The WorldBank FOROFFICIAL USEONLY Report No. 39906-AFR INTERNATIONALDEVELOPMENT ASSOCIATION PROPOSEDUMBRELLA RESTRUCTURING ANDAMENDMENT OFTHE FINANCINGAGREEMENTSFORTHE PROJECTS UNDER MULTI-COUNTRY HIV/AIDS PROGRAMFORAFRICA (MAP) May 29,2007 Country Department AIDS CampaignTeamfor Africa (AFTHV) Africa RegionalHumanDevelopment (AFTHD) This document has arestricted distribution andmaybeusedbyrecipients only inthe performance o f their official duties. Its contents may not otherwise be disclosed without World Bank authorization. ABBREVIATIONS AAP Africa Action Plan ACTafrica AIDS CampaignTeamfor Africa (AFTHV) AFTHD RegionalHumanDevelopment AFTQK RegionalOperationalQuality andKnowledge Services AIDS Acquired ImmunodeficiencySyndrome APL Adaptable Program Loan ART Antiretroviral Treatment ARV Antiretroviral (drug) ASAP AIDS Strategy andAction Planning Service AWARE! Action for West Africa Region - ReproductiveHealth BCC BehavioralChange Communications CAS Country Assistance Strategy CD Country Director CD4 Cluster o f differentiationmolecules CDC Centers for Disease Control CFP Country FinancingParameters CISLS Inter-sectoral Program CoordinationUnit (Niger) CMS Cornit6Mixte de Suivi CNLS National Committee for the Fight against AIDS Committee on Development Effectiveness cso CODE Civil Society Organization D C A Development Credit Agreement DflD Department for InternationalDevelopment DGA Development Grant Agreement DHS Demographic andHousehold Survey DO/PDO Development Objectives / ProjectDevelopment Objectives FMA Financial Management Agent GAC Ghana AIDS Commissions GAMET Global AIDS Monitoring and EvaluationTeam (HDNGA) GARFUND GhanaAIDS ResponseFund GFATM Global Fundto fight AIDS, TB and Malaria GHAP Global HIV/AIDS Program (HDNGA) o f the World Bank GRF Generic Results Framework GTT Global Task Team HDNGA Global HIV/AIDS Program HIV HumanImmunodeficiencyVirus HNP Health, Nutrition and Population IDA InternationalDevelopmentAssociation IEC Information, Educationand Communications IEG/OED Independent EvaluationGroup (formerly, Operations EvaluationDepartment) IP ImplementationProgress ISR ImplementationStatus andResults Report KPI KeyPerformance Indicators LEGAF LegalDepartment Africa Region LGA Local Government Authority LOA LoanDepartment M&E Monitoring and Evaluation MAP Multi-Country HIV/AIDS Programfor Africa MDA Ministries, Departments, District Assemblies MDG MillenniumDevelopment Goals M-SHAP Multi-Sectoral HIV/AIDSProject M S M Menwho have Sex with Men MTEF Mid-TermExpenditureFramework MTR MidTermReview NAC NationalAIDS Council or Committee NAS NationalAIDS Secretariat NGO Non-Governmental Organizations NSF National Strategic Framework OECD Organization for Economic Co-operation and Development PAD ProjectAppraisal Document PEPFAR President's Emergency Planfor AIDS Relief (U.S. Government) PLWHA People LivingWithHIV/AIDS PMTCT Preventiono f Mother to Child Transfer PNMLS Programme National Multisectoriel de Lutte contre le V W S I D A (DRC) PRSP PovertyReduction Strategy Paper PSI PopulationServices International QAG Quality Assurance Group QSA Quality of Supervision Assessment RVP RegionalVice President STI Sexually TransmittedInfections TACAIDS Tanzania Commission for AIDS TAP Treatment Acceleration Project TMAP Tanzania MultisectoralAIDS Project TST Technical Support Team UNAIDS The Joint UnitedNationsProgramme onHIVIAIDS Members: UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODE, ILO, UNESCO, WHO, andWorld Bank UNDP UnitedNations DevelopmentProgramme UNECA UnitedNationsEconomic Commission for Africa UNGASS UnitedNations General Assembly's Special Session onHIV/AIDS UNICEF UnitedNations Children's Fund UNITAID UnitedNations InternationalDrugPurchase Facility USAID United States Agency for InternationalDevelopment VCT Voluntary Counseling and Testing ZAC Zanzibar AIDS commissions Vice President: Obiageli KatrynEzekwesili (Vice President) Country Director: Gerard Byam (AFTQK), Yaw Ansu (AFTHD) Sector Manager: ElizabethL.Lule (AFTHV) Task Team Leaders: NadeemMohammad (AFTHV), Norbert Mugwagwa (AFTHD) Countryteams 1. Dem. Rep. of Congo Country Director: Pedro Alba (AFCC2) Sector Manager: Laura Frigenti (AFTH3) Task Team Leader: Jean-Pierre Manshande(AFTH3) 2. Ghana Country Director: Mats Karlsson(AFCW 1) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: EvelynAwittor (AFTH2) 3. Guinea, Republic of Country Director: Mats Karlsson(AFCW1) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: IbrahimMagazi (AF'TH2) 4. Guinea-Bissau Country Director: Madani Tall (AFCW3) Sector Manager: MaryBarton-Dock (AFTS4) Task Team Leader: DirkN.Prevoo (AFTS4) 5. Mauritania Country Director: James Bond (AFCW4) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: Vincent Turbat (AFTH2) 6. Niner Country Director: MadaniTall (AFCW3) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: Djibrilla Karamoko (AFTH2) 7. Senegal Country Director: Madani Tall (AFCW3) Sector Manager: Eva Jarawan (AFTH2) Task Team Leader: Aissatou Diack (AFTH2) 8. Tanzania CountryDirector: Judy O'COIUIO~ (AFCE1) Sector Manager: Dzingai Mutumbuka (AFTH1) Task Team Leader: E m a n u e l G.Malangalila(AFTH1) DATA SHEET-UMBRELLA RESTRUCTURING PROJECT PAPER (AFTHV), Norbert Mugwa Project ID: SeeAnnex 3 Country Director: GerardByam(AFTQK), Yaw Borrower: Democratic Republic o f Congo, Ghana, Republic o f Guinea, Guinea-Bissau, Mauritania, Niger, Senegal, Tanzania Responsible agency: SeeAnnex 3 FY SeeAnnex 3 Annual Cumulative Revisedclosingdate [ifapplicable]: Indicate ifthe restructuring is: Board approved Yes RVP approved Yes Does the restructuredproject require any exceptions to Bank policies? -Yes N o Have these been approved by Bankmanagement? -Yes II_N o I s approval for any policy exceptionsought from the Board? -Yes 1~No Revisedproject development objective/outcomes [Ifapplicable] Seesection V Does the restructuredproject trigger any new safeguardpolicies? Ifso, click here to indicatewhich one(s) [selection box like the one in the new ISR] None SeeAnnex 3 Table of Contents I. INTRODUCTION..................................................................................................... 1 I1. BACKGROUNDAND CONTEXT .......................................................................... 2 I11 MULTI-COUNTRYHIV/AIDSPROGRAM(MAP)PORTFOLIO........................ . 6 IV. SUMMARYOFPROPOSEDPROJECTAMENDMENTS..................................... 7 V. PROPOSEDPROJECTRESTRUCTURINGSEEKINGBOARDAPPROVAL.....9 VI ANALYSIS.............................................................................................................. 22 VI1 EXPECTEDOUTCOMES...................................................................................... 23 VI11 BENEFITSAND RISKS......................................................................................... 23 ANNEXES........................................................................................................................ 25 Annex 1-Issues Paper............................................................................................ 26 Annex 2 -The HIV/AIDSResultsScorecard......................................................... 35 Annex 3 - Project Data............................................................................................. 38 Annex 4 - Ahca RegionHIV/AIDSPortfolio........................................................ 40 I. INTRODUCTION 1. This Umbrella Project Paper seeks the approval o f the Executive Directors to amend the Financing Agreements o f HIV/AIDSProjects' (section IV) approved by the Board under Multi- Country HIV/AIDS Program (MAP1and MAP2) in2000 and 2001. The MAPwas designed on the principle o f learning by doing, o f continuously improving implementation in response to monitoring and evaluation and applying lessons of experience. This restructuring i s consistent with this underlying principle. The proposed restructuring takes into account the findings from MAP interim review (2004), OED/IEG evaluation o f global HIV projects (ZOOS), latest knowledge on prevalence, changed global financial architecture, as well as QAG supervision reviews andISRswhich identify major project implementationchallenges. 2. The proposed restructuringwill contributeto maximizing the effectiveness o f Bank support to the countries through improved Monitoring and Evaluation capacity, realigned indicators to national strategies, hnds directed to priority and high impact interventions and better coordinated institutional arrangements. The proposed restructuring will lead to more effective and efficient responses to HIV/AIDS prevention, carekreatment and mitigation interventions at the country level. 3. The region's progress will be reported through a HIV/AIDS Results Scorecard developed by the Africa Region in collaboration with the Global HIV/AIDS Program (HDNGA) and UNAIDS/WHO to facilitate country projects in harmonizing and standardizing HIV/AIDS indicators incompliance with indicators contained inthe globally agreed UnitedNations General Assembly Session on HIV/AIDS (UNGASS), Millennium Development Goals (MDG), IDA indicators, and OECD Paris Declaration on harmonization and minimization o f data requirements. Consolidating these indicators will: (i) significantly reduce a country's burden o f multiplereporting; (ii) amajor achievement towards harmonizing M&Eat the country levelin be line with the principle o f the "Three Ones2"; and (iii) provide the Bank with a better tool to report results on the Region's performance on the epidemic. 4. The proposed restructuringwill be implemented with immediate effect with the exception o f the project in the Central African Republic, Mozambique and the Sub-regional Treatment Acceleration Project, a learning project supporting scaling up o f treatment in Burkina Faso, Ghana, Mozambique, in partnership with WHO and UNECA. Restructuring o f these projects will bepresentedto the Board separately. 5. A background issuespaper on the challenges and lessons learned from HIV/AIDS projects under MAP in Africa i s attached in Annex 1. The key lessons learned include: (i)HIV Prevalence as a Project Development Objective (PDO) and performance indicator has proven unrealistic; (ii) slow implementation i s principally due to inefficient institutional arrangements, coordination and project design; and (iii) the need for a stronger and hnctional M&E systems to 1 Dem. Rep. o f Congo, Ghana, Republic o f Guinea, Guinea-Bissau, Mauritania, Niger, Senegal, andTanzania 2 On 25 April 2004, UNAIDS, the United Kingdom and the United States co-hosted a hgh-level meeting at which key donors reaffirmed their commitment to strengthening national AIDS responses led by the affected countries themselves. They endorsed the "Three Ones" principles, to achieve the most effective and efficient use o f resources, and to ensure rapid action and results-based management: (i)One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; (ii) One National AIDS Coordinating Authority, with a broad-based multisectoralmandate; and (iii) One agreed country-levelMonitoring and Evaluation System. 1 demonstrate impact, strategic management o f the epidemic and intense supervision due to the complexity ofthe nationalresponsesto HIV/AIDS. 11. BACKGROUNDAND CONTEXT A. BACKGROUND 6. HIV/AIDS continues to be a major development challenge in the region, particularly in southern Afhca, the epicenter o f the epidemic. Among other diseases, HIV is the main cause o f adult mortality and contributes to significant reversal o f life expectancy gains, erodes productivity, decimates the workforce, consumes savings and dilutes poverty efforts. Africa has an estimated 26 million people living with HIV/AIDS, and more than 23 million have died as a result o f infection. An estimated 5,000 lives are lost per day (2005). Africa accounts for more than 60% o f the global number of people living with HIV/AIDS. Women represent the majority o f those infected and young people especially young women are at hgh risk. More than 12 million children have been made orphans by the disease in Afhca. The epidemic diminishes economic growth by up to 1.5% per annum in the most affected countries3. The impact on human capital i s devastating. Life expectancy has fallen below 50 years in several countries, for example, in Zimbabwe the life expectancy at birth for women has reached as low as 34 years (Source: UNAIDS 2006). 7. In 1999, the World Bank developed a new strategy for Intenszfjing Action Against HIV/AIDS in Africa: Responding to a Development Crisis, making a long term commitment to combat against HIV/AIDS inAfrica. The aim was to provide urgent support to enable countries inAfrica to scale up their programs against the devastating epidemic. The strategy called for a new, flexible way to provide resources quickly, both to governments and civil society, within sound strategic frameworks. So the Multi-Country HIV/AIDSProgram- the MAP-became the first program to offer African countries substantial, long-term funding to support HIV programs o f national scale and coverage. The response was overwhelming, and in short order the M A P was supportingnearly every low-income country inAfrica with a credible national strategy. 8. To meet an anticipated growth in demand, the Bank's response was the Multi-Country HIV/AIDS Program (MAP) for Africa, designed as a fast, comprehensive, multisectoral, and renewable instrument to fund both the public and non-public sectors as emergency operations. The M A P broke ground in several ways: (a) it offered comprehensive support for national programs, going beyond traditional project support; (b) it was the first major program to support HIV/AIDS strategic andsystem investmentsat national level, rather thanjust select interventions (this helpedbuild capacity and eased the way for other donors); (c) it galvanized "demand" by channeling funds directly to communities and civil society organizations, recognizingthe role o f social mobilization incombating HIV/AIDS; (d) it was fast. At the time MAP was initiated, the average Bank project took more than 18 months to prepare. By taking a program approach, MAP projects could be prepared inroughly half that time; (e) by committing USD equivalent 500 million it raised the hding benchmark for other donors. This level and type of 3"HIV/AIDS: the impact on the Social Fabric and theEconomy - TheMacroeconomics of HIV/AIDS', Haaker, M- InternationalMonetary Fund, 2004. 2 commitment - Fund, PEPFAR, and other multi-billion dollar initiatives; and (9 It assured countries that the and the strong demand that followed - help lay the groundwork for the Global Bankwas committedto long-termsupport for HIV/AIDScontrol insub-Saharan Ahca. B.REASONSFORUMBRELLARESTRUCTURING 9. The need for restructuringHIV projects (section IV) emerged from: 0 Knowledge gained and more scientific evidence on the epidemiology o f the epidemic which shows that: (i) it is not one but different epidemics among countries and within countries and it changes over time; and (ii) o f `reduction in HIV/AIDS prevalence' use as a PDO and outcome indicator for MAP projects i s an inappropriate measure o f efforts to respondto the epidemic; The findings andrecommendations from an interim review o f MAP projects conducted with external partners (2004), and the LEG/OED evaluation o fMAPS in2005; and QAG assessments o f supervision and ICR Reviews o f 3 MAPSwhich have shed light on implementation challenges and how to improve the coordination and implementationo fMAPS amongthe development partners and governments. 