Document of The World Bank Report No: ICR00004035 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-49190) ON A CREDIT IN THE AMOUNT OF SDR 12.8 MILLION (US$20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF NIGER FOR A SECOND HIV/AIDS SUPPORT PROJECT August 31, 2017 CURRENCY EQUIVALENTS (Exchange Rate Effective April 30, 2017) Currency Unit = CFAF US$1 = CFAF 612 SDR 1 = US$1.36 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AIDS /SIDA Acquired Immune Deficiency Syndrome / Syndrome d’Immunodéficience Acquis ARV Antiretrovirals BCC Behavior Change Communication CAS Country Assistance Strategy CCT Conditional Cash Transfer CFAF Communauté Financière Africaine Franc CISLS Coordination Intersectorielle de lutte contre le SIDA (the National Intersectoral AIDS Agency) CFP Call for Proposals CNLS Comité de Lutte contre le SIDA (National AIDS Commission) CRLS Comité Régional de Lutte contre le SIDA (Regional AIDS Commission CSO Civil Society Organization CSW Commercial Sex Worker DHS/EDS Demographic and Health Surveys/Enquêtes Démographiques et de la Santé FAO Food and Agricultural Organization FSW Female Sex Worker GDP Gross Domestic Product GFATM Global Fund to fight AIDS, Tuberculosis, and Malaria GP General Population HIV/VIH Human Immunodeficiency Virus/ Virus d’Immunodéficience Humain HRG High Risk Group IDA International Development Association IEC Information, Education, Communication IEG Independent Evaluation Group IPPF International Planned Parenthood Federation ISHSSP Institutional Strengthening and Health Sector Support Project ISR Implementation Status Report MAP Multi-country AIDS Program for Africa M&E Monitoring and Evaluation MOH Ministry of Health MSM Men who have sex with Men MTR Mid Term Review NGO Non-governmental Organization i NHP National HIV/AIDS Program NSF National Strategic Framework NSP National Strategic Plan ORAF Operational Risk Assessment Framework OVC Orphan Vulnerable Children PAD Project Appraisal Document PBC Performance-based Contracting PDO Project Development Objective PLWHA Person(s) living with HIV/AIDS PMTCT Prevention of Mother-to-Child Transmission PNLS Programme National de Lutte contre le SIDA (National AIDS Program) QER Quality Enhancement Review RBF Results-based Financing RH Reproductive Health RF Results Framework STI/IST Sexually Transmitted Infection/ Infection sexuellement transmise SW Sex worker TB Tuberculosis TTL Task Team Leader ULSS Unité de Lutte Sectorielle Santé / Health Sector Coordination Unit UNAIDS United Nations Joint Program on HIV/AIDS UNFPA United Nations Population Fund UNDP United Nations Development Program UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund VCT Voluntary Counseling and Testing WFP World Food Program WHO World Health Organization Senior Global Practice Director: Timothy Grant Evans Practice Manager: Trina S. Haque Project Team Leader: Djibrilla Karamoko ICR Author and Team Leader: Aissatou Chipkaou ii REPUBLIC OF NIGER SECOND HIV/AIDS SUPPORT PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 7 3. Assessment of Outcomes .......................................................................................... 15 4. Assessment of Risk to Development Outcome......................................................... 23 5. Assessment of Bank and Borrower Performance ..................................................... 24 6. Lessons Learned ....................................................................................................... 26 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 27 Annex 1. Project Costs and Financing .......................................................................... 28 Annex 2. Outputs by Component ................................................................................. 29 Annex 3. Economic and Financial Analysis ................................................................. 32 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 40 Annex 5. Beneficiary Survey Results ........................................................................... 42 Annex 6. Stakeholder Workshop Report and Results................................................... 45 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 46 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 68 Annex 9. List of Supporting Documents ...................................................................... 69 MAP iii A. Basic Information HIV/AIDS Support Country: Niger Project Name: Project 2 Project ID: P116167 L/C/TF Number(s): IDA-49190 ICR Date: 06/30/2017 ICR Type: Core ICR Lending Instrument: SIL Borrower: REPUBLIC OF NIGER Original Total XDR 12.80M Disbursed Amount: XDR 12.79M Commitment: Revised Amount: XDR 12.80M Environmental Category: B Implementing Agencies: The National Intersectoral AIDS Agency (CISLS) Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 03/18/2010 Effectiveness: 08/10/2011 09/09/2011 06/23/2014 08/22/2014 Appraisal: 03/10/2011 Restructuring(s): 03/04/2016 03/13/2016 Approval: 04/26/2011 Mid-term Review: 06/30/2014 03/17/2014 Closing: 06/30/2016 12/31/2016 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Substantial Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: iv C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry No None at any time (Yes/No): (QEA): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Moderately NA NA Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Major Sector/Sector Public Administration Public administration - Health 15 15 Compulsory health finance 25 25 (Historic)Health and other social services Other social services 18 18 Health 42 42 Major Theme/Theme/Sub Theme Human Development and Gender Disease Control 100 100 HIV/AIDS 100 100 E. Bank Staff Positions At ICR At Approval Regional Vice President: Makhtar Diop Obiageli Katryn Ezekwesili Acting Country Director: Paola Ridolfi Mary Kathryn Hollifield Practice Manager: Trina S. Haque Eva Jarawan Project Team Leader: Djibrilla Karamoko Djibrilla Karamoko ICR Team Leader: Aissatou Chipkaou ICR Primary Author: Aissatou Chipkaou F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The objective of the Project is to increase access to HIV/AIDS and STI-related services by high- risk groups in the Recipient's territory. v Revised Project Development Objectives (as approved by original approving authority) NA (a) PDO Indicator(s) The table below contains a total of 33 indicators: 20 original, 9 new indicators added during the August 2014 restructuring and 4 added at ICR stage (fourteen indicators were dropped1 during the restructuring but thirteen are included in this table for clarity). The assessment of the PDO uses information on the achievement of indicators by two project phases, before and after restructuring. The table below identifies the achievement of each indicator for the phase it measures. Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Indicator 1: Sex workers using a condom at their most recent sexual encounter Value 94.8% (8/22/2014) quantitative or 84.66% 90% 95% 88.60% Qualitative) (12/31/2016) Date achieved 12/31/2008 06/30/2016 08/22/2014 12/31/2016 Original – Target Surpassed (190%) for Phase 1; not achieved (38%) for Phase 2. The target for this indicator was revised from 90% to 95% during the 2014 restructuring, given the fact that this indicator achieved a higher percentage during three consecutive Comments years: 2012 (94%); 2013 (94.8%) and 2014 (94.8 %). However, the percentage dropped (incl. % from 94.80% in 2015 to 88.60% in 2016. This drop is mainly due to the methodology achievement used to collect the information for the indicator by asking whether the condom has always /sometimes/never been used during sexual intercourse with casual partners during a specified period of time is subjected to a recall bias. Indicator 2: Pregnant women living with HIV who received antiretroviral to reduce the risk of MTCT Value quantitative or 1,603 2800 1,301 Qualitative) Date achieved 12/31/2009 06/30/2016 08/22/2014 Original - Not achieved. Phase 1. This indicator was dropped in 2014 and replaced by a new indicator #5 (see below) using the % rather than the number and the mention of Comments "complete prophylaxis� was included. The drop in this indicator is explained by the (incl. % introduction in 2016 of the new treatment protocol in the sector and the use of a new achievement definition of this indicator. In order to have a complete prophylaxis treatment, the positive women would need to take 2 to 3 medicines (ARV) instead of 1 which was the requirement before the introduction of the new protocol. Source: GARP Reports. 1 This includes the sub-indicator: Supply Chain Management vi Indicator 3: Adults and children with HIV receiving ARV therapy Value quantitative or 7,445 9,300 11,286 Qualitative) Date achieved 12/31/2009 06/30/2016 08/22/2014 Comments Original - Target surpassed (207%). Phase 1. Indicator dropped during the 2014 (incl. % restructuring. Source ULSS Annual Reports. achievement Indicator 4: Number of sex workers treated for STI Value 0.00 quantitative or NA 5,000 12,621 Qualitative) Date achieved 12/31/2011 NA 08/22/2014 12/31/2016 Comments New - Target surpassed (252%). Phase 2. Indicator added during the 2014 restructuring. (incl. % Source CISLS/NGO. achievement) Percentage of positive pregnant women who received a complete prophylaxis treatment Indicator 5: for mother-to-child transmission Value quantitative or 10.4% NA 25% 35% Qualitative) Date achieved 12/31/2011 NA 08/22/2014 12/31/2016 New - Target surpassed (168 %). Phase 2. Indicator revised during the 2014 restructuring. It replaced the indicator measuring the number of pregnant women living Comments with HIV who received antiretroviral for MTCT. The number of pregnant women (incl. % receiving ARVs does not necessarily reflect improvement in service delivery. The achievement) indicator expressed as a percentage gives more insight on improvement on HIV/AIDS positive pregnant women treated. The baseline for the new indicator (49.4) and the target (55) in RP were a typo. The correct values are the ones above. Source PMTCT Reports Percentage of migrant workers with more than one partner in the past 12 months who Indicator 6: used a condom the last time they had sex Value quantitative or 45.20% 80% 92.4% Qualitative) Date achieved 12/31/2011 06/30/2016 12/31/2015 Comments New – Target surpassed (135%). This indicator was added at ICR stage to supplement the (incl. % RF to better assess the progress against the PDO. The target comes from the National achievement) Strategic Plan (2013-2017). Source: SSG reports 2011 & 2015. Percentage of (military, security forces) men and women aged 15-49 who had more than Indicator 7: one partner in the last 12 months and used a condom the last time they had sex Value quantitative or 50.90% 80% 91.50% Qualitative) Date achieved 12/31/2011 06/30/2016 12/31/2015 vii New – Target surpassed (139%). This indicator was added at ICR stage to supplement the Comments RF to better assess the progress against the PDO. This indicator was added at ICR stage to (incl. % supplement the RF to better assess the progress against the PDO. Source: SSG reports achievement) 2011 & 2015. Percentage of miners men and women aged 15-49 who had more than one partner in the Indicator 8: last 12 months and who used a condom the last time they had sex Value quantitative or 43.20% 80% 97.20% Qualitative) Date achieved 12/31/2011 06/30/2016 12/31/2015 New – Target surpassed (146%). This indicator was added at ICR stage to supplement the Comments RF to better assess the progress against the PDO. This indicator was added at ICR stage (incl. % to supplement the RF to better assess the progress against the PDO. Source: SSG reports achievement) 2011 & 2015. Percentage of truckers men and women aged 15-49 who have had more than one partner Indicator 9: in the past 12 months and who have used a condom during the last intercourse Value quantitative or 63.50% 80% 80.70% Qualitative) Date achieved 12/31/2011 06/30/2016 12/31/2015 New – target achieved. This indicator was added at ICR stage to supplement the RF to Comments better assess the progress against the PDO. This indicator was added at ICR stage to (incl. % supplement the RF to better assess the progress against the PDO. Source: SSG reports achievement) 2011 & 2015. (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Achieved Values (from Indicator Baseline Value Revised at Completion or Target approval Target Values Years documents) Component One: Strengthening Health Services Delivery for HIV/AIDS and STI Subcomponent 1.1 Improving the quality and availability of service delivery Indicator 1: Health personnel receiving training Value 7,500 8,483 (quantitative 0 or Qualitative) Date achieved 12/31/2011 06/30/3016 12/31/2016 Comments (incl. % Original – Target surpassed (113%). achievement) Indicator 2: TB patients test for HIV Value 0 (quantitative 80% 63.3% or Qualitative) Date achieved 05/20/2011 06/30/2016 08/22/2014 viii Original - Partially achieved (80%) – Phase 1. Indicator dropped during the 2014 Comments restructuring because the project did not intervene in the area of TB treatment HIV co- (incl. % infection. Source: Statistics directories/PNLT Report. achievement) Indicator 3: Sex workers screened for sexually transmitted diseases Value 0 (quantitative 4,000 4,907 or Qualitative) Date achieved 05/20/2011 06/30/2016 08/22/2014 Comments Original - Target surpassed (122%). Phase 1. Indicator dropped during the 2014 (incl. % restructuring. Source: CISLS/NGO. achievement) Health facilities offering PMTCT services Indicator 4: Value (quantitative 245 493 819 or Qualitative) Date achieved 12/31/2010 06/30/2016 08/22/2014 Comments Original - Target surpassed (231%). Phase 1 - Indicator dropped during the 2014 (incl. % restructuring because the project did not support directly the creation of PMTCT sites. achievement) Sources: PTME Reports. ART treatment sites offering high quality services Indicator 5: Value 44 (quantitative 12 17 or Qualitative) Date achieved 12/31/2009 06/30/2016 08/22/2014 Original - Target surpassed (640%). Phase 1. Indicator dropped during the 2014 Comments restructuring because the project did not support directly creation of ART treatment (incl. % sites. Source: ULSS Reports. achievement) Health facilities offering high quality HIV counseling and testing and referral services Indicator 6: Value 270 546 1,018 (quantitative or Qualitative) Date achieved 12/31/2010 06/30/2016 08/22/2014 Comments Original - Target surpassed (271%). Phase 1. Indicator dropped during the 2014 (incl. % restructuring because the project did not support directly VCT. Source: ULSS Report. achievement) ARV treatment centers with ARV products stocked out in at any time during the past Indicator 7: 12 months. Value (quantitative 5/12 0 0 or Qualitative) Date achieved 12/31/2009 06/30/2016 08/22/2014 Comments Original - Achieved. Phase 1. Indicator dropped in the 2014 restructuring. Global (incl. % Fund and Government fund ARV. Source: ULSS Reports. ix achievement) Number of pregnant women tested for HIV and who know their results during the past Indicator 8: year Value 0 278,457 354,098 (quantitative NA or Qualitative) Date achieved 05/20/2011 08/22/2014 12/31/2016 New - Target surpassed (127%) – Phase 2. Indicator added during the 2014 Comments restructuring. In 2014 the number was 278,457 and at the end of the project 354,098 (incl. % (Pregnant Women just tested not treated). Sources GARP Reports. achievement) Indicator 9: Number of sex workers seen at health facilities after referral by NGOs Value 0 (quantitative 7,500 12,907 NA or Qualitative) Date achieved 05/20/2011 08/22/2014 12/31/2016 Comments New - Target surpassed by (172%) – Phase 2.- Indicator added during the 2014 (incl. % restructuring. Source CISLS/NGO. achievement) Subcomponent 1.2. Piloting of Output-based financing for HIV/AIDS Services RBF pilot design validated by Government of Niger/MOH/CISLS Indicator 10: Value (quantitative YES/NO YES YES or Qualitative) Date achieved 05/20/2011 06/30/2016 12/31/2016 Original - Achieved. Phase 1&2. The RBF Planned to start in 2011 could only be Comments launched in 2014. Effective implementation began in July 2015 with the signing of the (incl. % first contracts with the health centers. Source: Manual of RBF Implementation in achievement) Niger. Indicator 11: RBF contracts signed with health centers Value (quantitative 0 0 27 or Qualitative) Date achieved 05/20/2011 06/30/2016 12/31/2016 Original - Achieved. Phase 1&2. The target is 0 because at the beginning of the project, it was difficult to determine the number of the health center that will be Comments covered by the RBF. (incl. % Source: Narrative report of one-year implementation of RBF in the Health District of achievement) Boboye. Pilot health districts with RBF results fully verified by independent third party Indicator 12: Value 0% 100% 100% (quantitative or Qualitative) x Date achieved 05/20/2011 12/31/2016 Comments Original – Target Surpassed. Phase 1 & 2 - Source: Reports of one-year (incl. % implementation of RBF in Boboye achievement) Component two: Prevention of HIV/AIDS and STI for high-risk group Orphan Vulnerable Children receiving care and Support Indicator 13: Value 0 95.8% (quantitative 80% or Qualitative) Date achieved 05/20/2011 06/30/2016 08/22/2014 Comments Original - Target Surpassed (119%). Phase 1. Indicator dropped during the 2014 (incl. % restructuring because the project did not support OVC. Source CISLS/NGO Reports. achievement) People in high-risk groups correctly identifying ways to prevent HIV and correctly Indicator 14: reject misconceptions Value (quantitative 10.89% 50% 32.9% or Qualitative) Date achieved 05/20/2011 12/31/2014 08/22/2014 Original - Not achieved (56%). Phase 1. Indicator dropped during the 2014 Comments restructuring because it was a composite indicator and was difficult to measure. Source (incl. % SSG Reports 2011 and 2015. achievement) Indicator 15: People in high-risk groups and PLWHA receiving peer education Value (quantitative 0 30,000 33,388 or Qualitative) Date achieved 05/20/2011 06/30/2016 08/22/2014 Original - Target surpassed (111%). Phase 1. Indicator dropped during the 2014 Comments restructuring because it was difficult to determine the real number of people reached (incl. % since many of them were counted more than once. Source CISLS/NGO Reports. achievement) Indicator 16: Peer educators providing peer education for HIV prevention to high-risk groups Value 0 2,000 (quantitative 2,555 or Qualitative) Date achieved 05/20/2011 12/31/2014 01/15/2015 Comments Original – Target Surpassed (128%). Phase 1 – Indicator dropped during the 2014 (incl. % restructuring. achievement) Indicator 17: PLWHA, sex workers and their clients trained as peer educators for HIV prevention Value 0 2000 2,185 (quantitative or Qualitative) Date achieved 05/20/2011 12/31/2014 01/15/2015 Comments Original – Target Surpassed (109%). Phase 1. Indicator dropped during the 2014 (incl. % restructuring. Source CISLS/NGO Reports. xi achievement) Indicator 18: Number of condoms distributed to sex workers by NGOs Value 0 (quantitative 3,694,375 3,410,286 or Qualitative) Date achieved 12/31/2013 08/22/2014 12/31/2016 New - Achieved (92%). Phase 2 - Indicator added during the 2014 restructuring. Target =5911*5*25*10*50% Comments 5= Estimated number of condoms/day (incl. % 25 =Estimated number of working days/month achievement) 10=Estimated number of months worked in year 50%=Objective of the needs covered by the project Indicator 19: Number of sex workers referred to health facilities for services by NGOs Value 0 (quantitative 10,000 16,558 NA or Qualitative) Date achieved 05/20/2011 08/22/2014 12/31/2016 Comments New - Target surpassed (165%) – Phase 2. Indicator added during the 2014 (incl. % restructuring. Source: CISLS/NGO Reports. achievement) Number of sex workers and their clients who participate in at least five prevention Indicator 20: awareness sessions Value 0 (quantitative 5,000 18,056 or Qualitative) Date achieved 05/20/2011 08/22/2014 12/31/2016 Comments New - Target Surpassed (361%). Phase 2. Indictor added during the 2014 (incl. % restructuring. Source: CISLS/NGO Reports. achievement) Component three: Management, Monitoring and Evaluation Indicator 21: Direct project beneficiaries Value (quantitative 0 45,000 125,521 or Qualitative) Date achieved 12/31/2009 06/30/2016 12/31/2016 Comments Original - Target surpassed (278%) for both Phase 1 & 2- Source CISLSS/NGO (incl. % Reports. achievement) Indicator 22: Female beneficiaries Value 65% (quantitative 66% 0 or Qualitative) Date achieved 12/31/2009 06/30/2016 12/31/2016 Comments Original – Target Surpassed (101%) for both Phase 1 &2. Source CISLSS/NGO (incl. % Reports achievement) Indicator 23: Number of reports produced by the national program according to the agreed standards Value 0 NA 4 13 xii (quantitative or Qualitative) Date achieved 05/20/2011 08/22/2014 12/31/2016 Comments New - Target Surpassed. Phase 2. Indicator added during the 2014 restructuring. (incl. % Source: CISLS/NGO Reports. achievement) Indicator 24: Number of stakeholder meetings per year at central and regional levels Value (quantitative 0 NA 12 19 or Qualitative) Date achieved 05/20/2011 08/22/2016 12/31/2016 New - Target Surpassed. Phase 2. Indicator added during the 2014 restructuring. Comments These include coordination meetings, orientation workshops and annual reviews. (incl. % Source: CISLS/NGO Reports. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 09/10/2011 Satisfactory Satisfactory 0.00 2 04/03/2012 Satisfactory Satisfactory 1.83 3 11/19/2012 Satisfactory Satisfactory 2.29 4 05/25/2013 Moderately Satisfactory Moderately Satisfactory 3.77 5 12/23/2013 Moderately Satisfactory Moderately Satisfactory 8.11 6 05/17/2014 Moderately Satisfactory Moderately Satisfactory 8.11 7 11/15/2014 Moderately Satisfactory Moderately Satisfactory 10.11 8 05/13/2015 Moderately Satisfactory Moderately Satisfactory 10.11 9 11/06/2015 Moderately Satisfactory Moderately Satisfactory 16.17 10 05/23/2016 Moderately Satisfactory Satisfactory 18.27 11 12/01/2016 Moderately Satisfactory Moderately Satisfactory 18.27 H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Key Approved Restructuring Date(s) Changes Made PDO Change DO IP in USD millions Level 2 restructuring consisted of change to (i) the Results 08/22/2014 N MS MS 8.11 Framework; (ii) Reallocation of proceeds; and (iii) Institutional arrangement change. Level 2 restructuring to extend 03/13/2016 N MS MS 18.27 project-closing date by 6 months to xiii allow Government to complete the remaining activities. I. Disbursement Profile xiv 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Niger is a large, poor, landlocked country in sub-Saharan Africa endowed with substantial natural resources. The gross national income per capita was estimated at US$368 in 2010. In 2010, real Gross Domestic Product (GDP) growth reached 7.5 percent. On the outskirts of the Sahara Desert, Niger faces recurrent droughts, and only about 12 percent of all its land is arable; rainfall in these areas averages less than 350 mm per year. In 2010, UNDP’s Human Development Report ranked Niger 167th out of 169 countries. Poverty is more acute though not limited to rural zones, with 63.9 percent of the rural population being poor and 30.3 percent extremely poor. However, the country is endowed with important mineral resources such as uranium, gold, and oil. Niger is the fifth largest producer of uranium in the world. 2. Niger faces challenges to meet the health needs of its young and growing population. Niger has one of the world’s highest population growth rates (3.7 percent per year). The population was estimated at 15.2 million in 2010. On average, women give birth to seven children over the course of their reproductive lifetime. Niger’s population is concentrated in the southern region of the country, as the northern two-thirds of the country is desert land. Over the last quarter century, desertification has pushed more Nigeriens to seek economic opportunities in urban zones. The population is very young; half of Nigeriens are under the age of fifteen, and two-thirds are under 25 years old. While the gross primary school enrolment rate had increased significantly from about 29 percent in the early 1990s to 68 percent in 2009, over 70 percent of adult Nigeriens are illiterate. The health sector struggles to meet the needs of the population, with a majority of households citing lack of financial means (65 percent), transport difficulties (51 percent) and distance (51 percent) as significant constraints to their ability to access care. Another challenge that the country was facing in 2011 was responding to people and communities affected by HIV/AIDS. 3. In 2011, overall HIV prevalence was still low and relatively stable (about 0.8 percent among adults2 in 2002 and 0.7 percent in 2006 – DHS3) the rates were worrisome among high-risk transmitters. For example, one in four Nigerien sex workers and one in five persons with tuberculosis was HIV-positive (CISLS 2008). In order to most effectively and efficiently break the chain of transmission and prevent new infections, it was felt that interventions should be aligned with the epidemiological trends and HIV transmission mode in the country. A socio-geographic mapping of hotspots for HIV transmission was undertaken by the University of Laval in Quebec during project preparation 4 . Zones where new HIV infections were observed were in Niamey and the urban areas of the regions of Diffa, Tahoua, and Agadez (where a large uranium mine and military base are located). Towns in the Maradi and Zinder regions that share a border with Nigeria 2 Niger, CARE-CERMES, Enquête Nationale de séroprévalence à l’infection à VIH/SIDA dans la population générale de 15 -49 ans, 2002 3 DHS, Demographic and Health Survey 4 Niger: Synthesis Reports of HIV/AIDS, 2011 1 (where HIV prevalence is 3.1 percent) also presented high HIV prevalence among sex workers. In Maradi, about three in five (60.6 percent) sex workers were HIV-infected. Niamey, Zinder, Maradi, and Tahoua include 84 percent of sex workers in Niger. Other sub-populations with a documented HIV prevalence above the general population were divorced women (6.4 percent), widowed women (3.9 percent), military (3.8 percent), prisoners (2.8 percent), pregnant women (2.02 percent), truck drivers (1.83 percent), non- military security forces (1.56 percent), teachers (1.4 percent) and migrants (1.03 percent). 4. Niger’s low education, high fertility, and young population (52 percent were less than 15 years old) made it critical to contain the HIV/AIDS epidemic and control STIs. Cultural norms pushing for large families and limited demand for family planning, sexual and reproductive health services made it challenging to reach the population of reproductive age. Niger’s high illiteracy rates and high levels of poverty also inhibited individuals from obtaining reliable information about HIV and AIDS, thus reducing their opportunity for prevention and care. The 2006 DHS showed that only 16 percent of males and 13 percent of females aged 15-24 years could correctly identify modes for HIV transmission and reject misconceptions about it. The low socioeconomic status of women further prevented them from seeking health care. If a pregnant woman was the first in her family to be tested for HIV during the antenatal care in the context of PMTCT, she would be stigmatized by her husband and family, increasing her vulnerability. 5. Extensive internal and external migration patterns – of truckers, merchants, security forces, miners and other men – and the context of society’s overall poverty were risk factors for HIV. As desertification and fewer agricultural opportunities led more Nigeriens to migrate to urban zones and surrounding countries, hotspots were intensified in cities and along main roads as higher risk behaviors for HIV transmission increased. At appraisal, in 2011, the high-risk behavior of an increasing number of mobile female merchants was also a concern of the Nigerien AIDS authorities. Migration, particularly seasonal migration, also made it more difficult for Nigeriens to regularly access health care and follow up. 6. Government Strategy to fight HIV/AIDS. At the time of appraisal, the Government’s National Strategic Plan for HIV/AIDS (2002-2006) was updated for 2008- 2012 and adopted by decree5 after a consultative process with stakeholders and technical support by ASAP6. The objectives remained identical to earlier goals: (i) to promote a multisectoral approach and make the coordination in the national response to HIV/AIDS/STI appropriate and effective within the framework of the “Three ones� 7; (ii) to reduce the prevalence rate in the general population and among specific groups; (iii) to reduce the economic and social impact of HIV/AIDS; (iv) to reduce the prevalence of sexually-transmitted infections (STIs) among the general population and among vulnerable groups; (v) to strengthen the prevention of sexually transmitted, blood- transfusion and drug injection-induced, and mother-to-child transmitted infection of HIV; 5 Decree No2009-074/PRN/MSP of February 26, 2009. 6 ASAP: AIDS Strategy and Action Plan team supported the strategy finalization and its costing (World Bank). 7 The “Three Ones� principles are: (i) One agreed HIV/AIDS Action Framework; (ii) One National AIDS Coordinating Authority; (ii i) One agreed country-level Monitoring and Evaluation System. 2 (vi) to improve counseling and testing for HIV; (vii) to improve the medical treatment and care of people infected with and affected by HIV/AIDS, including orphans and other children; and (viii) to strengthen the production and sharing of strategic information in order to build a sustainable M&E system in the sector. 7. Implementation of the national strategy was based on an institutional mechanism enabling the involvement of all key players with specific roles and responsibilities. This implementation structure consisted of : (i) The National Council for the Control of HIV/AIDS/STI (CNLS): National decision-making body, chaired by His Excellency the President of the Republic with dismemberments at decentralized levels; and (ii) The Intersectoral Coordination of HIV/AIDS/STI Control (CISLS): the central management and coordination body of the program, with divisions in the ministerial sectors and regions; and The Steering Committee: a body to monitor the implementation of the National Multisectoral Plan. In the sectoral ministries, the Ministry of Health (MoH) has its own HIV/AIDS coordination body (ULSS – Unité de Lutte Sectorielle Santé) which aims to coordinate the implementation of all prevention and care activities related to IST/HIV/AIDS. 8. Rationale for Bank involvement: The Second HIV/AIDS Project support, approved in 2011, was a part of the broader continuous effort by the World Bank and the entire development community to improve Niger’s health outcomes as well as to increase the utilization of prevention services by high-risk groups. From 2003-2009, the Bank financed the first HIV/AIDS Project, US$25 million, the outcome of which was rated as Moderately Unsatisfactory 8 by IEG in December 2010 9 . At its closure, the GFATM committed US$23 million to the national program to support treatment and prevention activities in the country until June 2012. The rationale to support the follow-on project by the Bank was mainly to ensure the continuation of the efforts made under the first HIV/AIDS Project to complement the prevention activities and to help mobilize the needed resources for the NSP. Therefore, the Bank’s US$20 million support to the second HIV/AIDS was critical to the program in order to continue and reinforce efforts already made as well as to expand support for STI control, care of people living with HIV/AIDS (PLWHA), and more intensive targeting of prevention measures to high-risk groups. Indeed, the Bank’s financing also had the advantage of needed flexibility to finance activities, including treatment, as a donor of last resort, if and when there were gaps in the program financing. Lastly, the Bank was also uniquely positioned to share its cross-country experiences in the design, implementation and evaluation of the Bank’s Multi-Country AIDS Programs (MAP) 2005. By appraisal, the Interim Review of the MAP was completed and the Bank team was able to incorporate some of the lessons of the review into the design of the project, particularly the high cost-effectiveness of prevention interventions focused on high risk groups. 8 The Outcome was rated Moderately Unsatisfactory as there were limited outcomes in strengthening national capacity to combat HIV/AIDS, and there was little evidence of efficiently-achieved outcomes. 9 IEG ICR Review, Date Posted: 12/28/2010 3 1.2 Original Project Development Objectives (PDO) and Key Indicators 9. The objective of the Project was to increase access to HIV/AIDS and STI-related services by high-risk groups in the Recipient’s territory. 10. The project’s original indicators included three PDO indicators and sixteen intermediate outcome indicators (IOIs). The PDO indicators were: (i) number of pregnant women living with HIV who received antiretroviral to reduce the risk of Mother-to- Child-Transmission; (ii) number of adults and children with HIV receiving antiretroviral therapy; and (iii) percentage of sex workers using a condom in their most recent sexual encounter. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 11. While the PDO remained the same, the RF was revised to include new indicators that better measured project performance with regard to activities targeting high-risk groups and the support made to the mother to child transmission program (PMTCT). The new PDO indicators added at the August 2014 restructuring were: (i) number of sex workers treated for STI; (ii) percentage of positive pregnant women who received a complete prophylaxis treatment for the mother-to-child transmission. In addition, the restructuring revised the RF by dropping two of the three PDO indicators: “number of pregnant women living with HIV who received antiretroviral to reduce the risk of MTCT and “number of adults and children with HIV receiving antiretroviral therapy�. Twelve intermediate outcome indicators were dropped10 and seven new intermediate indicators were added to better reflect project achievement. 1.4 Main Beneficiaries 12. The direct beneficiaries of the project were the high-risk groups: sex workers, their clients (truckers, miners and military and security forces, etc.), TB patients, and people living with HIV/AIDS (PLWHA), of which 60,000 estimated persons were HIV positive at time of appraisal, including mothers and children who would benefit from treatment of vertical transmission. The estimated 25,000 AIDS orphans and vulnerable children (OVC) would also benefit through social protection activities. Indirect beneficiaries of the project included health care workers as the Ministry of Health would strengthen its capacity for service delivery and health systems strengthening. The national AIDS coordination entity, the Coordination Intersectorielle de lutte contre le SIDA (CISLS and the MoH HIV/AIDS coordination body (ULSS), would benefit from increased capacity for program coordination, monitoring and evaluation, and program implementation. 10 This includes the sub-indicator: Supply Management 4 1.5 Original Components 13. The Project had three components. Component 1: Strengthening health services delivery for HIV/AIDS/STI (US$10.0 million) – implemented by the Health Sector Coordination Unit of the Ministry of Health. This component consisted of two subcomponents: Subcomponent 1.1: Improving the quality and availability of health service delivery, by: (a) Improving the quality of services provided by HIV/AIDS and STI testing, care and treatment centers in the Recipient's territory, through the provision of tests, drugs and equipment, and the training of medical staff in said centers; (b) Improving the management of the supply chain to support HIV/AIDS treatment, through: (i) the carrying out of an assessment of the MOH’s strengths and weaknesses for the management of the HIV/AIDS treatment supply chain; and (ii) the provision of equipment (including information technology equipment and software) and training to address weaknesses identified by said assessment; (c) Improving biosafety in HIV/AIDS and STI testing, care and treatment through the provision of training and equipment for the implementation of the Waste Management Plan; (d) Strengthening the prevention of mother-to-child transmission, through the provision of contraceptive, tests, drugs and equipment to health centers involved in providing reproductive health services, and the training of their medical staff; (e) Strengthening HIV/TB service integration, through the provision of tests, equipment and training to increase the percentage of TB patients tested for HIV, and the percentage of HIV-positive people screened for TB; and (f) Developing a second-generation surveillance of AIDS cases, new HIV infections, behaviors and characteristics of people at high risk, through: (i) the carrying out of an assessment of the strengths and weaknesses of the current surveillance system (including a proposal for the development of a second-generation surveillance system); (ii) the identification of health centers for the collection of data; and (iii) the development of tools, provision of equipment (including information technology equipment and software, as well as laboratory equipment) and training of staff in data collection and analysis. Subcomponent 1.2: Piloting the output-based financing11 of HIV/AIDS services: Implementation of Component 1.2. « Piloting the output-based financing of HIV/AIDS services� was done through supply side RBF 11 modalities/technics. 5 During project preparation, Government showed interest after a study trip to Rwanda, to implement RBF in the health sector broadly. Their engagement and interest was highlighted in the sector policy and adopted as a key sector reform in the National health development plan 2011-2015. RBF was included as a promising means for improving health services by improving their availability and quality to help achieve the MDGs in Niger. This sub-component was to pilot the RBF mechanism in the health sector, including HIV/AIDS services. The RBF pilot would rely on a robust verification system of the delivery of the Minimum Package of services (Curatives consultations; skill birth attendance; use of contraceptive; HIV testing; prenatal consultation; post-natal consultation; nutrition of child under 5.) This sub-component included the following 2 sub-tasks: (a) In the first two years, carrying out a feasibility study of the output-based financing of HIV/AIDS services, and based on the outcome of a feasibility study, developing tools, resources and capacity for the output-based financing of HIV/AIDS services, including: (i) the preparation of the Output-based Financing Procedures Manual; (ii) the selection and recruitment of the Independent Evaluator; and (iii) the provision of training to the staff involved in the provision of HIV/AIDS services in selected health facilities. (b) After the implementation of the activities included in Part 1.2(a) of the Project, implementing output-based financing of HIV/AIDS services, through: (i) a pilot for the provision of Output-based Grants to selected centers providing HIV/AIDS services; and (ii) after implementation of the pilot referred to in paragraph (i) immediately above in a manner acceptable to the Association, the provision of Output-based Grants to all centers providing HIV/AIDS services in the Recipient's territory. Component 2: Prevention of HIV/AIDS/STI for high-risk groups (US$7.0 million) – implemented by the Inter-Sectoral Program Coordination Unit. This component consisted of carrying out prevention activities for (i) the prevention of HIV/AIDS/STI targeting sex workers and/or their clients; and (ii) the provision of support to AIDS orphans (including children of sex workers). Component 3: Management, monitoring and evaluation (US$3.0 million) - implemented by the Inter-Sectoral Program Coordination Unit. This component aimed to strengthen CISLS capacities in management and coordination of activities in the fight against HIV/AIDS/STI subsector through the provision of administrative, management and fiduciary support, capacity building at the central, regional and local levels, technical support to enhance the design of policies and strategies and implement monitoring and evaluation. 1.6 Revised Components 14. No changes were made to Project components or proposed activities. 1.7 Other significant changes 15. There were two project restructurings: 6 First Project Restructuring (approved on August 22, 2014). This included: (1) reallocation of funds from category 1 and the unallocated funds to category 3 in order to complete the expenditure in Category 3 on prevention activities targeting high-risk groups and to allocate the remaining unallocated funds to the RBF pilot program in one District; (2) revision of the Results Framework (refer to section 1.3 above); (3) change in implementation arrangement with the shift of the procurement responsibilities from the Ministry of Health to the CISLS in order to expedite the procurement planned under Component 1. Second Restructuring (approved on March 13, 2016) extended the project Closing Date by six months to allow the Government to complete all activities including those related to project evaluation specifically: (i) the results evaluation on the activities implemented in the targeted groups; (ii) the evaluation of the RBF pilot implemented under the project; (iii) the preparation of the transition phase with the mobilization of all in-country partners to support the program; and (iv) the completion of the project evaluation report. