Document of The World Bank Report No: ICR0000615 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H0660) ON A GRANT IN THE AMOUNT OF SDR 12.2 MILLION (US$ 16.6 MILLION EQUIVALENT) TO THE REPUBLIC OF BENIN ON BEHALF OF THE FIVE WESTERN AFRICAN STATES FOR A HIV/AIDS PROJECT FOR ABIDJAN/LAGOS TRANSPORT CORRIDOR June 25, 2008 Transport Sector Country Department AFCRI Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective January 31, 2008) Currency Unit = CFA franc 1 CFAF = US$ 0.002268 US$1 = 441CFAF FISCAL YEAR January 1 ­ December 31 ABBREVIATIONS AND ACRONYMS AIDS: Acquired Immune Deficiency Syndrome ALCO: Abidjan-Lagos Corridor Organization ARV: Antiretroviral drug BCC: Behavior change communication CAS: Country Assistance Strategy CBO: Community-Based Organization CSO: Civil Society Organization ECOWAS: Economic Community of West African States EU: European Union FCFA: Franc of West African Monetary Union GTZ: Gesellschaft für Technische Zusammenarbeit (German Agency for International Cooperation) HIV: Human Immunodeficiency Virus IEC: Information, Education and Communication IEG: Independent Evaluation Group ISR: Implementation Status Report MAP: Multi-Country HIV/AIDS Program M&E: Monitoring and Evaluation MTR Mid-Term Review NGO: Non-governmental Organization OI: Orphans Infected OVC: Orphans and Vulnerable Children PAD: Project Appraisal Document PHRD: Japan Policy and Human Resources Development Trust Fund PDO: Project Development Objective PLWHA People Living with HIV/AIDS PPF: Project Preparation Facility RAP+AO: Réseau Africain des Personnes vivant avec le VIH/SIDA en Afrique de l'Ouest (Network of Africans living with HIV/AIDS in West Africa) RIAS: Regional Integration Assistance Strategy STI: Sexually Transmitted Infection UNAIDS: Joint United Nations Program on HIV/AIDS VCT: Voluntary Counseling and Testing Vice President: Obiageli Katryn Ezekwesili Country Director: Joseph Baah-Dwomoh/Mark Tomlinson Sector Manager: C. Sanjivi Rajasingham Project Team Leader: Siélé Silué ICR Team Leader: Nadeem Mohammad AFRICA HIV/AIDS PROJECT FOR ABIDJAN-LAGOS CORRIDOR TABLE OF 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 (if any)................................................ I. Disbursement Profile................................................. 1. Project Context, Development Objectives and Design............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 3 3. Assessment of Outcomes............................................................................................ 7 4. Assessment of Risk to Development Outcome......................................................... 11 5. Assessment of Bank and Borrower Performance ..................................................... 12 6. Lessons Learned ....................................................................................................... 14 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 15 Annex 1. Project Costs and Financing.......................................................................... 16 Annex 2. Outputs by Component ................................................................................. 17 Annex 3. Economic and Financial Analysis................................................................. 21 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 22 Annex 5. Beneficiary Survey Results........................................................................... 24 Annex 6. Stakeholder Workshop Report and Results................................................... 25 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 26 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 28 Annex 9. List of Supporting Documents ...................................................................... 30 Annex 10: Statistical Annex ......................................................................................... 31 Annex 11: Key Lessons Learned from ALCO Experience ............................................ 1 A. Basic Information HIV/AIDS PROJECT FOR ABIDJAN - Country: Africa Project Name: LAGOS TRANSPORT CORRIDOR Project ID: P074850 L/C/TF Number(s): IDA-H0660 ICR Date: 06/26/2008 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: BENIN Original Total XDR 12.2M Disbursed Amount: XDR 12.2M Commitment: Environmental Category: B Implementing Agencies: EXECUTIVE SECRETARIAT Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 07/19/2001 Effectiveness: 02/18/2004 02/18/2004 Appraisal: 11/18/2002 Restructuring(s): Approval: 11/13/2003 Mid-term Review: 01/23/2006 01/23/2006 Closing: 07/01/2007 12/31/2007 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Low or Negligible Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Overall Borrower Performance: Satisfactory Performance: Satisfactory i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Yes Quality at Entry None at any time (Yes/No): (QEA): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 27 13 General transportation sector 8 Health 41 60 Other social services 32 19 Theme Code (Primary/Secondary) HIV/AIDS Primary Primary Other communicable diseases Secondary Secondary Regional integration Secondary Secondary Social risk mitigation Secondary Secondary Trade facilitation and market access Secondary Secondary E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Mark D. Tomlinson Antoinette M. Sayeh Sector Manager: C. Sanjivi Rajasingham C. Sanjivi Rajasingham Project Team Leader: Siele Silue Stephen J. Brushett ICR Team Leader: Siele Silue ICR Primary Author: Jerome F. Chevallier F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The PDO is to increase access along the Abidjan # Lagos Transport Corridor to HIV/AIDS prevention, basic treatment, support and care services by underserved ii vulnerable groups with particular attention to transport workers, the migrant population, commercial sex workers and the local populations living along the corridor, especially at the border towns. It is expected that the project will contribute to the reduction of the spread of HIV/AIDS and to the mitigation of the adverse social and economic impact of HIV/AIDS along the transport corridor. Revised Project Development Objectives (as approved by original approving authority) The objective was not revised (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Indicator 1 : By end of 2006, at least 90% of the corridor commercial vehicle drivers can identify at least two ways in which to prevent HIV/AIDS Value quantitative or 68 percent At least 90 percent 82.7 percent Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments (incl. % 92 percent of the target value achieved. To address the issue of target population achievement) high mobility, the project initiated special information days. Indicator 2 : By the end of 2006, at least 90% of local population residing along the corridor can identify at least two ways in which to prevent HIV/AIDS Value quantitative or 50 percent At least 90 percent 84.4 percent Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments (incl. % 94 percent of the target value achieved due to many changes among the local achievement) population residing along the corridor during the various surveys. Indicator 3 : By end of 2006, at least 90%, of the sex workers along the transport corridor can identify at least two ways in which to prevent HIV/AIDS. Value quantitative or 59.5 percent 90 percent 87.9 percent Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments (incl. % 98 percent of the target value achieved. The project led many IEC activities for achievement) sex workers, including training for peer educators. By end of 2006, reduce by 30%, compared with the first year of the project, the Indicator 4 : incidence of reported sexually transmitted (urethritis) infections among male commercial vehicle drivers working along the corridor. Value quantitative or 6.7 percent 4.7 percent 11.5 percent Qualitative) iii Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments -244 percent of the target value achieved. The STI incidence has gone up because (incl. % of improved diagnostics and availability of treatment may have attracted more achievement) utilization of those infected with STIs. (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Completion or documents) Target Values Target Years By 2006, increase by at least 50%, compared with the first year of the project, the Indicator 1 : proportion of commercial vehicle drivers using a condom in their last act of sexual intercourse with a non-regular partner in the previous 12 months. Value (quantitative 59.3 percent 90 percent 78.8 percent or Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments 88 percent of the target value achieved. The condom distribution benefited a (incl. % large number of highly mobile people and also the restrictive interpretation achievement) given by commercial vehicle drivers to what is a non-regular partner can explain this result. Indicator 2 : By end of 2006, at least 80% of commercial sex workers along the transport corridor report using condoms with their clients of the previous week. Value (quantitative 58.8 percent 80 percent 70.5 percent or Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments 88 percent of the target value achieved. The sex workers move very frequently (incl. % from an area to another with lot of new arrivals. These movements can explain achievement) this result. By end of 2006, increase by 50%, compared with first year of the project, the Indicator 3 : number of condoms distributed through social marketing along the transport corridor. Value (quantitative 0.97 million 1.46 million 8.8 million or Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments 602 percent of the target value achieved. The project has produced its own (incl. % condom #The MIGRANT# distributed in the kiosks put in place by the project achievement) along the corridor. Indicator 4 : By end of 2006, each border crossing point of the corridor has at least one voluntary counseling and testing (VCT) center on either side of the border. Value (quantitative 3 8 16 or Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments 200 percent of the target value achieved. The project undertook strong IEC iv (incl. % campaigns. To satisfy the huge number of people interested by the test, the achievement) project doubled the number of the VCT centers. By end of 2006, increase by at least 50%, compared with first year of the project, Indicator 5 : the number of people who use voluntary counseling and testing centers along the transport corridor. Value (quantitative 1,000 1,500 27,639 or Qualitative) Date achieved 02/15/2005 07/30/2007 12/31/2007 Comments 1,856 percent of the target value achieved. The successful IEC campaigns led by (incl. % the project, including traditional chiefs, religion leaders, transport unions, achievement) PLWHA to promote VCT. G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 12/12/2003 Satisfactory Satisfactory 0.00 2 06/02/2004 Satisfactory Satisfactory 1.24 3 12/03/2004 Satisfactory Satisfactory 1.76 4 05/11/2005 Satisfactory Satisfactory 3.18 5 10/15/2005 Satisfactory Satisfactory 5.72 6 03/17/2006 Satisfactory Satisfactory 8.81 7 10/12/2006 Satisfactory Satisfactory 12.79 8 03/25/2007 Satisfactory Satisfactory 15.75 9 11/30/2007 Satisfactory Satisfactory 17.41 H. Restructuring (if any) Not Applicable v I. Disbursement Profile vi 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. In West Africa, major regional travel routes extend along the north-south directions between land-locked and coastal countries on one hand, and east-west directions (mainly the Abidjan-Lagos corridor) between the coastal countries on the other hand. National borders often divide populations from the same ethnic group. About 30 million people live along the Abidjan- Lagos corridor and 14 million people travel on the corridor annually. Travel along the major transport routes in the region is an essential requirement for its socioeconomic well-being; it also offers opportunities for faster transmission of sexually transmitted infections (STIs), including Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), among the people in the region. Commercial vehicle drivers, commercial sex workers, migrants and the people, who live in border areas along the major transport routes, are among the vulnerable groups that may be affected by HIV/AIDS. According to the social assessment done in 2001, about 300,000 HIV positive people were traveling along the corridor every year. 2. UNAIDS estimated that the HIV prevalence rates among the adult population in the five countries along the Abidjan-Lagos corridor ranged from 9.7 percent in Côte d'Ivoire and 3 percent in Ghana in 2001 (see Annex 10, Table 1). High prevalence rates among truck drivers and commercial sex workers were reported in the large cities along the corridor. For instance, 33 percent of the truck drivers and 80 percent of commercial sex workers in Lomé, the capital of Togo, were reported to be infected with HIV in 1992. Long delays in clearing border formalities along the corridor led to risky behavior by truck drivers. Experience demonstrates that prevention is more effective when it is carried out in places, where such risky behavior occurs. 3. The Country Assistance Strategies (CAS) of the five countries concerned (interim CAS or progress report as applicable) identified HIV/AIDS as an issue requiring Bank support. Country-specific programs for combating HIV/AIDS in the five countries were either being supported by ongoing projects under the Multi-Country HIV/AIDS Program (MAP) or were being prepared. The transport corridor project was designed to complement national efforts by addressing cross-boundary issues, such as HIV/AIDS, and targeting vulnerable groups that are not easily covered through country projects because they are highly mobile. The central focus of the regional integration assistance strategy for West Africa (RIAS), reviewed by the Board in July 2001, was the creation of a West African open, unified, regional economic space. Its secondary focus was on addressing issues that span borders, such as preventing communicable diseases, where there can be gains from greater regional cooperation. The project was fully aligned with the RIAS. It would complement national efforts in HIV/AIDS prevention and make a contribution to facilitating trade along the corridor. 