10. The summary o f key reasons to restructure the projects are presented below (Annex 1 provides detailed background): HIV Prevalence as a Project Development Objective (PDO) and performance indicatorhas provenunrealistic. HIVprevalence represents the cumulativenumber of HIV infections (new and old) minus those who have died. In contrast, HIV incidence reflects recent infections, usually expressed as the number o f new HIV infections acquired in the last year but i s much more difficult to measure. Therefore, HIV prevalence, which i s easier to measure, i s usedmore commonly than incidence. The MAP interim review in 2004 first flagged the limitations of usingHIV prevalence as a PDO andthese include: (a) HIV prevalence is slow to respond to changes inHIVriskbehavior and HIV incidence; (b) in concentrated epidemics, HIV prevalence in the general population reflects the tail-end o f a long infection chain; (c) HIV prevalence provides no timely information as to whether a project i s on or off track and does not enable management to manage by results; (d) HIV prevalence depends on the balance between incidence and mortality, which may be changed by increasing access to treatment; (e) HIVprevalence changes cannot be attributed to a single development partner's efforts - they reflect the totality o f national and international HIV responses; and (f) HIV prevalence measures may not be consistent or stable over time. Slow implementation is principally due to weak or inefficient institutional arrangements and project design. Based on experience, key areas of institutional and implementation arrangements, reflected in the ISRs and agreed with governments, need to be revised and strengthened to accelerate implementation. Challenges in the institutional, implementation and project arrangements include: (a) inappropriate procurement and financial management arrangements, and countries that were approved before May 2004 not benefiting from new Bank procurement guidelines (approved in May 2004 and revised in October 2006); (b) weak country level coordination o f donor 3 financing as well as weak coordination by the national AIDS authority, its secretariat, decentralized coordination entities, and public sector ministries including coordination with ministry o f Health; (c) unrealistic project cost estimates which will require reallocating funds between expenditure categories to support priority areas; (d) limitations inSpecial Account ceilings which constrain scaling up with communities; (e) project description and activities not geared to support modifications in targeting and prioritization; and (f) the need for closing date extensions to achieve the revised objectives. Key lessons learned from IEG4and QAG5 reviews: IEG reviews of ICRs underscore the need for: (a) stronger and functional M&E systems to demonstrate impact, especially inthe context of a learning-by-doing approach; (b) improving coordination for a more prioritized, multisectoral, and mainstreamed response; (c) baseline data by countries and donors; (d) carefully crafted community interventions using concern for one disease as an entrke for programs targeted at other diseases, as well as strengthening the related health systems; (e) strategic management o f the epidemic and to customize the multisectoral approach; and (f) the involvement o f health ministries for a successful response to HIV/AIDS. These reviews reinforcedthat HIV prevalence should not be used as a measure of success o fprevention efforts. QAG assessment: QAG assessed 3 countries for the quality o f supervision (QSA7). Their key findings point to the following: (i) supervision should draw more extensively MAP and use knowledge gained from other similar operations as well as from other similar reviews including M&E reports, surveys and MTWICRs; (ii)supervision and M&E needs to be intensive considering MAP support to decentralized response; (iii) roles the and responsibilities o f various entities responsible for coordination and implementation should be clear; (iv) coordination and harmonization need to be put inpractice; and (iv) uneven supervision support from the Bank adversely affects the project implementation performance. c. STEPSTAKEN IMPROVE PROJECTSPEFWORMANCE TO 11. In order to improve the effectiveness and efficacy o f the projects, by addressing the challenges identified above and to improve the portfolio performance (section 111), the Africa Regionhas decided to address the performance challenges ina comprehensive manner. An issues paper (Annex 1) has been prepared by the Africa Region and shared with project teams and the management. As a result of the various contributions provided, the following key steps have beentaken: 0 Comprehensive review of all active HIV/AIDS projects: In April 2006, the Africa Region reviewed all active HIV projects in collaboration with AFTHD, LEGAF, and HDNGA to identifyprojects that neededProject Development Objective changes andor restructuring to incorporate improved knowledge of the epidemic. Task Teams then identified other key areas for improvement based on the lessons learned and reviews by QAG and IEG; 4ICR reviews of Ethiopia, Eritrea and Ghana (fast generation MAP projects). 5QSA7 reviews ofBurundi, Chad, Republic of Guinea andNigeria. 4 0 Developing an HIV/AIDS Results Scorecard: In October 2006, the Afiica Region and HDNGA finalized an HIV/AIDS results Scorecard for all HIV projects. It was adopted by the Region for all ongoing and future HIV/AIDS operations. The scorecard is based onthree keyprinciples, namely that a mechanismand systems are inplace inall countries to report on indicators, indicators are agreed upon with all development partners, and indicators can provide aggregate results for Africa. The Scorecard (Annex 2) will: (a) reduce country burden o f multiple reporting; (b) be a major achievement towards harmonizing M&E at the country level; and (c) provide the Africa region with a better tool to report on the region's performance on the epidemic. The scorecard does not replace the country indicators but a subset and i s complementary. It is based on the indicators selected from globally agreed HIV indicators on prevention, care, treatment and mitigation required by UNGASS, MDG, and IDA. The indicators have been harmonized with the indicator sets o f other major partners in HIVIAIDS (U.S. Government PEPFARindicators andthe Global Fund'slist o f 'Top Ten' indicators). 0 Additional supervision support: AFTQK established an Escrow Account in 2005 to support problem projects and all HIV projects are encouraged to utilize this fund to address challenges; Improving quality at entry: The Region focused on improving quality at entry for all second generation HIV projects by adopting Committee on Development Effectiveness (CODE) recommendations on the IEG evaluation o f HIV/AIDS project in 2005. These recommendations are used as access criteria to the next generation HIV projects, including: financial gap analysis for the country, addressing lessons learned from the first generation project, areas o f support by other donors, and clarifying objectives and developing arealistic results framework; Intensified technical assistance: As an ongoing effort, ACTahca, AFTHD and GHAP (HDNGA) intensified their technical assistance to operations by supporting project supervision, portfolio monitoring, ISRreviews and extendingboth financial and technical support to problem projects. HDNGA, in partnership with UNAIDS and UNDP has rolled out a technical assistance program to assist countries inreviewing and developing their national HIV strategies and action plans. This service i s being provided under the AIDS Strategy andAction Planning (ASAP) support. ACTafrica established a Technical Support Team (TST) which provided informal but intense field reviews and recommendations to address institutional and programmatic challenges to improve project performance. Intensified support on Monitoring and Evaluation. The Global AIDS Monitoring and Evaluation team (GAMET) based inHDNGA, has intensifiedits technical support to all HIV/AIDS operations in the region. This assistance includes support in the review and development o f national strategic M&E framework, costed M&E action plans, synthesis of epidemiological analysis o f the country, integrating M&E in the review and development process o fprioritizednationalHIV/AIDSstrategy and actionplans. Established an Early Warning system. ACTafrica established an early warning system to use various Bank system data to identify potential challenges in the projects and to undertake corrective measuresby supportingproject teams. 5 111. MULTI-COUNTRYHIV/AIDSPROGRAM(MAP) PORTFOLIO 12. Since 2000 (FYOl), the response and demand from African countries far exceeded expectations, and the MAP funds were committed twice as fast as the Bank had expected. In FY02, the Board approved a second USD 500 million envelope for the MAP from IDA-13 resources, this time as grant hnding. By early FY04, all active IDA countries in sub-Saharan Africa had M A P projects approved or in the pipeline, and by late FY04, the initial USD1.O billion made available for the MAP had been fully committed. However, new commitments in 2005 and 2006 were modest. Table-1 shows annual IDA-financed projects inAfrica and average commitment per project: Table -1. MAP/IDA FinancedProjects* inAfrica (Amounts inequivalent USD million) Pipeline FiscalYear: 2001 2002 2003 2004 2005 2006 2007 No. of projects 7 10 5 9 5 3 6 Avg. per project (USD mil) 41 22 35 40 16 25 35 Total amount (USD mil) 287 297 173 356 80 98 210 IDA Credit 287 297 98 180 IDA Grant 173 356 80 30 IBRD (*) Includes 4 repeater, 4 additional financing and 4 sub-regional projects 13. As o f March 2007, the Bank has approved USD1.25 billion for 40 MAP projects. In the current FY six projects are in the pipeline (3 repeater projects and 3 additional financing). The equivalent o f about USD 900 million has been disbursed under the Africa MAP (including closed projects). 14. Second generation projects for Benin, Burkina Faso, Eritrea, Ethiopia, Ghana and Madagascar have been approved. Additional financing has also been approved for Cape Verde, Nigeria andRwanda. Botswana, Cameroon, and Kenya are under preparation and included inthe FY07/08 pipelines. All new and second generation projects will address the challenges and recommendations highlighted in Section I1above. About USD210 million is inthe business plan for FY07, w h c h includes USD$SO million additional financing for Nigeria. FY08 projects include USD40 million for Cameroon, USD5O million for Botswana (to be the first HIV/AIDS Afhcan IBRDproject), Mozambique i s likely to request additional funds as well (Togo and Cote d'Ivoire remain in non accrual status). The Uganda MAP project ended and Zambia will end soon and the two countries have not requested IDA support for follow on projects and are currently conducting financing andprogram gap studies. 15. Besides the challenges faced during implementation and overly ambitious PDOs and key performance indicators, by FY05 at-risk HIV projects increased to about 52%. Risk factors related very closely to the findings o f other reviews (section I1 above): very limited M&E capacity, slow disbursement, weak procurement performance and project management. In an 6 effort to respond to these poor performance factors, intensive efforts were made through focused technical support from the region and HDNGA to concentrate on improvements. Over the next 24 month period o f intense technical support (section II-C), the at-risk projects declined from 52% inFY05 to 19% by FY07with improved HIV/AIDS portfolio realism to 83%. As o f March 2007, six o f 33 active projects are "problem" projects with their DO/IP unsatisfactory or moderately unsatisfactory. Annex 4 provides an overview of the HIV/AIDS portfolio from 2001 to 2007 16. However, the HIV/AIDSportfolio remains susceptible to risks that are now the subject of proposed restructuringto addressbroadMAPaspects as well as country specific issues. IV. SUMMARYOFPROPOSEDPROJECTAMENDMENTS 17. The proposed umbrella restructuring would eliminate prevalence as a Development Objective indicator and refocus new objectives towards HIV/AIDS prevention, carekreatment and mitigation interventions at the country level. National responses would focus on improving monitoring and evaluation capacity, realigning indicators to national strategies, funding priority interventions as well as setting-up better coordinated institutional arrangements. This proposed restructuringwould include 8 projects worth the equivalent o f about USD 300 million o f active portfolio. Individual requests from the governments were receivedfrom all 8 countries. 18. The restructuring follows a wide range o f consultations with project Task Teams, AFTHD, AFTQK, HDNGA and its Global Monitoring and Evaluation Team, and all relevant client countries. 19. Table-2 shows the summary o fkey changes to 8 projects seeking Board approval: Table -2 AmendmentsRequiringBoardApproval (*) Such as increase indisbursement percentages,reallocation of funds, adopting of CountryFinancingParameters (CFP) 7 Projects to bepresented to the Board separately 20. Some projects including for the Central A h c a n Republic, Mozambique and the Sub- regional Treatment Acceleration Projectwould be presented to the Board separately as described below. Table -3 Projectsto be presentedto the Board Separately Key ChangesRevisions 21. The Central African Republic Multisectoral HIV/AIDS Project (Cr: IDA3.5840) - SDR 13.3 million (equivalent USD 17 million) was approved by the Board on December 14,2001 and didnot become effective due to CAR'Snon-accrual status after the Board approval. The country has recently come out o f its non-accrual status. CAR restructuring will be treated separately as the Government has not finalizedits positionregardingthe use o fthe remaining credit allocation. It might ask to use half of this allocation to contribute to the fight against HN-AIDS and the other halffor other urgenthealthand social investments. 