Document of The World Bank Report No: ICR00000424 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-HOI40) ONA GRANT IN THE AMOUNT OF SDR 15.4 MILLION (US$20.3 MILLION EQUIVALENT) TO THE REPUBLIC OF GUINEA FORA MULTISECTORAL AIDS PROJECT (MAP) JUNE 28, 2011 Human Development Sector Health, Nutrition and Population (AFTHE) Country Department 1 AFCF2 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective) Currency Unit = Guinean Franc (GNF) March 2002: US$1.00 = GNF 1978 _ July 2007: US$1.00 = GNP 3445.0 ABBREVIATIONS AND ACRONYMS AGBEF Association Guineenne pour Ie Bien-Etre Familial (Guinean Association for Family Well-Being) AGFfFM Agence de gestion financiere I Financial Management Agency AIDS Acquired Immuno-Deficiency Syndrome ANC Ante Natal Consultation ARV(T) Anti Retroviral Therapy ASAP AIDS Strategy and Action Plan Technical Advisory Group BCC Behavioral change communication CAS Country Assistance Strategy CBO Community-Based Organization CCM Country Coordinating Mechanism CDLS District/Local Committee to Fight HIVIAIDS CECOJ Center for Adolescent Counseling CMLS Ministerial Committee to Fight HIVIAIDS CNLS National Committee to Fight HIVIAIDS CNS National HIVIAIDS Strategic Plan CNTS National Blood Transfusion Center CPLS Prefectoral Committee to Fight HIVIAIDS CRD Rural Development Community CRLS Regional Committee to Fight HIVIAIDS DGA Development Grant Agreement DHSIEDS Demographic and Health Survey(Enquete Demographique et de Sante) DSRP Poverty Reduction Strategy Paper EA Environmental Assessment EMP Environmental Management Plan ENSS Enquetes Nationales de Surveillance Sentinelle ESCOMB Enquete de Surveillance Comportementale et Biologique FM Financial Management FMRlRSF Financial Management Report I Rapport de suivi financier GAMET Global AIDS Monitoring and Evaluation Team GFATMlGF Global Fund to Fight AIDS, TB and Malaria GNF Guinean Franc GTZ (now GIZ) Gesellschaftfor Technische Zusammenarbeit (German Agency for Technical Cooperation) lllPC Heavily Indebted Poor Countries mv Human Immunodeficiency Virus ICRR Implementation Completion and Results Report IDA International Development Association lEC Information, Education, and Communication ffiG Independent Evaluation Group ISR Implementation Status Report KtW Kreditanstaltfor Wiederaujbau (Reconstruction Credit Institute) KPI Key Performance Indicators LICUS Low-Income Country Under Stress MAP .Multi-Sectoral IllY/AIDS Program MDGs Millennium Development Goals M&E Monitoring and Evaluation. MIS, Management Information System MOSHP Ministry ofHealth and Public Hygiene MSM Men who have sex with men MTR . Mid-Term Review NGO . Non-Governmental Organization NSF National Strategic Framework 01 Opportunistic Infection OM Project Operations Manual OVC(OEV) Orphans and Vulnerable Children PACV Projet d'Appui aux Communautes Villageoises PAD Project Appraisal Document PCN Project Concept Note PDO Project Development Objective PHRD Policy and' Human Resources Development Fund PLWHAlPVVIH People Living with IllY and AIDS PMTCT Prevention of mother to child transmission PMS Projet multisectoriel de lutte contre Ie SIDA PNPCSP Programme national de la prise en charge sanitaire et de la prevention PPF Project Preparation Facility PPSG Projet Population Sante Genesique PRCI Programme de Renforcement des Capacites Institutionnelles(lnstitutional Capacity Building Program) PRSP Poverty Reduction Strategy Paper PSI Population Services