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 16. Soundness of background analysis and incorporation of lessons learned . This follow-on project benefited from a number of lessons learnt from the implementation of previous Bank-financed projects, as well as from the Bank’s Independent Evaluation Group comprehensive (IEG) assessment of the Bank’s assistance for HIV/AIDS control (2005) whose recommendations included the need to reduce the breadth of multisectoral engagement and focus on key high risk population groups, both of which better align with epidemiological trends and HIV transmission modes. During the preparation of this second operation, the Bank assisted the government to better align its response strategy with the modes of transmission of the epidemic, to target high-risk groups, and to use preventive interventions that were known to be successful. The project design was guided by lessons from the first HIV/AIDS project. Key lessons noted in the first project and reflected in the project design included: (i) the need for strong leadership and commitment for the National AIDS program financing and implementation; (ii) the importance of clarifying Institutional arrangements early on and to develop guidelines for the call for proposals and the Performance-based contracting (PBC) approach; and (iii) the need for good baseline data for proper project design and monitoring. 17. Assessment of Project Design. Project preparation was highly participatory, based on consultations with a wide range of stakeholders such as: government officials, Civil Society Organizations (CSOs), NGOs, and Development Partners (DPs) to identify key areas of support for the new project, the design was also heavily influenced by: (i) the prevailing coordination role that the CISLS played which made it logical to have the CISLS as lead agency; (ii) the role of MoH in leading the health sector response to HIV gave it a significantly larger responsibility than in the first generation HIV/AIDS projects. The project design was based on implementation experience from the first project which 7 focused on using of existing capacity for implementing programs that would had the greatest impact on the HIV epidemic. As such, the project was implemented through a phased approach, focusing initially on the four regions: Maradi, Niamey, Tahoua and Zinder. The prevention activities implemented by NGO/CSOs were pre-defined through a package of evidence-based interventions and standard operating procedures, focusing on the prevention of modes of transmission at risk for generating the majority of new infections. The project was engaged with NGOs and CSOs through performance-based contracts, which was an improvement on first-generation MAPs. 18. Risks and mitigation measures. The risk mitigation measures were generally adequate as reflected in the PAD following recommendations of the Quality Enhancement Review (QER) meeting February (2011). The key risks of the project were related to implementation and coordination capacity, specifically: (i) concern regarding the Ministry of Health’s role and capacity in assuring national coverage and quality of key HIV/AIDS/STI prevention, treatment, and care services; (ii) the inadequate capacity at different levels of country systems; (iii) the limited ability of NGOs and CSOs to support and empower high-risk groups; (iv) low capacity of the CISLS and its partners in their role of organizing and consolidating the national response, monitoring and analyzing data to guide the national response under the National HIV/AIDS Strategy framework; (v) the sustainability of the treatment program if the county is not committed to allocate funds through the health budget for ARVs; and (vi) fiduciary risks related to procurement and financial management. 2.2 Implementation Phase 1 (from approval on April 26, 2011 to restructuring on August 22, 2014) 19. By effectiveness in September 2011, two new coordinators for the two implementing agencies were appointed by the government to lead the national HIV/AIDS coordination body (CISLS) placed under the President Cabinet, and the health sector HIV/AIDS coordination unit (ULSS) in the Ministry of Health. 20. In 2013, Government approved a line budget of 3 billion CFA (equivalent to US$6 million) in addition to support from the Global Fund; the country did not experience any shortage of drugs and reagents. This contribution was also used to support maintenance of laboratory equipment, the purchase of additional equipment and nutritional care for HIV patients. The same amount was extended in the 2014 Finance Bill approved by Parliament. 21. Implementation of project activities had a good start during the first year. The selection of National and International NGOs to implement project activities in the four regions during first phase was completed on time and NGOs were selected and started their sensitization work towards most-at-risk population in the four regions (Maradi, Niamey, Tahoua and Zinder) of the country. The key achievements during the first Phase of the project included: 8  Training sessions were conducted to strengthen the capacity of various stakeholders of public and private health facilities involved in the implementation of the medical waste management plan.  The project supported the PMTCT program by funding only supervision visits to the PMTCT sites to increase the quality of services.  A second-generation surveillance of HIV/AIDS among most-at-risk population was conducted in 2011 and a follow-on survey was planned and supported by funding from different partners. The project also supported HIV sentinel surveillance data collection among pregnant women attending ANC clinics.  NGOs carried out sensitization activities towards most-at-risk populations in the 4 regions chosen for the first phase. They were also referring people from most-at- risk populations to health centers for STI treatment, VCT services, and HIV/AIDS care and support services.  The monitoring and evaluation was strengthened with training and field formative supervisory missions. The production of timely reports for monitoring and evaluation, data collection tools were produced and made available to NGOs to facilitate the collection in their respective zones of intervention. The management of the program was improved with the additional skilled staff hired by the project. The staff handled correctly the financial management and the procurement process within the CISLS and its decentralized units in the regions. 22. However, just over one year after effectiveness, the project started to face some challenges with the implementation of Component 1. These challenges were:  The RBF pilot phase did not take off as planned because of capacity constraints to start the program in the 4 districts. A Bank RBF expert was mobilized to assist in assessing the main issues and to resolve the bottlenecks of the program. Also, the recruitment of an external Technical Assistant was identified as a solution to advance the program in the single district as a way to simplify the pilot.  The waste management program was not in full compliance with environmental and social requirements applicable to this project, as enacted in the 2011-2015 Health Waste Management Plan Framework (HWMPF). The equipment and the protection kits for staff expected for the health centers were not in place because of the delay noted in the procurement process conducted by the MoH. In order to address this issue, an action plan with priorities intervention had been agreed upon and these actions were implemented before the mid-term review such as the distribution of the equipment purchased for the health facilities.  Some delays in the procurement of drugs (especially the STI drugs) were observed, but this did not have a serious negative impact on the implementation as 9 the national authorities resolved this issue quickly and the STI drugs had been purchased to strengthen the services delivery by the health facilities.  Delays in drugs procurement for selected health centers would have negatively impacted the work of the local NGOs when this last batch started referring members of most-at-risk populations to these health centers. It was agreed with national authorities to conduct urgently a situation analysis of STI drugs at central and regional levels in order to proceed to re-distribution of any drugs that may be in excess at one pharmacy to health centers faced with imminent shortage. The delay in the procurement was due to limited capacities of the Procurement Department of the Ministry of Health. It had been agreed after the MTR to transfer the procurement process to CISLS. 23. The November 2013 implementation support mission concluded that the project would be restructured to address some of these bottlenecks to the implementation through a level 2 restructuring and the discussions on potential revisions were to take place during the MTR. 24. The project Mid-Term Review was carried out in March 2014. The total disbursement at MTR was 41 percent. The key issues and main recommendations made by the MTR were as follows: (i) to pilot the RBF program in just one district instead of the four proposed at the beginning of the project; (ii) transfer the procurement function for Component 1 to the National Intersectoral AIDS Agency (CISLS) so as to resolve the important delays noted in the Ministry of Health; (iii) extend activities targeting MARPs to the remaining four regions to cover all the eight regions of the country; (iv) reallocation of funds between components; and (v) revision of the Results Framework to make it more specific to activities being directly supported by the project and redefine some end of project targets. Phase 2 (from August 22, 2014 to December 31, 2016) 25. After the MTR, the project was restructured. The various issues identified earlier were resolved and this allowed the project to successfully performed well during Phase 2. Some of the key achievements are highlighted below: 26. The RBF pilot phase was completed in September 2016, with significant results in improved quality of the services (improved availability of drugs, improved patient care, hygiene and improved diagnostic aids) and an increase in the use of the services by the population. Specifically, the RBF has:  Strengthened relationships between health providers and communities and improved access to services through the promotion of community participation, development and evaluation of Performance Improvement Plan (PIP), accountability of Management Committee (MC), reduction of disputes between Integrated Health Center (IHC) staff and MC; 10  Improved the satisfaction of beneficiaries in relation to the availability of medicines, ownership and hygiene of services, waiting times, availability of health workers, quality of care and charge of the indigent; and  Fostered a positive competition between the IHC, forcing them to be more creative. The management autonomy of the IHC under the RBF pilot enabled them to dispose of medicines in quality and quantity in a relatively short time and according to the needs. It has also led to more effective management, i.e. the Health District does not directly interfere with the internal management of the IHC and the District Hospital. 27. By project closing, the RBF was well implemented in the region of Dosso. A dedicated technical assistance specialist supported the implementation of the strategy. In order to streamline the implementation of the strategy in the health sector, a National “Cellule� was set up at the Ministry of Health and the funding will continue under the Health and Population Project (P147638) and other projects funded by bilateral donors namely Germany (KFW) and Belgium. 28. Delays in the implementation of the medical waste management plan were resolved and this helped to reduce accidents and risks of HIV infections and other infections in health facilities and in the general population who became aware of the risks through awareness campaigns, posters dissemination, etc. and through training of health workers and those in charge of the waste management. Waste management was also expanded and continues to be implemented with the support of the Population and Health Project (P147638) and the Sahel Malaria and Neglected Tropical Diseases project (P149526). 29. During the second phase of implementation, NGOs interventions were expanded to all 8 regions of the country. These NGOs carried out activities of HIV and STIs prevention (awareness, distribution of condoms, support to care for monthly follow-up care including screening for STI, HIV and medical care of infected people). The objective of making sex workers routinely use condoms and visit health centers every month was paramount with the project subsidizing a mandatory "monthly visit". This facilitated access to health care for sex workers and to overcome the existing financial barrier due to current cost recovery policy. 30. NGOs also completed the package of services provided to sex workers by organizing them in groups, helping them to have civil registration documents (birth certificate, etc.) and helping them access loans in line with support provided by the project and institutions of micro finance in the regions. Contracting with NGOs also allowed identification of OVC in the prostitution rings with aim to put them in touch with the relevant services of the public sector, whose mission was to support these children. The project also helped NGOs to integrate and support HIV prevention activities among inmates and prison staff. 11 31. The extension of the Closing Date from June 30 to December 31 2016 allowed the Bank team to conduct two technical missions that helped with (i) review of the project compliance with the safeguards policy; (ii) the preparation of a technical tools, guidelines and the training of staff in the implementation of the prevention of the activities for high risk group provided by the University of Manitoba. These tools will continue to be used after the project closing date. The Global Fund, which is the main donor in the fight against HIV/AIDS, also continued the implementation of these tools in the country after project closing date. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 32. Design. The Results Framework (RF) used at the beginning of the project was similar to the one under the MAP program but it did not take into consideration the country or project specific context. This is why the RF included indicators on treatment despite the fact that this project was not involved in providing ARV treatment. Consequently, discussions on revising the RF were initiated during the implementation support mission of November 2013 and the RF was revised during the 2014 restructuring where unrelated indicators were dropped. The new RF was designed to report on indicators directly related to what the project was doing, concentrating on prevention activities, which would enable a better measure of whether the project was reaching its development objective. 33. Implementation. The project M&E team collected data and produced information to support the national HIV/AIDS response. Monitoring the HIV epidemic and the behavior of targeted groups was done through studies conducted every two years in order to update key information on the disease and adapt the response accordingly. The SGSS was conducted in specific groups in 2011 and 2015. For the specific case of the health sector, surveillance necessitated the development of a system for collecting HIV data outside of the national information system. The system collected mainly data on HIV/AIDS and STI (medical follow-up of sex workers, active monitoring of people living with HIV/AIDS, etc.) 34. During the project, a number of achievements were made: (i) development of the National Strategic National Plan 2013-2017; AIDS-related expenditures review (REDES, 2015); Reviews of HIV epidemiological trends; the Second-generation surveillance surveys on HIV/AIDS in Niger (2015), HIV Allocative Efficiency and Financial Sustainability Study (2014); and the customer survey of satisfaction (2014) through an extensive participatory process. 35. Utilization: The results from the Demographic and Health Survey (2006); the Second-Generation Surveillance Survey (SGSS 2011 & 2015); Niger Synthesis report on the HIV/AIDS (2011) with the technical support of the University of Quebec (Canada); the Mapping of Professional sex workers in Niger (2013 & 2015) prepared by the University of Manitoba (Canada) were used to develop targeted interventions to reach a higher percentage of key populations at higher risk for HIV. The project strengthened the capabilities of the CISLS and the ULSS in monitoring and evaluation of HIV and the 12 RBF activities. The national information system was evolving with the introduction of a new platform (DHIS 2) and integrated Niger RBF website. 36. The 2015 SGSS pointed out the need to conduct other specific studies to identify more at-risk groups and especially the behaviors and current practices within those at-risk groups for an appropriate response: example of the Studies of HIV in prison in 2013. The level of infection and the lack of the awareness identified within the prisons, conducted the national program to implement specific activities for this groups as to decrease the level of prevalence in prisons from 2.7 percent in 2011 to 1.9 percent in 2015. 37. Overall, Monitoring and Evaluation was Substantial under the project. 2.4 Safeguard and Fiduciary Compliance 38. Safeguards. The project triggered OP/BP 4.01 – Environmental Assessment due to the increasing utilization of HIV-related services, notably VCT and ARV treatment, which could result in additional medical waste that needed to be safely disposed of at health centers and laboratories. The Country’s medical waste management plan was prepared in 2004, updated in 2010 and the latest version included the progress made in the implementation and the experiences gained in the management of infected materials. The Waste Management Plan which was publicly disclosed in Niger on March 7, 2011, was reviewed and considered valid for the purpose of Project appraisal along with specific areas for strengthening medical waste were also identified. These included training of health care workers on the handling of medical waste, training sessions conducted to strengthen the capacity of various stakeholders of public and private health facilities involved in the implementation of the medical waste management plan; and upgrading medical waste collection system and treatment facilities. 39. Compliance with Safeguards was consistently rated as Moderately Satisfactory in the Project Implementation Status Reports (ISRs), because the implementation of the waste management program was not in full compliance with the environmental and social requirements applicable to this project, as enacted in the 2011-2015 Health Waste Management Plan Framework (HWMPF). Despite some delay in the procurement process conducted by the MoH for the purchase of equipment and the protection kits for staff expected for the health centers, all planned activities were successfully completed in the end. 40. Financial Management. Financial management arrangements in terms of accounting, budgeting, flow of funds, internal control and financial reporting were rated as Moderately Satisfactory almost throughout the entire life of the project. 41. In designing the project, the FM team focused on identifying practical FM arrangements that were appropriate to the complexity of the project. The CISLS was assessed to have adequate FM capacity, systems, and experience gained through implementing the Multi-Sector STI/HIV/AIDS Support project (P071612), and was identified to co-assume, with ULSS the overall responsibility for project implementation 13 including financial management and disbursements aspects of the project. FM arrangements built on existing capacity and systems; but due to the nature of the project covering eight regions of the country, additional mitigation measures were proposed to ensure that funds proceeds were made for intended purposes only. Hence, the position of Internal Controller was established within CISLS to ensure a regular monitoring of project transactions in accordance to the World Bank’s agreement and policies and procedures. 42. There were some FM-related challenges during the project implementation, as follows, but these did not rise to the level of downgrading the rating below MS: (i) the project’s Annual Work Plan and Budgets (AWPB) were not being prepared and approved on regular basis; (ii) the utilization rate of annual budgets was low; (iii) the Interim Financial Reports (IFRs) to be submitted quarterly to the Bank were not received on due time, because of the lack of capacity of the central accountant and some regional coordinating units; (iv) the project’s FM procedures manual had not been periodically revised to reflect the implementation of the project, and also it was not appropriately disseminated among all the users. 