22. The Sub-regional Treatment Acceleration Project (TAP) - (Burkina Faso Cr: H1060; Ghana Cr: H1050; Mozambique Cr: H1040; UNECA Cr: H1080; WHO Cr: H1090) - SDR 41.4 million (equivalent USD 59.8 million) project was approved by the Board on June 17, 2004 and became fully effective for all countries and partners on March 14, 2005. The Project's closing date i s September 30, 2007. Due to the complex nature o f the project involving 3 countries, WHO and UNECA, a separate detailed restructuring request will be submitted to the Board by December 2007. The current Project Development Objective i s to assist the countries to scale up and implement comprehensive treatment programs for persons living with HIV/AIDS by providing a range o f quality services which are effective, affordable and equitable. This PDO does not reflect the learning aspects o f the project and all three country governments have agreed inprincipleto revise the PDOaccordingly. Theproposedrestructuringmaybeaccompaniedbya request for extension in order to allow time for the project to show results to beneficiaries and provide lessons learned. The project i s due to close on September 30,2007. As o f May 17 2007, the project has disbursed the equivalent o f USD34 million. The PDO and IP are both rated satisfactory. 23. Mozambique HIV/AIDS Response Project (Grant No HO30-Moz) was approved by the Board on March 28, 2003, and became effective on August 15, 2003. The project development objective i s to slow the spread o f HN/AIDS in Mozambique and mitigate the effects o f the epidemic through prevention and care activities. The project was rated unsatisfactory in May 2004 and has remained so up to March 2007. The proposed restructuring would include: (i) outsourcing o f subprojects management; (ii) reallocations o f funds to support a pool-funding 8 arrangement with other development partners; (iii)review o f procurement management arrangements; and (iv) extension o fproject closing date. V. PROPOSEDPROJECTRESTRUCTURINGSEEKINGBOARD APPROVAL 24. Board approval i s requested for the following project specific restructuring. Overall justification for restructuring i s provided inSection I1above: Democratic Republic of Congo: MultisectoralHIV/AIDS Proiect - (Cr. HOSOO) - SDR 68.4 million (USD equivalent 102 million): The project was approved as a grant by the Board on March 26, 2004 and became effective on October 8, 2004. The project's closing date is January 31,2011. 25. Current Project Development Objectives. The Project's development objective i s to mitigate the negative impact of the HIV epidemic on the development o f the recipient through reducingthe risk o f sexual, intravenous andvertical transmission ofHIV. 26. Proposed Project Development Objectives: To assist the Recipient in: (i) increasing the access to STI/HIV/AIDS treatment; (ii) mitigating the health and socio-economic impact o f HIV/AIDS at the individual, household, and community level; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. 27. Status. As o f May 17,2007, the Project has disbursed the equivalent o f USD 32.8 million. The DO is Unsatisfactoryand IP is Moderately Satisfactory. 28. The Project has financed: (i) preventive activities6, curative and mitigation measures through several public sector entities for about USD5.93 million and through NGOs, as well as other private sector entities for about USD3.45 million; (ii)local response activities by community-based-organizations for USD0.55 million; (iii) central coordinating unit and its 5 the provincial sub-units, M&E and capacity buildingfor USD9.54 million. Incoordination with the other donors7 supporting the government, the Project recently dropped its initial strategy under which several NGOs would be contracted to vertically implement elements o f the health related HIV/AIDSpackageinselected zones acrossthe country. The partners andthe government opted instead for adding the needed financial resources to the 150 health zones contracted under the Health Sector Rehabilitation Support Project (HSRSP) and the Emergency Multisectoral Rehabilitation and Reconstruction Project (EMW) that are covering an estimated 20 million people, to implement a comprehensive integrated continuum o f care health, including ARV treatment. 29. Project implementation was critically slowed because o f major procurement and financial issues. This was due to the weak performance o f the financial management agent (FMA), recruited by the Project to assist in procurement and financial management. A Bank initiated 6 12.24 million condoms distributed; 16,089 securedblood transfusions; 48,929 patients with sexually transmitted infection properly treated; 44,239 persons having voluntary counseling and testing, 4,402 orphans getting a scholarship, 4,776 AIDS patients under treatment, specific IEC modules for primary and secondary students. Global Fund,WHO, UNDP, UNICEF, USAID, CDC, DFID. 9 investigation reported that FMA overlooked financial and procurement mismanagements by the Project and M o H staff (these staff were later suspendedby the government). On the institutional arrangement side, the role and responsibilities o f the National AIDS Secretariat's Project Implementation Unit was unclear in terms o f its coordination responsibility and o f project implementation. This resulted in serious delays inthe decision-makmg hierarchy engaging NAS, the PIU as well as MoH. In addition, poor coordination o f other stakeholders' activities by the MAP financed NAS, adversely affected donor collaboration. Other donors perceived NAS as a World Bank entity. 30. Poor coordination with M o H and lack o f an integrated approach with other health sector programs EMRRP and HSRSP also delayed project implementation. The ongoing EMRRE' health component covering approx 10 million people and the recent advent o f the HSRSP, also covering approximately 10 million people, both provide a comprehensive package o f health services and offer an opportunity to integrate MAP activities. Coordination efforts with the Global FundHIV/AIDS interventions andthe upcomingDfDHIV/AIDS Project also provide an opportunity to better target MAP financing for health related HIV/AIDS activities (transfusion, PMTCT, ARV treatment and VCT). Through the restructuring, packaging o f MAP'Shealth- HIV/AIDS activities to NGOs contracted under the two health projects financed by the World Bank will significantly improve the component performance, coordination with MOH as well as with the Global Fund and DID. A new activity to complement the Global Fund and donor financing for ART will be included in the Project to provide nutritional support to PLWHA under treatment. 31. The Project Development Objective will be revised to be within the framework of the "Three Ones" principles. The original objective and K P I s were devised for a vertical approach and were either too ambitious or too narrow with regard to the current needs, available Project funding, andmore support from other donors. 32. In order to improve the institutional and implementation arrangements, the government agrees to: (i) channel resources for HIV/AIDS activities through contracted health zones within the framework o f the two ongoing health sector projects in coordination with the other major donors (GFATM, Belgium, USAID, CDC and soon DFID). This will simplify the implementation of the health related HIV/AIDS component in the MAP Project; (ii) an agreement with the government not to extend FMA's contract that is due to end in September 2007, and to hire a procurement agent as well as international technical experts inprocurement, internal auditing and financial management; (iii) the prevention component will be redesigned to take into account existing and planned interventions; (iv) HIV/AIDS interventions will be better integrated with TB and Maternal Child Health; and (v) in order to meet the principles o f the "Three Ones", the Programme National Multisectoriel de Lutte contre le VIWSIDA (PNMLS) coordination function will be detached from the PIU. Recently, USAID financed a consultation to review the managerial capacity o f the local institutions, EU financed a consultation on the Country Coordinating Mechanism and UNAIDS launched a local consultation to review the institutional HN/AIDS setting. However, the effort was not well coordinated and a highlevel concerted effort (including the Bank) will permit reaching a proper diagnosis and corresponding recommendations. This work i s plannedto be completed inthe current calendar year and will be initiated ina separate amendment to the financing agreement after ajoint donor review. 33. The proposed restructuring o f the DRC Project will benefit the country by: (i) reformulating the PDO and KPI to the realities in the country; (ii) separating the PNMLS and 10 coordination and implementation functions to strengthen institutional arrangements. Rationalization will also allow addition o f new activities including: (i) training on HIV related activities; (ii)conducting IEC activities on the effects o f HIV/AIDS; (iii) supporting the formal and informal education to promote behavioral changes; and (iv) promoting the use o f condoms. 34. Government Request. The government of DRC requests amendments to the financing agreement to: (i) modify the current PDO to realign it to the national strategy; (ii) K P I s to revise make them more realistic in view of the past experience and to include patient treatment with ARV. It is expected that the proposed amendments will significantly improve the efficiency and efficacy o fthe Project's support to DRC nationalHIV/AIDS program. 35. Recommended Amendments. The amendments for which Board approval is sought include: (i) Schedule 2: Objectives o f the Project; (ii) Schedule 6: Update indicators and their targets. Ghana Multi-Sector HIVIAIDS Proiect (M-SHAP) - (CrC41250GI.I) - SDR 13.9 million {USD equivalent 20 millionl: The project was approved as an IDA credit by the Board on November 15, 2005 and became effective on March 15,2006. The project's closing date i s June 30,201 1. 36. Current Project Development Objectives: The objectives of the repeater Project are to support the Government o f Ghana's program to: (i) reduce the new infection rate among vulnerable groups and the general population; (ii) mitigate the impact o f the epidemic on the health and socio-economic systems as well as infected and affected persons; and (iii) promote healthy life-styles, especially inthe area o f sexual and reproductivehealth. 37. ProposedProject Development Objectives: To increase access to HIV care, prevention and impact mitigation services for high risk groups, vulnerable populations and the general population. 38. Status. As ofMay 17, 2007, the Project has disbursedthe equivalent of USD 3.7 million. TheDO is rated Satisfactory and IP Moderately Satisfactory. 39. M-SHAPis one of the first MAP repeater projects and it finances the Ghana HIV/AIDS Program as a sector wide approach. The Project focuses on harmonizing the various on-going and future programs while strengthening Ghana AIDS Commission's capacity to efficiently monitor and coordinate resources and activities in support o f the National Strategic Framework I1(NSF-11). M-SHAPprogramdevelopment goals arethose oftheNSF 11. 40. It is noted that the current project (repeater MAP project) became effective before the results o f the first project were reviewed by the ICR and the recent PPAR conducted by IEG so that many but not all o f the lessons learned from the first project were addressed in M-SHARP design. Continuation o f a follow-up project right after the closing o f the first project was done at Government's request to avoid financial and programmatic gaps in the implementation of the national HIV/AIDS strategy. Further implementation improvements will be made as part o f supervision. 41. As the lessons learned from the review of the first project became available, Government requested that the PDO o f the repeater project be revised to remove reference to reducing new infections, which i s beyond the scope o f the project (but remains the longer-tern goal o f the 11 NSF-11).M-SHAPwill also improve targeting of vulnerable groups and prioritize its support to geographical areas where the need isjustified. 42. The key lessons learned from the first project include: (i) use o f HIV prevalence data the should not be a measure o f success o f a Bank funded HIV/AIDS project; (ii) the decision to design the project without a M o H component was not appropriate; (iii)mainstreaming HIV/ADS in the formal education sector was effective for comprehensive targeting of at-risk youth who reported reduction in number o f partners and increased use o f condoms; (iv) contracting an international auditor to assess the use o f funds by civil society organizations contributed to a balance between implementation facilitation and fiduciary responsibility; (v) decentralization o f the HIV/AIDS response i s successful as demonstrated by the strong ownership by provinces and districts; (vi) development partner collaboration and co-financing was successful and shouldbepromotedand expanded; (vii) an effective M&E system i s essential for optimal effectiveness o f the MAP "learning by doing" strategy; (viii) there i s a need to strengthen the focus on strategic management o f the epidemic and tailor the multisectoral approach to Ghana's contained and relatively stable epidemic; (ix) the private sector as an engine o f growth should be more systematically included in implementation; and (x) the financing o f salaries through donor funds should be considered with caution where it concerns the financing o f institutions that need continued and sustainable financing beyond the scope o f projects; (ref GARFUNDICR and IEGevaluation). 43. The Project is in an early stage o f implementation. So far, it has managed to bring all sectors and stakeholders together to determine priorities o f the national response and to put them together in an annual Program o f Work (POW). Efforts have begun to strengthen the Ghana A D S Commission (GAC) to enhance management o f the national response and coordinate resources. The M&Eteam i s working closely with GAMET to assess the progress and to prepare an improvement plan based on the recommendations o f the IEG review o f the ICR and PPAR. All development partners are working together on an M&E operational manual which will also help strengthenthe system. 44. One major bottleneck has been that the Ghana AIDS Commission (GAC) has not prepared the Sustainability Action Plandue by end 2006 andtherefore the non-salary aspects are not being implemented from January 2007. However the Government since January 1, 2006 has taken over some o f the GAC operational costs but not those at the regional and district levels. The GAC informed development partners that the Government will be considering the GAC sustainability issueswithin the broader context o f the public sector reforms currently on-going in the country. It is not yet known when the public sector reforms will be completed. The Government has been notified o f their non-compliance with a dated covenant and the need for the action plan has been raised as a matter o f urgency. In response, GAC management has prepared a draft which has been sent to the Ministryo f Finance and Economic Planning. 