1.2 Original Project Development Objectives (PDO) and Key Indicators 4. The objective of the project was to increase access along the Abidjan-Lagos transport corridor to HIV/AIDS prevention, basic treatment, support and care services by underserved vulnerable groups. Particular attention would be given to transport sector workers, migrant population, commercial sex workers and local populations living along the corridor, especially at border towns. The project was expected to contribute to the reduction of the spread of HIV/AIDS and the mitigation of the adverse social and economic impact of HIV/AIDS along the transport corridor. 5. Five outcome indicators were proposed. The first three had to do with knowledge about HIV/AIDS (at least 90 percent of the local population, the commercial vehicle drivers and the commercial sex workers residing and working along the transport corridor could identify at least two ways to prevent HIV/AIDS). The last two had to do with the reduction of the incidence of Sexually Transmitted Infections (STIs): reduce by 30 percent the incidence of STIs among male commercial vehicle drivers, and by 50 percent the prevalence of gonorrhea among commercial sex workers. Nine output indicators were proposed, including the establishment of one voluntary counseling and testing center on either side of each border, attendance at these centers; the use of condoms by commercial vehicle drivers and sex workers; and the reduction of the average time for clearing border formalities and of the number of informal checkpoints along the corridor. 1.3 Revised PDO The objective was not revised. 1.4 Main Beneficiaries 6. The project targeted the vulnerable populations along the Abidjan-Lagos transport corridor, with particular attention to: a) commercial vehicle drivers; b) People Living with HIV/AIDS (PLWHA); c) commercial sex workers; d) migrants; e) customs, police and immigration employees based at border towns along the corridor; f) local residents along the transport corridor, especially those in border towns. Public sector entities in the health, transport and trade sectors were expected also to benefit from the project. 1.5 Original Components 7. The project included three components, prevention, care and support, and project implementation and capacity building. · The first component, HIV/AIDS prevention, included two sub-components: a) implementation of an integrated Information, Education and Communication (IEC) and Behavior Change Communication (BCC) program, and b) social marketing of condoms in the eight border communities and along the transport corridor. · The second component, HIV/AIDS treatment, care and support services, included three sub-components: a) strengthening public and private health care facilities along the corridor to provide Voluntary Counseling and Testing (VCT) services and treatment of STIs and HIV/AIDS opportunistic infections; b) provision of grants to Civil Society Organizations (CSOs, including Community-Based Organizations - CBOs) to undertake community-based initiatives in HIV/AIDS care and support; and c) safe disposal of medical waste related to the project. · The third component (project coordination, capacity building and policy development) included: a) the development of strong HIV/AIDS inter-country coordination among governments and other stakeholders; b) capacity building among participating partners; c) implementation of transport sector policies aimed at expediting border crossing and removing informal barriers to the movement of people and goods, which would in turn help reduce the importance of sex markets at border towns. 1.6 Revised Components. The components were not revised 1.7 Other significant changes 8. Two reallocations of funds were approved in July 2006 and in July 2007. Allocations to categories 2 (consultant services and training) and 4 (equipment and drugs, tests and medical supplies) have been increased to take account of (a) key studies to address waste management issues and adopt the HIV/AIDS regional strategy, and (b) the need to provide medical supplies to a larger number of health facilities than initially envisaged. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 9. The project was fully consistent with the MAP2 eligibility criteria for sub-regional projects. It was consistent with the HIV/AIDS strategies of the five countries concerned and addressed cross border HIV/AIDS issues, which were beyond the reach of national programs. It was endorsed by the five heads of state, through a joint declaration. During project preparation, appropriate procedures were put in place to enable sub-regional and national stakeholders to participate effectively in project implementation and to ensure that IDA's safeguards requirements were met. 10. The project was also fully aligned with the RIAS. It was designed to complement national HIV/AIDS programs by mitigating a negative cross border externality and focusing on people not reached by national programs. It would also complement ongoing transport sector operations in three of the five countries concerned (Cote d'Ivoire, Ghana and Nigeria, which had all HIV/AIDS components). To facilitate trade and transport, the project included the surveillance of abnormal practices at borders, the effective application of Economic Community of West African States (ECOWAS) agreements governing transit and movement of goods and people, and the dissemination of information to commercial vehicle drivers. Transport facilitation was not mentioned as an objective of the project, however, even though indicators were proposed to measure improvements to the flow of traffic along the Abidjan-Lagos corridor. 11. The background analysis on the transport corridor was adequate. In the framework of the West Africa Initiative, an UNAIDS team carried out extensive assessments of vulnerable groups along the corridor and more specifically in border towns, which had high HIV prevalence rates and almost no services. A number of alternatives were considered, including relying on national programs to address the specific issues of the transport corridor. A range of options were explored concerning the institutional arrangements for project implementation, in close consultation with ECOWAS. 12. Lessons learned from international experience in fighting HIV/AIDS, and especially, country specific MAP1 projects, were fully incorporated in the project design. These lessons included addressing the regional implications of HIV/AIDS, insisting on strong political leadership and commitment at the highest levels, focusing on vulnerability factors, empowering local communities, designing a multi-sectoral response to HIV/AIDS, recognizing the complexity of MAP project supervision and the need to put in place a robust Monitoring and Evaluation (M&E) system, avoiding a culture of command and control in HIV/AIDS Secretariats, providing assistance to help CSOs prepare and implement their interventions and sequencing interventions to match the development capacity in the countries. 13. The objective of the project was well defined. Its design was straightforward. In addition to the complexity of MAP projects, the regional dimension of this project made it more complex than national projects. 14. The institutional framework for project implementation was elaborate. An assessment of the ECOWAS Secretariat showed that it did not have the capacity to implement the project. The Abidjan-Lagos Corridor Organization (ALCO) was established for that purpose. A Governing Body, including the heads of the national HIV/AIDS programs and the Transport Directors from each country, was responsible for the adoption of annual action plans, the supervision of their implementation and liaison with national HIV/AIDS programs. The Executive Secretariat, supported by a management consultant firm, was responsible for coordinating project implementation by CSOs and public sector organizations. An Advisory Body, with half of its members from private sector organizations, was also created to provide technical and policy advice to the Governing Body. It made comments on the draft annual work programs before their review by the Governing Body. Community-based border HIV/AIDS committees were created for coordinating the local response to HIV/AIDS in border areas. Finally, Inter-country Facilitation Committees, with representatives from all stakeholders, were established at the four border towns. An operational manual was prepared and adopted before Board presentation. 15. The commitment of the five governments to the project was strong. Stakeholders from all five countries, including civil society and public sector representatives, participated in project preparation through a series of workshops. In August 2001, representatives of the five Governments agreed to the basic principles of the project, and, in October 2001, the detailed institutional arrangements for the project. In April 2002, through a joint declaration, the presidents of the five countries confirmed their commitment to joint action to fight HIV/AIDS in the corridor, and to put in place the institutional framework for project implementation. They also agreed to a distribution of responsibilities among the five countries as follows: Nigeria would hold the Presidency of the Governing Body and Ghana the Vice Presidency. Benin would host the Executive Secretariat, which would be headed by an Ivorian. Togo would chair the Advisory Body. Finally, they agreed that Benin would be the recipient of the grant on their behalf. 16. The risk analysis, including mitigation measures, was adequate. The project was considered as high risk, because, on top of the risks usually associated with multi-sectoral HIV/AIDS projects, there was the additional risk stemming from the need to maintain a strong commitment from five governments throughout project implementation. All risks, including weak capacity of CSOs, poor cooperation among stakeholders, weak support from national HIV/AIDS programs to the Executive Secretariat, limited behavior change despite improved awareness of HIV/AIDS among the corridor population, and waning support from one or more governments concerned were rated as high or substantial. 2.2 Implementation 17. The Grant was declared effective 3 months and five days after Board approval, which underlines the commitment of the governments and of ALCO to the project. All effectiveness conditions were met on time, thanks to the preparatory work financed by a Project Preparation Facility (PPF) advance, PHRD grant and grants from other sources. Effective start up of project activities was delayed, however, because it took time and training to establish local organizations, which could participate in project activities and build capacity in border towns. 18. Project implementation took place in a difficult context. A severe political crisis was unfolding in Côte d'Ivoire and Togo, which hampered project implementation and supervision in these two countries, which were on non accrual status. 19. Procurement, involving a number of organizations in five countries with different procedures, was complex. Procurement officers in the Bank country offices provided well appreciated support. 20. The financial management of the project was rated unsatisfactory by the November 2004 Implementation Status Report (ISR), because the project was unable to ensure that participating CSOs would receive payment for their activities within a reasonable period of time (three months maximum). However, it is important to underline that these delays were mostly due to the absence of banking agencies in project sites and these problems were overcome. The unsatisfactory rating was changed after the next supervision mission. 21. Counterpart funding was contentious. The five countries agreed that they would each provide counterpart funding in an amount of US$50,000 per annum. The contribution amount in US$ was translated into national currency value at the time of the grant agreement. At the end of 2004, only Benin had paid its contributions for 2003 and 2004. Côte d'Ivoire, Ghana and Togo had paid their contribution for 2003, but not for 2004. Nigeria had not started paying. From 2005 to the closing date of the credit, the five countries paid all their dues, including Côte d'Ivoire and Togo, despite their non-accrual status. With the devaluation of the dollar, the three FCFA countries complained that they were paying more than the other two countries (US$80,000 equivalent, versus US$50,000 equivalent for the Anglophone countries). Eventually, it was agreed that the US$50,000 would be converted to local currency at the rate prevailing at the time of payment. The total contribution by the five countries to project cost amounted to US$1.41 million. 22. Initially, National programs were considered better positioned to provide anti-retroviral (ARVs) drugs. But during the Mid-Term Review (MTR) of the project attended by many donors, PLWHA associations requested that the project finance the ARVs and opportunistic infections drugs as well. The Bank agreed to that request in order to provide ARVs, principally to commercial vehicle drivers who tested positive in the health centers rehabilitated at border towns and ensure also the continuity of drug provision along the corridor. National programs would provide ARVs and be reimbursed by the project. The Bank's agreement facilitated the decisions made successively by all five countries, in 2006 and 2007, to make ARV available to PLWHA for free (Ghana continues to impose a nominal price, however). 23. The grant amounts were reallocated two times in line with the recommendations made during the MTR and the closing date was also extended by six month to December 31, 2007, to take account of the delays in launching actual implementation of project activities. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 24. A M&E manual was prepared during the first year of project implementation. Project outcomes were to be measured employing data from HIV surveillance, baseline, and end-point population-based surveys on knowledge, attitudes practices and behavior. Regular surveys were to be carried out to assess progress in reducing the time required for border crossing and harassment of commercial vehicle drivers along the transport corridor. The baseline survey was completed in 2005 only due to the fact that two calls for bids were unsuccessful. 25. The Executive Secretariat was responsible for monitoring overall project implementation through the management consultant, according to terms of reference agreed upon before Board presentation. The Secretariat was expected to organize annual reviews in a participative manner. Activities of CSOs and CBOs were to be monitored taking into account their contractual obligations. Adequate indicators were selected to monitor progress towards the development objectives of the project. 26. A strong M&E system was put in place led by the M&E specialist in the Financial Management Agency. The 87 agencies involved in project implementation produced monthly reports on their activities, which were used in the planning process. Five NGOs, one in each country, were recruited to monitor the activities of local NGOs supported by the project, and to prepare monthly and annual reports to the Executive Secretariat. During the mid-term review of the project in January 2006, it was agreed that M&E specialists in each of the national HIV/AIDS programs would provide support to the collection and analysis of data. A total of 141 people were trained in M&E in the project implementation agencies. Two consulting firms were selected to monitor progress for (i) the HIV/AIDS program; and (ii) the transportation facilitation component. The first consulting firm carried out three surveys at the eight border crossing points during one week each, in February 2005, December 2005 and in August 2007. The second consulting firm collected data on transport issues seven times from July 2005 to September 2007. 2.4 Safeguard and Fiduciary Compliance 27. During project preparation, it was agreed that the new agency responsible for coordinating project implementation would not handle procurement and financial management. These activities would be outsourced to a management consultant. The recruitment of the consultant was a condition of grant effectiveness. On February 12, 2004, an international consultant was appointed but his performance in financial management was weak in the first year and a half of project implementation under difficult circumstances. Reporting was late and inadequate, in part because of the difficulty of working in both an Anglophone and Francophone environment. With Bank prodding, the consultant changed its management process, and its performance improved and was eventually considered as fully satisfactory, by both the Executive Secretariat and Bank supervision missions. 28. The project was not expected to generate substantial adverse environmental effects. It was classified in category B. Possible environmental risks included inappropriate handling and disposal of medical waste. A medical waste management plan was prepared in consultation with different stakeholders before project appraisal. The third sub-component of project component 2 included the implementation of medical waste disposal requirements for all health facilities supported under the project, the training of health care professionals and community workers, and a public awareness campaign. The Executive Secretariat recruited an environment specialist to monitor implementation of the medical waste management plan. 2.5 Post-completion Operation/Next Phase 29. During project implementation the five governments concerned contributed to the financing of the project but it was clear from the outset that they would not be able to fully finance the HIV/AIDS program after project completion. Therefore contacts were established with a number of external partners for additional financing. As a result, based on the satisfactory achievements of the project, in May 2007, the Global Fund to Fight AIDS, Tuberculosis and Malaria agreed to provide US$45.6 million to finance a five-year follow-up program. The transport facilitation component of the project needs to be continued also. A comprehensive project is being prepared under the well established corridor approach, which combines physical investment to bring road conditions to acceptable standards and a package of transport facilitation measures. The personnel employed by the management consultant for the fiduciary and M&E aspects of the project have been transferred to the Executive Secretariat. Local capacity generated by the project will be used for implementation of the new HIV/AIDS program. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 30. The objective of the project is highly relevant today, as it was when the project was approved. HIV/AIDS along the Abidjan-Lagos corridor remains a major threat to the vulnerable populations, which benefited from the project. The fight against HIV/AIDS remains a high priority in the five countries along the corridor, as well as in the Bank's country assistance strategies for these countries. The design of the project was sound and its main features have been adopted under the new project financed by the Global Fund. Activities financed under the project will continue and expand with assistance from the new project, which will consolidate and amplify the results already achieved. 3.2 Achievement of Project Development Objectives 31. The project has achieved its objective. Access by underserved vulnerable groups along the Abidjan-Lagos transport corridor to HIV/AIDS prevention, basic treatment, support and care services has considerably increased. Access to prevention and basic treatment services increased much beyond original targets, as shown in three output indicators (number of condoms distributed, number of VCT centers and number of people using the services provided in these centers). On the other hand, out of four "outcome indicators", four were under target, slightly below for the three indicators concerned with identification of ways in which to prevent HIV/AIDS, well below for the incidence of STDs among truck drivers, but above for incidence of STDs among sex workers (see paragraph 33, below). These achievements are clearly attributable to the project, as national programs were not active in border areas. It is important to underline that increased access to services was the project's objective, accordingly, outcome indicators should have focused on that dimension, not on the impact of better services. 32. The project was expected to contribute to the reduction of the spread of HIV/AIDS. Prevalence rates are no longer used as indicators of success in HIV/AIDS project for a variety of reasons. It is useful, however, to provide information on this important dimension of the pandemic. Prevalence rates have been on a declining trend during the project implementation period (see table 1 Annex 10). The HIV prevalence rate observed among commercial vehicle drivers and sex workers, who voluntarily tested for HIV when the three surveys were carried out, is on a declining trend (see Table 3, Annex 10). The samples used are small, however, and the results should be taken with caution. The prevalence rate in the population who underwent voluntary testing during 2006/07 in project-rehabilitated health facilities was 7.4 percent. The project did not monitor new HIV infections. It is important to underline the difficulties to do so in a static population and almost impossible in a cohort of highly mobile population. However, ALCO agreed to track this indicator within Global Fund project and the Bank follow up project under preparation. 33. Three indicators were used to measure the impact of prevention messages. In the Project Appraisal Document (PAD) it was expected that at least 90 percent of commercial vehicle drivers, sex workers and the local population residing along the corridor would be able to identify at least two ways in which to prevent HIV/AIDS. The baseline value for these indicators, which came out of the February 2005 survey was respectively, 68 percent, 60 percent and 50 percent. In August 2007 the percentages were 83 percent, 88 percent and 84 percent respectively (local population aged 15 to 24). Two other impact indicators had to do with the reduction by at least 30 percent of the incidence of reported STIs among male commercial vehicle drivers, and by at least 50 percent of the prevalence of gonorrhea among commercial sex workers. While the second indicator was achieved beyond expectations, the first one was not. The incidence of STIs among male commercial vehicle drivers is reported to have increased by over 70 percent. The worsening of the indicator does not mean that the health situation has deteriorated, however. It may reflect the improvement of quality of diagnostics and health services available to commercial vehicle drivers at border towns with project's assistance. It may also be the result of differences in sampling. 34 As shown in Table 2 in Annex 10, most process indicators and several output indicators (number of condoms distributed, number of VCT centers and number of people using VCT services) are much higher than targeted. Two output indicators gauged behavioral change among the target population. The proportion of commercial vehicle drivers and commercial sex workers using condoms (with non-regular partners in the previous 12 months for the former and with their clients of the previous week for the latter) was expected to increase by 50 percent for the former and by 80 percent for the latter. These targets were set during appraisal without the benefit of a baseline survey. Actually, the proportion increased by 33 percent in the case of the drivers and 20 percent for the sex workers. This increase was achieved in less than two years, which is quite remarkable. 35. Indicators used to gauge the success of the first component (HIV/AIDS prevention) included the use of condoms by commercial vehicle drivers and clients of commercial sex workers, the number of condoms distributed through social marketing along the transport corridor, and the holding of an annual rally at each border crossing point to mark World AIDS Day. Progress in this area is somewhat paradoxical. Indeed, while the number of condoms distributed has soared far beyond expectations during project implementation (it was multiplied by a factor of about 6 instead of a doubling), the two indicators concerned with the use of condoms (see paragraph 34 above) were lower than targeted. On the other hand, the proportion of people aged 15 to 24 using condoms increased by 80 percent. The apparent paradox can be explained by three factors: condom distribution benefited a large number of highly mobile people, the restrictive interpretation given by commercial vehicle drivers to what is a non-regular partner, and the success of the condom brand designed for the project. 36. Three indicators were proposed to measure progress under the second component, (HIV/AIDS treatment, care and support services) including the existence of at least one voluntary counseling and testing (VCT) center at each border crossing point, the increase by 50 percent of people using VCT services, and adequate supply of antibiotics for the treatment of STIs in 90 percent of health facilities along the corridor. These indicators have been met beyond expectations. Indeed, the project has rehabilitated and/or equipped 16 centers close to the border crossing points to enable them to provide VCT services. The number of people who benefited from HIV testing increased from a negligible number (about 1,000) at project's inception to 27,639 in 2007. With the project's assistance 36 health facilities, including 8 hospitals, have received an adequate supply of drugs and equipment for treatment of STIs and opportunistic infections. All facilities continue to be adequately supplied thanks to the synergies developed between national programs and the project. 37. Three indicators, all addressing transportation facilitation issues, were proposed to gauge progress under the third component (project coordination, capacity building and policy development services). Following the recommendations made during the mid-term review, the formulation of indicators proposed in the PAD changed, but not the substance. The first two had to do with the reduction of average time for commercial vehicles to clear border formalities along the entire corridor for the first, and, more specifically, at the Nigeria-Benin border for the second. The reduction of the number of informal checks along the corridor was the third indicator. 38. The average time for clearing border formalities at one crossing point by a heavy truck declined from 162 minutes during the mid-term review to 128 at project completion. While this is a substantial progress, it is still higher than the objective of 90 minutes. In any event, this indicator does not convey the full picture, because, for various reasons, which remain to be adequately analyzed, the time spent for clearing border formalities is a small fraction of the time wasted by truck drivers in front of a border. Parking spaces at borders are saturated and waiting trucks clog the roadway. At the Benin/Nigeria border several hundred trucks are stranded in chaotic conditions for weeks and even months. Police forces are overwhelmed and helpless. The target of 3 checkpoints every 100 km has not been reached, but the total number has been reduced. Authorities in the five countries are reluctant to remove controls on the ground that it might threaten their security by facilitating the trafficking of weapons and drugs. This situation contributes to increase the costs of transport in the corridors. 