International PSW Professional sex workers QAG Quality Assurance ~oup QER Quality Enhancement Review QSA Quality of Supervision Assessment SA Service Adapte SDR Special Drawing Rights SE Executive Secretariat ofthe CNLS SIL Specific Investment Loan SOE Statement of Expenditure STD Sexually Transmitted Disease TA Technical Assistance TB Tuberculosis TTfITL Task Team!Task Team Leader UN United Nations UNAIDS Joint United Nations Program on mY/AIDS UNDP UN Development Program UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special UNICEF United Nations Children's Fund USAID United States Agency for International Development usn US Dollar VCT Voluntary Counseling and Testing WHO World Health Organization Vice President : Obiageli K. Ezekwesili Country Director : McDonald Benjamin (Acting) Sector Manager : Eva Jarawan Project Team Leader : Ibrahiin Magazi ICR Team Leader : Jean-Jacques deSt. Antoine GUINEA MULTI SECTORAL AIDS PROJECT Table of Contents A. Basic Information _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ ftKEYDares ____________________________________ C. Ratings Summary ______________________________- - - - - - - D. Sector and Theme Codes ________________________________--'U E. BankStaff _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ii F. Results Framework Analysis ______________________________ iii G. Ratings ofProject Performance in ISRs ___________....:.-_______________ x H Restructuring ____________________________________ x 1 Disbursement Profile _ _ _ _ _ _...,-_____________________~_ _ xi 1. Project Context, Development Objectives and Design _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 1.1 Context at Appraisal 1 1.2 Original Project Development Objectives (PDO) and KEY Indicators (as approved) 3 1.3 Revised PDO (as approved by original approving authority) and KEY Indicators, and reasonsljustification_3 1.4 Main Beneficiaries and Benefits _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3 1.5 Original Components 4 1.6 Revised Components 5 1.7 Other significant changes 5 2. Key Factors Affecting Implementation and Outcomes _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _,S 2.1 Project Preparation, Design and Quality at Entry 5 2.2 Implementation 8 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 9 2.4 Safeguard and Fiduciary Compliance 1I 2.5 Post-completion Operation/Next Phase 12 3. Assessment of Outcomes _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 13 3.1 Relevance of Objectives, Design and Implementation 13 3.2 Achievement ofProject Development Objectives 14 3.3 Efficiency 19 3.4 Justification of Overall Outcome Rating 20 3.5 Overarching Themes, Other Outcomes and Impacts 21 3.6 Summary ofFindings ofBeneficiary SurvEY and/or Stakeholder Workshops 22 4. Assessment of Risk to Development Outcome _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _22 S. Assessment of Bank and Borrower Performance _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 22 ~J Ban~Peryrormance __________________________________________________________22 5.2 BQrrower Peryrormance 24 6. Lessons Learned 25 7. Comments on Issues Raised by Borrower/Implementing AgencieslPartners 26 Annex 1: Project Costs and Financing 27 Annex2a: Descriptive summary of project outputs 28 Annex 2b: Summary Quantitative Results oftbe Project 31 Annex 3: Economic and Financial Analysis 35 Annex 4: Bank Lending and Implementation Support/Supervision Processes 37 Annex 5: Beneficiary Survey Results 39 Annex 6: Stakebolder Worksbop Report and Results 39 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR 40 Annex 8: Comments of Co-fmancing partners and Otber PartnerslStakebolders 42 Annex 9: List of Supporting Documents 43 MAP of Guinea 15.4 Million 15.4 Million B Executive Secretariat 1National AIDS Committee and Other External Partners: NIA 06/21102 09/05/07 12/13/02 02/01106 05/29/06 07/31108 12/31108 !Implementing AgencylAgencies: Moderately Bank Performance: lOverall Borrower Performance: Potential Problem Problem Project at any time (YesINo): DO rating before ClosinglInactive status: i 40% 0% 25% 3% 15% 35% 10% 40% 10% 0% administration sector 20% 100% 0% 25% 25% 24% 13% nriva1:e sector 13% Sector P ..n·ip.~t Team Leader: ICR Team Leader: de St. Antoine ICR Author: ii F. Results Framework Analysis Project Development Objectives 1 The objective of the Project is to support the Recipient's multi-sectoral efforts to limit and contain the spread of the mY/AIDS epidemic through: (1) implementation of the Recipient's mY/AIDS National Plan to increase access to .prevention services as well. as care and support for those infected and affected by mY/AIDS; and (2) promotion of civil society and community initiatives for mY/AIDS prevention. Revised Project Development Objectives (as approved by original approving authority) The objective of the project is to: (i) increase mY/AIDS knowledge and promote low risk behaviors; and (ii) improve the coverage and use of mv/AIDS prevention, care, treatment and support services. (a) PDO Indicator(s) Value (Quantitative or Qualitative) target was achieved for 4 of the 5 five priority populations. (2003): At least 50% of people who are aware of AIDS have used a condom with a partner than their in the last 12 months. Value (Quantitative or : 27.0% f1y.uI,II;;~; 37.2% lQualitative) !.t"elna1~:s:· 17.6% ! ""IUAI""~. 25;8% 1999: EDSG-II: Tabs 12.16- ! EDSG-ill, Tab 15.16) Comments (incl. % target was partIally achieved by the time of the Demographic and Health Survey (DHS) :achievement) 005; no DHS has been c~nducted since.~.Q05. .. ilndicator 3 : A (2003): The mv prevalence rate among urban pregnant women between ages 15 to 24 ____ ~ears old is below 5% by 20~~_.___.____.__.___ .------.-.. --.--.1 Value (Quantitative or 14.4% . :<5% : 004: 4.2% (Conakry) I Qualitative) K2001: ESSIDAGUI) 008: 5.7% (Conakry) I _____. _.___~. _ . _ _._._._ _ _ _ _.________.__.____.____ 004 (ENSS~ Tab_.Y.L._____...J 1 The POOs are taken from the Development Grant Agreement (DGA). The Project Appraisal Document (PAD) presents the PDOs as follows: The project's development objective is to limit and reverse the trend of the epidemic by preventing new infections. The Umbrella restructuring presents the original PD~ by combining the wording in the DGA and the PAD; see. Par. 47. iii , , : 1200s (ENSS, Tab VI) I Date achieved ....--_. _-," 12/3112001, ~_, "____. . . .:.___'_"'''_" __ _ _ _,_'''~3112004!l~31/200-S-.J !Comments (incl. % Though achieved in 2004, the situation had worsened by 200S and the target was not achieved. I !~£~!eve~~!!!L___ "",""""," "-----,-,----,"---"--------""-""'---"-""-'"---""-"---,--"-""-"'"--"'-"---'""""-"-""--'-''''-"'''"-'-1I IIndicator 4 : DGA (2007): At least 95% of sex workers used a condom in their latest sexual encounter. , , Value (Quantitative or 72% 19W!litative) Date achieved , _ 195.0% , 99.S% 2001: ~SSIDAGUI) ---,---------_.._ ....._--------" ::.:._----,---"-'""""-,--""""'"--,---;: 12/3112001 ... 