45. GovernmentRequest. Government o f Ghana requests to amendthe Financial Agreement to change the project development objective to: "Increase access to HIV care, prevention and impact mitigation services for high risk groups, vulnerable populations and the general population". This will align the project to the goals o f the National Strategic Framework I1as it has become clear that t h s Project alone cannot achieve the national objective which i s only contributing to the implementation o f the National Strategic Framework 11. The project team recognizes the need to fully align the current list o f KPIs with the HIV results scorecard (Annex- 12 2). The project team will address the alignment o f project indicators in the next supervision missionto ensuregovernment andpartner buy-inand agreement on the Scorecard indicators 46. Recommended Amendments. The amendments for which Board approval i s sought include: (i) Schedule 2: Objectives o f the Project; and (ii) Schedule 5: Key Performance Indicators. Republicof Guinea: MultisectoralAIDS SIL (FY03) -(Cr: 30140-GUI)-SDR 15.4 million {USD equivalent 20.3 million): The project was approved as an IDA grant by the Board on December 13, 2002 and became effective on March 28, 2003. The project's closing date is July 31,2008. 47. Current Project Development Objectives. The objective o f the Project is to limit and reverse the trend o f the epidemic by preventing new infections. This would be achieved by supporting Government's multisectoral efforts to limit and contain the spread o f the HIV/AIDS epidemic through: (i) implementation o f the Recipient's HIV/AIDS National Plan to increase access to prevention services as well as care and support for those infected and affected by HIV/AIDS; and (ii)promotion o f civil society and community initiatives for HIV/AIDS prevention. 48. Proposed Project Development Objectives. Increase in HIV/AIDS knowledge and promote low risk behaviors; and improvement in the coverage and in the use o f HIV/AIDS prevention, care, treatment and support services. 49. Status. As ofMay 17, 2007, the Projecthaddisbursed the equivalent ofUSD 17.9 million. The DOis Moderately Satisfactory and IP i s Satisfactory. 50. According to the 2005 DHS, the project's performance indicators show a positive trend towards improving sexual behavior among the `at risk' groups inGuineawith the results that: (i) 87% o f sex workers used a condom intheir last sexual encounter; (ii) numbers o f truck stops the that offer an HIV prevention program to drivers reached 93%. Service coverage also improved with 100% of line ministries and the two main labor unions having their HIV/AIDS work plans implementedthereby attaining the target for the end o f the project. Also, 100% o f condom sale points did not report condom shortages during the three years o f implementation. On service quality, the project continues to finance the blood safety in Guinea and 100% o f blood units in the hospitals are regularly and adequately screened. All national and regional hospitals have facilities to dispose o f hospital waste and use them regularly. However, only one private service delivery point received yearly quality logo (whereas initially it was expected to have five per year). 51. The recent QSA7 by QAG recognizes that the project has been learning by doing and undertaking corrective measures to achieve its goals. The project supervision was rated highly satisfactory. Nevertheless, the original PDO that commits the country to reverse the HIV incidence with the Project's support i s an overestimation o f the country's capacity to achieve. Therefore, based on the experience and lessons learned from the implementation o f project activities in the last 3 years, acknowledging that measuring HIV incidence i s currently beyond the country's capacity, and because it i s not possible to determine if the Project interventions would be solely responsible for having an impact on the incidence, the Government has requested the Bank to change the PDO to make it more realistic and achievable. 13 52. Inaddition, during Project implementation it was realized that there was a greater need to invest in capacity building than was envisaged during Project preparation in 2002. Weak capacity is also recognized as the major bottleneck in government and its partners' capacity to deliver the objectives o fthe nationalHIV/AIDS strategy. 53. Concerning the revision o f the national strategy on HIV/AIDS, discussions are ongoing between CNLS, UNAIDS and ASAP (AIDS Strategy and Action Plan), and an action plan i s beingproposedto all stakeholders for adoption. 54. Government Request. The government has requested: (i) change the current PDO to to "Increase in HIV/AIDS knowledge and promote low risk behaviors" and "Improvement in the coverage and in the use of HIV/AIDS prevention, care, treatment and support services"; (ii) to drop the KPIs that are not realistic to measure, and (iii) to adopt the new Bank procurement guidelines o f May 2004 (revised October 2006) and remove procurement thresholds o f the aggregate amount for some procurement methods (within the new guidelines) to avoid implementationdelays. 55. Recommended Amendments. The amendments for which Board approval is sought include: (i) Schedule 2: Objectives o f the Project; (ii)Schedule 3: Procurement; and (iii) Schedule 6: KeyPerformance Indicators. Guinea-Bissau:HIV/AIDS GlobalMitigationSupport Proiect-(Cr. H110-GUB) -SDR 4.7 million(USD equivalent 7.0 million): The project was approved as an IDA grant bythe Board on June 2, 2004 and became effective on January 17, 2005. The project's closing date i s December 31,2007. 56. Current Project Development Objectives. The objective o f the Project is to assist the government o f Guinea-Bissau in: (i)reducing the spread o f HIV/AIDS infection in the population; (ii) increasing the access to STI/HIV/AIDS treatment; (iii) mitigating the health and socio-economic impact o fHIV/AIDS at the individual, household, and community level; and (iv) buildingstrong andsustainable nationalcapacity to respondto the HIV/AIDS epidemic. 57. ProposedProjectDevelopmentObjectives.To assist the recipient inincreased access to HIVprevention, care, treatment andmitigation services. 58. Status. As of May 17, 2007, the Project had disbursed the equivalent o f USD 4.7 million. The latest draft ISR following the Mid-Term Review rates the DO as Moderately Satisfactory and the IP as ModeratelyUnsatisfactory. 59. Since the grant supporting the Project became effective inJanuary 2005, some progress has been made by the country. Prevention activities have gradually expanded and now include all key ministries and there is an increased access to condoms to all sexually active age groups. A national communications strategy was launched with the help o f rural radios and Non- Governmental Organizations (NGOs) to focus on reducingthe spread o f HIV/AIDS infection; its effectiveness i s presently being assessed. Access to treatment for sexually transmitted diseases and HIV/AIDS has been expanded and it is planned to continue to do so in the five priority regions as part o f a multi-donor collaborative effort (250 persons receiving anti-viral treatment, expanded support for preventiono fmother to c l l dtransmission). Finally, NGOshave continued to provide education, health and nutrition support to those affected by HIV/AIDS. A scheme to 14 increase access to micro-credit for this group i s presently under preparation incollaboration with the UnitedNations Development Program. 60. The project has a number of specific challenges which will have significant negative impact on the outcomes of the Project ifnot addressed through this restructuring: (i) overall M&E and specifically, data collection and reporting, remains the critical bottleneck in the national M&E system. This will require the revision and realignment o f key performance indicators and their targets to the reality and the capacity o f the country to collect and report progress; (ii)the current PDOneeds to be revisedto acknowledge that the country does not have the capacity and adequate resources to reduce the spread o f HlV infection (as defined in the current PDO) especially within the project timeframe; (iii) increased support to Ministry o f Health i s needed to develop and roll out the ART strategy to strengthen the integrated health network. Support to development o f health sector infrastructure to improve access to treatment was planned to be included in the National Health Sector Development Project - this did not materialize. Since improving access to ART i s not a possibility without support from the current Project, reallocations are needed in some expenditure categories; (iv) the roles o f the National AIDS Council and its Secretariat need to be strengthened for better integration of the Bank financed and the Global Fund financed interventions. This will support the country in meeting the principles o f the Three Ones; (v) social marketing o f condoms has been stopped by PSI and given the limited capacity in-country for sustainable social marketing, the emphasis will be shifted to distribution through pubic sector agencies as well as one or two national NGOs; and (vi) skills building to support income generation activities for PLWHA and commercial sex workers needs to be targeted and prioritized to reflect limited resources and capacity. In addition, it would be difficult to attain the current DO within the project implementation period given the precarious state o f national infrastructure and the level o f international support. Therefore the project needs to be extendedby 12months. 61. The proposed restructuring also takes into account the nature o f the epidemic in Guinea- Bissau. Based on limiteddata, the epidemic i s primarily concentrated among those 25 years and older, and in particular in the age group 45 years and older. N o overall prevalence data are available and Guinea-Bissau has only formally reported on sub-groups such as the military or from donors to the nationalbloodbank. Early sexual activity (10% by age 1l), multiple partners coupled with lack of knowledge o f methods o f transmission and low condom use require that prevention activities are focused in particular on the younger age groups, while a mixture o f prevention, care and mitigation activities will be focused on older groups. Inaddition stigma to HNpositivepeople is very strong, which is why the project has provided support to strengthen the National Association o fPeople Livingwith HIV/AIDSand anti-discrimination legislation. 62. The proposed restructuring will refine the DO and key performance indicators in line with the existing capacity and resources, target resources to the vulnerable groups, strengthen institutional and coordination mechanisms with other donors, strengthen nationalmonitoring and evaluation capacity, and integrate the ART strategy o f Ministry o f Health and provide support to improve infrastructure. 63. Government Request. The government o f Guinea-Bissau requested amendments in the financing agreement to: (i) the current PDO to increase access to HNprevention, care, modify treatment and mitigation services; (ii)revise KPIs and incorporate them in the financial agreement (current financial agreement does not contain indicators); and (iii) revise project desigddescriptionto reflect the changes proposed above. 15 64. Recommended Amendments, The amendments for which Board approval is sought include: (i)Schedule 1: Withdrawal o f proceeds o f the Credit; (ii)Schedule 2: project Description; (iii)Schedule 4: Program implementation; (iv) Schedule 6: Objectives of the Project and KeyPerformance Indicators; and (v) extension o fthe closing date by 12months. MauritaniaHIV/AIDS MultiSectoralControlProiect (Cr. IDA-H0570) - SDR 15.3 million [USD equivalent21 million). The project was approved as anIDA grant bythe Boardon July 7, 2003 andbecame effective on January 12,2004. The project's closing date is March 31,2009. 65. Current ProjectDevelopmentObjectives. The development objective ofthe Project is to maintain the level o f human immunodeficiency virus (HIV) infection that causes the acquired immunodeficiency syndrome (AIDS) below the prevalence rate o f 1% and reduce opportunistic infections. 66. ProposedProject Development Objectives. To increase the coverage and utilization of HIV prevention services, of medical treatment and social care, especially for high risk and vulnerable populations. 67. Status.As o f May 17, 2007, the Projecthas disbursed the equivalent of USD 13.6 million. BothDO and IP are Satisfactory. 68. The HIV prevalence rate in Mauritania is still low (below 1%) in the general population, but the current data (UNAIDS 2006) indicates that the epidemic i s evolving. With project activities aiming at building structures and capacities for prevention and treatment o f HIV infections, the project contributes, together with other interventions, to an improvement o f the situation. For example, agreements have been signed with eight line ministries for activities that focused on sensitization and distribution o f contraceptives. The Ministry o f Defense has introduced systematic testing o f all new recruits. Also, with regards to the health sector response, the project has financed eight sentinel sites covering the majority o f the country. An ambulatory treatment center was created thanks to a partnership among the Government, IDA, the French cooperation and French Red Cross. Furthermore, a center for Prevention of Mother to Child Transmission (PMTCT) was opened based on collaboration among the Government, IDA, UNICEF, and AWARE. The project has also financed the establishment o f three voluntary counseling and testing (VCT) centers as well as for distribution o f contraceptives. The Civil Society response has been important, and a private sector Coalition o f Mauritanian Enterprises for HIVIAIDS control has been set up with the support o f the project. Progress has beenmade to improve the M&E capacity with the identification o f the need to institute a bio-behavioral surveillance survey for HIV, the development o f the TOR for the study and the initiation o f the studywhich isnow inprogress (withGAMET support). 69. The project was designed during a period when the Bank was the principal financier resulting in a rather detailed project design which left little room for adaptation to the current situation inthe country. The data collection and reporting situation were also very poor at the time and did not permit targeting. Therefore, without changing the core activities o f the project, the Government proposed a simplified project design better targeting high-risk and vulnerable groups, while at the same time continuing efforts at targeting the general population. The four project components are maintained while the sub-components are reduced from 16 to 9. The eliminated sub-components do not merit being stand-alone sub-components, but will be eligible 16 for financing through other parts o f the project. A sub-component not considered a priority for the project at this point i s the financing o f HIV/AIDS activities included in other projects, either Bank or other donor financed. Also, the PDO is recognized as unrealistic due to inclusion o f HIV prevalence for several specific target groups. The KPIs are not realistic and need to be adapted to the changed PDO. To support implementation o f the simplifiedproject, a reallocation of funds is needed to drop the activities that are not longer appropriate to achieve the project outcomes. 