3.3 Efficiency 39. Funds provided under the project by the Bank and the five governments concerned were managed with due consideration to results and efficiency. All implementing agencies which received funds under the project for activities at community level submitted quarterly technical and financial reports to the Executive Secretariat. These reports were reviewed by the five country accountants, who systematically visited all implementing agencies each quarter. The management consultant reviewed all reports provided by the implementing agencies to check that funds were used for project purposes, with due consideration to economy and efficiency. Overall, operating costs remained below initial allocations 3.4 Justification of Overall Outcome Rating 40. The project achieved its objective. Access by the beneficiary populations to HIV/AIDS prevention, care and support services has considerably increased. Most people along the corridor have been sensitized. The social marketing of condoms was highly successful. The gains achieved are clearly attributable to the project, which focused sharply on the beneficiary groups identified at appraisal. As a result, knowledge on HIV transmission and prevention improved substantially, risky behaviors (unprotected sexual relations among young population) are changing and the incidence of STIs declined sharply among sex workers. The PLWHA reported that discrimination against them is being reduced. The increase of STI among commercial vehicle drivers does not indicate a worsening of the STI situation among truck drivers, however, as explained earlier. Rating: Satisfactory Outputs by component 41. HIV/AIDS prevention services. The project supported 66 implementation agencies for the development and implementation of IEC/BCC activities at the community level. An integrated IEC/BCC strategy was formulated, validated by the five countries and widely disseminated. Messages were broadcast through 32 radio networks. The AIDS world day was celebrated by the eight border AIDS committees, and, with support from the Coca-Cola Foundation, two itinerant information and sensitization campaigns on HIV/AIDS (called Love Life Caravans) were organized along the corridor. A large number of information materials were disseminated. The social marketing of condoms was contracted out. The project established 625 sales points along the corridor, including at the 8 border posts. Commercial sex workers were given preference in manning these sales points. A new brand of condoms (called Migrant and Femigrant) was established, mostly because each country had licensed a brand of condoms and did not accept that condoms in use in other countries be imported in their countries. As indicated above, the number of condoms distributed far exceeded expectations. 42. HIV/AIDS treatment, care and support services. The project supported the adoption and dissemination of a common reference document on the continuum of care and the policy for access to STI/HIV/AIDS treatment. As indicated above, 36 public, private and community-based health facilities were upgraded, equipped and provided with an adequate supply of drugs and other pharmaceuticals. Staff in these facilities was trained. The project renovated 16 facilities close to the 8 border posts to provide VCT services. In close coordination with the five HIV/AIDS national programs, it financed antiretroviral (ARV) drugs for about 100 PLWHA in each of the five countries concerned. In partnership with the West African Network of People Living with HIV/AIDS (PLWHA), the project provided grants to a total of 21 organizations for community support to PLWHA and Orphans and Vulnerable Children (OVC). Finally, under this component, the project prepared and implemented a medical waste management plan. Nine incinerators and nine skeptic tanks were installed at the health centers located close to border points, and the staff was trained. 43. Project coordination, capacity building and policy formulation. The Executive Secretariat established strong HIV/AIDS inter-country coordination and partnerships with a large number of organizations and community leaders. It organized training sessions for customs and security agents for an effective application of ECOWAS transport regulations. It established an Observatory of Abnormal Practices along the Corridor, to monitor obstacles to the free movement of people and goods. It also helped establish the Association of Professional Truckers and Drivers, which played an important role in disseminating messages on HIV/AIDS prevention and transport facilitation. Training sessions were organized for uniformed agents and commercial vehicle drivers, and information materials on border crossing were widely disseminated. A large number of training sessions was also organized for building the capacity of implementing agencies in project management, IEC, health issues, and transport (see Annex 2, table 1 for details). The project helped local organizations build capacity. 3.5 Overarching Themes, Other Outcomes and Impacts 44. (a) Poverty Impacts, Gender Aspects, and Social Development: The project's objective was to improve access to HIV/AIDS prevention and care services by underserved vulnerable groups, with particular attention to commercial sex workers, truck drivers, out of school youth and the migrant population. A study along the transport corridor showed that (i) HIV/AIDS aggravated gender inequities and discrimination; (ii) the impact of HIV/AIDS differed markedly along gender lines: the stigma against HIV infected women was stronger than for men, reducing their access to social services; and (iii) the epidemic increased women's economic vulnerability and dismantled their social network. The decline of the HIV prevalence rate among commercial sex workers during project implementation is significant, and is expected to continue under the follow-up project. Such decline has a substantial impact on poverty reduction. 45. People living with HIV/AIDS and their associations received support from the project, as well as orphans and other vulnerable children. ARVs were made available to 539 people; this number is expected to increase under the follow-up project. PLWHA associations are in place and prepared to expand their activities. 46. (b) Institutional Change/Strengthening:. The project helped establish an institutional framework, which has demonstrated its effectiveness, and is being used under the follow-up project. A large training program has been implemented under the project, in particular to help participating civil society organizations deliver services to their members and manage projects. Local associations have been empowered. This is the case in particular of the Association of Professional Truckers and Drivers, which will continue to play a key role in HIV/AIDS prevention and transport facilitation. 47. (c) Other Unintended Outcomes and Impacts (positive or negative): A positive outcome of the project is the establishment of a regional capacity to undertake activities of common interest to the five countries concerned. The project made the demonstration that regional programs can work when countries are highly committed to their success, take appropriate measures to ensure that the implementing agency receive adequate support, and do not interfere in its management. Similar corridor projects in other parts of Africa and the world have been prepared. The Great Lakes Initiatives on AIDS (GLIA) and Southern Africa Transport Corridors HIV/AIDS Project (SATCA) have benefited from the experience learned from the Abidjan ­ Lagos corridor project. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 48. A completion workshop was held in early February 2008 with representatives from main project organizations. It endorsed the completion report prepared by the Executive Secretariat and stressed that the results achieved were due in large part to extensive community mobilization efforts, a strong appropriation of the project by all participating organizations and a highly efficient Executive Secretariat. Further support is required for strengthening local capacity, however. The workshop recommended that local authorities in border towns be closely involved in providing support to and monitoring project activities, and national and local budgets gradually increase their contribution to the project's budget. The workshop stressed that the high turnover of agents at borders is a problem. Finally it emphasized that a regional program should complement, not substitute national programs. Annex 6 provides more details on the workshop. 4. Assessment of Risk to Development Outcome 49. Lack of adequate funding for the continuation of project activities, including the operation of health facilities rehabilitated under the project and of civil society organizations involved in HIV/AIDS prevention and care, would undermine the sustainability of results achieved. This risk is small, however, as the five governments concerned have confirmed their strong commitment to the project, and the Global Fund has agreed to finance a follow-up operation to support the continuation and expansion of activities undertaken with assistance from the Abidjan-Lagos corridor project under review. The Bank new transport facilitation project under preparation will include a HIV/AIDS component1. 50. Continuous support from the national HIV/AIDS programs to the transport corridor is dependent on these programs receiving adequate funding from the international community and being strengthened. This is the case for the national programs in Benin, Ghana and Nigeria, which are financed by the Bank, and Togo, which is financed by the Global Fund. A project is being prepared in Cote d'Ivoire for Bank financing. Table 1 in Annex 10 provides information on HIV prevalence rates and availability of funds for HIV/AIDS programs in the five countries concerned. 51. A weakening of the capacity built under the project would sap the momentum obtained with project support in fighting HIV/AIDS along the corridor. GTZ and ALCO did a good job in capacity building. Their project staff was trained in procurement, financial management and M&E. The GTZ contract ended in June 30, 2007 and since then, its staff has been successfully transferred to ALCO. As a result, the momentum obtained has been maintained. Rating: low 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance 52. (a) Bank Performance in Ensuring Quality at Entry: The project was seen as an excellent entry point for promoting regional cooperation on two critical issues, HIV/AIDS prevention and transport facilitation. Project issues were correctly identified. The objective of the project was well defined and the indicators selected were appropriate, with the reservation noted in paragraph 31 above. Measuring progress during project implementation would have been easier; however, had the baseline indicators been available before appraisal. The baseline survey was delayed, however, due to two failed attempts to contract a firm to do the work under the PHRD funding provided for the project. The lessons from experience were fully incorporated in the design of the project. The preparation team worked extensively with the governments concerned to reach agreement on basic principles and establish the institutional framework before project approval. It insisted that the project coordination unit remained a lean organization. The operational manual was adopted before project approval, but project implementation was delayed because there was little capacity on the ground for initiating project activities. The risk analysis was fully adequate. Rating: Satisfactory 53. (b) Quality of Supervision: Supervision missions visited the countries at regular intervals. They were issues and results oriented. Their focus on fiduciary and environment issues was fully adequate. Bank managers were proactive. Despite the fact that the project was managed by the Transport Sector, the issues were correctly identified and actions taken on time to address them. The mid-term review in January 2006 was well prepared and was carried out in a highly participative manner. It focused in particular on all activities required to complete the project and achieve its objective, on measures to ensure the sustainability of the operation and on 1 The five countries agreed to contribute about US$1 million each to finance the activities of this component. strengthening the M&E system. In retrospect, more efforts should have been invested in improving the quality of the surveys carried out by consultants for monitoring project's outcomes. The Bank should have also insisted that the time required for border clearance formalities be placed in the broader context of the time wasted in front of a border. There was a remarkable continuity in the Bank's core team from inception to completion. Country offices provided valuable support. Rating: Satisfactory 54. (c) Justification of Rating for Overall Bank Performance: The project was innovative. It combined fighting HIV/AIDS with transport facilitation. The Bank saw an opportunity to support progress on these two fronts along the Abidjan-Lagos transport corridor, a major link between key ECOWAS members. It emphasized the establishment of an appropriate institutional framework for program implementation. It provided strong support to implementing agencies to ensure that the objective of the project would be achieved in an efficient way and on time. Bank management provided the budget required for a thorough preparation and intensive supervision of the project. Rating: Satisfactory 5.2 Borrower Performance 55 (a) Government Performance: The five governments concerned were highly committed to a regional approach to HIV/AIDS prevention and care, but less so to removing obstacles to the free flow of people and goods along the Abidjan-Lagos transport corridor. The five