2007: ESCOMB, Tab 17)" 12/31/2007 I i !Comments (incl. % The target was achieved. I , I iachievement) ! , - - - - - - - , - - ~_(200~LAt leas~,§O% ~ftruck driv~rs ~~~..:.~~0l!do~_~~g their latest sexual encounter. ""---I IIndicator 5 : Value (Quantitative or 3 2 % ' , ; . i60.0% 73.3% I Qualitative) ~_001: ~~S~AGUI)_,__,:_ _,_, ____~_,____ '(2007: ESCOMB, T!l!?}7) _-1 ~-"-'-'-"'--""----- Date achieved 12/3112001: 12/3112007: IComments (incl. % The target was achieved. lachieV:~,!llent) __" i ~;dic~tor6";----"-'~GA (2007):-At le&;i-7S% of minhtg ~ork~;:S-iisedacO~d~m d~ing their latest se~~-l-'-'-- ncounter. Value (Quantitative or 50% !75.0% 49.7% lQualitative) 2001: ESSIDAGUI) 2007: ESCOMB, Tab 17) Date achieved !Comments (incl. % 12/3112001 ---_._-,-,----'--..... I ogress was not made, and the target was not achieved. _-_ ....- .. _- 12/3112007 --I I ~~i~!~!!l~!!.Q____,_""'_ --"---------,--'''''--,--"'-,,-"'---"'-,,-,--,,-- . I ------""-,--1 lIndicator 7 : A (20()7): 40% of women and 55% of men age4 15-24 who have had sex with more than onel artner in the last 12 months ------------r--------"-- Value (Quantitative or ales: 35.0% iMales: 55% iQualitative) emales: 25.7% remales: 40% 2005: EDSG-ll, Tab. 15.15) ~ , Date-achieved ---"-' 12/3112005 --------~-------;-'----'-" ""----"--"""'---,-,--, Comments (incl. % e EDSG-N scheduled for 2009-10 but delayed until 2011 would have provided the data; at J ~~~!~!e~c;mt)__,,_"__ !Indicator 8 : r~~~~~~j;~~~~~~: ::;~~e~!~~e~~to!:eh~:e~~d m~~~ th~ ~~e ~;xual"-'--"1 __""__'" J ~er in t!Ie p~ 12_~~!!ths ~"'p'ort~,g the ,!~~~f a_~~~~~m d~in& tI!~ir 1a8!"..se~~!,~!erc~~~e. Value (Quantitative or ales (15-49): 32.1% !Males: 55% lQualitative) emales (15-49): 26.1% !Females: 40010 005 (EDSGll+, cited in ________-+_GASS 200S, Tab. 13) Date achieved _, _ _ _ _ _, _ _ 12/3112005 _ _ ___ _ _ _,_ _ _- ' - -_ _ ,_ _ _ L _ _ _ _ _ _ ,_ _ ,_ _ _ ". Comments (incl. % The EDSG-N scheduled for 2009-10 but delayed until 2011 would have provided the data; at ~~~ievem~!!L"__, ," ,_"res~!!!..!!"!s not p~~!~,!~, to me~ure_~e ach}~vement of the target. _____""_"___"'' _' "'_""'' ' '_' ' '__" " iIndicator 9 : GA (2007): 10% of persons aged 15 and older who received counseling and testing for mv and received their test results. ------+-:...-.-- --,----'--- Value (Quantitative or'1.5% )0.0% 10.6% I 9u~itati,,-~ DSGll+ 2005 007 (ESCO~, Tab 22) --1' Date achieved 12/3112005 12/3112007 >---"--,,- 1;::.---------"'------"'---'-----"--'----"--'-------" !Comments (incl. % lIne target was achieved. ~c!ievemen~L ____L '__- - 'J iv ·---··-·-·-·--···------..--T...:;:-.. .------·--·_--..---·---..-.__.-.. - . -.---._-'------.-.-----.._ . _. ---'' - ...-----.---.---.~ !Indicator 10 : JUGA (2007): 4,500 pregnant women living with IllY who received antiretrovirals to reduce the --_._--_. __ '. k f ----------_.._---_.._-------._.._.,-_._._--_. ._---- ris 0 MT T. Value (Quantitative or 410 C . ; ~500 ..- _._._.-------_.. ._-- 2207 __ __ Qualitative) l2004-05: Acces 2008, p. 20) . . (2004-05:Acces 2008, p. 20) . p. 38) , : -..---.-.. --.. -----.--.-- (2006:.Point 2009, --.-------r-------.---.-..-.-.--------. 2006-08 (point 2009, p. 38) . ---------.------.---- !Date achieved 12/3112006 . : 12/3112008 IComments (incl. % !The target was partially achieved. !achievement) !Indicator 11 : iDGA (2007): 500 adults and children with advanced IllY infection receiving antiretroviral [combination therapy. : Value (Quantitative or ,ISO ; :500 720 iQualitative) K2006: SElCNLS) _____ 1(2008: SE/CNLS) __. - -__M__+_N---_.