70. GovernmentRequest. The government of Mauritania requests to: (i) the PDO tomodify increase the coverage and utilization o f HIV prevention services, medical treatment and social care, especially for high risk and vulnerable populations; (ii) review the project for 100% financing by the Bank within the current Country Financing Parameters set by the Bank; (iii) revise project description to simplify its design; and (iv) change current institutional arrangements for better functioning o f decentralized structures and timely execution o f regional activities includingdecentralization o fProject finance management. 71. Recommended Amendments. The amendments for which Board approval i s sought include: (i)Schedule 1: Withdrawal o f Proceeds o f the Credit; (ii)Schedule 2: Project Development Objective; (iii)Schedule 2: Project Description; (iv) Schedule 4: Program Implementation; and (v) Schedule 6: KeyPerformance Indicators. Niger Multisectoral STI/HIV/AIDS Proiect (Cr. IDA-H031O) - SDR 18.2 million (USD equivalent 25 million): The project was approved as an IDA grant by the Board on April 4, 2004 andbecame effective on October 10, 2004. The project's closing date is June 30,2008. 72. Current Project Development Objectives. The development objectives o f both the National HIV Program and the Project are to: (a) slow the spread o f HIV/AIDS in the general population; (b) mitigate the negative impact o f HIVIAIDS on individuals and communities; and (c) strengthen the country's capacity to formulate, manage, implement, monitor, and evaluate a viable cost-effective HIV/AIDS Program. 73. Proposed Project Development Objectives. The objective o f the Project is to assist the Recipient to implement its STI/HIV/AIDS Strategic National Framework, in order to slow the spread, and mitigate the impact, o f the STI/HIV/AIDS epidemic, through a multisectoral approach by: (i) the extension to youth, women of childbearing age and other vulnerable groups nationwide o f access to STI/HIV/AIDS prevention, care, mitigation services and treatment; and (ii) strengtheningofthecapacity ofpublic, privateandcommunityinstitutionsto design, the carry out and monitor Work Programs and Subprojects. 74. Status. As of May 17, 2007, the Project haddisbursedthe equivalent o fUSD 14.0 million. BothDO and IP are Moderately Satisfactory. 75. The project supports capacity-building activities necessary for the public sector and civil society to be able to effectively and efficiently implement HIV/AIDS prevention, care, and support activities in the country. Progress toward the objective is on track despite implementation delays. The project finances the work plans o f 23 line Ministries aiming at sensitizing the personnel within their ministries and within the different entities directly linked with their ministries. The health system work plan has been based on care and treatment, and also plays a pivotal role in preventive activities. Despite some difficulties in the treatment o f 17 persons living with AIDS, the project has supported: (i) creation o f 9 voluntary counseling the testing centers out o fthe 8 envisaged (with the support o f the Global Funds); (ii)the settingup o f a mother-to-child transmission program; (iii) the treatment o f 684 patients living with AIDS under an antiviral free-distributionprogram; and (iv) the settingup of blood testing centers in42 health districts inregional andnational hospitals, and inkey maternity centers. The treatment of patients i s provided free of cost countrywide. Altogether, 265 non-governmental organizations (NGOs) have been financed around the country to develop prevention and health care promotion campaigns. Real impact on the behavior change within the communities cannot be seen yet, however, which is partly due to the very limited period inwhich the support to NGOs and their scope o f activities was carried out and, inaddition to weaknesses inimplementationcapacity. 76. While the eligible civil society activities are critical to the national response, they only capture a subset o f what constitutes an effective national response to control and prevent HIV/AIDS. At the same time, some key areas o f the national response remain under-funded. Therefore, the proposed restructuring focus on facilitating the use o f project grant resources to bridge current and future financing gaps in the civil society initiatives. Achieving this goal would require two sets o f actions. First, it i s important to expand the eligibility o f expenditures under the original Project design to match the scope o f activities included in the annual implementation plan o f the National Strategic Framework. Second, simplified administrative project procedures need to be introduced. Strengthening the coordination of the national responsewould also become a centralcomponent o fthe restructured Project. 77. The Government's action plan for 2007-2010 faces two main challenges: first, the acknowledgment that a sound and reliable national monitoring and evaluation system i s paramount to measuring outcomes; and second, the importance o f an efficient coordination mechanism especially for the utilization o f external resources. In addition, with the increased financial support from other sources such as the Global Fund, the CISLS's absorptive capacity to manage these funds has presented difficulties. Proposed changes will support government to enhanceits capacity for a better coordinated response to HIV. 78. Niger's government established a multisectoral coordinationunit as part o f the institutional framework for the management o f the HN/AIDS program including the IDA project. However, there was some tension from the start, which i s continuing today, regarding the respective roles and responsibilities o f the different lead agencies (the CISLS - Coordination Intersectorielle de Eutte contre le SIDA which leads the implementation o f the program, the PresidentialHIV/AIDS Adviser, the Ministry o f Health and the NGO's acting as implementation agencies). One o f the principal reasons for the low program implementation performance was the lack o f communications and clear assignment o f responsibilities within the project implementation unit. The MTR requested an organizational audit of the PMU, which has not been completed at this time. To resolve this lack o f action, the project implementationunit (CISLS) will be assessed by an independent consultant within 3 months o f restructuring to identify the remainingbottlenecks and challenges affecting implementation and reach agreement on pro-active strategies to get the project back on track and more importantly, obtain rapidresults on the ground. 79. Government Request.The Government requested amendments to the financing agreement to: (i)modify the PDO to realign it to the national strategy; (ii) incorporatenecessary changes in the implementation arrangement for implementationefficiency; (iii) the project financing review for 100% financing by the Bank (under the current CFP); (iv) adopt a simplified disbursement schedule; (v) adopt May 2004 (revised October 2006) procurement rules to benefit from 18 abolishing aggregate thresholds for all procurement methods and the mandatory use of a annual procurement plan would support the planning and coordination across implementing agencies; and(vi) extend the project closingdatebyone year to implement the proposed amendments. 80. Recommended Amendments. The amendments for which Board approval is sought include: (i) Schedule 1: Withdrawal o f proceeds o f the Grant; (ii) Schedule 2: Description of the Project; (iii)Schedule 3:Procurement; (iv) Schedule 4: Implementationprogram; (v) Objectives o f the Project and Key Performance Indicators; and (vi) extension o f project closing date by 12 months. Senegal HIV/AIDS Prevention and Control Proiect (Cr: IDA-36010) - SDR 21.5 million (USD equivalent 30 million): The project was approved as an IDA credit by the Board on February 7, 2002 and became effective on January 31, 2003, The project's closing date is September 30,2007. 81. Current Project Development Objectives. The overall development objective of the project is to assist the Government in: (i) preventing the spread o f HIV/AIDS by reducing transmission among high risk groups; (ii) expanding access to treatment, care and support for people living with HIV/AIDS (PLWHA) in Senegal to serve as a pilot for the implementation o f Anti- Retroviral Treatment (ART) in Sub-Saharan Africa; and (iii)supporting civil society and community initiatives for HIV/AIDS preventionandcare. 82. Proposed Project Development Objectives. To contribute to the Government's efforts in controlling the HIV/AIDS epidemic by expanding HIV/AIDS prevention interventions among vulnerable groups (youth, women) and highrisk groups (commercial sex workers, TB patients, MSM, truck drivers); expanding access to treatment, care and support for people living with HIV/AIDS (PLWHA) in Senegal; and supporting civil society and communities initiatives for HIV/AIDS prevention and care. 83. Status. As o f May 17, 2007, the Project has disbursed the equivalent o f USD 21.9 million. DO is Moderately Satisfactory and IP is ModeratelyUnsatisfactory. 84. Senegal has significantly scaled up its HIV interventions towards universal access and i s on target to meet the MDG on HIV/AIDS as a result of institutional growth, decentralization and capacity building efforts undertaken. The project financed the key public sector interventions (health, youth, armed forces, women, and labor) and more than 600 civil society and private sector proposals, which allowed to set up intervention sites in all the 11regions. This led to an unprecedented increase in the utilization o f HIV-AIDS voluntary counseling and testing, which has risen ten-fold (from 9,900 people in December 2002 to 94,130 people in December 2006). Likewise, utilization o f care and support services by people living with HIV/AIDS has been expanded and the number o f AIDS patients receiving antiretroviral treatment has increased from 870 in December 2002 to 5,158 in December 2006. Moreover targeted efforts were led by the health sector and civil society towards services for commercial sex workers that reports great progress in condom utilization with client. Senegal i s also implementing a unique intervention that targets men having sex with men through a cohort o f 750 people who receive comprehensive medical and psychosocial care as well as behavior change communication messages. This noticeable progress in selected key performance indicators i s greatly enhanced by the very encouraging results obtained from the 2006 behavioral surveillance survey that provided preliminary data on high risk groups such as MSM, commercial sex workers, truck drivers and 19 fishermen. Almost all groups report increased knowledge and greater adoption o f safer behavior practices towards STIs and HIV/AIDS. The vulnerability and risk mapping implemented during the project midterm reviewhas allowed the identification o fpriority areas and groups that will be targeted by the newly approved sector plans, integrated regional plans, as well as civil society and private sector proposals. Data is available for tracking and reporting on KPIs. The government will further align =Is o f the project and the HlV Results Score Card, within the context o f the national M&E system. This will include a review o f existing data collection strategy /methods and institutional arrangements for data collection, to ensure availability of data for reportingon the score cardandother requiredproject indicators. 85. Nevertheless, HIV prevalence among pregnant women i s reported to have increased from 1.45 to 1.7% (Epidemiological bulletins No. 9 for 2002 and No. 12 in2006, respectively). Also, during the Project implementation, and considering the changing dynamics of the disease, it is clear that the Bank cannot claim attribution o f reduction in HIV transmission through a short term project, as this requires long term and sustained behavior change. Recognizing this challenge, and considering that the current PDO could only be measured through incidence data which cannot be collected on a wide scale in Senegal because o f the cost implications, it is imperative to revise the PDO to make it more realistic inthe context ofthe country. 86.Beside the key advancements in reaching out and scaling up the national response to HIV/AIDS, in the past 6 months the implementation o f the national program has deteriorated sharply. The latest ISRunderscores major implementation challenges: (i) slow disbursementdue to cumbersome procedures to finance relevant subprojects for bothpublic sector and civil society and insufficient capacity to manage the procurement plan, especially in the area o f civil works and purchasing o f antiretroviral and other HIV-related commodities; (ii) an excessive focus on capacity building and sensitization, instead o f focus on behavioral change and targeted prevention among highrisk groups and vulnerable children; (iii) delays in finalizing the impact analysis o f the first round o f proposals before second generation subprojects are financed by the NAS; (iv) overloaded and understaffed NAS to manage funds from the Bank and the Global Fund, resulting in poor coordination; and (v) contract/procurement mismanagement, including issues related to misprocurement regarding4 subprojects (of the 2,073) receivedby the NAS. 87. With guidance from the Bank team, the NAS cancelled several contracts that were not properly awarded, took strong action against staff suspected o f collusion, including firing some o f them. Besides restructuring the Project to realign PDO and K P I s to national strategy and capacity o f the country, the region is putting together a Technical Support Team to conduct a detailed review o f the implementation and programmatic challenges identified in the latest ISR and recommend options to improve implementation. This review will be carried out within the current FY. The Project will also support operations research studies to understand better interventions for higher risk groups such as Menhaving Sex with Men (MSM), Commercial Sex Workers and Intravenous Drug Users, taking advantage o f ongoing BCC and care sub-projects that target them. 88. Government Request. The government o f Senegal requests amendments in the financing agreement to: (i) change the project development objective to contribute to the Government efforts in controlling the HIV/AIDS epidemic by: PDO1: expanding HIV/AIDS prevention interventions among vulnerable groups (youth, women) and high risk groups (commercial sex workers, TB patients, MSM, truck drivers); PD02: expanding access to treatment, care and support for people living with HN/AIDS (PLWHA) in Senegal; and PD03: supporting civil 20 society and communities initiatives for HIV/AIDS prevention and care; (ii) adopt new Bank to procurement guidelines (approved May 2004 and revised October 2006); and (iii) remove K P I s that claim to reduce prevalence or that report on the data that cannot be currently collected. 