the issue those testing positive­ with family ready to be referred for members. treatment. Before, they'd commit suicide. Reduced stigma on care and support of any family member who has tested positive. Hillacondji, Benin Increased Increased access to and Knowledge of (Benin-Togo awareness of use of VCT services. medical staff on border) HIV/AIDS ­ even (from 5-7 tests/month waste disposal. among our elders. to 700). 24 hour testing. Even that there are NGOs here ­ "We had 1 NGO before now we have 12." If the demand for condoms is anything to go by, condom use has increased. Sanveekondji, Increased Increased demand for Togo awareness of VCT services. No VCT (Benin-Togo HIV/AIDS. service ­ we refer them border) to Hillacondji. Kradjviakope, Greater awareness Increased access to for Knowledge of No visible Togo of HIV/AIDS. use of VCT services. medical staff on impact yet. waste disposal. Condom use has increased. Aflao, Ghana Greater awareness Awareness of the Better awareness Greater (Togo-Ghana in the community availability of care and among health awareness of border) of HIV/AIDS. support services in the providers, district travelers on community. assembly medical documentation staff and patients. needs. 52 Stakeholders Prevention Treatment, Care and Medical Waste Transit time Support Management at Border Aflao, Ghana Awareness on VCT is not as `scary' No visible (Togo-Ghana benefits of and use as before; increases in impact as yet. border) of condom is number of people increasing. going for VCT. Elubo, Ghana Greater awareness Increased demand for Awareness No (Ghana-Cote in the community VCT services. among some improvements D'Ivoire border) of HIV/AIDS. health officials as yet. on waste. Awareness in Ghana is higher ­ 95% know about HIV/AIDS. Compared to 2003, there is more awareness and use of condoms. Noe, Cote d'Ivoire Greater awareness (Ghana-Cote in the community D'Ivoire border) of HIV/AIDS. 53 Annex J: Summary of Factors Affecting Successful Project Implementation Stakeholders Contributing Factors Impeding Factors Seme, Nigeria The strong political will of the Amount of grant very small to (Benin-Nigeria stakeholders in the community. implement a meaningful program. border) Assigning responsibility to the Duration of project too short to indigenes will help to ensure the ensure continuity, e.g. steady continuity. follow-up on PLWHAs is not possible. BCC/IEC materials printed in different Need to develop other income dialect, helped to get the message generating activities for CSW. across to target audience. Using PLWHAs in the program has greatly reduces stigma. Competence of Secretariat ­ direct access and with Executive Secretary, responsive staff and good communication. Selection of NGOs with track record and experience. Project package/design that includes prevention and treatment and care. Krake Plage, Project package/design that includes Extend the project to include Benin (Benin- prevention and treatment and care. Cotonou which is on the corridor. Nigeria Can't ignore such big cities that are border) `destination' points. Synergy and common strategies for Financial management and IEC/BCC with Seme. procurement procedures are tedious. Strong local commitment. Selection of NGOs with experience. Hillacondji, Design package is an advantage ­ good Important target groups that need Benin continuum of service. attention are the load carriers or (Benin-Togo haulers. They are usually homeless border) and can be exploited. Does not depend on the classical way Border Committees include people of fighting HIV/AID ­ innovative in its from different sections and on a multi-sector design. volunteer basis. Difficult to get them all to meet as often as needed. So information across members varies at times. Involvement of all key players in the Stability of the members is key for community incl. traditional healers. uniform services especially. NGOs are well coordinated into three thematic groups (awareness, treatment/ care, medical waste). No duplication. 54 Stakeholders Contributing Factors Impeding Factors SanveeKondji, Capacity building of local NGOs and Don't have a VCT center ­ no Togo peer educators and counselors in the national program either ­ so we (Benin-Togo area ­ and from different target have to refer our people to Hilla. border) groups is a positive feature of design. Strong community level commitment and participation. Kradjviakope, Togo Local NGOs involvement is very Necessary to adapt the messages (Togo-Ghana helpful. Good coordination ensures no more to the local context. border) duplication and good information sharing and learning from each other. Given that the country has no well- Since situated so close to Lome ­ functioning national program, the difficult to tell the populations apart corridor project fills an important gap. ­ get more coverage but also need to cater to a larger population. Need to translate the OEC material into local languages. Aflao, Ghana Program design ­ not just prevention, Distinguishing between orphans of (Togo-Ghana but treatment and care. Combining AIDS victims from other orphans is border) this with transit time is a great idea. difficult. Strong commitment on the part of Stigma and discrimination of project and the local population. orphans from AIDS makes beneficiary mobilization difficult. Use of experienced NGOs meant Absence of motivation for getting activities underway faster. volunteers and care-givers to sustain their volunteer work especially in the border committees. Coordination of NGOs and their work No permanent VCT site. is a great strength. No final dump for medical waste. Elubo, Ghana Program design: multi-sector and Stigmatization remains