43. However, it is worth mentioning that the external audit reports were regularly submitted on timely basis and deemed acceptable and auditors' opinions have always been unqualified. Moreover, during the final months of project implementation, the overall project FM performance improved considerably. As a result, two months before the project Closing Date, the disbursement rate was 97.37 percent (October 31, 2016). This allowed, based on the results of the last FM supervision work, carried out in November 2016, to upgrade the project FM ISR rating to Satisfactory. 44. Procurement. The handling of procurement improved throughout the implementation period, with proper application of all procurement procedures. The major issue, as described above, was the persistent delay in the procurement processes for Component 1 due to weak capacity within MoH. This was corrected during the 2014 restructuring by shifting procurement responsibilities from MoH to CISLS, which had qualified procurement specialists. The procurement organization was also in accordance with the Nigerien Public Procurement Code. Given delays experienced, procurement process has been constantly rated as Moderately Satisfactory until project closing. 2.5 Post-completion Operation/Next Phase 45. Even though there is no follow-on operation to this Second HIV/AIDS Support Project, the Bank is still engaged in Niger in the health sector. There are currently three ongoing projects: The Population and Health Support Project approved in 2015 in the amount of US$103 (Closing Date 12/31/2021); the Sahel Malaria and Neglected Tropical Diseases approved in 2015 in the amount of US$37 million (Closing Date 12/31/2019); and the Sahel Women’s Empowerment and Demographics approved in 2014 in the amount of US$53.5 million (Closing Date 12/31/2019). While RBF funding will continue under the Population and Health Support Project, the Global Fund will continue its 14 support to national program in prevention activities among the CSW group for a total of €20 million: €7 million for 2017 and €13 million for 2018-2020. 3. Assessment of Outcomes 46. The project outcomes are assessed across two phases, before and after the 2014 restructuring. 3.1 Relevance of Objectives, Design and Implementation 47. The relevance of objectives is High across both Phases. The project was and remains highly relevant to global priorities, the country’s HIV/AIDS situation and development objectives, and the Bank’s Country Assistance Strategy (CAS) of May 2008 and Country Partnership Strategy (FY13-FY16). Addressing and ending the HIV/AIDS epidemic is a global priority and remains central to the Sustainable Development Goals (SDGs) and is included in the overarching goal on health issues (SDG3) that aims to ensure healthy lives and promote the wellbeing for all age groups; with Target 3.3. focused on ending the AIDS epidemic by 2030. The Government of Niger prioritizes the prevention, treatment, care and support of those infected and affected, and most-at-risk groups among the general population as articulated in the current NSP (2013-2017). 48. The project was and remains highly relevant to the Bank’s priorities and development objectives including contributing to the Bank’s twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent. At the sectoral level, the Bank’s Health, Nutrition and Population Strategy aims to support countries’ efforts to control communicable diseases including HIV/AIDS through health systems strengthening and a strong results-focus. Although the prevalence rate of HIV/AIDS has dropped from 0.7 percent in 2006 to 0.4 percent in 2012 (EDSN-MICS3 2012), the epidemic is concentrated in high-risk groups, notably sex workers, their clients and partners, groups that were identified in the National Strategic Framework for HIV. Therefore, the PDO to increase access to HIV/AIDS and STI related services by high-risk groups is as relevant today as it was when the project was designed. 49. Relevance of project design was Substantial during Phase 1 and High during Phase 2. The project’s components were well-designed to achieve the project development objective and were not changed. Only the design of the RF was adjusted to better measure the PDO. Also, the project targeting high risk-groups was and is highly relevant according to international norms. The project planned to reach these groups through targeting using a socio-geographic mapping of hotspots for HIV focused on high risks groups in priority regions where the majority of new infections were generated; and prioritizing four regions with high HIV prevalence during the initial phase. The project’s design supported the preparation of technical tools, guidelines and the training of staff who were involved in the implementation of the prevention activities for high-risk groups. 50. Relevance of project implementation was Modest for Phase 1 and Substantial for Phase 2. The original design overestimated the procurement capacity of the MoH, which led to a persistent delay in the implementation of Component 1. As a result, 15 procurement activities for Component 1 were shifted to CISLS during the 2014 restructuring. The current design of implementation arrangement between CISLS and ULSS at MOH remains substantially relevant in the fight of HIV/AIDS/STI in the context of Niger because these two agencies have a successful track record of working together. The CISLS has demonstrated it still has the capacity to implement HIV/AIDS operations in a very efficient way with its current managerial and technical staff. Project implementation was in line with the PDO. The project used the main prevention approach measures under Component 2 to implement the planned activities. This involved contracting a number of NGOs and Associations in two phases with a first phase focusing on interventions in the four regions that have high HIV prevalence among sex workers and their clients, and a second phase with an expansion to all eight regions of the country. These NGOs had carried out activities of HIV and STIs prevention (awareness, distribution of condoms, support to care for monthly follow-up care including screening for STI, HIV and medical care of infected people). 51. The overall rating for relevance of the project is rated as Substantial for Phase 1 and High for Phase 2. 3.2 Achievement of Project Development Objectives 52. The assessment of the PDO (increased access to HIV/AIDS services by high-risk groups) is based on progress against key performance indicators and overall project implementation during Phase 1 and Phase 2. The table below presents a summary of achievement of PDO and Intermediate Outcome indicators (IO) across the two phases. Table 1: Assessment of PDO and IO Achievement Level of Achievement Phase 1 (April 2011- Phase 2 (August 2014 – August 2014) December 2016) PDO Indicators Surpassed (100%+) 5 5 Achieved (85-100%) 1 1 Not Achieved 1 1 Total 7 7 % Surpassed & Achieved 86% 86% Rating S S IO Indicators Surpassed (100%+) 12 9 Achieved (85-100%) 3 3 Not Achieved 1 Total 16 12 % Surpassed & Achieved 94% 100% Rating S S Overall Rating Substantial Substantial Scale: HS (100%+); S (85-100%); MS (70-84%); MU (55-69%); HU/U (<54%) 16 53. During Phase 1, overall achievement was substantial for the PDO indicators, with 5 out of 7 outcome indicators surpassing their targets, as follows: (“Percentage of sex workers using a condom at their most recent sexual encounter� by 90 percent and “Number of adults and children with HIV receiving ARVs� by 107 percent�). The following indicators added at ICR stage “Percentage of migrant workers with more than one partner in the past 12 months who used a condom the last time they had sex� surpassed its target by 35 percent; “Percentage of (military, security forces) men and women aged 15-49 who had more than one partner in the last 12 months and used a condom the last time they had sex� surpassed by 39 percent; and “Percentage of miners men and women aged 15-49 who had more than one partner in the last 12 months and who used a condom the last time they had sex� surpassed by 46 percent. Also 1 indicator was fully achieved. 54. Overall, the results of these 6 surpassed and achieved indicators shows the significant extent to which the project achieved its main objective of increasing access to HIV/AIDS services by high risk groups. As for the indicator, which was not achieved - “Number of pregnant women living with HIV who received antiretroviral to reduce the risk of MTCT�, the indicator did not meet its target and was changed in 2014 using the percentage and the mention of “complete prophylaxis� which is a much more appropriate measure of success. Had the team used the percentage correctly since the beginning of the project, it would show great improvement in women PMTCT. As a result, this indicator was changed and included as a new indicator #5. In addition, 12 of the 16 IO indicators were surpassed in Phase 1 as the table above indicates. 55. The project achievement in Phase 2 was equally Substantial, as was during Phase 1. Five of the 7 PDO indicators surpassed their end target (see Phase 1 above) and 1 fully achieved its target. The two indicators which were added at the 2014 restructuring surpassed their targets: “Number of sex workers treated for STI� surpassed its target by 152 percent and this supports the PDO part on increased access to STI services. Also, the PDO indicator on “Percentage of positive pregnant women who received a complete prophylaxis treatment for mother-to-child transmission� surpassed its target by 68 percent. The indicator on “Sex workers using a condom at their most recent sexual encounter� which was surpassed in Phase 1 was not achieved at the end, against the higher target of 95 percent. With respect to the IO indicators, 9 had surpassed their end- targets and 3 were fully achieved. Overall, this is a significant achievement under the project and the NSP. 56. Combining the significant and successful achievement under both Phases, it is worth mentioning that the project has achieved its development objective by increasing the access of high-risk groups to HIV/AIDS and STI services. The project reached 12,621 sex workers surpassing the end target of 5,000. A total of 819 PMTCT centers were made operational for offering testing and care management for HIV-positive pregnant women. Given this high number of functional PMTCT centers, the proportion of women who received a full prophylaxis was (35 percent) a full 10 percentage points increase compared to the project end target of 25 percent. 17 57. Over the life of the project there was a decline in HIV prevalence rates in the general population. In 2006 the HIV prevalence rate was 0.7 percent and decline to 0.4 percent in 2012 and remained stable since then. The increase in the number of ARV prescribing sites from 28 in 2012 to 54 in 2015 increased the number of people put under ARV treatment from 11,651 people (2011) to 15,265 (2016) living with HIV/AIDS. This meant that people infected with HIV were living longer with the disease. 58. The project was engaging with NGOs in activities for high risk groups in a concentrated way. These NGOs carried out activities of HIV and STIs prevention (awareness, distribution of condoms, support to care for monthly follow-up care including screening for STIS, HIV and medical care of infected people). The objective of making sex workers routinely use condoms and visit health centers every month was paramount with the project subsidizing a mandatory "monthly visit". This facilitated access to health care for sex workers and to overcome the existing financial barrier due to current cost recovery policy. This result can be almost solely attributable to the project as it has changed the landscape of HIV prevention in Niger. 59. The RBF pilot also allowed the project to have significant achievements in the Boboye District by significantly boosting HIV testing by patient. Indeed, before the RBF, less than one patient (0.89) per day was recorded for a VCT in the district, compared with about 7 patients per day with the RBF. The evolution of HIV testing for pregnant women in the framework of PMTCT showed that 5,610 pregnant women were tested between July 2014 and June 2015, i.e. a rate of 35 percent, compared with 14,521 women between July 2015 and June 2016, i.e. 89 percent. This increase seems to be linked to the motivation of the personnel who has created better conditions to attract clients in order to obtain more results therefore more subsidies. The quality of the services provided by the health facilities was evaluated on a quarterly basis using a quality evaluation form for the IHC and HD (see Graph 1 below). Graph 1: The overall trend of the Quality Score for the Health Structures gives a positive trend as shown below12 Rapport de l’Evaluation externe, Financement Basé sur les Résultats dans le district sanitaire de Boboye, Ministère de la San té, 12 Novembre 2016 18 100 86.71 75.5 79.4 S 65.3 Q 55.7 C U 50 O 28.1 A R L E I 0 T D E E PERIODE D'ENQUETE 60. Estimated new HIV infections by population group. The two-primary group that were targeted in Component 2 are Female Sex Workers and Men having sex with Men as showed in the graph below. It is showing in the Optima modeling prepared by the WB in 2014 a decline from 350 in 2012 to 241 in 2017 (31 percent) for FSW and a decline for MSM from 96 in 2012 to 80 in 2017 (17 percent) by the closing of the project and it is estimated to decline even further by 2035. With regards to other group of Migrants/mobile populations the decline in the rate of new infections is from 464 in 2012 to 324 in 2017 (30 percent); Mine workers from 30 in 2012 to 21 in 2017 (30 percent) and Truckers from 27 in 2012 to 19 in 2017 (30 percent). 19 13 Graph 2: Estimated new infections by population (2012-35) 450 400 350 300 250 200 150 100 50 0 2012 2015 2017 2025 2035 Female sex workers Men having sex with men 3.3 Efficiency 61. Targeting most-at-risk populations is currently recognized by the international community as a high effective and efficient means of intervention. In addition, prevention of mother-to child transmission has also been recognized as a cost-effective approach. The project contributed in the creation of 819 PMTCT centers that have been made operational for offering testing and care management for HIV-positive pregnant women. Given this high number of functional PMTCT centers, the proportion of women who received a full prophylaxis was 35 percent, a 10 percent increase compared to the project end target of 25 percent. The project also contributed in identifying new sites of prostitution as well as new ways of transmitting infections, allowing the implementation of most appropriate and most effective HIV and STIs prevention, treatment and care strategies. 62. The Second-Generation Survey of MARPs, conducted to look closely at the beneficiary groups, was another effort to sharpen efficiency and gain information on the size and nature of vulnerable groups. 63. Although the project supported the National Program, an analysis of the expenditures and results in the specific targeted group, helped to understand the assessment of the efficiency (see Economic Analysis in Annex 3). The expenses of the project for the prevention and the control activities within the targeted groups was increased from 27 percent in 2013 to 35.15 percent in 2015. Prevention activities are crucial for this high-risk group and they represent respectively 28 percent and 35 percent of the resource used by the program in 2013 and 2015. Of these expenditures, 29 percent 13 Niger’s HIV response: Targeted investments for a healthy future/Annex A2.1 20 went directly to prevention activities to high-risk groups, such as sex workers 14 . The contribution of the project made it possible to reach and surpass the target of treating 5,000 sex workers for STIs, thus enabling many cases of STIs to be managed (12,621). 64. In 201415, an HIV allocative efficiency and financial sustainability study on the prevention of new HIV infections was prepared in collaboration with the WB using the Optima model. It was estimated that HIV spending from 2007–12 averted close to 3,900 infections in those six years (Figure 1). Furthermore, the downstream impact of these prevented infections was much larger, since secondary HIV infections and onward transmission were also averted. By 2035, the spending from 2007–12 will have averted an estimated total of 12,600 infections, at a cost of Euro 3,500 (US$3,934)16 per infection averted if only HIV program spending is considered, and Euro 4,600 (US$6,200) if all HIV spending—including management and coordination costs—is included. The cost effectiveness ratio of similar programs ranges from US$1,000 (Vietnam HIV program US$ 890–US$1,200 per infection averted) to US$6,400 per infection averted (men who have sex with men (MSM) program in Thailand, US$1,600–US$6,400). In this regards, the cost effectiveness of the HIV/AIDS Program in Niger falls in the middle of this spectrum, suggesting that it might be possible in future to implement the same programs at a lower cost without compromising their effectiveness17. Figure 1: Number of infections averted based on historical HIV spending figures from 2007-12, Niger (2007-35) 14 Estimation des Flux de Ressources et des Dépenses Nationales de Lutte contre le VIH, le SIDA et les IST (EF-REDES) au Niger, Année 2015 -Rapport Final Version du 05/04/2016 (Mars 2016) 15 Source: Niger Allocative Efficiency and Financial Sustainability Study (2014) 16 Exchange rate as of May 23, 2017 17 Niger’s HIV Response Targeted Investment for a Healthy Future, Findings from the HIV/Allocative Efficiency and Financial Sustainability Study, The World Bank Group (2014) 21 65. Moreover, as cost-benefit analysis of both the specific project activities under Component 2 related to MARPS (commercial sex workers and their partners, as well as MSM), as well as the general prevention and treatment activities under Component 1, found that the project contributed to averting 1076 new infections, resulting in 38,736 year of lives saved. Considering the productivity gains as well as the avoided cost of care, this analysis shows an NPV of US$8.9 million, and an IRR of 18.3 percent. Given, these achievements, the efforts made to improve implementation, and only a six-month extension that enabled the project to complete all activities and disburse fully, the overall Efficiency of implementation is considered Substantial for both Phase 1 and 2. 3.4 Justification of Overall Outcome Rating 66. As indicated in the summary table below, given the split rating evaluation, the overall outcome rating of the project is Satisfactory. Table 4: Project Overall Outcome Ratings 22 Phase 1 (2011-2014) Phase 2 (2014-2016) Relevance Substantial High Objective High High Design Substantial High Implementation Modest Substantial Efficacy Substantial Substantial Efficiency Substantial Overall (Outcome) Satisfactory Satisfactory Rating Value 5 5 Total Disbursed (US$ million) $8.11 $10.63 Weight in % (total 0.43 0.57 disbursed/final disbursed amount of US$) Weighted value (Rating Value 2.15 2.85 X % Weight) Final Outcome rating 5 →→→→→→→→→→ S Note: HU (1); U (2); MU (3); MS (4); S (5); HS (6) 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 67. There is general acknowledgement that HIV/AIDS contributes to the persistence of poverty. HIV/AIDS affects the ability of the infected person and the household to fully contribute to economic development of the community and further propels households into poverty. The project developed income generating activities which supported economic expansion particularly for women in both rural and urban areas. As women became more economically independent their vulnerability to HIV/AIDS decreased because they were less reliant of commercial sex work. This positive affect creates a gender economic balance which enabled the country to control new infections to HIV/AIDS. Consequently, through scaling up of prevention, which averted infections, improving treatment, which in turn reduced deaths, the project made a very positive impact on the lives of women in general. The ICR mission interviewed beneficiaries of whom a number of women. Many of these women confessed that they learned their HIV status because of this project. Therefore, the economic empowerment of women is critical in reducing the vulnerability of women to HIV/AIDS. (b) Institutional Change/Strengthening 68. The project has strengthened the capabilities of the CISLS and ULSS in monitoring and evaluation of HIV/AIDS and RBF activities and supported the development of broad ownership and strong institutional coordination mechanisms for an expanded response, which included the involvement of all relevant key stakeholders. 