89. Recommended Amendments. The amendments for which Board approval is sought include: (i)Schedule 2: Objectives o f the Project; (ii) Schedule 3: Procurement; (iii) Schedule 5: Key Performance Indicators; and (iv) extension o fproject closing date by 12months. Tanzania Multisectoral HIV/AIDS Proiect (Cr: IDA H0590) - S D R 51.5 million W S D equivalent 70 million): The project was approved as an IDA grant by the Board on July 7,2003 andbecame effective onOctober 15,2003. The project's closing date is September 30,2008. 90. Current Project Development Objectives. The objective o f the Project i s to support Tanzania's (Tanzania Mainland and Zanzibar) multisectoral efforts to attack the HN epidemic by scaling up and accelerating its national response to the HIV/AIDS epidemic as outlined inits National Multisectoral Strategic Framework on H N / A I D S through: (i) mainstreaming of HN/AIDS activities into the work programs o f all line ministries and local government authorities, and supporting community based and private sector initiatives; (ii) the prevention and mitigation ofthe adversehealth and socio-economic impacts o fHIV/AIDS at the individual, household and community levels; and (iii) strengthening of the country's national capacity to respond to the epidemic. 91. Proposed Project Development Objectives. The objectives are to: (i)increase HIV preventive knowledge and behavior; (ii)increase coverage and utilization of preventive, treatment and support services; and (iii) a multisectoral response by enabling sectors to support coordinate, implement, monitor and evaluate aspects of the HIVresponse. 92. Status. As of May 17, 2007, the Project had disbursed the equivalent o f USD 38.5 million. BothDO and IP are Satisfactory. 93. Extensive data onprevalence o f HIV is available inTanzania. Two population-based HIV surveys were undertaken inthe last three years that provide excellent HIV prevalence estimates. The prevalence i s 7.0% (male 6.3 and female 7.7%). There are about 2 millionpeople livingwith HIV/AIDS inTanzania with close to 2 million orphans. A study undertakenin2005 inZanzibar indicated that the prevalence amongst needle-sharing injecting drug users was 30%, signaling that Zanzibar may have a concentrated epidemic and pointing to the need for more surveillance works amongst most riskpopulations inZanzibar. 94. Service delivery achievements to which the project contributed considerably until FY06, include the following: (i)all regional and district hospitals are providing comprehensive sexually-transmitted infections (treatment) services and anti-viral therapy (over 100,000 AIDS patients have been enrolled); (ii) for condoms has substantially increased but stock-outs demand inthe public sector continue to be a challenge; (iii) has been a rapid uptake of voluntary there counseling and testing services; (iv) there are 334 Prevention o f Mother-to-Child Transmission centers in the country and some o f these centers serve as an entry point for Eull antiretroviral services for the entire family, thus protecting the family unit and reducing the tragedy o f a generation of orphans; (v) there are a number o f programs run by non-governmental organizations, supported by the project, that aim to protect youth; and (vi) all line ministries and 21 local government authorities are mainstreaming HN/AIDS activities into their Medium-Term ExpenditureFramework andreceivingfunds from the project. 95. Nevertheless, challenges remain. The PDO as defined in the DGA and the PDO as definedinthe PAD are different from each other. There are also indicator inconsistencies: First, the Key Performance Indicators (KPIs) inthe Project Appraisal Document (PAD), the indicators inthe DevelopmentGrant Agreement (DGA) and the indicatorsinImplementationStatus Report (ISR) are inconsistent with each other; second, there are some indicators that are inthe ISR,but not in the PAD or DGA; third, there are indicators that are in the DGA, that are not KPIs or in the ISR. The project indicators need to be restructuredto be better aligned with the PDOs and to reflect the national HIVM&Esystem and HIV Scorecard indicators. . 96. Since the start o f the project, GAMET has assisted both Tanzania AIDS Commission for AIDS (TACAIDS) and Zanzibar AIDS Commission (ZAC) to develop national HIV M&ERoad Maps for both TACAIDS and ZAC. The two road maps define, on an activity by activity basis, what i s required from the M&E system to measure the performance o f TMAP grants. Specifically, the additional activities that need to be funded for Mainland Tanzania and Zanzibar are: (i) capacity building efforts in M&E; (ii) systems strengthening activities at district M&E level; (iii)surveys; (iv) increased data dissemination and data use; (v) surveillance o f most at risk populations; (vi) supervision and data auditing at the decentralized levels; and (vii) scaling up o f HIV/AIDS interventionsinthe healthsector. 97. To accommodate changes in the PDO, KPI and the new activities, and considering implementation challenges faced during the past years, the government o f Tanzania has also requested to increase the threshold o f the Special Account from the equivalent o f USD 5 million to USDlO million. Reallocationo fthe funds amongthe expenditure categories will be required. 98. Government Request. The Government o f Tanzania requests to: (i) the project change development objective to: PDO 1: Increased HIV preventive knowledge and behavior; PD02 : Increased coverage and utilization o f preventive, treatment and support services; and PD03: Support a multisectoral response by enabling sectors to coordinate, implement, monitor and evaluate aspects o f the HIV response; (ii) revise all K P I s within the Generic Results Framework and to make them consistent in the PAD, Financing Agreement and in the ISR; (iii) add a new activity for capacity building insurveyingto improve monitoring o f the new national HIV/AIDS framework; (iv) reallocate funds among the components and expenditure categories to accommodate the changes in PDO/KPI and the new range o f activities for the national HIV M&E Road Maps; and (v) increase the Special Account ceiling from USD5 million to USDlO million. 99. Recommended Amendments. The amendments for which Board approval is sought include: (i) Schedule 1: Withdrawal o f the proceeds o f the grant; (ii) Schedule 2: Objectives o f the Project; (iii)Schedule 4: Program Implementation and description o f the project; (iv) Schedule 7:KeyPerformance Indicators; and(v) extensiono f project closing date by 12months. VI ANALYSIS 100. The proposed changes do not adversely affect the original economic, financial, techmcal, institutional, or social aspects o f the project as appraised. The proposed restructuring will 22 significantly improve the effectiveness o f the projects by buildingon new knowledge gained in this rapidly evolving multisectoral and challenging field, as well as lessons learned from implementation experience, and reviews by QAG and IEG. This is consistent with the principle o f learningby doing of the MAPapproach. 101. Table 2 (Section IV) shows the changes inthe projects by country. The proposed changes do not raise the environmentalcategory o fthe project or trigger new safeguard policies. 102. The proposed restructuringdoes not involve any exceptions to Bank policies. VI1 EXPECTEDOUTCOMES 103. As indicated in Table 2, all 8 projects require change in their Project Development Objectives and 4 o fthemrequire changes intheir keyperformance indicatorsandtargets. This is based on better understanding o f the epidemic in the countries and the radically changed implementationenvironment as well as changes inglobal AIDS financing architecture. 104. The Global Monitoring and Evaluation Team (GAMET) o f HDNGA i s the lead team (designated by UNAIDS co-sponsors') to provide policy, strategic guidance and technical assistance to all countries in national M&E development, implementation. GAMET will continue to provide technical assistance and guidance to the restructured projects with contributions from MAPprojects. 105. It is expected that the proposed restructuring will: (a) significantly improve project focus on more realistic and deliverable objectives, based on the lessons learned inthe country as well as from other Ahcan country programs; (b) improve institutional arrangements with clearly definedroles and responsibilities that will support better coordination o f the national HIV/AIDS program in partnership with other donors; (c) improve hnd utilization in terms o f reallocation among activities and interventionsthat have greater effectiveness inresponding to the HIV/AIDS challenges. Reallocation among expenditure categories are not only consistent with the cost saving policy o f the Bank (OPBP 13.25) but there will be better use o f available fimds for priority areas that have greater impact on containing the epidemic; and (d) enhance the MAP project contribution to prioritized nationalHIV/AIDS strategies and action plans. VI11 BENEFITSAND RISKS 106. The major benefit o f the proposed restructuringwill be to the beneficiaries o f the national HIV/AIDSprogram supported by IDA financing. The proposed restructuring will make project objectives and performance indicators more realistic and realignedwith the nationalpriorities by considering the new knowledge and lessons learned from implementation. Through the restructuring, it is expected that project outcomes will be achieved through better understanding of the epidemic, with improved service delivery options, and better management o f the available project resources. Better project performance will enable countries to achieve longer-term goals * UNHCR, UNICEF, WFP, UNDP,UNFPA,UNODC, ILO, UNESCO, WHO, andWorld Bank 23 andresults set out intheir national HIV/AIDS strategic plans, and would benefit those who are infected and affected by the epidemic through the provision o f prevention, care/treatment and mitigationintervention. 107. National monitoring and evaluation systems exist in all countries but much needs to be done inharmonizing national indicators, regular and reliable reporting, to help national decision makers be more evidence-based in taking action. The HIV/AIDS Scorecard will reduce the burden on countries in HIV/AIDS reporting, and will be o f benefit to both client countries and the external community. 108. The proposed restructuring i s expected to make national H N authorities more efficient in coordinatingnationalresponses, throughthe public andprivate sectors, as well as civil society. It will also allow national HIV/AIDS authorities to focus on its leadership and coordinating role, andbecome more strategic inguidingthe national response. 109. A key risk i s the time required to realize the benefits from the effects o f the proposed restructuring. This risk i s mitigated by the planned intensive and increased support from HDNGA, ACTafrica and AFTHD. ACTafrica will increase its technical support to country teams in the areas o f policy and strategic dialogue for prioritized and costed national strategies and annual plans, assessments and evaluations, and provide direct technical assistance in the technical areas identified by project teams and continue to support learning and knowledge sharing from the improvedmonitoring and evaluation. 24 ANNEXES 25 ANNEX 1-ISSUESPAPER ImprovingPerformanceofthe Multi-CountryAIDS Program(MAP) inAfrica 1.Introduction 1. As o f 2006, HIV/AIDS still remains an unprecedented crisis for Afnca. Nearly 25 million Africans are living with HIV/AIDS, the vast majority o f them adults in the prime o f their working and parenting lives. In 2005, more than 2 million people died (about 5,000 per day). The epidemic has erased many o f the development gains o f the past generation and now threatens to undermine the next. About twelve million African children have been orphaned. Life expectancy has decreased in many countries, and in the worst-affected countries dramatically (for example, in Zimbabwe life expectancy for women at birth has dropped to 34 years). AIDS i s costing sub-SaharanAfrican countries with highHNprevalence rates by some estimates, 1% o f economic growth each year, while imposing a mounting burdenon households, firms, and the public sector and slowing down efforts to reduce poverty. In 2006, more people became infected with HIV and more died from AIDS than in any previous year. Despite increased international efforts to expand access to treatment and lower prices of ARVs, millions o f Africans with AIDS are not being treated. Unless far more aggressive action i s taken across the Continent to scale up, improve implementation and sustain current programs, HIV/AIDS will continue its rapid advance and progressively stall other development efforts for many years to come (Source: UNAIDS December 2006). 2. To respond to this development crisis in 1999, the World Bank adopted a strategy to help combat the growing HIV/AIDSepidemic inAfrica. The strategy focused on increasing advocacy to increase demand for action against AIDS, expand resources for AIDS programs, strengthen the Bank's capacity and expand knowledge using the principle o f learning by doing. In December 2000, the Bank's Board approved a Multi-Country AIDS Program (MAP),whose goal was to dramatically increase access to prevention, care, treatment and prepare countries to deal with the burden o f HIV/AIDS. The Board authorized a USDSOO million credit from the InternationalDevelopment Association (IDA)-12 and in2002 the Board subsequently authorized another USDSOO million from IDA-13 that allowed for grant resources for AIDS programs in IDA eligible countries. ACTafrica was also established in 2000 to support and coordinate the Bank's multisectoral response. 3. At the time, the Bank recognized that mitigating the epidemic was a long-term challenge, and committed itself to a 12-15 year program o f support, in three phases. Phase 1(MAP 1 and MAP 2) involved an emergency response in almost every eligible Sub-Saharan country (supporting 29 countries and four regional programs) with IDA credits and grants totaling about USD1.32 billion. The guiding principle o f the first phase was learningby doing and focused on advocacy and institutional building. Phase 2 would involve applying lessons learned and mainstreamingo f interventions that provedmost effective, continued expansion o f coverage, and addressing implementation issues. Phase 3 would begin as the number o f new infections declined and wouldhave a sharp focus onprevention. 26 4. The World Bank portfolio on HIV/AIDS in Sub-Saharan Africa is relatively young and includes significant IDA commitments (USD1.25 billion) available to support the explicit objective to place HIV/AIDS at the center o f the development agenda and mainstream it in all aspects o f the work in Africa and in all channels o f dialogue. The goal was to help clients intensify and expand their multisectoral national responses to factor HIV/AIDS into policies and projects. HIV/AIDS was established as a corporate priority and aprimary partnership issue. 