governments provided adequate support to the Executive Secretariat for project implementation through the Governing Body and paid regularly their counterpart funding after initial delays. Their national HIV/AIDS secretariats were closely involved in project activities in their respective countries. Benin played a leadership role by agreeing to provide the facilities required for the Executive Secretariat and making commitments on behalf of Cote d'Ivoire and Togo, which were in non- accrual status. The Governing Body played a most useful role in ensuring continued support from the five governments concerned and coordination with national HIV/AIDS programs. The Ministers of Health and Transport of the five countries were closely involved in project supervision, particularly during the mid-term review. Heads of States participated in the project activities, particularly in the two caravans organized jointly with the Coca Cola Foundation. Rating: Satisfactory 56. (b) Implementing Agency or Agencies Performance: The Executive Secretariat was able to coordinate the implementation of an impressive work program by a large number of public and private sector organizations and ensure its completion within the agreed upon timeframe. It managed to establish and maintain a consensus among the five countries concerned on priorities, common policies and operational programs. It remained a lean organization. Contrary to the situation found too often elsewhere, its actual operating cost was lower than initially allocated. It prepared a well documented completion report on time and best practice toolkit which can help in the preparation of similar projects. Rating: Satisfactory 57. (c) Justification of Rating for Overall Borrower Performance: The five governments and the institutions established for project coordination and implementation performed well. The governments provided strong support to the Executive Secretariat and greatly facilitated project implementation at border crossing points. The Executive Secretariat identified a large number of public and private organizations for implementation of project components and organized a large capacity building program to help them deliver results. Thanks to the strong institutional arrangements set up, the complexity of the project was overcome. Rating: Satisfactory 6. Lessons Learned 58. Complementarily with national AIDS programs: Regional HIV/AIDS programs are most useful when they complement national programs and focus on border areas and target vulnerable groups associated with the trucking industry. They should not substitute national programs. Developing synergies between 5 national AIDS programs and a sub-regional program was challenging, particularly in the areas of operational level harmonization of clinical aspects, referral system, and communications strategy. The Governing Board greatly facilitated the process. A program combining the fight against HIV/AIDS with trade facilitation offers strong opportunities for synergies, though it is easier to reach a consensus among governments on the former than on the latter, as emphasized in the Independent Evaluation Group (IEG) assessment of regional programs. 59. Design of the project: There was no precedence of a sub-regional HIV/AIDS project addressing the threat of HIV on the transport sector and transport sector's contribution in checking the spread of the epidemic. The project design was innovative and heavily relied on a participatory process that engaged a variety of stakeholders. This approach resulted in strong ownership from the heads of states down to the community levels. The project design was realistic, simple and based on the key results to be delivered. The beneficiaries were clearly identified and the project kept its focus on the target groups throughout implementation. The project incorporated the five design features, which the IEG found vital to regional programs' success, namely - strong commitment to regional cooperation, objective matching regional capacity, clear delineation and coordination of the roles of national and regional institutions, accountable governance arrangements and planning for sustainability of project outcomes. 60. Sustainability, Bank's role and partnership. The Bank played a catalytic role in supporting an innovative initiative by taking high risks. The project documents indicate that at initiation, with the exception of UNAIDS, other development partners did not show interest in joining the project. On the other hand, UNAIDS, on behalf of other UN agencies, provided a solid technical and financial support to bring the project concept to fruition. Strong partnership between the Bank and UNAIDS was a critical factor in the design and delivery of the project. It is critical that strong partnership is built prior to initiating the project design. 61. Institutional arrangements: Establishing the institutional framework for program implementation is an essential step during the preparation phase, but this requires time, particularly in the case of a regional program. Government ownership and leadership is a core requirement for successful institutional arrangements. Participating member governments should be in the forefront of decisions related to which country would house the headquarters, how its management would be staffed to ensure openness, transparency and equal opportunity to all nationalities. The responsibilities of the project were successfully shared by all the five countries. The offer made by Benin to provide the office space for the Executive Secretariat greatly facilitated reaching an agreement. 62. Coordination: Emphasizing the facilitation and coordination role of the Executive Secretariat was essential for ensuring that civil society organizations be empowered. Contracting out the fiduciary and M&E aspects of project implementation to a management consultant proved highly positive. The Executive Secretariat focused heavily on community development, training staff and disseminating management tools. This was the recipe for success and highly appreciated by all stakeholders. 63. Challenge of easing the flow of persons and goods across borders: Accelerating border clearing formalities may not be sufficient to reduce significantly the time spent by trucks in front of a border. A comprehensive program, combining physical investment and regulatory and behavior change, is urgently required to address the root causes of the chaotic conditions prevailing at some borders, in particular the Benin/Nigeria one. The ministries of transport in all 5 countries recognize the challenge, but they have no responsibilities over key issues, such as differences in customs duties and security concerns. Other ministries should be associated to the dialogue and ECOWAS should play a more active role in pushing the regional integration agenda. 64. Baseline survey: Preparation of the baseline survey was delayed for a variety of reasons, including two failed attempts to contract consultants before project appraisal and, the delay to set up the institutional framework for project implementation. In the absence of a survey before appraisal of the project, it was difficult to set a realistic value for project indicators in the PAD. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners 65. (a) Borrower/implementing agencies: The Executive Secretariat sent written comments on the draft ICR. It agreed with the assessment, but suggested that more consideration should be given to the pilot nature of the project and the constraints encountered. It suggested a very satisfactory rating for the first and second components of the project and a better recognition of the commitment of the governments concerned and of the role played by the Governing Body. Most comments have been taken into account in the revised version. See Annex 7 for details. 66. (b) Co-financiers: The Director of UNAIDS Regional Support Team for West & Central Africa sent her comments on the project. She indicated that the success of this project was mostly due to the institutional framework, in which all five countries were equitably involved and also it's complementary with national HIV/AIDS programs. She also highlighted UNAIDS' role during the preparation and implementation stages. Finally, she raised five challenges to be addressed to sustain the achievements of the project, notably information sharing and development of local response. See Annex 8 for details. 67. (c) Other partners and stakeholders: Community leaders, traditional chiefs, uniform personnel, people infected and affected by HIV/AIDS openly testified on the accomplishments of the project in their lives. The Mayors of Krake Plage and Sanvee Condji, who were closely involved in the project, underlined the important role played by the corridor project in filling the gaps of the national programs at the borders. Most stakeholders recommended that the Bank continue its support to HIV/AIDS programs. Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Estimate Actual/Latest Components Percentage of (USD millions) Estimate (USD millions) Appraisal 1. HIV/AIDS PREVENTION SERVICES FOR THE 2.20 4.60 210 TARGETED POPULATION 2. HIV/AIDS TREATMENT, CARE AND SUPPORT SERVICES FOR THE 7.90 6.90 88 TARGETED POPULATION 3. PROJECT COORDINATION, CAPACITY BUILDING AND 6.60 7.60 115 POLICY DEVELOPMENT. PHYSICAL CONTINGENCIES 0.60 PRICE CONTINGENCIES 0.60 Total Baseline Cost 17.90 19.10 107 (b) Financing Appraisal Actual/Latest Source of Funds Type of Estimate Estimate Percentage of Cofinancing (USD (USD Appraisal millions) millions) Borrower Grant 1.30 1.40 108 IDA GRANT FOR HIV/AIDS Grant 16.60 17.70 105 Annex 2. Outputs by Component Output indicators are in Table 2, Annex 10. Component 1: HIV/AIDS prevention services for the targeted population 1. Implementation of an integrated IEC/BCC policy for fighting HIV/AIDS along the transport corridor. The project supported 66 implementing agencies for the development and implementation of IEC/BCC activities at the community level. An integrated regional IEC/BCC strategy was developed, validated by the five countries and widely disseminated. Through the IRIN Radio station network, partnerships were established with 32 radio stations in the five countries ­ national radio stations as well as community radios ­ for the production and broadcasting of radio programs on the project. Over 30 million people were sensitized. All major events were used as opportunities for mass dissemination of information, including the celebration of the AIDS World Day by the 8 Border AIDS Commissions in all sites of the project. In collaboration with the Coca-Cola Foundation, the project organized two itinerant information and sensitization campaigns on HIV/AIDS along the corridor, called "Love Life Caravan". These events enabled to reach directly 3 million people along the corridor, and indirectly many more thanks to the mobilization of national and international media. A large number of IEC/BCC materials were produced and distributed along the corridor to support and consolidate awareness raising activities on STI/HIV/AIDS. These included large double-face billboards, leaflets, posters, stickers, wallets, log books, etc. 2. Social marketing of condoms along the corridor. The project contracted Moriah Trust Limited for the implementation of the social marketing of condoms. It established 625 new sales points along the corridor ­ including 16 kiosks at the 8 border posts, which increased the condom distribution network to 784 sales points. Moreover, 20 automatic condom dispensers were installed at the 5 borders of the 3 francophone countries of the corridor. Specific brands of male condoms (Migrant) and female condoms (Femigrant) have been developed by the project. Promotional materials were produced and distributed, including: 28,000 leaflets, 158,000 stickers, 3,640 T-shirts, 7,750 calendars, 6,600 posters, 2,810 caps and 1,094 bags. The following IEC materials were put in place: 8 giant billboards, 8 signboards indication information centers, 400 signposts for sales points and 400 streamers. For mass media, 4 radio commercials and 4 TV commercials were produced, each of them in French and English. These commercials were broadcasted on the local and national radio stations and TV channels of the five countries of the corridor, with a total of 2,978 radio commercials, 54 TV commercials and 18 educational radio and TV programs broadcasted. Component 2: HIV/AIDS treatment, care and support services for the targeted population. 3. Strengthening of public and private health care facilities identified along the corridor to provide services in the areas of VCT, treatment and HIV/AIDS. The project developed a common reference document on care and access to STI/HIV/AIDS treatment. Since its validation, this document became the reference in terms of care and treatment for the whole corridor. It helped 36 health facilities along the corridor improve their capacity to diagnose and provide treatment of STIs and opportunistic infections. They received drugs and other materials (STI kits, reagents and audio visual materials). Blood transfusion facilities also received reagents and consumables. In each off the 36 healthcare facilities selected, health service providers were given pertinent training in the area STI/HIV/AIDS care. The number of people benefiting from care for STIs increased from 3,572 in 2005 to 14,202 in 2007. In regards to VCT services, the project renovated and equipped 8 health centers at border posts and 8 reference hospitals to bring them up to standard. Staff was trained. The demand for VCT services, which was negligible in these facilities increased by a factor of 27. 