-_--M. ~:----.--------.----.-.--- ----..--·------·----·-·U·--- ~-.- !Date achieved 12/3112006 i ': 12/3112008 . (Comments (incl. % !'The target was achieved. lachievement) I' (b) Intermediate Outcome Indicator(s) . · .· l ·fl·'.~;/:Ar+Mal 'fjl.~il~.·.A.,.c::....'L. at.·.;~ . ··.·{(}ijPal••(:.~.*. . . .~.:,. , . ~'.F .:.'i$i· on ·'· · ikI.'· · ·.;· ~· ·.~a·It.'.·.·.... . . ny . .'.'.". . •.fg '". . · .· . .•. .~~ . ·:.j..;;,;;;.ii-,-, .. W .•..•..·.·.,,; ..•....,... ... .. .... ................ ··:~'e;V..lt.;i).. . . ;.' ... , 'j .. . .oj:- . .' ; > , . ". ~a:t .. '/~;,: .Valbes. >t'· ;~h".~u~Pt~~~?:ot:~et ~~ . d .•..... n.m ts .......... .>-... ' . .... ,.. .'" ' " ~"""""-'-=:";'i...~~~~~ IIndicator 1 : GA (2003): Decrease by at least 20% the % of women arid men who do not know any means to prevent I !transmission of the IllY or who have erroneous knowled e of it from its 1999 level of 30010. ......j Value (Quantitative ales: 29.5% 10.0% !NO'1 lor Qualitative) emales: 29.8% ______-----.-1_ ',1 1999: EDSG-II: Tab 12.8.1-2) . iDat;achleV~ 1273iTt999 --- '-"'---1 Comments (incl. % e indicator was included in the 1999 DHS but not in the 2005 DHS; thus it is not possible to measure I ~£~ieveme!lt) ro ss in meeting the target. i lIn~.icator 2 : A (2003 and 2007): 100%oftruck stops offer an mY/AII'S prevention program to truck drivers. '1 Value (Quantitative % (0 of27) 1100% (27 of27) ",100% (27 of27) ;100% (27 of27) -'---1 ,or Qualitative) 2003: SElCNLS) . 2008: SElCNLS) : !Date achieved ·12/3112003 I . ;_12_/3_1_12_0_0_8_ _---,--_ _ _ _ _1 [Comments (incl. % e target was achieved for both the original grant and the restructured grant. I~chievement) !Indicator 3 : .- GA (2003): 85% of yoii""th ag~(fi5-24 ye~i-have-knowiedge-of sexually transmitted diseaSes (SIDs) --I d of ways to prevent IllY/AIDS ~ Value (Quantitative jKIlow STDs: 85% ! Male STDs: (M:63.9%; F: 40.6%)" I !Or QUalitative) IllY revention: 85% FOW !Female STDs (M: 36.0%; F:65.9%) I IlllV (M: 35.4%; F: 39.4%)' 'I :2007 (1ST: ESCOMB, Tab 25/26) . :2007 (VIH: ESCOMB, Tab 19) , !Date achieved _._._-----_. , - - 12/3112003 ----_.- ---- -..-l1213112007. __._-----,I ._. iComments (incl. % me targets for knowledge of STDsand of ways to prevent mv1 AIDS were not achieved. ~ !achievement) ---L . ii;di~~;~- IDGA (2003): 90% of all sa~intS didn't have lack of condoms in last month by 2004 and thereafter. IValue (QuantitativeF-----· I i2004: 92% (128/139) I '-'1 ~!Q~ali!ati~~) ___'____.___ I _. -L . :2005-06: 81%.(6191763) __.__.1 v ·-.---.----..~.-...---.....--....--.-.-r_-..----....--..-..--...-----.---...-.--.--,-.----.---.--..-----.-..-...----..-.-.-.----·-·--.,.......-·----..---·----·----..--....·--·;·-·-1 i . II i :2004 (SElCNLS); ; i . :2005-06 (population Services ! :. IIntemational - PSI) I ~!!.."-!ch.i_~y~.~.___. ____...12!~!!~OQ.~. __________. ._____._______. . _____-L._.__. _________ J2/~_!~00_~;,...12!~.1I2O'Q.6_. ___.__. :. .. __. .C ts C I % The target was achieved at the end of 2004, but only partially achieved in 2005-06. In 2007, PSlchanged, : ~~en t)c. 0 its strategy from retailing condoms to wholesaling them; as a result, tracking of condom availability at I ~~~;~:~;-----.-- ~~~f[~~3~~2~~WiWO~!~fb~_unit;~ho~pit;Ii~7;-guTarl"-·;;d. ;d~1-·~en~b-. 200s:-·--·. . 