5. Since 2000, the Bank's Multi-Country AIDS Program for Africa (MAP) has been the mainstay o f emergency responsesto the needs o f IDA countries facing the HIV/AIDS challenge. MAP projects were approved in almost every IDA country in Sub-Saharan Africa with credits totaling USD1.25 billion in 29 countries and four sub-regional programs, and about 70% o f the resources have been disbursed to date. The M A P approach has been to support national AIDS strategies, a national coordinating entity and a consolidated monitoring and evaluation system, withresources anchored ina demand-driven approach to prevention, care, support andtreatment, accessible byboth the public sector and civil society. 2. ChangingEnvironment 6. Since the M A P was initiated in 2000, major changes have taken place in the overall environment for addressing the AIDS epidemic in Africa. Major new global funding has been committed by the Global Fundfor AIDS, Tuberculosis andMalaria (GFATM), the U S PEPFAR initiative, private foundations, and the private sector. Domestic resources from governments for AIDS programs have also increased. The G8 and countries committed to universal access to AIDS services in2005 and an international financing facility to procure AIDS, TB and Malaria drugs (UNITAID) has recently been established. There i s intense focus to scale up treatment with growing concerns on strengthening health service delivery in both the public and private sectors as well as ensuringsustainable financing - a life long commitment to millions already on treatment. Information on the epidemiology of the disease and behaviors i s growing and methodologies are improving but data on coverage and impact o f the interventions i s still inadequate. Donor coordinationremains a major challenge. UNAIDS has promulgated the Three Ones concept, to improve donor collaboration but much more needs to be done to achieve harmonization. Lessons o f experience on effective interventions are emerging from the M A P program and others. The changing environment and lessons o f experience have implications for MAPandfor the World Bank's future response. To better reflect these issues, the Africaregion is updating its 1999 HIV/AIDSstrategy and developing an Africa AIDS Agenda for Action for 2007-2011 which will align itself to the Africa Action Plan (AAP), the Global HIV/AIDS Program of Action, the Africa Health, Nutrition and Population (HNP) Strategy and the global HNP strategy underpreparation. 3. ImplementationChallenges 7. In2004, ACTafnca initiated an Interim Review of MAP to review the validity of the M A P approach, highlight progress made, the suitability o f interventions and to identify lessons learned. The review concluded that the MAP objectives were still appropriate, highlighted implementation challenges and recommended that the MAP needed to become more strategic, collaborative, and evidence-based. In 2005, OED (aka IEG) conducted a separate independent 27 assessment o f the Bank's global HIV assistance to examine the assumptions, design and implementation o f 24 country level AIDS projects. The OED report recommended a focus on capacity building, developing strong national and sub-national institutions, investing strategically inpublic goods andactivitieslikelyto havethe largest impact, creatingincentives for monitoring and evaluation, and using local evidence to improve performance. From these assessments, the Committee onDevelopment Effectiveness (CODE) has recognizedthe achievements made inthe HIV (MAP)programs andapproved key recommendations for further improvementinall future HIV operations. CODE reaffirmedthe Bank's role, together with other development partners, in responding to the complex and pressing issue o f HIV/AIDS, the need for bold, innovative, and flexible responses, and also reconfirmed the need for a multisectoral approach to this development challenge. 8. Table A2 provides a brief overview o fthe key recommendations from the MAP Interim Review report (October 2004), OEDIIEG Reportg, and CODE" response and actions taken by the Africa region. TableA2 Overviewofthe KeyRecommendations - Recornmendations Measures undertakenby the Africa repion (i)poverty Integrate HIV/AIDS indevelopment planning, IBRDandWBIincollaboration withUNDPhave held reductionstrategies, budget allocation two regional workshops to buildcapacity o f country strategies and mainstream inthe country assistance officials to integrate HIV/AIDS inPRSPs, MTEFS. strategies ACTafiica will also continue to ensure that HIV/AIDS i s sufficientlv incomorated inthe CAS. (ii)Support the development o fprioritized, nationally The Bank and other partners ( U N A I D S and UNDP) owned strategies with a nuanced understanding o f have rolled out the AIDS Strategy and Action Planning the country epidemic, identificationof cultural and (ASAP'') program to provide direct technical support to social factors contributing to the spread, and assist countries on a demand-driven basis inreviewing and governments to be selective and prioritize activities producing evidence-based, prioritized, and costed that achieve the greatest impact. strategies and annual programs. (iii)Adopttargetedapproachinallnextgeneration Adopted as a criteria for all second generation projects. projects inlow prevalence countries. Bank and UNAIDS collaborated on a regional conference o ntargeting vulnerable groups. ACTafrica is also assessingthe effectiveness of goodpractices targeting vulnerable groups. (iv) Improve governance and accountability measures The regioncontinues to buildcapacity on improved withinprojects to mitigate misuse o fproject funds fiduciary management and has developed a Guidance and ensure that funds are utilized for the intended Note on Disbursement inHIVIAIDS Projects to assist in beneficiaries. determining the appropriate fiduciary steps for various levels. ACTafrica is initiating a study o n governance and anticorruption practices at the community level by engaging grassroots level women groups inseveral countries and will develop guidelines for civil society organizations and local government authorities in addressing governance and corruption. 9 ''Committing to Results:Improvingthe Effectiveness of HIV/AIDSAssistance -An OED Evaluationof the World Bank's Assistance for HIV/AIDSControl," July 2005. lo Committee on Development Effectiveness (CODE), Chairman's Summary, Appendix Mto OED/IEG Report 'I UNAIDShasraisedUS$5milliontofinancetheseactivities,whichincludeworkshops anddirectassistancefromtheBankandUNDP. 28 Recommendations Measures undertaken by the Africa region (v) Ensurethe development o fa common, functioning 3AMET12has significantly increasedtheir efforts to M&Esystem at country levelworking with other help countries buildboth their clinical and non-clinical partners, develop clear criteria and outcome indicators and data collection mechanisms, and all indicators for improved data collection, and repeater MAPSinclude more attention and financing for improve the evidence-base for decision-makers scaling up M&Eactivities inpartnership with UNAIDS through local capacity building and rigorous andother donors. OngoingMAPoperations are also ' analytic work. providing increased financing for M&Eimplementation. GAMET and ACTuJFicu developed a generic inOctober 2006. (vi) Improve donor coordination andharmonization A Global Task Team (GTT) comprisingkeyUN efforts to avoid duplication of efforts with the agencies and development partners agreed on a division multitudeofactors. o f labor for all agencies that countries can use in identifying technical support needs. Several countries have adoptedjoint annual reviews to encourage more harmonization o f activities. (vii) Encourageperformance-based disbursements. O n going discussions with TTLs on methods for integrating tlus into HIV projects without hindering access to services. (viii) Continue to fully support the community response, Civil Society organizations are more actively involved which is an important stakeholder group, by than before inHIV activities. The Africa region plans to engaging them inthe design o f interventions and carry out a situation analysis o f CS engagement. improved procedures for financing but also evaluate ACTafrica hosted a consultation with civil society the effectiveness o f the community response. representatives f i o m all MAPcountries to brainstorm the roles, responsibilities and partnerships o f CSO in responding to HIV. These recommendations are being incorporated inthe revision o f the Bank strategy for HIV/AIDS inAfrica (2007-2011). (ix) Prioritizedmulti-sectoral approachto respondto the MAPScontinue to use the multisectoralapproach and complexity o f HIV as a broad development address HIV/AIDS as a broad development issue. challenge and focus on sectors that have the ACTafrica will ensure that this continues to be reflected greatest potential impact such as health, education, inthe CASs. Secondgeneration MAPSwill focus on transport, military and others depending o n the sectors with the greatest potential within each country country context setting. (x) Clarify the role ofthe Ministryo f Healthto ensure MOHi s engaged inall MAPprojects as evident from that they are a principal partner inthe national the MOHbeingthe second largest beneficiary o f MAP response and buildMOH capacity while continuing financing after the civil society component. All next to work with other sectors. generation MAPprojects will clarify the role and c-^ responsibilities o f MOH as well as address issues relatedto strengthening health systems that canbe integrated into HIV projects. (xi) Ensure consistency withBank commitments to The Bank i s fully engaged with the GTT and will other global initiatives and partners and improve continue its close partnership with UNAIDS. The Bank donor collaboration. has also taken the lead incollaborating with the Global Fund,PEPFAR, and other development partners and held a meeting inJanuary 2006 to improve coordination. Global AIDS MonitoringandEvaluationTeam(GAMET), hostedby the Bank onbehalfof the Bank and UNAIDS. 29 9. Financial and Procurement Challenges. MAP projects faced various fiduciary challenges, these included: (i)use o f old Bank procurement guidelines that limited aggregate amounts for the procurement of goods and services; (ii) prior review thresholds; (iii) savings in some low cost expenditure categories due to the availability o f additional financing from other donors such as GFATM and underutilization o f funds; (iv) need for targeting project funds to prioritized interventions and beneficiaries; (v) increased need to invest in capacity development o f public sector and civil society organizations to deliver results; (vi) use of old Country Financing Parameters; (vii) decentralization o f the nation HIV/AIDS responses (fiduciary responsibilities) to regionddistricts; (viii) need to adjust cost estimates due to government decision to increase provision of free treatment; (ix) promotion of cash transfers to communities that are involved in the development of HIV/AIDSprograms inrelation with actions undertaken under the ongoing Community Driven DevelopmentProject; and (x) slow disbursements due to cumbersome procedures to finance community subprojects from both public sector and civil society, especially at the community level and insufficient capacity to manage the procurement plan; 4. Key Recommendations from IEGreviews of ICRs Ethiopia The potential benefits of fast-track project preparation, even in a situation o f extreme crisis, are likely to be outweighed by the costs o f neglecting careful and rigorous preparation activities. More intensive staffing and supervision, with focus on content as well as process, are required for success in a rapidly prepared, `learning-by-doing' project. Monitoring and evaluation activities must assume high priority if a project i s to achieve demonstrable impact, especially inthe context of a "learning by doing approach." Inthe absence o f effective M&E, it i s unclear how inputs are translating into outputs and outcomes, and interventions cannot be adjusted to maximize effectiveness and impact over time. Care must be exercised inthe establishment o f a coordinating institution for the response to HIV/AIDS. The existence o f such an institution does not guarantee a multisectoral response, nor does it guarantee a coordinated, prioritized, mainstreamed response. Eritrea "Learning-by-doing" cannot be accomplished ina haphazard manner, but instead requires careful and specific planning and supervision. Simply creating a dedicated M&E component does not create an incentive to do it. For a project in which pre-existing infrastructure and human resources are lacking, a very specific design and implementationplan for M&E i s even more critical than usual. While the concept o f integration across disease areas i s sound, the successful implementation o f that concept depends on strong central management o f component activities, careful monitoring, and effective incentives for integration. Otherwise, resources will be wasted on unnecessary duplication o f activity, and data collection and programmatic activity will remaintrapped intraditional "silos." 30 Behavior change communication and IEC, even when successkl in changing knowledge and attitudes, does not necessarily lead to behavior change. Careful evaluation of BCC activities, includingthe collection o f comprehensive baseline data, i s essential. Community ownership i s important, but it cannot be permitted to drive the direction o f programactivities. Inthis case, the preference o f community facilitators for interventions against malaria crowded out the project's multi-disease, multi-sectoral approach. On the other hand, carefully crafted community interventions can use a population's concern for one disease (malaria in this case) as an entree to programs targeted at other areas (HIV/AIDS). Ghana The MAP "learning by doing strategy" cannot be realizedinthe absence of well-designed monitoring and evaluationactivities andthe incentives to implement them. There i s an urgent need to strengthen the focus on strategic management o f the epidemic andtailor the multisectoral approachto Ghana's concentrated epidemic. HIV prevalence, an indicator of the scope of the epidemic, should not be considered a measure o f success o fprevention efforts. Design o f an HIV/AIDS project without M o H involvement and mandate can undermine bothprocess and results. The financing o f salaries through donor funds should be considered with cautionwhere it concerns the financing o f institutions that need continued and sustainable financing beyond the scope o f projects. 