ICRR 11224 Report Number : ICRR11224 ICR Review Operations Evaluation Department 1. Project Data: Date Posted : 06/27/2002 PROJ ID : P000308 Appraisal Actual Project Name : Population/aids Control Project Costs 34.5 26.4 US$M ) (US$M) Country : Burkina Faso Loan/ US$M ) 26.3 Loan /Credit (US$M) 23.3 Sector (s): Board: HE - Health (71%), Cofinancing 2.7 2.7 Central government US$M ) (US$M) administration (16%), Other social services (13%) L/C Number : C2619 Board Approval 94 FY) (FY) Partners involved : Norway Closing Date 12/30/2000 09/30/2001 Prepared by : Reviewed by : Group Manager : Group : Timothy A. Johnston John R. Heath Alain A. Barbu OEDST 2. Project Objectives and Components a. Objectives The project's objectives were to : (i) enhance the onset of fertility decline by increasing the prevalence of modern methods of contraception, and (ii) slow the spread of HIV infections by promoting behavioral change and treating sexually transmitted diseases (STDs). The project design document established ambitious targets for improving contraceptive prevalence and reducing HIV transmission . The project's objectives were not revised, but greater emphasis was given to HIV/AIDS activities (inside and outside the health sector ) following the 1998 midterm review. b. Components The project had three components : Supporting the implementation of the government's population policy (US$15.6 million), including: (i) improving quality of and access to maternal and child health /family planning services through expanding services and outreach programs (civil works, equipment, contraceptive provision, provider training, establishment of community-based contraceptive distributors (CBDs), and support for "village ambulances" for obstetric emergencies); (ii) promoting information, education, and communications (IEC) programs (media campaigns, workshops for opinion leaders, and enhanced public understanding of women's rights ); and (iii) institutional strengthening for the Inter-Ministerial Population Committee (CONAPO), the MOH's Family Health Directorate and the Family Promotion Directorate (Ministry of Social Affairs and Family). Strengthen national capacity to contain the spread of HIV /AIDS/STDs (US$14.9 million), including (i) strengthening the national AIDS committee and health system capacity; (ii) promoting behavior change through IEC campaigns; (iii) provision and promotion of condoms; (iv) treating STDs; (v) strengthening clinical management and community care for persons with AIDS . Encourage private sector and NGO participation in family planning and HIV /AIDS (US$4.0 million) through establishing a fund to finance NGO and community activities . c. Comments on Project Cost, Financing and Dates The closing date was extended by nine months to allow completion of project activities, and to lay the groundwork for a follow-on multisectoral HIV/AIDS project. Project co-financing from Norway supported the NGO component . According to Annex 2 of ICR, US$3.0 million of the credit was canceled at closing, distributed roughly in proportion to the size of each component . The reasons for cancelation are not given . 3. Achievement of Relevant Objectives: The Project's outcomes were mixed. With regard to family planning, a number of activities were completed, but progress toward stated objectives was modest. From 1993 to 1999, the contraceptive prevalence rate (CPR) increased only slightly from 17 % to 20 % in urban areas, and from 1.5 % to 2.6 % in rural areas, against (unrealistic) initial CPR targets of 32 % and 9 % for urban and rural areas, respectively . The total fertility rate in urban areas fell from 5.0 to 4.1, but did not change in rural areas, where most of the population lives . The proportion of women who reported knowledge of modern contraception increased from 62 % in 1993 to 76 % in 1998/99. But it is not clear how much project investments contributed to urban improvements, as compared to socioeconomic factors or other donor activities . The project's sought to "slow the spread of HIV infection " -- a vaguely worded objective. Although the project helped establish five HIV sentinal surveillance sites, there are no nationally representative data on HIV prevalence (estimated at about 10 percent), and the rate of new infections is not known . Similarly, there are no reliable trend data in STD infections . Available evidence suggests modest progress in reducing risky sexual behavior, particularly among men. The project completed most of the planned activities under this component, however, and appears to have made important contributions to strengthening the national response to HIV/AIDS, both among government and nongovernmental organizations (NGOs). 4. Significant Outcomes/Impacts: General awareness of HIV/AIDS was already high at the start of the project, and there was modest progress in translating awareness into behavior change . 78 % of men changes in sexual practices due to HIV /AIDS (compared to half of women), and the percentage of unmarried men reporting 2 or more sex partners decreased from 26 % in 1993 to 13 % in 1998/99. Reported condom use among men increased to 26% (against a target of 20%), and 57% of men report condom use during high -risk sex. Although a number of other donors are active in promoting behavior change, project -sponsored IEC campaigns may have contributed . The project also helped produce and disseminate a new code for women 's rights . The 1998/99 DHS reported a modest decline in female circumcision (64% of 15-19 year-olds, compared to 71% of women 20-24) The project provided family planning equipment for 300 health facilities; supplied nearly all the contraceptives used by the national family planning program; piloted a community based contraceptive distribution program in 15 villages; supported the construction of 50 "village ambulances" (40 with motorcycles, 10 with donkeys); and supported