4. Provision of grants to CSOs to undertake community based initiatives in HIV/AIDS care and support. Through a partnership with the West African Network of PLWHA (RAP+AO), the project provided support to a total of 21 organizations: 5 national networks of PLWHA; 6 VCT organizations and 10 organizations (associations and NGOs), in the five countries of the corridor, for community support to PLWHA and OVC, and fight against stigma and discrimination on the 8 border sites. Overall, 73 people from these organizations benefited from capacity building in these areas. These organizations reached 3,177 PLWHA and provided care and support to 1,248 PLWHA and 1,084 OVCs. The project supported a broad range of activities in favor of these two categories. The project financed the provision of ARVs to 539 PLWHA, in close coordination with national programs to avoid duplications. 5. Disposal of medical waste related to the project. The project developed and implemented a medical waste management plan. All concerned stakeholders were involved in the preparation of the plan and the drafting of a regional policy document, which was validated by the five countries. The project developed and disseminated a standardized training plan and a manual for medical waste management. The project provided appropriate material and equipment to 25 health facilities for appropriate sorting and storage of medical waste and their disposal. The project established 9 incinerators and 9 skeptic tanks. These incinerators use butane instead of wood to reduce pollution. In each of these sites, an NGO was selected to take care of the collection and transport of medical waste. They were provided tricycles for that purpose. At the end of 2007, each border site had a medical waste management plan, which is implemented by the community and health centers. A total of 348 people were trained in medical waste management. The NGOs organized 142 public awareness sessions, which reached over 1,200 people. A total of 12,000 leaflets and 6,000 posters were produced. Component 3: Project coordination, capacity building and policy development. 6. Development of strong HIV/AIDS inter-country coordination and partnerships among the governments and other project stakeholders of the five participating countries. The project promoted exchanges and dialogue between institutions, professional organizations and NGOs, particularly during the development of harmonized policies and strategies, but also during the implementation and monitoring of the activities. Through these activities involving advocacy, policy formulation and partnership development, the Executive Secretariat established solid links with the networks and associations of PLWHA, religious and community leaders, trade unions in the transport sector, as well as national, sub-regional and international institutions. The project collaborated closely with the health authorities of the five countries concerned. A large number of studies were produced with project's assistance. 7. Implementation of policies and programs for smooth movement of commercial traffic along the corridor. The Executive Secretariat organized training sessions and high-level meetings with customs, police, immigration and transport directorates and conducted advocacy activities in the five countries for an effective application of the various ECOWAS regulations. It also pointed out inconsistencies between national and ECOWAS regulations. The project established an observatory of practices along the corridor. It is an effective instrument for monitoring obstacles to the free movement of goods and people along the corridor. 8. The project established four Inter-border Facilitation Committees; all managed by officials working at border points, including representatives from police, immigration, transport unions, etc. These committees helped train 97 persons on HIV prevention and implementation of ECOWAS regulations concerning the free movement of people and goods. IEC campaigns were launched to provide information to all concerned on requirements for border crossing. A total of 120,000 leaflets, 35,000 posters, 1,200 folders, 45,000 stickers and 15,000 bags were produced and disseminated, which have considerably improved the knowledge on rules concerning the free movement of people and goods. Billboards were installed to facilitate border clearance formalities. At each of the 8 border crossing point, an information unit was established, including an office, a meeting room and a shelter with a capacity to accommodate about 100 people. These units have been extensively used to disseminate information on HIV/AIDS and formalities for crossing borders. 9. Capacity building among implementing partners. The project organized a number of training sessions, which benefited to a total of 3,762 people. Table 1 below shows the number of people who have benefited from the various training sessions organized by the project. Table 1: Training for capacity building Area Content Profile Number Coordination Planning and management of sub-projects Members of focal units 37 Young girls in border areas, Training of peer educators truckers, CSWs, uniform 1,460 personnel IEC Capacity building for the dissemination of information on Journalists of partner radios 46 the media Distribution of condoms Managers of sales points, NACs, members of NGOs 625 Health Syndromic management of STIs Health center providers 101 Medical care of OIs Health center providers 80 Voluntary Counseling and Health center providers testing 100 MTCTP Health center providers 97 Psychosocial care and support Health center providers services for PLWHA 97 Laboratory Health center providers 35 Prescription of ARVs Health center providers 93 Medical doctors, nurses, Health Care Waste pharmacist, lab technicians, Management traditional birth attendants, 348 artisans Psychosocial advisers for community care and support Members of PLWHA 223 services for PLWHA and OVCs associations and PEC NGOs Transport Principles of free movement of goods and people Uniform personnel 97 Observatory of practices at borders (data collection & Youth living in border areas. 100 management) Financial Training on the simplified management manual for financial Members of NACs and NGOs management, procurement and subsidized by the Project 225 M&E Annex 3. Economic and Financial Analysis Not applicable Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/ Specialty Lending Stephen Brushett Sr. Transport specialist AFTTR Former TTL Siélé Silué Sr. Transport Specialist AFTTR TTL Bachir Souhlal Lead Operations Specialist Development AFTHV Hitoshi Shoji Sr. Transport Specialist AFTTR Former Co-TTL Karen Hudes Sr. Counsel LEGAF Agnes Albert-Loth Finance Officer LOAG Jocelyne do Sacremento Operations Analyst AFTTR Antoine Lema Consultant AFTTR John Stephen Osika Consultant AFTTR Nadeem Mohammad Sr. Operations Officer AFTHV Linda Patnelli Team Assistant AFTTR Hugues Agossou Sr. Financial Management Specialist AFTFM Itchi Gnon Ayindo Procurement Specialist AFTPC Sylvie Charlotte Ida do Rego Team Assistant AFMBJ Supervision/ICR Siélé Silué Sr. Transport specialist AFTTR TTL Hugues Agossou Sr. Financial Management Specialist AFTFM Itchi Gnon Ayindo Procurement Specialist AFTPC Ayite-Fily D'Almeida Sr. Operations Officer AFTH2 Alexandre K. Dossou Sr. Transport. Specialist AFTTR Assiata Houedanou Soro Disbursement Assistant AFMCI Karen Alexandra Hudes Sr. Counsel LEGST Pamphile Kantabaze Sr. Operations Officer AFTH3 Alain L. Labeau Lead Specialist AFTTR Nadeem Mohammad Sr. Operations Officer AFTHV Africa Eshogba Olojoba Sr. Environmental Specialist AFTEN Farida Khan Operations Analyst AFTTR Pepita Hortense C. Olympio Team Assistant AFMBJ Juliana Victor-Ahuchogu Monitoring & Evaluation Specialist HDNGA Bertille Mapouata Team Assistant AFTTR Aissata Soro Houedanou Disbursement assistant AFMCI Sylvie Charlotte Ida do Rego Team Assistant AFMBJ (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle No. of staff weeks USD Thousands (including travel and consultant costs) Lending FY02 17 224.38 FY03 25 157.69 FY04 7 90.56 Total: 49 472.63 Supervision/ICR FY04 21 187.96 FY05 40 165.85 FY06 37 127.32 FY07 18 68.41 FY08 15 90.11 Total: 131 639.65 Annex 5. Beneficiary Survey Results 1. A beneficiary assessment was prepared by CEFORP in December 2007. The survey was carried out in four of the eight border points. Beneficiaries included PLWHA, commercial sex workers, youth and truckers. In each site four focus groups were organized, including 8 to 12 participants each. Overall, 17 focus groups were organized and 12 individual interviews were conducted during the period December 12 to 18, 2007. 2. Participants were well aware of project activities, mainly those concerning STI treatment, condom distribution, voluntary testing and support to PLWHA. Most participants were satisfied with services provided. Despite efforts made by the project, however, ignorance on HIV transmission and risky behavior persisted, particularly among truckers. PLWHAs signaled that some delays were incurred by health facilities in getting drugs. They also indicated that they needed more food aid. Stigma persists, particularly at border towns. Youth are generally well informed on HIV transmission. They like the condom dispensers installed at the borders but commercial sex workers mentioned that, despite prevention campaigns, many men refuse to use condoms. 3. In the area of transport facilitation, participants indicated that much remains to be done to reduce time loss, insecurity and racket. They also requested larger parking areas and recommended that forwarding agents in uniform be present at the borders. Annex 6. Stakeholder Workshop Report and Results 1. A completion workshop was held in Cotonou on February 4 and 5, 2008. Representatives of main beneficiaries (local authorities, CSOs, PLWHA, commercial sex workers, customs agents, etc.) were invited, as well as representatives of international organizations (WHO, UNAIDS, ECOWAS) and Foundations (North Star). The main beneficiaries expressed their satisfaction for the support received from the project. 2. Participants emphasized the following positive features of the project. Its objective was simple. It was a regional project, which complemented national HIV/AIDS programs. Directors of national HIV/AIDS programs were members of the Governing Body. Border committees were established to facilitate and monitor project implementation. Civil society organizations were mobilized. The operating cost of the Executive Secretariat remained below projections. 3. The project achieved its objective (improved access to HIV/AIDS prevention and care by vulnerable groups). The workshop reviewed all project indicators. Some of them were below target value, but the HIV/AIDS prevalence rates in the five countries and among target groups appear to have declined. ALCO played a major role in improving key indicators. Testimonies by representatives of vulnerable groups indicated that behavior is changing. A large number of truckers, commercial sex workers and youth use testing services provided by the project. 4. Harmonization of treatment protocols is a major achievement. Capacity building was strongly pursued by the project. Gender was not sufficiently emphasized initially. This was corrected, however during project implementation. For instance commercial sex workers were recruited for the sale of condoms and a female condom has been developed and promoted by the project. 5. The workshop made a number of recommendations, including the need to (a) improve coordination with national institutions and programs; (b) ensure that ECOWAS rules be applied by all states; (c) associate local elected officials to the project as early as possible; (d) increase gradually counterpart funds provided by national and local governments; and (e) reduce work mobility of border agents. A single project cannot achieve sustainable results. Follow-up projects are needed, in particular a transport corridor project to facilitate trade along the corridor. Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR 1. In January 2008, ALCO prepared a well documented completion report, which is available upon request. Its executive summary is here below: 2. Thanks to the social marketing of condom (SMC), the demand and use of condoms have greatly increased along the corridor. Another significant result of the project is the improvement of the availability, functional capacity and quality of the services of diagnostic and STI treatment and management of OI, and of voluntary counseling and testing (VCT). This is followed by a significant increase in the attendance of public and private health centers for the treatment of STI and OI, and for the HIV test. 3. Through a partnership with the West African Network of PLWHA (NAP+WA), the Project supported communities activities that enabled to significantly improve the quality of life of PLWHA and OVC, by reducing discrimination and stigmatization which they suffer. Thanks to the support of the Project, an innovative, effective and original system of healthcare waste management has been developed, then applied not only at the 8 border sites of the Project, but even beyond. 4. The coordination of the project is one of its major strengths. The project facilitated and favored at both the inter-country level and intra-country level collaboration and dialogue among institutions, professional organizations and NGOs. Even if the component related to the facilitation of transport has not achieved all its objectives, major progress has been made. The capacity building of implementing institutions and various service providers has been central to the implementation strategy of the Project. Thus, thanks to the Project the capacities of 3762 people were built in various areas (coordination, IEC, health, transport, fiduciary management). 5. The project has been implemented between February 2004 and December 2007, at an original cost estimated at US$17.9, out of which US$16.6 (equivalent to 12.2 million of DTS) represents the IDA grant amount. 