5. Portfolio Performance 2001-2006 9. From FYOl to FY05, at-riskI3HIV projects within the HNP sector board increased from 25% to about 52%. Significant increases were caused by issues with M&E, slow disbursements, procurement performance, and project management. These areas were the HIV portfolio's key challenges in the initial years o f MAP. The regional management, task teams, I HlVlAlDS portfolio, FY97-07" AFTQf, ACTafrica and GAMET undertook several key steps to address the implementation challenges. ACTafrica ACtNe Ropcts and HDNGA intensified their support II Ropcts through technical assistance, additional atllsk TA financing, andregionalworkshops and technical consultations. These efforts q4G q4@ +4@ p' k4@ *4Q' ,4Q* resulted in a significant decline in overall peQ .* at-risk projects from 52% in FY05 to 16% by FY07. Note that exogenous flags (Country Environment and Country Record flags) have significantly affected the HIV portfolio. If these flags are not considered in the HIV portfolio, the portfolio performance jumps to above 88% satisfactory level. '3 "At-risk ratings provide a betterpicture of the current state of theportfolio than IP/DO rating taken in isolation, because they are more comprehensive andprovide an early warning ofpotential failures and their causes", QAG ARPP FY06 31 --~-2007 --- 1 32 Net ComrnAmt 0 % A t Risk 6 % Potential 0 21 11 12 23 12 6 % Eff Dly 0 7 0 6 - 6 % Safeguards 0 0 210 _-15 0 6 18 13 I % M&E 25 14 0 12 26 15 9 % Lglcov 0 0 0 13 3 3 %Slow Disb 0- - 0 5 '50 3 0 0 % Proc Prob 25 14 0 19 13 3 3 % Mgt Prob 25.0 7.1 0.0 11.5 16.1 12.1 9.4 % Ctry Env 25 43 42 38 35 33 34 % Ctry Record 75 57 58 58 48 " 48 50 % Long-Term 0 7 5 4 3 6 6 % Gldn Flag 0 0 0 0 0 6 6 % Fin Mgmt 0.0 0.0 0.0 3.8 9.7 9.1 3.1 % Cntrpt Fndg 0.0 0.0 0.0 3.8 19.4 9.1 9.4 Ongoing efforts to improve portfolio performance 0 Umbrella restructuring of all HIVprojectsfor improved performance: InApril 2006, the region reviewed all active HIV projects in collaboration with AFTHD, LEGAF, and HDNGA to identify projects that needed restructuring to incorporate recommendations. A technical consultation with all TTLs was heldinNairobi on the challenges o f including HIV prevalence in project development objectives and key performance indicators, institutional challenges in meeting objectives, and an initial draft generic results framework was shared. InAugust 2006, the region established a core team to review and lead the work on restructuring (retrofitting) projects for improved performance. Led by ACTafiica and AFTHD, the core team includes, LEGAF, LOA, HDNGA (GAMET) and AFTRL. The core group developed and sent to all task teams a Restructuring Questionnaire (prepared within the framework o f new guidelines o f restructuring projects). AFTHD and ACTafiica engaged SECBO and OPCIL in clarifying the process for umbrella restructuring considering that this would be a unique exercise that involves one theme (HIV) engaging several countries. 0 Developing a Generic Results Framework (GRF): In October 2006, the region and HDNGA (GAMET) finalized a Generic Results Framework (GRF) for all HIV projects that addressed: (a) Tier 1 and 2 indicators, for country and Bank needs respectively; (b) IDA14 and UNGASS indicators; (c) indicators for the Afiica Action Plan. The development o f the GRF was based on three key principles: (a) there i s a mechanism available in all countries to report on the indicators; (b) indicators are agreed upon with all development partners; and (c) indicators canprovide aggregate results for Afr-ica. Additional supervision support: AFTQK established an Escrow account in 2005 to support problem projects and all HIV projects are encouraged to utilize this fund to address challenges. Improving quality at entry: The region focused on improving quality at entry of all second generation HIV projects (and QERs) by adopting CODE recommendations as access criteria to the next generation HIV projects, including: (a) financial gap analysis 32 for the country; (b) addressing lessons learned from the first generation project; and (c) clarifying objectives and developing results framework. IntensiJied technical assistance: As an ongoing effort, ACTahca has intensified its technical assistanceto operations by supporting project supervision, portfolio monitoring, ISRreviews andextending bothfinancial andtechnical support to problemprojects. Governance and anticorruption: The region is establishing a task force on governance and anticorruption to develop an appropriate review methodology, selection criteria o f projects, implement the diagnostic reviews and develop recommendations in collaboration with INT. ACTafiica i s working closely with the Kenya team to use lessons of experience. ACTafrica i s also preparing a proposal to request an IDF grant and engage grassroots level community groups to assess governance and anticorruption practices from the communitypoint o fview, develop guidelines andrecommendations. 10. It is expected that the Africa region's ongoing efforts to improve portfolio performance including the umbrella restructuring initiative would comprehensively address the recommendations of the Interim Review (2004), IEG assessment (2005) and CODE recommendation (2005) andresult in: i. SignificantlyimprovingtheportfolioperformancebyrevisingPDOsandKPIs as recommended by the evaluations. This would also reduce the net disconnect .. difference o f IEGrating and final ISRs; 11. Improved results focus by adapting Generic Results Framework (retrofitting) enabling the region to report on globally agreed indicators for which reporting mechanisms exist at the country level. This would also enable the region to report on aggregate progress in the region (as for IDA requirements). The second major advantage would be that the donor support to M&E would be more effective - considering that all would be supporting already agreed indicators and the reporting mechanism. This would result in more impact evaluations by retrofitting impact assessments in ongoing operations and in new projects under preparation (supported byAFTRL andHDNVP ChiefEconomist); iii. Improvedharmonizationandresourceutilizationatthecountrylevel;and iv. Integrated governance and anticorruption actions and guidance for all projects. Other Challenges that need to be urgently addressed i. Strengtheningof HealthSystems. AlthoughMAPShavestrengthenedhealthsystems in various countries to build capacity of MOH, addressed human resources issues, strengthened laboratory infrastructure, strengthened fiduciary, procurement and program management, improved supply chains, strengthened drug distribution systems, the results have been mixedand much more needs to be done to strengthen the healthcomponents of the MAP andHealth SWAPS. ii. More Explicit Integration between HIUAIDS and TB, Reproductive Health, and Nutrition services Better integration o f HIV activities with TB (due to the growing co-infection and emerging XDR TB). A WHO secondeei s beingrecruitedto assist inthis area. 33 0 Reproductivehealth, integrationwith HIV services would improve prevention and greatly improve the coverage and access o f PMTCT care and support, as well as helping to reduce stigma for women who would not be labeled as HIV-infected when attendingANC services. 0 Nutrition i s a critical aspect o f successful HIV treatment and care and support. Where possible, nutrition support should be included particularly for people on ART to ensure the efficacy of the treatment and limit the development of drug resistance. iii. SpeciJicattention to Youth, Women and Gender issues 0 Gender inequalities fuel the spread o f HIV/AIDS. 57% o f women are infected in Africa and the majority are young women aged 15-24. Interventions to address gender inequality should be included inMAP projects. Reversalo f HIV infections inAfrica cannot occur without the engagement of males inthe HIV response so scaling up male-involved activities and interventions would also be critical. The 2006 World Development Report emphasizes the importance of addressing high risk behaviors o f youth and identifies HIV/AIDS as a major risk to the formation o f human capital in Africa. MAPSshould be highly responsive to addressing high-risk youth and scaling up the education sector programs for in- school and out-of-school youth. Other RegionalIssues i. Supportingpublicgoodandsustainingtheresponsetocrossborderissues: Several regional projects that address cross border issues have been supported through IDA 13 grants. Many will be ending soon so how do we continue to support regional public goods? .. 11. Middle income countries: Middle income countries in southern Africa are now the epicenter o f the epidemic and can potentially dilute efforts in neighboring IDA countries because o f labor mobility etc. Our response has been mainly through IDFs and trust funds. We are exploring a buy down arrangement for Botswana. How do we further scale up our support inthese countries? 34 ANNEX 2 -THEHIV/AIDSRESULTS SCORECARD Africa Action Plan and IDA Reporting 1. The HIV/AIDS Results Scorecard. The Region has analyzed all HIV/AIDS projects and developed a toolkit to support the countries in preparing their project specific Results Framework. This toolkit, a Generic Results Framework (GRF),has been discussed and shared with the countries, other development partners, and project Task Teams. The GRF i s based on: (i) indicatorsselected&omgloballyagreedHIVindicatorsonprevention,care,treatmentand the mitigation required by UNGASS, MDG, IDA; (ii) several countries have the capacity to report on the indicators; and (iii) the OECD's Paris Declarationon harmonizationandminimizing data requirements. The GRF proposes indicators for both groups o f countries where the epidemic has reached the general population and for the countries where it i s still within the concentrated populations. All GRF indicators are not mandatory. The GRF i s a tool for task teams to use as a basis when developing or updatingproject's specific results framework 2. A small set of mandatory indicators have, however, been extracted from the GRF to measure the overall progress with the HIV response to which the World Bank contributed inthe Afhca region. The Scorecard will therefore be used to measure progress under the Afnca Action Plan as well as on IDA financing. The Scorecard contains both indicators for measuring long term results at the regional level, and indicators for measuring results to which specific Bank-fundedHIV assistance projects have contributed. Two types data sources will be used to determine the values o f the two types o f scorecard indicators on an annual basis: (i) regional level data will be extracted from internationalreports and verified data sources with the support o f GAMET and UNAIDS; (ii) project level data will need to be reported by all HIV projects usingtheproject ISRs; andbyACTahca through its annual MAPquestionnaire. 3. Adopting the scorecard inall ongoing and future HIV operations will reduce the burden on the countries and the task teams interms o f reporting progress. It will also enable the region to report on the aggregate achievements under IDA financing. The indicators, when fully adopted in all ongoing and future HIV operations, would be a major step towards achieving harmonization and alignment on M&E at the country, regional and global levels. These indicators are selected from globally agreed UNGASS, MDG and IDA indicators and are based on reporting capacities o f the countries, availability o f baseline data and agreement o f our key partners such as UNAIDS and withm the OECD's Paris declaration on harmonization and minimizing data requirements. 4. The indicators inthe Scorecard have been harmonized, where possible, with the indicator sets of other major partners in HIV/AIDS (US government's PEPFAR indicators and the Global Fund'slist o f"Top Ten" indicators). 5. Neither the GRF indicators nor the Scorecard indicators are based on attribution, but rather on contribution. The scorecard and GRF therefore does not suggest that a separate World Bank HIV M&E system is requiredfor a project; on the contrary, it suggests that indicator data from the national HIV M&E framework be reportedto the World Bank on a regular basis. 6. Table A.l presents the HIV Scorecard for the Afhca Region. Indicators 4 to 13 in the Scorecard i s mandatory for all for all ongoing, pipeline and future HIV operations inthe region to report on through the ISRs. 35 7. Key benefits of the Scorecard includes: (a) Compliance with the Paris Declaration (to reduce burden o n the countries); (b) Harmonization with UNAIDS (UNGASS) and other key financers (such as Global Fund and PEPFAR in reporting on HIV/AIDS; (c) Supporting Regional IDA financing and the A h c a Action Plan; and (d) Using existing country capacities in data collectionandreporting. 8. The Scorecard data will be collected through the following arrangements (per Africa Action Plan's 6 standard reporting sections: I A H o w data will be collected? -Demographics B-Development challenge indicators UNAIDS and WHO global reports C -Intermediate results indicators UNAIDS and WHO global reports D-Output indicators Annual ACTafrica M A P questionnaire and ISRS E-Financingindicators Client Connection, donor websites and their focal points 9. The responsibility to report the Scorecard will be on: (a) All country project teams; (b) GAMET will provide technical assistanceto the Project teams; (c) GAMET and ACTafvica will gather data from the sources identified above, as well as from UNAIDS and update the A h c a Action Planprogress reporting system; (d) TTLs needto assure that the Scorecard i s agreed upon with their counterpart, with support from ACTahca and GAMET. GAMET will provide technical support to country project teams and to TTLs in getting agreement with counterparts, and ACTafrica will provide support inintegratingthe Scorecard into the Bank system. 36 Table A1- The HIV/AIDS Results Scorecard Note:The Africa regionHIV scorecard uses the newUNGASS wordinginline withthe new 2008 UNGASS rmidelines (released Ami1 2007). combination thera 1 I 10. Male and female condoms distributed I World Bank INumber ISR(bornWunuyM~Esystrm) smW FBO) Amount ISR (Gornmuntly M&Esystem) 12. Public sector organizations supported World Bank Number ISR (born muntlyM&Esystem) I I xmounr I IbK (earnwunuyM&Eswan) I I 15a. Country commitmentsfor HIVAIDS, USDmillion Notes: A: All of the indicatorsinthe scorecard are based on the latest internationalthinkinginterms o f indicator wording. As there are currently efforts underway to harmonize indicators, the indicators in the scorecard may be slightly revised in2008, when the harmonizationprocess will be complete. B: Detailedindicatordefinitions will bereleased once the global indicatorregistryhasbeendeveloped C: Projects are only required to report on indicators 9 to 13. 37 r- o! d Y- N 2m z x m 2 2 8 N N N d. c? aJ 8 8 8 8 8 8 0 0 8 8N 2m 8 I- - m m 8 m 5m a, .-mC8c $ C Lc 0 Lc 0 tm0 I EcE c C I c a, c c E E EE EE a, 5 : (3 89 c3 89 m m m m m 7 .r I- co s2 0 0 0 c! 0 0 c 7 3e 7 Q, 7 co I- co Y- 0 0 0 2 s2 O 0 0 0 c 7 c! 0 m 7 3$ 0 55 0 0 0 d 0 co 0 N 0 0 0 0 d N 0 N 0 N 0 N 0 N 2 0 7 I- O a .-m C F2 m 2 hl n! r hl 2 r n! r r 2w 2w .-9 -3 c .-9 m - I m 5 5 3 0 0 _. 0 d T