the construction of an NGO family planning clinic in Ouagadougou and a youth counseling center in Koudougou. The project provided US$2.6 million in financing for about 60 NGO and community sub-projects, mostly for HIV/AIDS prevention and care, but also for Family Planning and discouraging female circumcision . An evaluation carried out in 2000 concluded that these activities contributed to raising knowledge of HIV /AIDS and encouraging behavior change . Despite initial difficulties, the project helped to strengthen local NGO capacity, partly by linking smaller NGOs/associations with national umbrella organizations and /or international NGOs. During the 9-month project extension, the project initiated a pilot scheme for community -driven HIV/AIDS activities (which financed 600 micro-projects reaching 95 % of villages in Poni), and supported HIV/AIDS work programs in a number of line ministries. This helped test approaches that will be scaled up under the subsequent multisectoral HIV/AIDS project. 5. Significant Shortcomings (including non-compliance with safeguard policies): The project made only modest progress in strengthening the capacity of the inter -ministerial population committee. Despite support for various community -level family planning activities (such as Community-based distributions), the impact and long-term sustainability of these activities is unclear . Even though this project was multi -sectoral in design (involving three different ministries ), in practice the various project activities were not well integrated -- either nationally or in terms of service delivery . Moreover, the decision not to base the project in the Ministry of Health -- together with the increased focus on HIV /AIDS -- created tensions with the MOH and with family planning programs . For example, there is now both an intersectoral population committee and an intersectoral AIDS committee, but the latter is receiving considerably more funds and attention from donors . In the community pilot districts, local officials expressed some concern that the major focus on HIV/AIDS was diverting attention from other priorities . The project initially significantly overestimated the planning and implementation capacity of local NGOs . Partly as a result, a number of problems were encountered with the preparation and implementation of subprojects in the initial years. Most of these were subsequently resolved, however . A review of STD treatment quality found that treatment was appropriate in only a third of the cases, despite project support for STD drugs, training, and protocol development . It is unclear whether these investments had an impact on STD incidence. Because of shortcomings in project monitoring and evaluations -- and the incomplete coverage of the HIV surveillance system -- policymakers still do not have a good understanding of the magnitude and dynamics of the HIV epidemic, nor of the interventions most likely to have an impact on reducing HIV transmission . 6. Ratings : ICR OED Review Reason for Disagreement /Comments Outcome : Unsatisfactory Moderately The originally stated objectives were not Unsatisfactory achieved, particularly with respect to family planning. But the project made a number of useful contributions in HIV/AIDS, and laid the groundwork for future activities. Institutional Dev .: Substantial Modest Institutional development was modest at best for the family planning component, but arguably substantial for HIV /AIDS and NGO support. Sustainability : Likely Likely The HIV/AIDS activities in particular are likely to be sustained, although sustainability of family planning investments is less certain. Bank Performance : Satisfactory Satisfactory Borrower Perf .: Satisfactory Satisfactory Quality of ICR : Satisfactory NOTE ICR rating values flagged with ' * ' don't comply with OP/BP 13.55, but are listed for completeness. NOTE: 7. Lessons of Broad Applicability: There are several useful lessons, many of which are reflected in the design of the follow -on multisectoral AIDS project. Multisectoral projects do not necessarily lead to effective integration of activities . The Bank and project design need to consider the institutional framework for coordination, as well as the incentives among organizations and individuals for cooperation. Consistent with experience elsewhere, changing behavior is a slow process, and increased knowledge of HIV/AIDS and family planning alone is insufficient to bring about behavioral change . The capacity of NGOs and communities to implement projects needs to be carefully assessed, and appropriate arrangements established for contracting with a large number of NGOs and to build capacity and assist with implementation and evaluation. For this project, use of bilateral funds for NGO activities reduced the administrative problems encountered in many similar Bank -financed projects. The the Poni pilot scheme experience suggests that community -driven approaches to HIV/AIDS are feasible and potentially effective, but attention must be given to : (i) adapting the approach to the socio -cultural context; (ii) clearly specifying the rules; (iii) assuring integration with other local activities . The lack of realistic indicators and baseline surveys undermined project monitoring and evaluation 8. Assessment Recommended? Yes No Why? An evaluation of this project would contribute to OED's forthcoming review of HIV /AIDS. 9. Comments on Quality of ICR: The ICR is frank and provides a useful summary of project activities and key outcome indicators, and a thoughtful discussion of lessons learned . It might have devoted somewhat more attention, however, to assessing whether project activities might plausibly have contributed to reported changes in outcome indicators, or conversely, why some outcome indicators (in family planning particularly) showed little change despite completion of project activities .