23 69. The use of the mapping tool for identification of intervention target groups among sex workers is mastered by the national program and the various NGOs/Associations in the 8 regions of the country with the support of the World Bank through the University of Manitoba. The CISLS has finalized and adapted tools to continue the interventions in high-risk groups. This continuation of the interventions started in 2017 with the financing of the Global Fund in all regions of the country. Through mapping, new forms, and new sites of prostitution have been identified allowing the implementation of most appropriate and most effective HIV and STIs prevention, treatment and care strategies. 70. The monitoring team was strengthened with the hiring of a data manager funded by the project. He has continued working after the closure of the project with the support of the Global Fund to improve the data collected from HIV and STIs prevention activities among sex workers, including those from the NGOs/Association in the National Health Information System. (c) Other Unintended Outcomes and Impacts (positive or negative) NA 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops See Annex 5 4. Assessment of Risk to Development Outcome Rating: Substantial 71. Because of the nature of HIV/AIDS in Niger, the project focused on specific interventions with regard to: (i) the choice of the strategy implemented by NGOs/ Associations who work within the targeted population; (ii) the training of stakeholders on methodology for identifying high risk population, for activities planning and using approaches for the provision of services (prevention and care); (iii) the creation of beneficiaries’ economic interest groups and their support for income-generating activities which will likely help to reduce their vulnerability; (iv) the support for monthly visits in order to maintain and strengthen their reflex in the use of health centers every month. The effectiveness of the methodology and its focus on the target population led to its adoption by the GF as part of its grant for the fight against HIV/AIDS in Niger from 2017 onwards. 72. In spite of these measures, however, the risk to development outcome remains Substantial. First, despite significant achievements, HIV/AIDS remains a threat to overall economic development in Niger. The problems with influx of migrants and refugees due to civil unrest in neighboring countries may increase HIV prevalence among the general population due to increase prostitution that may accompany this influx of refugees. Secondly, this environment has been further challenged by the reductions in external financing. Given limited budget allocation, there is both an operational risk that the country will not be able to sustain the momentum built by the Project; and a technical risk that the country will not be able to further develop and maintain an institutionalized and sustainable core group of professionals to implement the NSP. Finally, stigma and 24 discrimination remains high, and continues to affect both adherence to care, and risk taking behavior. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 73. This project built upon the successes and lessons learned from the previous HIV/AIDS project and recommendations of IEG of the Bank’s assistance for HIV/AIDS Control (2005). The Bank team performed well in delivering the project in about thirteen- month period. Important risks were identified and the risk mitigation measures were generally adequate. While the project design was solid and took into account extensive analysis to inform the design, two challenges which had a negative impact on the pace of implementation, as discussed above: (i) the Results Framework did not take into consideration the specific project context; and (ii) project preparation overestimated the procurement capacity of the MoH, which led to a persistent delay in the implementation of Component 1. 74. The QER (2011) held before the decision to proceed to appraisal endorsed the design: “The Panel complimented the Team on considering the IEG recommendations when designing this project. In addition, the Panel stated that successful strategies to address AIDS in a concentrated epidemic situation were well established and urged the team to strongly consider further focusing project interventions on commercial sex workers and their clients such as truckers and miners. With regards to RF, the QER panel asked the team to focus on a few critical indicators such as condom usage, STI prevalence and HIV prevalence, as well as to emphasize bio-behavioral surveillance by monitoring a limited number of KPIs (HIV/AIDS Project for Abidjan-Lagos Corridor is a good example, in which a bio-behavioral surveillance was incorporated). The project team took this advice on board but there remained issues with the RF, as described above. Rating: Moderately Satisfactory (b) Quality of Supervision 75. A seasoned, strongly committed and proactive task team leader based in the country office supervised the project. This was an advantage because of his deep understanding of the country context and dynamics and easy access to and for the client. There was strong continuity in the team membership with different expertise as needed. The mutual respect and excellent working relationships between the project team and counterparts were clear. Project implementation proceeded relatively smoothly with no change in working relationship. Implementation support missions were regular and Implementation Supports Status Reports (ISRs) as well as Aide-memoire were filed accordingly. The reports reflected attention to detail with precise recommendations and follow-up actions for all aspects of the project. In total, eleven implementation support missions were carried out during project implementation period. The team was diligent in monitoring safeguards, and ensuring fiduciary compliance throughout. The team should 25 be complimented for the effort made in supporting and encouraging donor coordination in the interest of an overall harmonized HIV/AIDS as well as to the project restructuring to correct for issues with the Results Framework. During the final year, the project team made strong effort to have all activities completed and project allocation fully disburse by Closing Date. Rating: Satisfactory (c) Justification of Rating for Overall Bank Performance Rating: Satisfactory 76. Given the discrepancy between the rating at preparation and supervision, the overall rating for Bank performance is Satisfactory because of the need to correlate the rating with the overall outcome rating of Satisfactory (see ICR Guidelines). 5.2 Borrower Performance (a) Government Performance 77. Government, leadership, ownership and commitment to the overall project objective was clear and strong. This was seen in high-level public statements specifically by the President, who attached particular importance to the objectives of universal access to prevention, treatment and care as stated in the NSP. 78. The government appointed two coordinators in their area of expertise to CISLS under the President Cabinet and ULSS at the Ministry of Health to manage and oversee the project with minimal turnover. 79. The government provided a supportive policy and legislative environment for the project, most notably by creating a line of budget that has been increasing over time to fund ARV so as to avoid drug stock outs and ensured the maintenance of the laboratory equipment. Rating: Satisfactory (b) Implementing Agency or Agencies Performance 80. The Ministry of Health and the CISLS were committed and effectively overseeing the project. While the MoH was technically strong in HIV/AIDS prevention and treatment with qualified personnel, equipment and facilities, nevertheless, monitoring and coordinating implementation, contracting NGOs/Associations, and resolving issues remained with the CISLS, whose capacity was strengthened due to experience gained from previous project. These contracted NGOs have carried out under the coordination of the CISLS, HIV and STIs prevention activities (awareness, distribution of condoms, support to care for monthly follow-up care including screening for STI, HIV and medical care of infected people). 26 81. The CISLS coordinated the preparation and adoption of strategic documents on HIV/AIDS such as the National Strategic HIV Plan 2013-2017; AIDS-related expenditures (REDES, 2015); the Second-generation Surveillance Surveys (2011 & 2015); Reviews of HIV epidemiological trends; the Customer Satisfaction Survey (2014); and HIV Allocative Efficiency and Financial Sustainability Study (2014). 82. In addition, the CISLS and ULSS had participated in all related project missions in collaboration with the Bank’s team and contributed to different Aide memoire and project reports. Both CISLS and ULSS had teamed up to coordinate the project Mid Term Review by organizing meetings, site visits and workshop with all stakeholders involved in HIV/AIDS in the country. They also participated in studies, training, and capacity building with development partners. This capacity building has been developed jointly with the Global Fund to ensure a continuity in the coordination of the program after the closing date of the project. For example, the use of mapping as a tool for identification of intervention of target groups among sex workers as the continuation of the interventions started in 2017 with the financing of the Global Fund in all regions of the country. 83. There were several weaknesses such as: (i) late planning on procurement-related issues; (ii) delays in the submission of Interim Financial Reports (IFRs); (iii) delays in submitting the Annual Work Plan & Budgets; (iv) delay in updating the project Financial Management Procedure Manual. In addition, there were delays in the implementation of Component 1 by MoH that included the RBF pilot program and the PMTCT program. However, with the Bank’s support, the implementing agencies helped to ensure that all procurement and FM related activities were completed and all other issues resolved in the final months of the project implementation. Given the overall achievements of the National HIV/AIDS Program (NHP), the efforts made to fully disburse project funds, and the hard work by implementing agencies to implement the restructured project, the rating for the performance of the Implementing Agencies is on balance Satisfactory. Rating: Satisfactory (c) Justification of Rating for Overall Borrower Performance Rating: Satisfactory 6. Lessons Learned 84. Based on the project experience, the lessons learned are as follows:  Sustained continued support over a longer time period in implementing behavior change interventions is critical in order to have a maximum effect.  The mapping of the sites frequented by the key populations facilitated their access to the package of combined prevention activities (sensitization, referral to health facilities, condoms). 27  Community involvement in communication activities for behavioral change, referral of key populations (CSWs, prison population) to health services for HIV and STI screening and treatment is a major strategy for Synergy of actions between the public and the community.  The recruitment of NGOs in charge of carrying out activities at Community level must take place during project preparation, thus avoiding the delay in the implementation of Community interventions.  During Project preparation, the overall environment for procurement should be assessed and the design of procurements should balance accountability and transparency. For example, the handling of procurement by MOH during MAP 1 and this project was not effective and ended up with a transfer of all procurement activities to the CISLS as was the case with this project. In addition, the weak capacity, could have been addressed through intensive and hands on training to prevent delays.  In light of the delay experienced by the project when recruiting NGOs, it would have been useful in retrospect to have begun the bidding process during preparation. This would have ensured that NGOs who had the comparative advantage to implement activities would have been properly contracted and ready to begin implementation soon after project effectiveness.  Results Based Financing pilot performance in the Boboye Health District has demonstrated that this strategy improves the quality of services, health indicators, staff motivation, collaboration between providers and communities in the management services.  Projects should focus on “indicators directly related to what the project should be doing�. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies (b) Cofinanciers (NA) (c) Other partners and stakeholders (NA) 28 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) Strengthening Heath Service Delivery for HIV/AIDS/STI 10.00 9.25 92.5% HIV/AIDS/STI/Prevention for 7.0 6.58 94% high-risk groups Management and M&E 3.0 2.91 97% Total Project Costs 20.00 18.74 94% (b) Financing Appraisal Actual/Latest Percentage of Source of Funds Estimate Estimate Appraisal (USD millions) (USD millions) Borrower 0.00 0.00 0.00 International Development 20.00 18.7418 94% Association (IDA) 18 Historical disbursement from Client Connection 29 Annex 2. Outputs by Component The Second HIV/AIDS Support Project completed most planned activities, and exceeded targets for many. The following summarizes the outputs delivered within the project period by component: Component 1: Strengthening health services delivery for HIV/AIDS/STI (US$9.25 million) Subcomponent 1.1. Improving the quality and availability of health services delivery for HIV/AIDS/STI  Reagents and consumables for screening and biological follow up of Sex Workers  Drugs and consumables for STI screening and treatment  Acquisition of office and informatics equipment  Acquisition of 7 vehicles  5,402 health workers trained on STI syndromic approach and care for PLWHIV  1,761 health workers were trained in the rational use of ARV and medical inputs  A national budget line created for the acquisition of ARV, which increased from CFA 200,000,000 in 2011 to CFA 3,000,000,000 in 2015, thus, contributing to avoid the ARV drugs stock-outs.  Baseline study on the basic situation of the medical waste management plan carried out in 2014  Training of 2 national trainers on medical waste management in 2012  3,081 health workers trained in medical waste management  Awareness campaign and capacity-building of health workers, civil society actors, local elected officials and traditional leaders in the eight (8) regions of the country on the management of health care waste in 2014 and 2015.  Reproduction of 15,000 posters on the medical waste management in 2015  Commissioning of 14 hydro-claves and 36 power generation of neutral anolyte installed at health facilities in 2014  Reproduction of 6,000 copies of guidelines and procedures for medical waste management  1,556 kits of personal protection equipment (pairs of boots, gloves, masks, insulation gowns)  50 trainers trained on data collection tools for PMTCT  1,134 health workers trained on data collection tools for PMTCT  1,275 health workers trained in PMTCT in situ  13 quarterly supervisions of PTME sites in 2013, 2014, 2015 and 2016 including 1 supervision to youth friendly centers  Supply of contraceptive to health centers providing reproduction health services  Workshops for the revision and validation of data collection tools for the medical follow up of sex workers in 2012 and 2014  Conduct of 5 quarterly supervision missions in 2014-2015 30  Sentinel surveillance surveys for pregnant women carried out in 2012 and 2014  Reproduction of revised data collection tools for the medical follow up of sex workers in 2012 and 2014  1,232 health workers trained on the medical follow up tools of sex workers in 2012 and 2013  105 sentinel surveillance agents trained  16 responsible agents in charge of epidemiological surveillance trained on the FUCHIA software in 2013  Reproduction of the revised data collection tools for STI/HIV/AIDS in 2012 Subcomponent 1.2. Piloting the output-based financing of HIV/AIDS services  Feasibility study of RBF in 2012  Study tour of 8 people to Cameroon in 2011 on RBF and training of 1 agent from ULSS in Rwanda in 2013  Technical assistance team of RBF put in place in February 2015  Situation report and signature of RBF contracts with 25 Integrated Health Center, Hospital District, District team of Boboye and the Regional Directorate of Public Health of Dosso  Validation of the RBF manual of procedures for Niger in 2015  Identification of community-based organizations in charge of conducting community surveys  RBF launch workshop in 2014  10 executives from the Regional Directorate of Public Health, Health Districts, RBF team of Boboye were trained in RBF in Benin in 2015  78 health workers and chairmen of management committee were trained in RBF  The performance improvement plans validated and payment of subsidies for upgrading health facilities (FCFA 101 295 065 million) were completed in July 2015.  Baseline quality survey carried out for all health facilities in July 2015 Component 2: Prevention of HIV/AIDS/STI for high-risk groups (US$6.58 million)  Contracts signed with NGO/consortiums (Farhan/Karakara, Animas-Songes- Renip, GIN/PDSS, CCISD in 2013, ONG/consortiums (Farhan Karakara, Animas-Songes-RENIP, SARED, CCISD, PSI/ANBEF/Soltis/Lafia Matassa in 2015  Mapping of the prostitution sites in the 8 regions in 2015  12 orientation workshops were organized in the 8 regions from 2013 to 2015  4,057 peer educators were trained in IEC/BCC (Behavioral change communication) from 2013-2016  17,924 educational chat sessions by peers in BCC for 52,718 from 2013-2016  21,302 sex workers have benefited from lubricants distribution 31  66,254 condoms for men and 12,098 condoms for female were distributed free of charge from 2013-2016  Distribution of 3,410,286 condoms for men and female; 6,454 tubes of lubricants and 8,035 packets of gel to professional sex workers and their clients  167 groups of sex workers comprising of 956 members were set up from 2013- 2016  70,990 sex workers referred were received by health facilities for STI screening and treatment  13,734 sex workers referred were received by health facilities for HIV/AIDS screening  2,098 orphans and other vulnerable children from high risk groups were identified par community organizations from 2013-2016 Component 3: Management, monitoring and evaluation (US$2.91 million)  Acquisition of 11 vehicles for the CISLS and informatics equipment  Recruitment of NGO/consortiums and for making funds available for them to finance their work plan  19 consultation meetings organized at central level from 2011-2016  Held several meetings with partners  Held the mid-term review of the second HIV/AIDS Project in 2014  Recruitment of an M&E Assistant  Supervision of the central level (CISLS and ULSS) towards structures of coordination, monitoring and evaluation (DRSP, CRISLS, districts, ONG teams and consortium) of the regional level  Supervision of on-site proximity by the NGO services and consortiums by the management team from the Regional Directorate of Public Health and CRISLS. 32 Annex 3. Economic and Financial Analysis Context 1. Project relation to the development context in Niger. The project has been relevant during the entire implementation cycle, both from an epidemiological and an economic perspective. From an epidemiological perspective, the increasing share of HIV/AIDS in Niger’s burden of disease justifies a systematic response to prevent the HIV epidemic from significant increases. Furthermore, targeted interventions are justified, provided the disproportionate share of the burden of disease borne by high-risk groups, and provided the high potential to prevent new infections linked to reducing risky behaviors. From an economic perspective, the project’s relevance is explained by financial constraints faced by the Government of Niger. The financing gap experienced in 2014 and 2015 hampered the implementation of the NSP. In this context, the project’s support – strongly in line with the priorities identified by the NSP – has been of utter importance to the achievement of the goals of the NSP and the provision of preventive care to the target populations. 2. On top of this, the project’s pilot of RBF in Niger coincided with national efforts to introduce this financing mechanisms, as described by the NSP. RBF was identified as a means to achieve Universal Health Coverage (UHC) in the country, and to speed up the achievement of the MDGs, including the HIV/AIDS-related target. 