6. The assessment of the financial performance of the Project is on the overall very positive. Towards the end of the project, the disbursement rate was very close to 100 percent. On the whole, the Requests for Funds Withdrawal (RFW) after disbursement were handled in a satisfactory manner. The level of mobilization of the counterpart of the States has passed the 100 percent bar. The accounting procedures used were conformed to the procedures of the Bank. The respect of measures taken throughout the project has enabled the finance team to produce all the expected reports within the required deadline, and the Executive Secretariat (ES) to regularly and in a transparent manner make report on the use of the funds. 7. In accordance to the directives related to procurement funded on the IDA Funds, principles of equity, transparency, equality of opportunities, economy and efficiency governed the procurement procedures during the implementation of the project. In spite of the multi-country aspect of the project, the various activities identified for procurement during the period 2004- 2007 were 100 percent achieved. 8. The different functions which the different stakeholders (IDA, UNAIDS, Governments, ALCO and its ES) were all satisfactory. Also, their overall performance can be considered as satisfactory. 9. The sustainability of the project can be considered as very likely. The interventions and strategies initiated during the project continue to be of a capital importance to the new paradigm "Transport/Health". The progress made thanks to this project are a testimony of the anchoring of this pilot cross-border initiative, and of its added value, hence the need has received funding for the consolidation and extension of: "Joint Regional STI/HIV/AIDS project in the Abidjan-Lagos transport corridor". Moreover, in September 2007, ALCO was chosen to implement the new "Abidjan-Lagos transport and transit facilitation project" (ALTTFP) of the World Bank, under the supervision of ECOWAS. 10. The executive secretariat sent written comments on the draft ICR. It agreed with the assessment, but suggested that more consideration should be given to the pilot nature of the project and the constraints encountered. It suggested a very satisfactory rating for the first and second components of the project and a better recognition of the commitment of the governments concerned and of the role played by the Governing Body. Most comments have been taken into account in the revised version. Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders 1. The following paragraphs are a summary of a note sent by the Director of UNAIDS Regional Support Team for West & Central Africa, on the project. She highlighted the role of UNAIDS during the preparation and implementation stages, the key dates of the project and the challenges to be addressed to sustain the project achievements. 2. Correlation between migratory movements and STDs: The Abidjan ­ Lagos Transport Corridor links the major economic centers in West Africa. About 63 percent of economic activity in ECOWAS takes place in the areas served by the corridor. About 30 million people live along the corridor and 14 million people travel on the corridor annually. The West African Initiative identified a high correlation between migratory movements and STDs, including HIV. Travel, involving long time spent away from home, increases the likelihood of unsafe sex. In 2005, the HIV prevalence rate among the highly mobile population living at border towns was estimated at 8.8 percent. The high HIV prevalence rate observed among commercial vehicle drivers and commercial sex workers pointed to the need to strengthen prevention and care services along transport corridors, including the Abidjan-Lagos one. 3. The key events of the project: Preparation of the Lagos-Abidjan corridor project was initiated during a regional workshop organized by UNAIDS in July 2000. Main events were as follows: · July 2000: first meeting with UNAIDS support in Accra · May 2001: first Bank preparation mission · July 2001: first meeting of the Ministers of Health of the five countries, facilitated by UNAIDS, which established a working group and a provisional secretariat in Benin, and reached a consensus on the institutional framework for the project · April 2002: Joint Declaration of the five Heads of State · March 2003: Negotiations of the grant · November 2003: Approval of the project by the Board of the Bank · December 2003: Launch of the project by the President of Benin · February 2004: Effectiveness of the grant · August 2004: Signature of the Headquarters Agreement · February 2006: Mid-term review · July 2006: Mobilization of additional resources with the help of UNAIDS · October 2007. Meeting of the representatives of the five countries with the Global Fund to agree on the institutional framework 4. UNAIDS played an important role: The success of the project is mostly due to the institutional framework, in which all five countries are equitably involved. It was designed to complement national HIV/AIDS programs. UNAIDS has helped initiate, prepare and implement the project. It has contributed to the definition of vulnerable people, particularly among mobile people, through a study conducted in 1997. It has helped design the institutional framework and supported its establishment. It has contributed to the development of the monitoring and evaluation system, including the formulation of indicators. It has worked closely with CSOs to help them participate in project activities. Finally it has provided technical assistance for the preparation of the project document for Global Fund financing. 5. Main challenges and opportunities: UNAIDS raised five important issues which need to be addressed carefully: · Sustainability of project achievements at the end of Global Fund financing, · Information sharing with national programs in real time, · Ensuring that the principles of equity, transparency and project performance are applied, · Development of local response, and · Extension of the approach to other transport corridors. Annex 9. List of Supporting Documents 1. ALCO: Joint Regional Project for STI/HIV/AIDS Prevention, Care and Support along the Abidjan-Lagos Transport Corridor. Completion Report, January 2008 2. HIV/AIDS and Transport, Best Practices in the Abidjan-Lagos Corridor, December 2007 3. Arc Ingenierie: Mission de Conception et Mise en Place des Observatoires de Suivi des Déplacements le long du Corridor de Migration Abidjan-Lagos, Rapport d'Etude, Novembre 2007. 4. CAC : Evaluation de la stratégie IEC/BCC, January 2006 5. CEFORP : Synthèse des études de base, May 2005 6. CEFORP : Evaluation à Mi-Parcours du Corridor, Volet Biologique, January 2006 7. CEFORP : Etude sur la Satisfaction des Bénéficiaires, January, 2006 8. CEFORP : Audit des indicateurs, January 2006 9. CEFORP : Evaluation a Mi-Parcours, February 2006 10. CEFORP : Rapport Final Volet Biologique , December 2007 11. CEFORP: Audit des indicateurs, December 2007 12. CEFORP: Etude sur la Satisfaction des Bénéficiaires, December 2007 13. Global Excel: Evaluation des ONG, January 2006 14. Global Excel: Audit de la gestion des médicaments et condoms, September 2007 15. The Global Fund : Program Agreement, July 2007 16. Kaseka and al: Etude sur le tourisme sexuel le long du corridor, November 2005 17. Moriah Trust : Etude sur les obstacles à l'utilisation du condom féminin, February 2007 Annex 10: Statistical Annex Table 1: HIV prevalence rates and funding for national HIV/AIDS programs (US$ million) HIV prev. Global Fund PEPFAR World Bank Total Country rate 2003 - 03/07 2004-2006 2001- 12/08 funding 2001 2006 Benin 3.6% 1.8% 39.0 0 58.0 97.0 Cd'I 9.7% 7.1% 51.0 115.3 0 166.3 Ghana 3.0% 2.3% 45.8 0 45.0 90.8 Nigeria 5.8% 3.9% 74.4 344.8 140.3 559.5 Togo 6.0% 3.2% 25.7 0 0 25.7 Source: World Bank. PEPFAR (President's Emergency Plan for AIDS Relief) is a US Government initiative Table 2: Project Indicators Indicator Baseline Target Value (2005) (2007) PDO Indicators By end of 2006, at least 90% of the corridor commercial 68% 90% 82.7% vehicle drivers can identify at least two ways in which to prevent HIV/AIDS By end of 2006, at least 90% of local population residing 50.4% 90% 84.4% along the corridor can identify at least two ways in which to prevent HIV/AIDS (people aged 15 to 24) By end of 2006, at least 90% of commercial sex workers 59.5% 90% 87.9% along the transport corridor can identify at least two ways in which to prevent HIV/AID By end of 2006, reduce by 30%, compared with the first year 6.7% 4.7% 11.5% of the project, the incidence of reported sexually transmitted (urethritis) infections among male commercial vehicle drivers working along the corridor By end of 2006, reduce by at least 50%, compared with the 8.9% 4.5% 3.8% first year of the project, the prevalence of gonorrhoea among commercial sex workers along the corridor. Output Indicators By 2006, increase by at least 50%, compared with the first 59.3% 90% 78.8% year of the project, the proportion of commercial vehicle drivers who report using a condom in their last act of sexual intercourse with a non-regular partner in the previous 12 months. By end of 2006, at least 80% of commercial sex workers 58.8% 80% 70.5% along the transport corridor report using condoms with their clients of the previous week. By end of 2006, increase by 50%, compared with the first 0.97 1.46 8.8 year of the project, the number of condoms distributed million million million through social marketing along the transport corridor By 2006, each border crossing point along the transport 0 16 24 corridor annually organizes a rally to mark World AIDS Day with the participation of residents, commercial truck drivers and civil society organizations from both sides of the border By end of 2006, each border crossing point of the corridor 3 8 16 has at least one voluntary counseling and testing (VCT) center on either side of the border. By end of 2006, increase by 50%, compared with the first 1,000 1,500 27,639 year of the project, the number of people who use voluntary counseling and testing centers along the transport corridor By end of 2005, at least 90% of the health facilities along the 30% 90% 100% corridor report adequate supply of antibiotics for the treatment of antibiotic-sensitive sexually transmitted infections, over the previous six months By end of 2006, average time for trucks to clear border 180 90 128 formalities does not exceed 90 minutes on average By end of 2006, average time for busses to clear border 105 45 81 formalities does not exceed 90 minutes on average By end of 2006, the number of checkpoints per 100 km along 9 3 5 the entire corridor reduced by at least 50%, compared with the first year of the project A project progress report is prepared at least once every six 0 1 1 months Process Indicators By the end of 2004, all the countries along the transport 0 5 5 corridor have adopted a common HIV/AIDS strategy for the transport corridor By end of 2006, train at least 500 residents of border towns 37 500 1,460 along the transport corridor as key community HIV/AIDS IEC activists By 2006, increase by at least 50%, compared with first year 4 8 173 of the project, the number of trained HIV/AIDS counselors working in voluntary HIV/AIDS counseling and testing centers along the transport corridor By end of 2005, at least 40% of total disbursements to sub- 0% 40% 66% projects will have been through civil society organizations By 2005, at least fifty people from civil society organizations, 0 50 225 working on HIV/AIDS along the corridor, have been trained on financial management of sub-projects By 2005, at least fifty people from civil society organizations, 0 50 223 working on HIV/AIDS along the corridor, have been trained on community HIV/AIDS care and support By 2005, at least fifty staff of health facilities along the 0 50 287 transport corridor, have been trained on basic management of PLWHA Source ALCO. The three output indicators for transport facilitation are not strictly those of the PAD. Table 3: HIV positive rates among truck drivers and commercial sex workers, size of sample and date of data collection Feb. 2005 Dec. 2005 Aug. 2007 No truck drivers 260 334.0 533.0 % HIV positive 5.0 2.7 1.7 No CSW 93.0 142.0 188.0 % HIV positive 30.1 12.7 20.7 Source: CEFORP Annex 11: Key Lessons Learned from ALCO Experience 1. The following sections highlight key lessons learned from design to the implementation completion of Abidjan-Lagos HIV/AIDS Transport Corridor Project, financed by the Bank under its Multi-country HIV/AIDS Program (MAP). These lessons may be useful for other ongoing and future sub-regional HIV/AIDS projects or programs. The project was a high-risk undertaking which adopted innovative approaches during its implementation and benefited from the leadership of the 5 governments. Bank's Transport Sector (AFTTR) demonstrated an exemplary dedication and ownership of the project. The project greatly benefited from significant technical and financial support of UNAIDS, ACTafrica (AFTHV), HDNGA and AFTTR during its preparation and implementation that resulted in overall a better design and impressive implementation performance. 2. The PDO, Strategic Alignment and Focus. The project development objective was realistic, simple and was developed based on evidence and recognition of the complexity of the challenge to address HIV/AIDS in the mobile settled populations along the Abidjan-Lagos corridor, especially at the border areas. The foundation of the PDO was based on assessments done in 2001 at the border areas that estimated about 300,000 HIV positive persons traveling across 5 borders annually and the time to clear cargo trucks at the border areas that resulted in delays from a few days to months, in some cases. Considering that the corridor provided about 65% of trade facility to the 5 West African countries, the affect of HIV on the mobile populations and settled populations along the corridor was enormous. Stakeholders recognized that the traffic flow must be improved, number of checkpoints should be reduced, and customs clearance procedures be streamed lined. These challenges were considered during the PDO design. However, considering that the improvement of traffic flow, customs clearance and border security issues, which engaged several agencies and sensitive border policies ­ the project design team did not include traffic facilitation as one of the objectives in the PDO but addressed this challenge in the project implementation as a project activity. The PDO should be developed based on evidence and well informed estimates of what can be realistically achieved. Objectives that are critical but their achievement is too risky can still be part of the project design but do not necessarily be part of the overall PDO. A wider and earlier stakeholder consultation in the development of the PDO and KPIs is critical. The project narrowly identified the target groups and beneficiary populations and kept its focus on the target throughout its implementation. 