very high ­ (Ghana-Cote multi country approach is a good idea. both Elubo and Noe are relatively D'Ivoire border) remote from any big cities. So has been difficult to get the messages across. Competition between border towns People are more illiterate than in and each knows that if the other fails, towns ­ greater need for IEC/BCC it will not serve the cause. Good but material in main local languages healthy competition ensures regular and visual aids. information sharing, joint activities. Need income-generating work for CSW. Need to expand the group of health workers we train on waste disposal. Noe, Cote d'Ivoire Haven't gotten far as yet ­ unlike (Ghana-Cote other border towns. Not much on D'Ivoire border) treatment and care as yet. We refer people to Ghana to test. 55 Annex K: Summary of Selected Activities in Border Towns (as reported to IEG mission team in September 2005) Seme Krake Plage Hillacondji Sanveecondji Kradjviakope Aflao Elubo Noe Border Border Border Committee NGOs Committee NGOs Committee NGOs Background Population of the town 126000 10282 25000 35000 16000 10246 2557 Estimates re migrant population 7000/day Prevention/Awareness: Mass Media Campaigns 97 2 5 5 2 9 * Estimates on persons reached 25973 50000 4500 8500 n/a 3500 Radio Shows 4 55 36 6 6 13 8 2 4 Film Shows 37 319 85 63 2 8 3 1 * Estimates of people reached 11725 1974 1531 515000 520000 10000 Est of people reached on World AIDS Day/Lovelife Caravan 3250 10000 6000 15000 n/a 6000 Nos. of posters, stickers, and IEC materials distributed 70000 32686 16364 32195 2683 1500 2856 2500 2730 13500 Advocacy Meetings * No of meetings 5 1119 30 14 38 15 5 4 * People reached 133 >50000 8863 15880 1222 3227 291 263 80 Outreach/Educational programs * No of programs 2 16 * People reached 3250 1590 Group Chats * No of sessions 134 10 2711 507 258 162 1678 500 * People reached 23212 1246 17279 41815 7088 950 3498 32064 2023 Condoms Sold (male & female) 21144 7680 2372 44892 1228000 96610 Condoms Distributed 90698 105300 91663 71676 16291 44850 19822 86252 40,200 56500 85640 56 Seme Krake Plage Hillacondji Sanveecondji Kradjviakope Aflao Elubo Noe Border Border Border Committee NGOs Committee NGOs Committee NGOs Treatment Workshops * No of workshops 4 * People reached 800 Focus Groups * Number 1848 348 1035 4 * People counselled 623 4174 2280 10840 150 VCT * Nos demanding a test 2922 1518 1243 n/a * Tested for HIV 360 1431 676 279 410 34 2877 * HIV positive 17 151 32 30 23 1 223 * Referred for care and support 17 151 32 30 17 1 0.0775 * STI tested 311 296 12 123 * Diagnosed as positive for STIs 25 246 248 814 1 10 * Treated for STIs 23 246 208 124 n/a * Hepatitis B tested n/a 20 * Referred for Hepatitis B n/a 3 * Nos treated for OIs 2 146 8 10 n/a Nos. counselled - psycho/spiritual 20 59 Care and Support No of support groups 15 96 8 124 n/a No of advocacy sessions 7 78 21 15 Estimates of people reached 434 187 569 n/a Nos reached through house visits 18 76 81 64 100 OVC: * Registered 169 214 76 48 * No receiving care and support 12 96 40 * No of OVS receiving food rations 48 * No of care givers trained 20 57 Seme Krake Plage Hillacondji Sanveecondji Kradjviakope Aflao Elubo Noe Border Border Border Committee NGOs Committee NGOs Committee NGOs * No. of caregivers w/ seed money 16 People Living with HIV/AIDS: * No receiving food rations 20 259 25 * No of care givers trained 25 * Nos w/income generating activity 15 3 Medical Waste Management No of health providers trained 50 18 No of health centers with facilities 20 2 2 No of bins procured and in place 12 60 10 20 82 40 No of pvt collectors 2 30 No of workshops 24 39 86 8 * People reached 418 228 843 235 No.of school sensitization session 2 * People reached 1557 Other Border Committee Meetings 8 7 16 4 6 18 13 6 Apr- Operational Since Sep-04 Feb-04 Apr-05 Feb-04 Apr-05 Feb-04 05 Jul-04 n.a. No of joint BC meetings (w/ other side) 2 2 2 No of joint awareness campaigns 1 2 2 No of peer educators 234 40 180 40 130 66 362 755 100 Training of Peer Educators 57 20 58 Annex L: Lack of Comparable Data from Border Towns Table L.1: No Comparable Data on Border Town Prevention/Awareness Activities Activities Data Range No. of Advocacy meetings Ranges from 4 (Noe) ­ 1119 (Krake Plage) Estimates of people reached through Ranges from 80 (Noe) ­ 50000+ (Krake Plage) advocacy meetings No. of group chats Ranges from 4 (Krake Plage Border Committee) ­ 2711 (Krake Plage NGOs) Estimates of number of people Ranges from 2 in Sanvee Condjee to 173 in Seme reached per group chat No of radio shows Ranges from 2 (Elubo) to 55 (Krake Plage) No of television /documentary shows Ranges from 1 (Noe) to 319 (Krake Plage) Estimates of people reached through 1531 (Hilla Condjee) to 515000 (Sanvee Condjee) radio/TV shows Table L.2: Slow Progress on Voluntary Counseling and Testing Services Activities Achievements No. of people counseled on VCT 18000 (data from 5 towns) No of people tested 3190 (all border towns except Noe and Sanvee Condji) No. of HIV+ cases 254 No of STIs diagnosed 1344 (data from 5 towns) No of STIs treated 601 Table L.3: Slow Progress on Medical Waste Management Activities Achievements No. of bins procured/installed 224 bins in all towns except Noe and Hilla Condji No of health centers with 3 border towns (20 in Krake Plage, 2 in Aflao, 2 in Hilla medical waste mgmt. facilities Condji) No. of health workers trained 68 (only in Seme and Aflao ­ 2 border towns) No of workshops 157 workshops reaching about 1724 people (in 4 out of 8 border towns) wb308751 C:\Documents and Settings\wb308751\My Documents\Final Background Papers\W AFR HIVAIDS Proj. for Abidjan-Lagos Transp. 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