3. HIV prevalence in Niger is low relative to other countries in the region, and it is decreasing (see Table 1). The relative importance of HIV/AIDS in Niger’s burden of disease, however, increased significantly between 2000 and 2015 (see Figure 1). Furthermore, the prevalence of HIV is highly concentrated in high-risk groups (see Figure 2). Table 1- HIV prevalence in SSA 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Central 4.2 4.1 4.0 3.9 3.8 3.7 3.5 3.4 3.3 3.1 Eastern 5.8 5.6 5.5 5.4 5.4 5.3 5.2 5.1 5.0 4.9 Southern 21.9 21.7 21.7 21.5 21.5 21.4 21.4 21.4 21.3 21.2 Western 2.0 1.9 1.9 1.8 1.7 1.7 1.6 1.5 1.5 1.5 Niger 1 0.9 0.8 0.8 0.7 0.6 0.6 0.5 0.5 0.5 Source: World Development Indicators (2017) 33 Figure 1- Niger's burden of disease Source: Institute of Health Metrics and Evaluation (2017) 34 Figure 2- HIV prevalence by population and time Source: Niger Allocative Efficiency and Financial Sustainability Study (2014) 4. Modelled estimates show a stark decline in new HIV transmissions (see Figure 3). Sustaining low prevalence and low incidence rates in the future will be challenged by ongoing changes in Niger’s socio-economic context. Niger is undergoing a process of urbanization, and the relocation of young females from rural to urban areas can be linked to an increase in the number of sex workers. Economic growth, in turn, allows men to have more disposable income, which is associated with a higher demand for transactional sex (5% of men in Niamey reported having engaged in transactional sex19). Moreover, the development of the mining sector encouraged further internal migration and mobility, which can increase the risk of HIV transmission20. 19 DHS (2012) 20 Niger Allocative Efficiency and Financial Sustainability Study (2014). 35 Figure 3- New infections, 2000-2020: National Source: Niger Allocative Efficiency and Financial Sustainability Study (2014) 5. In response to the above-mentioned challenges, the Government of Niger has developed the HIV National Strategic Plan (NSP) 2013-2017. The NSP sets the strategic direction for the policies and programs developed to fight against the HIV epidemic, and it is organized following UNAIDS’ vision of zero new infections, zero AIDS-related deaths and zero discrimination. There have been financing gaps for the completion of the activities identified in the NSP, despite the steady increase in funding from the Government of Niger (see Figure 4). Figure 4- NSP Financing gaps and evolution of central government funds allocated to finance the NSP. Source : Estimation des Flux de Ressources et des Dépenses Nationales de Lutte Contre le VIH, le Sida et les IST (EF- REDES) au Niger (2016) NSP Financing gaps Central government funds 12000 2000 1800 10000 1600 8000 1400 Million FCFA 1200 Million FCFA 6000 1000 800 4000 600 2000 400 200 0 0 2013 2014 2015 2013 2014 2015 -2000 NSP Prevision Actual expenditure Financing gap 36 6. Economic Analysis. In 2014, the World Bank evaluated the technical and allocative efficiency of Niger’s HIV response. The study provided a detailed qualitative and quantitative estimation of the impact of financing for HIV in Niger. The findings of the study, summarized below, provide relevant guidance for the economic analysis of the project. Modelled estimates were produced using OPTIMA. This tool was also applied for the estimation of the figures used to investigate the project’s overall cost -benefit performance, as well as its allocative and technical efficiency. 7. According to the study, investments in HIV have had a strong impact on the decline in HIV incidence. The scope for efficiency improvements is moderate, with a potential reduction of an additional 12 percent in HIV incidence, if resources are allocated optimally. Better allocation includes geographic targeting to areas of high HIV burden and areas with high transmission rates, and targeting investments to specific high- risk groups, such as female sex workers. Access to ARTs, in turn, was found to be limited. In addition, the report emphasizes the challenges to reducing mother-to-child transmission, given the general low access to health services and the limitations of the health system in Niger. 8. Allocative efficiency. The project’s activities focus primarily on HIV prevention. It should be noted that the impact of HIV prevention programs is difficult to determine for a variety of reasons: HIV incidence data rarely exist, particularly for high-risk groups; the lack of an effective surrogate marker for HIV; and few national programs are randomized or have exogenous variation to develop an appropriate counterfactual for the number of HIV infections if the program had not been implemented. However, the recently completed OPTIMA study provides estimates of reductions in the incident of HIV, and shows that populations targeted by project interventions show some of the largest reductions in new infections per thousand population. 9. In terms of the allocative efficiency of prevention, evidence suggests that preventive measures, such as those financed by the project (including quality improvement measures like the training of health workers, and the referral of high-risk population to health centers), are efficient. The active engagement of other donors in the treatment of HIV/AIDS in Niger (in particular the Global Fund) provides further support to the project’s focus on prevention. Duplications are major sources of inefficiencies. Furthermore, Sweeney et al. (2011) argue that HIV/AIDS services (both preventive and curative) should be integrated to the delivery of other health services. Health service delivery integration reduces the costs of delivery, compared to stand-alone interventions. In light of this evidence, the introduction of RBF and the integration of HIV prevention with other health services is considered highly effective. 10. Technical efficiency. The project has two salient sources of technical efficiency. The first source relates to the nature of the intervention. Preventive activities that actively refer patients to health centers and foster health-seeking behaviors have been found to be more efficient than other preventive measures such as general information campaigns. The second source of technical efficiency is the targeting of preventive activities. Compared to preventive measures for the general 37 population, preventive measures targeting high-risk groups are highly efficient. Interventions financed by the project have a clear focus on reducing incidence among female sex workers and mother-to-child transmission. According to the World Bank’s study mentioned above, resources spent on the prevention of HIV for these sub- populations would represent optimal investments. Female sex workers are 43 times more likely to be seropositive than females in the general population, and only 1 percent of all HIV investment targets this sub-population 21. 11. In terms of vertical transmission, children bare a high share of the HIV burden and this is mostly explained by the poor implementation of preventive measures to reduce mother-to-child transmissions. It should be noticed, however, that even though prevention of mother-to-child transmission is highly efficient, compared to other preventive measures, the effectiveness of the interventions financed by the project is majorly affected by the low level of health-seeking behavior among pregnant women. In addition, the introduction of RBF has increased the efficiency of the interventions financed by the project. Furthermore, the pilot’s costs were low22. 12. In quantitative terms, the technical efficiency can be estimated by calculating the project’s Net Present Value (NPV). The absence of an economic analysis in the Project Appraisal Document (PAD) hinders the assessment of the project’s impact, as no clear benchmark can be identified. Moreover, in the absence of reliable data to estimate the averted cost of care due to the prevention of opportunistic infections, the NPV calculated below represents a conservative estimate of the overall project’s NPV. 13. The number of infections averted is the difference in number of people newly infected with HIV between the without-and-with-project scenarios. Given the nature of the project interventions, it is estimated that the project is directly responsible for virtually all of the reductions in infections for female sex workers, their primary clients (miners and truckers) and MSM, and about 20 percent of the reduction in infections in the general population. The benefits from these averted infections are calculated in Table 2 and are comprised of averted productivity losses (by remaining in the workforce) and savings on in-patient care and on treatment of opportunistic illnesses.  On average, an averted infection provides an individual with thirty-six more years of productive life. This figure is calculated as pension age of 60 years minus average age of infection of 24 years.  Average annual productivity is valued at US$856, which is average GNI per capita during the implementation period. 21 Niger Allocative Efficiency and Financial Sustainability Study (2014). 22 The external evaluation found that the pilot’s total cost per capita was USD4, while the recom mended standard was USD4-5. Per capita performance payments averaged USD1.88, which is lower than the recommended standard of USD3. 38  The average annual cost of care per patient is US$1,059, which is calculated as 14 hospital days at $61 per day + $200 in palliative care and prevention/treatment of opportunistic infections. Given the lower life expectancy of PLWHA, it is assumed that this cost would be avoided for 21 years.  Benefits accrue five years after the infection has been averted for the disease to progress and translate into productivity losses and health care costs for the individual. Table 2 - Project benefits Productivity Infections Years of life Averted Year Year losses Total benefits averted saved cost of care averted 2013 77 2,772 2018 2,376,449 1,712,403 4,088,852 2014 154 5,544 2019 4,752,898 3,424,806 8,177,704 2015 232 8,352 2020 7,160,210 5,159,448 12,319,658 2016 282 10,152 2021 8,703,359 6,271,398 14,974,757 2017 331 11,916 2022 10,215,645 7,361,109 17,576,754 Total 1,076 38,736 33,208,560 23,929,164 57,137,724 The stream of costs and benefits is shown in Table 3. Based on these costs and benefits, the NPV is US$8.9 million, based on a 10 percent discount rate, and the IRR is 18.3 percent. Table 3- Cost-Benefit Analysis Year Costs Benefits Net Benefits 2011 1,694,140 -1,694,140 2012 442,576 -442,576 2013 5,605,609 -5,605,609 2014 1,963,389 -1,963,389 2015 6,304,450 -6,304,450 2016 2,729,836 -2,729,836 2017 0 2018 4,088,852 4,088,852 2019 8,177,704 8,177,704 2020 12,319,658 12,319,658 2021 14,974,757 14,974,757 14. Using OPTIMA’s estimations, by 2035, the spending from 2007–12 will have averted an estimated total of 12,600 infections, at a cost of Euro 3,500 (US$3,934) per 39 infection averted if only HIV program spending is considered, and Euro 4,600 (US$6,200) if all HIV spending—including management and coordination costs—is included. The cost effectiveness ratio of similar programs ranges from US$1,000 (Vietnam HIV program US$ 890–US$1,200 per infection averted) to US$6,400 per infection averted (men who have sex with men (MSM) program in Thailand, US$1,600– US$6,400). In this regards, the cost effectiveness of the HIV/AIDS Program in Niger falls in the middle of this spectrum, suggesting that it might be possible in future to implement the same programs at a lower cost without compromising their effectiveness. 15. Operational efficiency. The implementation of the project was successful. This assessment is based on the following premises: (i) the project was timely executed. The project was extended by 6 months. In the context of Niger, this period is considered short. Moreover, the project extension was decided in order to ensure an adequate evaluation of the interventions, and for the preparation of the transition phase; (ii) 99.9% of the resource envelope was disbursed during the implementation cycle. Despite initial delays in disbursements, the project managed to fully disbursed the funds budgeted during the PAD. 40 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Helene Bertaud Lead Counsel LEGESLegal Wolfgang M. T. Chadab Senior Finance Officer WFALA Finance Jean J. De St Antoine Lead Operations Officer AFTHW-Operations Aissatou Diack Senior Health Specialist GHN07Health Ibrahim Cheik Diop Consultant AFMNE Communication Nicole Hamon Temporary GHNDR Administrative Support Djibrilla Karamoko Senior Health Specialist GHN07Management & Coordination Jody Zall Kusek Consultant OPSPFMonitoring & Evaluation Karima Laouali Ladjo Program Assistant GMF07Administrative Support John F. May Consultant GEDDR Demography Nko Etesin Mutangana Resource Management Officer BPSHCResource Management Africa Eshogba Olojoba Lead Environmental Specialist GEN05Environment Ibrah Rahamane Sanoussi Senior Procurement Specialist GGO07Procurement Abdoul Wahabi Seini Senior Social Development Spec GSU01Social Development Sidy Diop Procurement Specialist GGO13Procurement Josue Akre Financial Management Specialist GGO26Financial Management Amadou Konare Consultant Safeguards Beth Wanjeri Mwgangi Resource Management Analyst BPSGP Financial Management Celestin Adjalou Niamien Sr. Financial Management Specialist GGO26 Financial Management Gyorgy Bela Fritsche Sr. Health Specialist GHN07 RBF/Health Medou Lo Consultant GENDR Safeguards Rachel Hoy Deussom Junior Professional Associate AFTHE Health Iris Semini Senior HIV/AIDS Specialist HDNHE HIV/AIDS Andre Zombre Consultant GGODR Procurement Supervision/ICR Dominic Haazen Lead Health Policy Specialist GHN13 Health Policy Djibrilla Karamoko Senior Health Specialist GHN07 Health Enias Baganizi Senior Health Specialist GHN07 Health/HIV/AIDS Maria Gracheva Senior Operations Officer GHNGE Operations/ M&E/ICR Aissatou Chipkaou Operations Analyst GHN13 Operations Nejma Cheikh Operations Analyst GHN05 Operations Abdou Moha Consultant GHN07 Health Nicolas Rosemberg Consultant GHN01 Economics Amba Denise Sangara Program Assistant GHN07 Administrative Support Salimata Bessin Dera Team Assistant AFMNE Team Support 41 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending: FY11 43.05 137,032.44 Supervision/ICR: FY12-FY17 99.25 305,342.71 Total: 142.3 442,375.15 42 Annex 5. Beneficiary Survey Results 1. A Beneficiary Survey was carried out from August 24 to September 7, 2014. A total of 1,267 female sex workers (FSWs) and Men who have Sex with Men (MSM) were surveyed. The survey show that the majority of sex workers surveyed are in the 5 to 29 age group (82.2 percent). They are on average without any level of education (43.3 percent). The majority are from Niger (69.6 percent). Islam is the main religion (86.5 percent) of the SWs surveyed. In addition, 60.1 percent are divorced and 31.9 percent single. 2. The results of the survey also indicate that 62.9 percent of the surveyed SWs are tenants. The latrines / pits constitute 75.2 percent the main type of toilet used and serve as the place where condoms are disposed of. With regards their source of lighting, it is essentially the battery lamp and the electricity, which are used respectively by 50, 4 percent and 47, 1 percent of these SWs. Regarding the level of satisfaction of services provided by NGOs and health facilities of reference, it is clear from the survey results that: 3. The proportion of SWs surveyed who are satisfied with the prevention services provided by NGOs is 83 percent. This satisfaction of the SWs surveyed was recorded mainly in Maradi and Zinder where 89 percent and 85 percent of the SWs surveyed said they were satisfied with the activities of the NGOs. Niamey and Tahoua, with a rate of 79 percent and 76 percent respectively, appear to be the regions with lower satisfaction. 4. The proportion of SWs surveyed who are satisfied with the prevention and care services offered by the reference health facilities is 91 percent. The Maradi and Zinder regions recorded the highest satisfaction rates, with 93 percent of the SWs generally satisfied, followed by Tahoua (92 percent). On the other hand, the satisfaction of the Niamey SWs with reference health facilities is lower (85 percent) compared to the results recorded in the other regions. 5. The level of satisfaction of the SWs surveyed with regards to prevention services offered by the NGOs gave the following overall results: 1. Availability: 94% 2. Accessibility: 77% 3. Quality: 96% 4. Amount / Quality: 99% 5. Relational Competence: 98% 6. As for the satisfaction of the SWs surveyed on the prevention and health care services offered by the health facilities it is: 6. Availability: 91% 7. Accessibility : 89% 8. Quality : 97% 9. Quantity/Quality : 96% 10. Relational Competence : 97% 43 11. Environment : 98% 7. Unlike the FSWs, MSM were very difficult to find in the field. In the course of this survey, only 60 MSM were found and interviewed in all four (4)-target regions. These 60 MSM respondents are overwhelmingly young, aged 20-24 (43 percent) and 25- 29 (33.3 percent). Fifteen (15) have no grade level, eighteen (18) have a primary level, twenty-one (21) have a junior high, three (3) have a junior high. 8. The distribution of the 60 MSM surveyed, according to their nationality, shows that only two nationalities were found on the ground during this survey: Niger, fifty-five (55) or 91.7 percent, and National of Nigeria, five (5). 9. With regards to their practicing religion, all MSM interviewed declared themselves to be Muslim (100.0 percent). The overwhelming majority of MSM surveyed, 95.0 percent are single. With regards to their living conditions, it is noted that the MSM surveyed are mainly housed in family dwellings (34), or are housed free of charge (18). Few MSM respondents are tenants (5) or owners (1). It is also noted that of the 60 MSM surveyed, the majority (78.3 percent) use latrines / pits mainly to wash their hands. 10. Like the majority of surveyed SWs, it is also found that the majority of MSM surveyed (73.3 percent) mainly dump their household garbage into the wild. In addition, of the 60 MSM surveyed, fifty-two (52) mainly dump wastewater into the wild as well. 11. It is also noted that 60 MSM surveyed, fifty-one (51) of them primarily use electricity as their source of light and nine (9) use battery-operated lamps. Given the very low numbers found and surveyed in the field, the analysis of MSM satisfaction focused on absolute numbers to enable the users of this study to make a fair and objective assessment. Thus, with regard to the satisfaction of MSM on the services offered by NGOs, it is firstly noted that of the 60 MSM surveyed, only 44 benefited from NGO services at least once during the reference period. 12. Overall, of these forty-four (44) MSM respondents, thirty-one (31) were satisfied with the advice given by NGOs. 13. The dimensional analysis of the services offered by NGOs to men who have sex with men has yielded the following results: Dimension Satisfied not satisfied Not at all satisfied Actual survey Availability Dimension 42 2 0 44 Accessibility Dimension 39 4 2 44 Quality Dimension 42 2 0 44 Quality/Quantity Dimension 43 0 1 44 Competence Relational Dimension 43 0 1 44 14. The results of the survey show that of the sixty (60) men who had been identified and interviewed, only thirty (30) had been in consultation or medical examination on STI/HIV/AIDS during the reference period. 44 15. The level of satisfaction of these thirty (30) MSM on the services provided by the referenced health facilities is summarized as follows: Dimension Satisfied not satisfied Not at all satisfied Actual survey Availability Dimension 29 1 0 30 Accessibility Dimension 29 1 1 30 Quality Dimension 30 0 0 30 Quality/Quantity 30 0 0 30 Relational Competence Dimension 30 0 0 30 Environment Dimension 30 0 0 30 16. Thus, apart from the Accessibility Dimension, which is an important component but whose level of satisfaction appears lower at the level of the two providers, it can be concluded that overall the activities carried out by the NGOs and the health facilities were judged satisfactory by MSM surveyed. 17. Quality / Quantity Dimensions, Relational Competence and Service Quality are assets to bring to scale in all regions. 18. The availability of services is to be maintained while the accessibility of services from both NGOs and reference health facilities is the priority action to improve the level of satisfaction, in particular the accessibility of male condoms. 45 Annex 6. Stakeholder Workshop Report and Results NA 46 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Translation REPUBLIQUE DU NIGER Fraternité – Travail – Progrès PRESIDENCE DE LA REPUBLIQUE Coordination Intersectorielle de Lutte contre les IST/VIH SIDA Implementation Completion Report Second HIV/AIDS Support Project World Bank Financing 2011-2016 February 2017 47 1. Context 1. In Niger, the HIV epidemic is characterized by a national prevalence of 0.7 percent (EDSN-MICS3 2006). This low prevalence hides disparities between regions and socio-professional groups, especially sex workers and their clients. Thus, it varies between 1.7 percent in Diffa and 0.3 percent in Maradi (EDSN-MICS3 2006). Among sex workers, seroprevalence is 20.9 percent (SSG 2008). 2. By region, the HIV prevalence among sex workers is as follow: Agadez (24.5 percent), Diffa (not covered by the survey), Dosso (19.8 percent), Maradi (60.6 percent), Tahoua (43.5 percent), Tillaberi (16.7 percent), Zinder (41.7 percent) and Niamey (35.6 percent). 