3. Project design. There was no precedence of a sub-regional HIV/AIDS project addressing the threat of HIV on the transport sector and transport sector's contribution in the spread of the epidemic. The project design was innovative and heavily relied on a participatory process that engaged a variety of stakeholders. This approach resulted in strong ownership from the head of the states down to the community levels. The project design was realistic, simple and based on the key results to be delivered (in prevention, care, treatment and coordination areas). A simple project design that is focused on outcomes and well defined target beneficiary groups results in successful implementation including better monitoring. A simple project design does not warrant less preparation effort and budget, rather much higher preparation fund that is primarily required for gathering evidence. 4. Sustainability, Bank's role and partnership. The Bank played a catalytic role in supporting an innovative initiative by taking high risks. The project documents indicate that at initiation, with the exception of UNAIDS, other development partners did not show interest in joining the project. It is well documented that UNAIDS provided an extraordinary technical and financial support to bring the project concept to fruition. . Strong partnership between the Bank and UNAIDS was a critical factor in the design and delivery of the project. After the Mid-Term Review, ALCO qualified to receive $45 million from the Global Fund for 5 years. Fiduciary management and M&E was contracted out to a management firm on the build-operate-transfer basis. The BOT approach worked well and by the time project closed, ALCO successfully took over the fiduciary and M&E roles. It is critical that strong partnership is built prior to initiating the project design. ALCO project confirms that Bank can play a catalytic role, undertake high risks, build effective institutions, attract substantial financing and deliver results. Subcontracting critical but routine tasks pays off in terms of time and money, especially for a new organization in a complex setting. 5. Mainstreaming in the Transport Sector. The project sets an impressive example of mainstreaming HIV/AIDS in the Transport sector in the Bank operations. This has significantly raised awareness of the impact of HIV on the sector's development and high risk of sector's contribution to the spread of the epidemic. The ministries of transport in all 5 countries recognize the challenge and have been fully engaged in the project (evident from stakeholder consultations). However, evidence of key results delivered by the transport ministries in terms of improved partnership with the border entities to streamline customs formalities and facilitating traffic flow has not been significant. It is critical to actively engage the transport sector, customs and uniformed services to mitigate the impact of stagnant traffic at the borders. Without adequate parking facilities/infrastructure, access to the basic health services and information ­ the mobile populations may not only be contributing to the spread of HIV but other diseases including TB and respiratory illnesses. Bank financed transport infrastructure operations should address such challenges as a safeguard issue at the borders as well as in-country main road arteries. Future operations should be designed with critical thinking that transit facilitation (including infrastructure and customs clearance) are key to the success in curtailing the epidemic. 6. Innovative implementation approaches (not envisaged during the project design). It is evident that the project has been innovative in seeking solutions to various key challenges. The support of the Governing board (head of the national AIDS program managers) has been exemplary in supporting such innovations: · Establishment of border committees and training them for peer-to-peer learning. Border communities were mobilized and trained for community mobilization and awareness. ALCO coordinated the training not only to support the community level subprojects but also for peer-to-peer learning. This approach proves to be cost efficient and giving a clear mandate and operational objective to the committee members. · Harmonized communications strategy. Considering 5 countries, two foreign languages, several local dialects, multiple cultures, conflict in Cote d'Ivoire, non-accrual status of Togo; the project was impressively successful in developing a sub-regional communications strategy including standardizing key terms and messages along the border. The impact of the harmonized communication strategy is evident from behavioral survey and direct observations. · Localized radio channels. An integrated regional IEC/BCC strategy was developed, validated by the five countries and widely disseminated. At the operational level, various approaches were used depending on the targets. Through the IRIN Radio Station, partnerships were established with 32 radio stations for the five countries ­ national radio stations as well as community radios- for the production and broadcasting of radio programs in 17 local languages. In 15 months of activities, over 30 million people were sensitized through the radio programming approach. The initiative resulted in significant increase in demand for VCTs. The established radio coverage can be used to promote other awareness on PMTCT, TB/HIV. · Condom social marketing and alternate job opportunities for CSWs. The approach to the social marketing of both male and female condoms was innovative. Special brand for the corridor was created and registered in all 5 countries, cost were reduced by localizing the adverts. CSWs were mobilized to protect themselves as well as to adopt alternate means of income by selling the condoms. · Observatories at border behavioral monitoring and traffic flow time recording. Observatories were installed at all borders for direct monitoring of behavior of various target groups as well as sample recording of time required to clear the border formalities. Observatories were critical in a constant data flow allowing ALCO management to focus on the areas requiring more attention. · Subcontracting M&E. M&E was subcontracted to the management firm. Despite initial slow start, the M&S system was built, operated and then transferred to ALCO by the end of the project. Development of an M&E system from the scratch and ensuring data flows, synthesis and its utilization in stakeholder consultations and action planning has been impressive. Include the identification and contracting to 5 local NGOs as intermediary agents for supervision, quality assurance, M&E and technical assistance to NGOs. · ART referral system. The project soon learned that access to ART for non-citizens was a challenge. ALCO negotiated with all countries on a referral system. A non-citizen, when tested positive was issued a referral slip through which s/he could have access to ART in any member country. At the end of each month, the referral records were consolidated and ALCO would reimburse the cost to that country where ART was provided. The system helped MoH in all countries to harmonize ART for the mobile populations and non-citizens. This approach also facilitated the national AIDS programs to better plan for the ART needs and services. · Waste management. ALCO retroactively developed a corridor waste management strategy and plan and hired a fulltime environment and waste management officer. Incinerators were installed at all border posts meeting or exceeding WHO standards. Community sensitization on waste management was integrated in the IEC programs. · Increase in CYP. The annual number of couple year protection (CYP) resulting from all condoms distributed through the social marketing component increased from 9,778 in 2003 to 109,319 by the end of 2007. 7. Institutional arrangements. The institutional arrangement for the complex implementation challenge was simple and lean. Having project targets well defined and target groups well identified it was comparatively easier for the institutions to focus on the deliverables. A lean management group with routine accounts management, procurement management and monitoring and evaluation system development contracted out has proven to be cost efficient and resulted in an efficient management. Government of Benin volunteered, agreed by all 5 countries, to house the ALCO headquartered and offered to finance the overhead and housing of the ALCO Secretariat. The government also offered to receive the project funds on behalf of all 5 countries including Togo (non-accrual) and Cote d'Ivoire (rapidly slipping into conflict). Government ownership and leadership is a core requirement for successful institutional arrangements. Participating member governments should be in the fore front of decisions related to which country would house the headquarters, how its management would be staffed to ensure openness, transparency and equal opportunity to all nationalities. 8. ALCO succeeded in developing a strong coalition and partnership among the countries on HIV/AIDS. This partnership is largely due to early engagement of the political leadership (head of the states) from all countries. Top level engagement and commitment greatly facilitated in the preparation and implementation of the project. The governing body members included the head of the national AIDS programs to ensure synergies between the national programs, respective ministries of health, transport and uniform services and the sub-regional project. High level political engagement of participating countries and reaching a broad consensus consumes time but this is time well spent. Once there is a political level consensus ­ other operational and institutional aspects of the projects are much easier to develop and implement. 9. Stakeholder engagement. ALCO management and the approach to the coordination of the project were highly participatory at all stages from project concept inception to the project completion. Reviews and action planning were consulted with the stakeholders and agreements were reached for implementation priorities. It is evident that participatory processes and stakeholder engagement plays a key role in creating strong ownership and responsibilities among the stakeholders and partners. Key challenges were faced during implementation 10. The successes came with challenges. Most of these challenges resulted in innovative approaches by ALCO mentioned above. The following provide key challenges during the project implementation: · Project coordination was highly labor intensive with significant diplomatic and political risk. Coordination among five countries (1022km of corridor) was difficult due to two languages, multiple cultures and local dialects, multiple religious believes, and believes on traditional and spiritual healings, engagement of 5 Ministries of health, transport and uniformed services. · Developing synergies between 5 national AIDS programs and a sub-regional program was challenging. Although the Governing Board facilitated the process, operational level harmonization of clinical aspects, referral system, and communications strategy was difficult. Subcontracting fiduciary management and M&E greatly facilitated ALCO to focus on programmatic and thematic harmonization. · Developing M&E from the scratch for the corridor, considering that only a few countries had a national M&E system, was a daunting task. Bringing 5 countries to agree on the M&E standards, software, data collection and reporting took time in the beginning. · The objective of addressing different border closing policy at different borders and several check points on the 1022km corridor (especially in Cote d'Ivoire during the conflict) was not achieved. According to the border security agencies, such initiatives would have compromised the national security. Nevertheless, the border agencies fully cooperated in the dissemination of the IEC interventions. · Border areas are estimated to have prevalence as high as twice the national figures. Changing behavior in the mobile population is more difficult than the settled population. Special strategy and approach is required to make behavioral change interventions in the mobile populations. · Building grassroots capacities has been exhaustive and should not be underestimated. Changing behavior, especially in CSWs, to alternate income generation opportunities is equally difficult without a longer term vision and consistent support. · It has been very challenging to monitor/surveillance of mobile target groups. In a mobile target group it was difficult to have absolute data. Monitoring of new incidents is the settled population is doable but in a mobile target group would require high investments, an implementable methodology and medium-long term consistent financing. In order to allow for flexibility, it is better to keep financing expenditure categories to a minimum in complex projects. Expenditure categories need not be elaborate ­ maximum amounts may be allocated to an unallocated category so that the project could benefit from the flexibility and allocate resources based on the previous 12 months of implementation progress, and allocating costs to the next 12 months of priority interventions.