3. Other population groups have an HIV prevalence that is above that of the general population: Defense and Security Forces (1.7 percent), prison population (2.7 percent), truck drivers and truckers (1.83 percent), and migrants (1.03 percent) (SSG 2008). 4. In addition, sentinel surveillance of pregnant women in 2009 shows a national prevalence of 1.7 percent with a variation ranging from 2.7 percent in Tahoua and 1.1 percent in Maradi; this situation exposes newborns to an increased risk of HIV infection. 5. The healthcare system in Niger is still facing problems, linked to the lack and high mobility of human resources, the levels of service delivery and management, the inadequacy of laboratory equipment and the weakness of the supply chain, which results in frequent drug shortages and emergency procurement. This system is also characterized by large geographical disparities, with more services available in urban areas than in rural areas with low coverage of services. 6. To tackle the situation, Niger has developed a strategic framework 2008-2012 that has been supported by technical and financial partners, including the World Bank under MAP1. It envisages the revision of this framework into a national strategic plan 2013- 2017, which will take into account the epidemiological distribution of HIV and the weaknesses observed in the response to HIV, in particular those related to the health system. 7. The situation of sex workers led the Intersectoral Coordination of HIV/AIDS/STI (CISLS) with the support of the World Bank to undertake a study on the state of the HIV situation in Niger and the determinants of high seroprevalence among sex workers in 2010. 8. This study highlighted high-prevalence geographic areas (Niamey, Zinder, Maradi and Tahoua), but also enabled the mapping of prostitution sites. The findings of this study-helped guide the negotiation of a World Bank funded HIV project. The country obtained financial support from the World Bank to implement the second HIV/AIDS Support Project for the period 2011-2016. 48 9. In line with the priorities set by the country and to have the best impacts, the project targets three strategic components:  Strengthening Heath services delivery for HIV/AIDS and STI;  Prevention of HIV/AIDS/STI for high-risk groups (CWs and their clients);  Management, monitoring and evalutation. 2. Objectives assigned to the different components of the project 10. The project's development objective was to increase access to HIV/AIDS and STI-related services by high-risk groups in Niger. 11. The Project specifically aimed to support the implementation of the National Strategic Framework to: (a) expanding the provision of prevention services; (b) increasing the utilization of HIV/AIDS/STI services; (c) improving the Monitoring and Evaluation (M&E) by establishing one overall national M&E system including a biological and behavioural surveillance system. 12. Its implementation was carried out through three components: (i)  Component 1 « Strengthening health services delivery for HIV/AIDS and STI », implemented by the Ministry of Health (MoH) through the Health Sector Coordination Unit (ULSS), the Directorate of Studies and Programming (DEP), the Directorate of Mother and Child Health (DSME), the Directorate of Public Hygiene and Education for Health (DHP/ES). This component had two subcomponents:  Improving the quality and availability of health service delivery;  Piloting the output-based financing of HIV/AIDS services;  Component 2 «Prevention of HIV/AIDS and STI for high-risk groups » implemented by the NGOs and managed by the National Intersectoral AIDS agency (CISLS);  Component 3 «Management, monitoring and evaluation» implemented by the National Intersectoral AIDS Agency (CISLS). 13. The direct beneficiaries of the Project were people living with HIV/AIDS (PLWHA), and high-risk groups in Niger: sex workers, their clients, and TB patients, HIV/AIDS/STI patients, orphans and vulnerable children. Indirect beneficiaries of the Project are those seeking medical care, as the Ministry of Public Health will strengthen its capacity for service delivery and health systems strengthening. The National AIDS Commission (CNLS) and the CISLS will benefit from increased capacity for program coordination, monitoring and evaluation, and program implementation. 49 14. The first phase of the project covered four regions (Maradi, Tahoua, Zinder and Niamey) due to their high HIV prevalence among sex workers and their clients; and in view of the group's workforce in these regions. 15. Following the mid-term review of the project in 2014, which showed encouraging results and based on lessons learned from implementation, interventions were extended at the national level, i.e. to all eight Regions. 3. Results achieved and impacts noted 3.1. Achievement 16. The implementation of the project made it possible to record the following results by component: 3.1.1 Component 1: Strengthening health services delivery for HIV/AIDS/STI 3.1.1.1 Improving the quality and availability of health service delivery:  Acquisition of revolving stock of drugs, computer and office equipment; Reagents and consumables for the detection and biological monitoring of CSWs, drugs and consumables for STI screening and management;  Training of 5,402 health workers in the management of the STI syndromic approach of people living with HIV/AIDS (PLWHIV), 1,232 health workers on the medical monitoring tools of TB; 3,081 health workers on medical waste management, 50 trainers on PMTCT data collection tools, 1,134 health workers on PMTCT data collection tools, 1,275 health workers in PMTCT in-situ; 105 Sentinel surveillance in pregnant women, 16 heads of epidemiological surveillance centers of prescribing sites on the FUCHIA software;  Reproduction of 15,000 posters on medical waste management, 6,000 copies of the medical waste management manual of procedure, revised data collection tools for medical follow-up of CSWs;  Commissioning of 14 hydro-claves and 36-power generation of neutral Anolyte units installed in the health facilities, 1,556 of personal protection equipment (pairs of boots, gloves, and mask insulation blouses).  Quarterly supervision of PMTCT sites (13) including 1 youth-friendly centers;  Conducting a baseline study of the Health Care Waste Management Plan (HCWP);  Preparation of sentinel surveillance surveys in pregnant women in 2012 and 2014. 3.1.1.2 Piloting the output-based financing of HIV/AIDS services 50  Feasibility study of RBF and study tour of 8 people to Cameroon and Rwanda;  Establishment of an RBF Technical Assistance Team;  Development and validation of the RBF manual of procedure for Niger;  Situation report and signature of 30 RBF contracts including 27 Integrated Health Centers, the Hospital Districts, Districts Team of Boboye and the Regional Directorate of Public Health of Dosso;  Identification and signing of contracts with 20 community-based organizations in charge of community surveys;  RBF training of 2 ULSS officers, 10 managers from the Regional Directorate of Public Health in Dosso, Health District of Boboye and RBF team, 78 health workers and chairmen of management committees;  Regular payment of subsidies to health facilities;  Realization of a basic quality survey for all health facilities; Regular supervision of health facilities. 3.1.2 Component 2: Prevention of HIV/AIDS/STI for high-risk groups  Signing of contracts with NGOs and Consortiums;  Realization and updating of the cartography of the Prostitution Sites;  Organization of 12 orientation workshops in the 8 regions from 2013 to 2015;  Training of 4,057 peer educators in IEC / BCC in 2013-2016 by NGOs;  Realization of 17, 924 education chat sessions by peers;  Sensibilization of 81,604 sex workers and their clients through the pair education;  Sensibilization and referral of 70, 990 sex workers by NGOs to health facilities for STI screening and treatment;  13,734 sex workers received for HIV testing in health facilities;  48 ,097 cumulative cases of STIs detected and treated among professionals;  Distribution of 3, 410,286 male and female condoms, 6,454 gel tubes and 8,035 packets to sex workers and their clients;  Implementation of 167 sex workers groups in 2013-2016 with 956 members;  Identification of 167 orphans and other vulnerable children from high-risk groups and support to 160 by community-based organizations in 2013-2016. 51  3.1.3 Component 3: Management, Monitoring and Evaluation  Reinforcement of the car-motorcycle park, generators, and computers for the CISLS;  Recruitment of NGOs / consortiums and making funds available to finance their work plans;  Organization of consultative meetings at central level;  Holding of several meetings with partners;  Carrying of the mid-term review of the second HIV/AIDS Support project financed by the World Bank in 2014;  Support to the functioning of the CISLS and ULSS;  Supervision of activities at the central level (CISLS and ULSS) towards the coordination, monitoring and evaluation structures (DRSP, CRISLS, districts, NGO teams and consortium) at the regional level;  On-site supervision of NGOs and consortium services by the DRSP and CRISLS management team. 3.1.4 Financial Management 3.1.4.1 Financial allocation by Component (CFA Francs) Amount Total Components Allocated (CFA) realization Percentage Strengthening health services delivery for HIV/AIDS/STI 5,050,000,000 4,824,761,422 96% Prevention of HIV/AIDS/STI for high-risk groups 3,535,000,000 3,389,743,512 96% Management, monitoring & evaluation 1, 515, 000,000 1, 861, 910,809 123% TOTAL 52 3.1.4.2 Disbursement Status by Category of Expenses Categories Description Amount Disbursement Commitments Realization Percentage Allocated GDS, NON-CS, CS Part 1 3 424 724 1 2 106 796 875 3 424 724 814 - 163% and TR&Audits 814 2 Output-based Grants 1 795 117 188 790 361 534 676 110 791 037 644 44% GDS, NON-CS, CS Parts2&3 3 4 667 304 688 4 328 073 704 59 922 633 4 387 996 337 94% and TR&Audit DISB - OPERATING 749 609 4-A 458 504 561 194 156 318 652 660 879 87% COSTS Part 1 375 DISB - OPERATING 512 890 4-B 819 996 069 819 996 069 160% COSTS Parts 2 & 3 625 268 281 5 PPF REFINANCING - - 0% 250 - DA-Q Designated Account - - 10 076 415 Total 10 100 000 000 9 821 660 682 254 755 061 99,77% 743 Amount are in C.F.A Francs 3.2 Impacts observed In summary, the implementation of the project allowed to:  Reduce new infections and the level of the HIV epidemic since the various studies have shown that seroprevalence in CSWs has decreased from 17.3 percent in 2011 to 16.6 percent in 2015 and among inmates from 2.7 percent in 2011 to 1.9 percent in 2015;  Enhance the use of health services by high-risk groups;  Increase the number of adults and children who are at an advanced stage who are put on ARV treatment from 7,445 in 2009 to 14,729 at June 30, 2016;  Strengthen the capacity of health personnel in the following areas: HIV/AIDS and STI Care, Caregiver-Initiated Screening, PMTCT, Biosafety and Waste Management, Results-Based Funding;  Improve the coverage of HIV-positive pregnant women who have received comprehensive antiretroviral prophylaxis to reduce the risk of transmission of the 53 virus to children from 10.4 percent in 2011 to 35 percent as at 30 September 2016;  Experimentation of RBF in the District of Boboye (Dosso) with 30 contracts signed with the health centers. 4 Project Implementation Performance The framework document for the project includes strengthening the Supply Chain Management framework. Because of the financing of the Global Fund to Fight Malaria, Tuberculosis and AIDS, this package of activities has not been implemented on the World Bank project to avoid duplication, but also to have greater efficiency in the use of resources. For example, the Global Fund has provided Niger's National Office for Pharmaceutical and Chemical Products (ONPPC) with a refrigerated truck and three vehicles for the supervision of the delivery of products to the different regions of the country, Improvement of the storage capacity of the ONPPC, training of personnel in stock management. This funding also made it possible the monitoring of meetings of the Tuberculosis-HIV Co-infection Management Committee and those of the Supply Group. 17. In terms of performance, it can be said that the project has achieved its objectives, because for all indicators the targets were surpassed (11,453 Sex workers screened for STIs out of 4,000 planned, 70,990 Sex workers referred by NGOs to health services out of 5,991 planned). 18. Concerning the evaluation of the project by the actors, the survey carried out among the beneficiaries in 2015 and the documentary film of 2014 show satisfaction with the implementation of the project (see beneficiaries’ satisfaction survey report and documentary film). 19. The evaluation of the results-based funding approach showed that all stakeholders appreciated this strategy very much. It has improved the attendance of services in the pilot area, the quality of health care services, the availability of resources and the financial autonomy of health facilities. 20. In total, the second project to support the fight against AIDS in Niger is a promising experiment that will have to be continued and expanded, focusing on the populations most at risk (sex workers, detainees, men having sex with other men). Strategies such as results-based financing should be maintained and extended to all future activities including those for NGOs. 5. Assessing the performance of the World Bank 21. The project was a response to the National Strategic Framework of Niger 2008- 2012 and the PSN 2013-2017 in order to break the HIV transmission chain at early stage and more effectively and prevent new infections in the general population. 54 22. The relevance of the project has also enabled the preparation of technical tools, guidelines and training of personnel involved in the implementation of prevention and care activities for high-risk groups. 23. The project has achieved its development objective by increasing the access of high-risk groups to HIV / AIDS and STI services. At the end of October 2016, two (2) indicators out of three (66.66 percent) of the development objective were met. 24. The role of the project (repayable loans) in the financing of the fight in Niger is essential and the REDES 2015 mentioned an increase of the contribution of Niger from 27 percent in 2013 to 35.15 percent in 2015. 25. Prevention, which is the focus of the project intervention, used 28 percent of resources in 2013 and 35 percent in 2015 with a use of 29.09 percent allocated for activities targeting sex workers. The project's resources have made it possible to reach the target of 48,097 cases of STIs among sex workers. 26. Throughout the implementation of the project, the World Bank has consistently provided technical and financial assistance to support stakeholders (CISLS, MoH), thus achieving great results. The contributions of the World Bank were as follow:  The ease and speed of processing non-objection applications;  Disbursement facilities ;  The flexibility of administrative, financial and accounting procedures made it possible to extend the project's intervention to PMTCT and the prison population;  Meetings with the various actors involved in the implementation of the project;  Implementation Support Mission from the WB HQ Team;  The acceptance of the second revision, which covered the extension of the closing date from June 30 to December 31, 2016. 27. In conclusion, the financial and technical support of the World Bank team was decisive in the success of the project. This positive approach should be maintained in pursuing the partnership with the World Bank. 6. Lessons learned  The mapping of the sites frequented by the key populations facilitated their access to the package of combined prevention activities (sensitization, referral to health facilities, condoms);  The decentralization of the medical follow-up to the integrated health centers and community structures; 55  Community involvement in communication activities for behavioral change, referral of key populations (CSWs, prison population) to health services for HIV and STI screening and treatment is a major strategy for Synergy of actions between the public and the community;  The recruitment of NGOs in charge of carrying out activities at Community level must take place during the preparation of the project, thus avoiding the delay in the implementation of Community interventions;  Results Based Financing pilot performance in the Boboye Health District has demonstrated that this strategy improves the quality of services, health indicators, staff motivation, collaboration between providers and communities in the management of services;  The implementation of the management plan for waste management resulting from health care has improved the health environment through individual and collective means of protection and the installation of incinerators;  The disbursement-based reporting system allowed not only the justification of spending, better to avoid cash-flow tensions throughout the implementation of the second project;  The Bank's technical support coupled with regular consultation meetings is the best way to share information and make decisions on time. 7. Recommendations To the Government of Niger  Accelerate the development and adoption of a new 2018-2022 Strategic Plan that takes into account HIV issues in relation to the Sustainable Development Goals (SDGs);  Develop a new project resulting from the 2018-2022 strategic plan;  Undertake negotiations with the World Bank to finance the new project; To the World Bank  Continue its technical and financial support in Niger in view of the achievements of the HIV/AIDS/STI program, but also to achieve one of the MDG targets of "Stopping the AIDS epidemic in the 2030 horizon ". 56 REPUBLIQUE Du NIGER Niamey le 20 j Fraternité — Travail — Progrès PRESIDENCE DE LA REPUBLIQUE Coordination Intersectorielle de Lutte contre les IST/VlH/Sida Direction de la Programmation La Coordonnatrice Nationale NO_705 CAB/PRN/CISLS Madame la Ministre du Plan Transmission rapport d'achèvement projet d'appui à la lutte contre les IST/VIH sida 201 1 - 2016. Madame la Ministre, Par lettre en date du 12 juillet 2017, le Bureau de la Banque Mondiale Niger, vous a transmis le « Rapport d'achèvement provisoire du Deuxième Projet d'Appui a la Lutte contre le VIH/Sida (Crédit IDA-49190), élaboré par la Banque mondiale à l'issue de la mission d'achèvement du projet, qui a séjourné à Niamey du 16 au 27 janvier 2017. Ce projet dont l’instance de coordination est la Coordination Intersectorielle de lutte contre les IST/VIH/sida (CISLS), avait pour objectif, d’Accroître l’accès des groupes à haut risque aux services liés à la lutte contre le VIH/sida et les IST au Niger. La mise en œuvre a été assurée par le Ministère de la Santé Publique à travers l’Unité Sectorielle de Lutte contre les IST/VIH/sida (ULSS), la Coordination Intersectorielle de Lutte Contre les IST/VIH/sida (CISLS) et les organisations de la société civile. Ayant pris connaissance du contenu dudit rapport, nous notons que les observations formulées par la CISLS lors du processus d’élaboration du présent rapport ont été prises en compte. 57 Au vue de la particularité des objectifs du projet, des efforts dans l’encadrement des partenaires de mise en œuvre, des supervisions effectuées jusqu’au niveau opérationnel, du niveau d’atteinte des différents indicateurs y compris des indicateurs de développement, nous ne sommes pas très à l’aise avec le degré d’appréciation au niveau de la Rubrique C2-Evaluation détaillée de la Performance de la Banque et de l’Emprunteur. Recevez, Madame la Ministre, l'expression de ma considération distinguée, 58 REPUBLIQUE DU NIGER Fraternité – Travail – Progrès PRESIDENCE DE LA REPUBLIQUE Coordination Intersectorielle de Lutte contre les IST/VIH SIDA Rapport d’achèvement du Deuxième Projet d’appui à la lutte contre les IST/VIH sida 2011-2016-Financement Banque Mondiale 59 Février 2017 60 3. Contexte Au Niger, l’épidémie du VIH se caractérise par une prévalence nationale de 0,7% (EDSN-MICS3 2006). Cette faible prévalence cache des disparités selon les régions et les groupes socioprofessionnels notamment les professionnels de sexe et leurs clients. Ainsi, elle varie entre 1,7% à Diffa et 0,3% à Maradi (EDSN-MICS3 2006). Chez les professionnels de sexe, la séroprévalence est de 20,9% (SSG 2008). Par région, la situation se présente comme suit : Agadez (24,5%), Diffa (non couvert par l’enquête), Dosso (19,8%), Maradi (60,6%), Tahoua (43,5%), Tillabéri (16,7%) Zinder (41,7%) et Niamey (35,6%). D'autres groupes de la population ont une prévalence du VIH qui est au-dessus de celle de la population générale : les forces de défenses et de sécurité (1,7%), la population carcérale (2,7%), les routiers/camionneurs (1,83%), les enseignants (0,3%) et les migrants (1,03%) (SSG 2008). Par ailleurs, la surveillance sentinelle réalisée auprès des femmes enceintes en 2009 montre une prévalence nationale de 1,7% avec une variation allant de 2,7% à Tahoua et 1,1% à Maradi ; cette situation expose les nouveau-nés à un risque accru d’infection à VIH. Le système de santé au Niger fait toujours face à des problèmes, liés au manque et à la forte mobilité de ressources humaines, aux niveaux de la prestation et de la gestion des services, à l’insuffisance de matériels de laboratoire, ainsi qu’à la faiblesse de la chaîne d’approvisionnement, qui se traduit par des ruptures fréquentes de stocks de médicaments et qui entrainent des achats d’urgence. Ce système se caractérise aussi par des grandes disparités géographiques, avec plus de services disponibles dans les zones urbaines que dans les zones rurales avec une faible couverture des services. Pour faire face à la situation, le Niger a élaboré un cadre stratégique 2008-2012 qui a bénéficié de l’appui des partenaires techniques et financiers dont la Banque mondiale dans le cadre du MAP1. Il envisage, la révision dudit cadre en plan stratégique national 2013-2017 qui prendra en compte la distribution épidémiologique du VIH et les faiblesses constatées dans la riposte au VIH en particulier celles liées au système de santé. La situation au sein des professionnelles de sexe a conduit la Coordination intersectorielle de lutte contre les IST/VIH/sida (CISLS) avec l’appui de la Banque mondiale à réaliser une étude l’état de la situation du VIH au Niger et sur les déterminants de la forte séroprévalence au sein des professionnels de sexe en 2010. Cette étude a fait ressortir les zones géographiques à forte prévalence (Niamey, Zinder, Maradi et Tahoua) mais aussi a permis de faire la cartographie des sites prostitutionnels. Les résultats de cette étude ont permis d’orienter les négociations d’un projet de lutte contre le VIH financé par la Banque mondiale. C’est ainsi que le pays obtenu l’appui financier de la Banque mondiale pour mettre en œuvre le 2ème Projet d’appui à la lutte 61 contre les IST/VIH sida pour la période 2011-2016. En lien avec les priorités définies par le pays et pour avoir les meilleurs impacts, le projet cible trois composantes stratégiques :  le renforcement du système de santé en lien avec le VIH ;  la prévention des infections à VIH chez les groupes à haut risques (PS et clients) ;  le renforcement de la coordination et du suivi évaluation de la lutte contre les IST/VIH sida. 4. Objectifs assignés aux différentes composantes du projet L’objectif de développement du projet est d’accroître l’accès des groupes à haut risque aux services liés à la lutte contre le VIH/sida et les IST au Niger. Le Projet vise de manière spécifique à accompagner la mise en œuvre du Cadre Stratégique National pour : (a) l’extension de l’offre des services de prévention ; (b) l’augmentation de l’utilisation des services de lutte contre les IST/VIH SIDA ; (c) l’amélioration du suivi-évaluation (S&E) en mettant en place un mécanisme national de suivi incluant un système de surveillance biologique et comportementale. Sa mise en œuvre se fait à travers trois composantes : (i)  Composante 1 « Renforcement des services de santé dans le domaine de la lutte contre le VIH/sida et les IST », exécutée par le Ministère de la Santé Publique à travers l’Unité de Lutte Sectorielle Santé (ULSS), la Direction des études et programmation (DEP), la Direction de la Santé de la Mère et de l’Enfant (DSME), la Direction de l’Hygiène Publique et Education pour la Santé (DHP/ES). Cette composante a deux (2) volets :  Accroissement de l’accès à des services de santé de qualité ;  Financement basé sur les Résultats d’actions de lutte contre le VIH/sida, à titre Pilote (FBR) ;  Composante 2 « Prévention du VIH/Sida et des IST chez les groupes à haut risque » mise en œuvre par les ONG et gérées par la Coordination Intersectorielle de Lutte contre le Sida (CISLS) ;  Composante 3 « Coordination, Gestion, suivi et évaluation » gérée par la Coordination intersectorielle de lutte contre les IST/VIH sida (CISLS). Les bénéficiaires directs du Projet sont les personnes vivant avec le VIH et les groupes à haut risque au Niger notamment les travailleurs du sexe, leurs clients, et les personnes vivant avec la tuberculose pour qu’ils aient un meilleur accès aux services de lutte contre les IST/VIH sida, les orphelins et enfants vulnérables. Les bénéficiaires indirects du Projet sont les demandeurs de soins médicaux, car le Ministère de la Santé Publique renforcera ses capacités d’offre de services du système de santé. Le Conseil national de lutte contre les IST/VIH sida (CNLS) et la CISLS bénéficieront d’un renforcement de capacité afin d’assurer la coordination, le suivi-évaluation et la mise en œuvre du programme national de lutte contre les IST/VIH sida. Le projet a dans sa première phase couvert quatre régions (Maradi, Tahoua, Zinder et Niamey) du fait de leur prévalence élevée du VIH chez les professionnels de sexe et leurs clients et aussi compte tenu des effectifs de ce groupe dans ces régions. Suite de la revue à mi-parcours du projet en 2014, 62 qui a fait ressortir des résultats encourageants et sur la base des leçons apprises de la mise en œuvre les interventions ont été étendues au niveau national, c’est à dire à toutes les huit régions. 5 Résultats atteints et impacts constatés 3.1. Résultats atteints La mise en œuvre du projet a permis d’enregistrer les résultats suivants par composante : 5.1.1 Composante 1 : Renforcement des services de santé dans le domaine de la lutte contre le VIH/SIDA et les IST 5.1.1.1 Accroitre l’accès à des services de santé et leur qualité :  Acquisition du matériel roulant, matériel informatique et bureautique ; de réactifs et consommables pour le dépistage et suivi biologique des PS, médicaments et consommables pour le dépistage et la prise en charge des IST ;  Formation de 5 402 agents de santé en prise en charge (PEC) syndromique des IST et PEC des personnes vivant avec le VIH sida (PVVIH), 1 232 agents de santé sur les outils de suivi médical des PS, 3 081 agents de santé en gestion des déchets issus des soins de santé (GDISS), 50 formateurs sur les outils de collecte des données PTME, 1 134 agents de santé sur les outils de collecte de données PTME, 1 275 agents de santé en PTME in situ, 105 agents en surveillance sentinelle chez les femmes enceintes, 16 responsables de centres de surveillance épidémiologie (CSE) des sites prescripteurs sur le logiciel FUCHIA ;  Reproduction de 15 000 affiches sur la GDISS, 6000 exemplaires du guide de procédures pour la GDISS, des outils révisés de collecte des données pour le suivi médical des PS ;  Mise en service de 14 hydro-claves et 36 appareils de production d’Anolyte neutre installés au niveau des formations sanitaires, 1556 kits équipements de protection individuelle (paires de bottes, gants, masques blouses d’isolation).  Supervisions trimestrielles des sites PTME (13) dont 1 des centres amis des jeunes ;  Réalisation d’une étude sur la situation de base du plan de gestion des déchets issus des soins de santé (PGDISS) ;  Réalisation en 2012 et 2014 d’enquêtes de surveillance sentinelle chez les femmes enceintes ; 5.1.1.2 Développer à titre pilote les actions de lutte contre le VIH/sida sur la base des résultats (FBR) 63  Réalisation d’une étude de faisabilité du FBR et missions d’étude de 8 personnes au Cameroun et au Rwanda ;  Mise en place d’une Equipe d’assistance technique FBR ;  Elaboration et Validation du manuel de procédures FBR pour le Niger ;  Réalisation d’un état des lieux et signature des 30 contrats FBR dont 27 Centres de Santé Intégrés (CSI), l’Hôpital de District (HD) et Equipe Cadre de District (ECD) de Boboye et la Direction Régionale de la Santé Publique (DRSP) de Dosso ;  Identification et signatures de contrats avec 20 organisations à base communautaire chargées des enquêtes communautaires ;  Formation en FBR de 2 agents de l’ULSS, 10 cadres de la DRSP de Dosso, du District Sanitaire (DS) de Boboye et de l’équipe FBR ,78 agents de santé et présidents de comités de gestion ;  Paiements réguliers des subsides aux formations sanitaires ;  Réalisation d’une enquête qualité de base pour toutes les formations sanitaires ;  Réalisation de supervisions régulières des formations sanitaires. 5.1.2 Composante 2 : Prévention du VIH/sida et des IST chez les groupes à haut risque  Signature de contrats avec les ONG et Consortiums ;  Réalisation et mise à jour de la cartographie des Sites prostitutionnels ;  Organisation de 12 ateliers d’orientation dans les 8 régions de 2013 à 2015 ;  Formation de 4 057 pairs éducateurs en IEC/CCC en 2013-2016 par les ONG ;  Réalisation de 17 924 séances de causeries éducatives par les pairs ;  Sensibilisation de 81 604 professionnels de sexe et leurs clients à travers la paire éducation ;  Sensibilisation et référence de 70 990 PS par les ONG vers les formations sanitaires pour le dépistage et traitement des IST ;  13 734 PS reçus pour dépistage VIH dans les formations sanitaires ;  48 097 cas cumulé d’IST dépistés et traités chez les professionnels ;  Distribution de 3 410 286 préservatifs masculins et féminins, 6 454 tubes de gel et 8 035 sachets aux PS et leurs clients ; 64  Mise en place de 167 groupements de PS en 2013-2016 comprenant 956 membres ;  Identification de 167 orphelins et autres enfants vulnérables issus des groupes à haut risque et soutien à 160 par les organisations communautaires en 2013-2016 ; 5.1.3 Composante 3 : Gestion, suivi et évaluation  Renforcement du parc auto-moto, de groupes électrogènes, et parc informatique pour la CISLS ;  Recrutement des ONGS/consortiums et mise des fonds à leur disposition pour financer leurs plans de travail ;  Organisation de réunions de concertation organisées au niveau central ;  Tenue de plusieurs réunions avec les partenaires ;  Tenue de la revue à mi-parcours du 2ème projet financé par la Banque Mondiale en 2014 ;  Appui au fonctionnement de la CISLS et ULSS ;  Supervision des activités du niveau central (CISLS et ULSS) en direction des structures de coordination, de suivi et évaluation (DRSP, CRISLS, districts, équipes ONGs et consortium) du niveau régional ;  Supervision de proximité sur site des prestations des ONGs et consortium par l’équipe cadre de la DRSP et CRISLS. 5.1.4 Gestion financière 5.1.4.1 Situation des décaissements par catégorie de dépenses Catégorie Description Montant Alloué Décaissement Engagements Réalisations Taux GDS, NON-CS, CS 1 Part 1 and 2 106 796 875 3 424 724 814 - 3 424 724 814 163% TR&Audits 2 Output-based Grants 1 795 117 188 790 361 534 676 110 791 037 644 44% GDS, NON-CS, CS 3 Parts2&3 and 4 667 304 688 4 328 073 704 59 922 633 4 387 996 337 94% TR&Audit DISB - 4-A OPERATING 749 609 375 458 504 561 194 156 318 652 660 879 87% COSTS Part 1 65 DISB - 4-B OPERATING 512 890 625 819 996 069 819 996 069 160% COSTS Parts 2 & 3 PPF 5 268 281 250 - 0% REFINANCING - - DA-Q Designated Accon - - Total 10 100 000 000 9 821 660 682 254 755 061 10 076 415 743 99,77% 5.2 Impacts constatés En résumé, la mise en œuvre du projet a permis de :  Réduire les nouvelles infections et le niveau de l’épidémie du VIH puisque les différentes études ont montré que les séroprévalences en milieu PS est passée de 17,3% en 2011 à 16,6% en 2015 et chez les détenus de 2,7% en 2011 à 1,9% en 2015 ;  Rehausser l’utilisation des services de santé par les groupes à haut risque ;  Rehausser le nombre d’adultes et enfants à un stade avancé qui sont sous traitement ARV de 7 445 en 2009 à 14 729 au 30 juin 2016 ;  Renforcer les capacités du personnel de santé dans les domaines suivants : Prise en charge des IST et du VIH/sida, Conseil dépistage à l’initiative du soignant, PTME, biosécurité et Gestion des déchets, Financement basé sur les Résultats ;  Améliorer la couverture des femmes enceintes séropositives qui ont reçu une prophylaxie antirétrovirale complète pour réduire le risque de transmission du virus à l’enfant passant de 10,4% en 2011 à 35% au 30 septembre 2016 ;  Expérimenter le FBR dans le District de Boboye (Dosso) avec 30 contrats signés avec les centres de santé ; 6 Performance d’exécution du projet Dans le document cadre du projet, il est prévu le renforcement du cadre de Gestion de la chaîne d’approvisionnement. Du fait du financement du Fonds Mondial de lutte contre le Paludisme, la Tuberculose et le Sida qui prend en compte ce volet, ce paquet d’activités n’a pas été exécuté sur la Banque mondiale pour éviter les doublons, mais aussi pour permettre d’avoir une meilleure efficience sur l’utilisation des ressources. C’est ainsi que le Fonds mondial a permis de doter l’Officier national des produits pharmaceutiques et chimiques (ONPPC) du Niger en camion frigorifique et en 3 véhicules pour la supervision pour l’acheminement des produits vers les différentes régions du pays, l’amélioration de la capacité de stockage de l’ONPPC, la formation du personnel en gestion de stocks. Ce financement a permis également la prise en charge des réunions du comité de suivi de la coinfection tuberculose-VIH et celles du groupe Approvisionnement. 66 En termes de performance, on peut dire que le projet a atteint ses objectifs, car pour tous les indicateurs les cibles atteintes sont largement au-dessus des prévisions (11 453 Professionnels de sexe dépistés pour les IST sur 4000 prévues, 70 990 Travailleurs du sexe référés par les ONG vers les services de santé sur 5 991 prévues). Concernant l’appréciation du projet par les acteurs, l’enquête réalisée auprès des bénéficiaires en 2015 et le film documentaire de 2014 font ressortir une satisfaction sur la mise en œuvre du projet. (voir rapport enquête de satisfaction des bénéficiaires et film documentaire). L’évaluation de l’approche financement basé sur les résultats a montré que toutes les parties prenantes ont beaucoup apprécié cette stratégie. En effet, elle a permis d’améliorer la fréquentation des services dans la zone pilote, la qualité des prestations des soins de santé, la disponibilité des ressources et l’autonomie financière des formations sanitaires. Au total, le deuxième projet d’appui à la lutte contre le sida au Niger constitue une expérience porteuse qu’il va falloir continuer et étendre en mettant l’accent sur les populations les plus à risque (professionnels de sexe, détenus, hommes ayant des rapports sexuels avec d’autre homme). Les stratégies comme le financement basé sur les résultats doit être maintenue et étendue à toutes les activités avenir y comprises celles dédiées aux ONG. 7 Appréciation de la performance de la Banque mondiale Le projet a été une réponse au Cadre Stratégique National du Niger 2008-2012 et le PSN 2013-2017 afin de briser très tôt et plus efficacement la chaîne de transmission du VIH et de prévenir les nouvelles infections dans la population générale. La pertinence du projet a également permis la préparation d'outils techniques, de directives et la formation du personnel impliqué dans la mise en œuvre des activités de prévention et de soins pour les groupes à haut risque. Le projet a atteint son objectif de développement en augmentant l’accès des groupes à haut risque aux services de lutte contre le VIH/Sida et les IST. En fin octobre 2016, deux (2) indicateurs sur 3 (66,66%) de l’objectif de développement ont été atteints. La place du projet (Prêts remboursables) dans le financement de la lutte au Niger est primordiale et le REDES 2015 donne une progression de la contribution de l’Etat du Niger de 27% en 2013 à 35,15% en 2015. La prévention qui constitue le point central de l’intervention du projet a utilisé 28% des ressources en 2013 et 35% en 2015 avec une utilisation de 29,09% des ressources de prévention pour le groupe unique des professionnels du sexe. Les ressources du projet ont permis d’atteindre la cible permettant ainsi la prise en charge de 48 097 cas d’IST chez les professionnels du sexe. 67 Tout au long de la mise en oeuvre du projet, la Banque mondiale a constamment apporté une assistance technique et financière pour accompagner les parties prenantes (CISLS, MSP), ce qui a permis d’atteindre les résultats obtenus. Les contributions de la Banque mondiale se sont traduites par :  Les facilités et rapidité de traitement de dossiers de demande de non objection ;  Les facilités de décaissements ;  La flexibilité des procédures administratives, financières et comptables a permis d’étendre l’intervention du projet à la PTME et à la population carcérale ;  Les réunions avec les différents acteurs de mise en œuvre du projet ;  Les missions d’appui de l’équipe du siège de la Banque Mondiale ;  L’acceptation de la deuxième révision qui a porté sur l’extension de la date de clôture du 30 juin 2016 au 31 décembre 2016 et approuvée le 16 décembre 2015. En conclusion, l’accompagnement financier et technique de l’équipe de la banque mondiale a été déterminant dans la réussite du projet. Cette approche positive devrait être maintenue dans la poursuite du partenariat avec la Banque mondiale. 6. Leçons et enseignements tirés  La cartographie des sites fréquentés par les populations clés a permis de faciliter l’accès de celles-ci au paquet d’activités de prévention combinée (sensibilisation, référence vers les formations sanitaires, préservatifs) ;  La décentralisation du suivi médical des PS aux centres de santé intégré et aux structures communautaires ;  L’implication du communautaire dans les activités de la communication pour un changement de comportement, la référence des populations clés (PS, population carcérale) vers les services de santé pour le dépistage et le traitement du VIH et des IST constituent une stratégie majeure pour une synergie d’actions entre le public et le communautaire ;  Le recrutement des ONGs en charge de la réalisation des activités au niveau communautaire doit intervenir pendant la préparation du projet, évitant ainsi le retard de mise en œuvre des interventions communautaires ;  Le financement basé sur la performance à titre pilote dans le district sanitaire de Boboye a prouvé que cette stratégie améliore la qualité des services, les indicateurs sanitaires, la motivation du personnel, la collaboration entre les prestataires et les communautés dans la gestion des services ;  La mise en œuvre du plan de gestion de gestion des déchets issus des soins des soins de santé a permis d’améliorer l’environnement sanitaire grâce aux moyens de protection individuels et collectifs ainsi que la mise en place des incinérateurs ; 68  Le système de décaissement base rapport a permis non seulement la justification des dépenses, mieux d’éviter les tensions de trésorerie tout au long de la mise en œuvre du deuxième projet ;  Les appuis techniques de la Banque couplés aux rencontres périodiques de concertation constituent la meilleure façon de partager des informations et de prise de décisions à temps. 8. Recommandations Au Gouvernement du Niger  Accélérer l’élaboration et l’adoption d’un nouveau plan stratégique 2018-2022 qui prend en compte les questions de VIH en lien avec les Objectifs de développement durable (ODD) ;  Elaborer un nouveau projet issu du plan stratégique 2018-2022 ;  Entreprendre des négociations avec la Banque mondiale pour le financement du nouveau projet. A la Banque Mondiale  Poursuivre son appui technique et financier au Niger au vue des acquis obtenus par le programme de lutte contre les IST/VIH sida mais aussi pour l‘atteinte des objectifs assignés dans le cadre des ODD à savoir « Mettre fin à l’épidémie du sida à l’horizon 2030 ». 69 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders NA 70 Annex 9. List of Supporting Documents  Aide Memoire for all World Bank missions conducted under the project  Country Assistance Strategy, May 2008  Financing Agreement (May 2011)  Implementation Status & Results Report (Seq#1 to Sep#11)  Integrated Safeguards Datasheet Appraisal Stage (March 2011)  Issues Paper for Mid-Term Review (February 2014)  Minutes of Project Negotiations (March 2011)  Minutes of Quality Enhancement Review (February 2011)  Minutes of Decision Meeting (March 2011)  Minutes of Concept Review Meeting (April 2010)  Project Appraisal Document (March 2011)  Project Concept Note (March 2010)  Project Information Document – Appraisal Stage (March 2011)  Restructuring Paper (March 2016)  Restructuring Paper (August 2014)  Report: Annual Report of ULSS  Report: Findings from the HIV Allocative Efficiency & Financial Sustainability Study (2014)  Report: Estimating the Flow of STI / HIV / AIDS Resources and Expenditures in Niger (September 2015)  Report: Second Generation Surveillance on HIV/AIDS in Niger 2015  Report: Beneficiary Satisfaction Survey (2014)  Report: Evaluation of the Results Based Financing in Boboye District (2016)  Report: National Monitoring & Evaluation Strategic Plan (2013-2017)  Report: National Strategic Framework for HIV/AIDS (2008-2012)  Report: National Strategic Framework for HIV/AIDS (2013-2017)  Report: Behavioral Change Survey in Prison (2014)  Reports: Cartography of Prostitution Sites (Dosso, Diffa, Maradi, Niamey, Tillabery, Tahoua, Zinder) 71 72