1 1100% :2005: 100% 100% Value (Quantitative lor Qualitative) I I I , :2008: 100% '1 1<2005: Point, 2009, p. 33) , I __+-1 ___.__~OO~.:...UNq~~~, 20.!0, p.~ZL.__ !Date achieved ~12/3112005; 12/3112008 iComments (incl. % e target was achieved for both the original grant and the restructured grant. ~_c_h_~_v_emen_t~)____I~__________________________________~________~__________________ ~ __ vi !Comments (incl. % e target was partially achieved. .-_. -r lachievement) iInd~t~~-7 : Value (Quantitative !Or Qualitative) i . OOA (2003): 70% orp-;;;-D"~ living with IDV1 those with TB treated by 2006 , . ".' 1 I.. AIDS'-(pLWA) benefit from treatment of STIs and 70%--' '1"---- r;;:-- .. ---.----.-.-~ It'VVllI: 49% (2008) !J3: 61.3% (2007) . . 1(20081PVVllI: Acces 2010, p. 23) I i !I I 1(20071TB: Acces 2010, .22) !Date l!C~~!..ed __ 12/3112003.. ____.__. _ .1213112007; !~~31~2008 _.__. _ lComments (incl..%. e targets were' not achieved. I i::~::~;!:t~--~GA (2003): 5% 'increase in the number of private service deliverY' poiniSr;;ceiving the yearly quality ~_ __ . ~OgO each year. --1 ~ Value (Quantitative 125 logos awarded I :13 logos awarded I lor Qualitative) t K2005: SElCNLS) !!?~te achieved ,12/3112003 ____._ ____ ______ 12/3112008 ._~ IComments (incl. % e target was partially achieved. In 2003, 1 logo was awarded; in 2004 2 new logos were awarded; , [ac~~vem~nt) __ . e ; ; ~_~51:~.s2~~~:S:msa:;:.):rvi~~~.~e~ awarde_~~Og~. {NB. Th~ proj.ect un~:rst~~ ~~_. _"_ I Value (Quantitative % (0 of9) 100% (9 of9) 100% (9 of9) :2007: 100% (9 of9) lor Qualitative) ! . 1 2008: 100% (9 of9) . . ____.___._. _____ 1(20~~_: SEI~S) _ _ _._. ___._____________ i(2~08: SElCNLS) ____. . __. iDate achieved 12/31/2003 1:1213112007; 1213112008 !Comments (incl. % iThe targets for both the original and the restructured projects were achieved. lachievement) lIndicator 10: -.--.-.---~-. lor Qualitative) 10 Value (Quantitative jV I.. ----..--.---r;"".------.. GA (2003): 250 traditional healers trained in IDV/AIDS prevention and coup.seling by 2006. 50: ----L-. -r--...-----.----..-------.--.-.· - - - - - -..·. -1 ~325 1(2008: SElCNLS) .. ----.-..J I I 1Q~!.~~hieved .__~~_!!.~09'!_..:.. __ _ . ___. ._.________.L_________._)2/3_1.!..2008 . '. --.-.--i IComments (incl. % Fe target was achieved. I !achi.evem~nt) -.-..-r;:...-;-----------.------.-.--.--.-.--.. ----.--.. . .--.--.-..- . - -...-----.-.---.---.-.-----..-.-..-~ IIndicator 11 : IL'GA (2003): 100% of Ministries and 2 main Unions have IDV/AIDS work plans by end 2003. . Value (~titativelO% (0 of29'~inistries) 1~0~ {~9 of29 II 169% (20-29 min~stries) "jor QualItative) I" 10% (0 of2 umons) 1(2003: SElCNLS) -----------r,---.-.---- ~ions)·· ~----.--.-. !ministries) 10?% (2 of2 L I JOO% (2 of2 unions) ~2008: SElCNLS; AGF) -'--1 iDate achieved 12/3112002 . i 112/3112003 i . !Comments (incl. % Though the targetfor ministries was partially achieved; 20 ministries had produced work plans by the end! ,achievement) of2003 and 3 additional ministries produced work plans by the end of January 2004. i vii -------..--. . ----------.-----------".-----.---.----.-",,-----.----------1 Indicator.12: jDGA (2003): 80% of the 303 CRDs are implementing 80% of their annual IDV/AIDS plans by 2007. I Value (Quantitative % (0 of 303) 80% (242 of303) ICRD:'100% (303 of303) i or Qualitative) I I ISubproject expenditure >80%: 87% ! Da~achle-;ed--·---tu/3Tt2002·--~-·-"---""-· ,,-·--·--,-·-·---i~·--·-------·-----~~~I~~l--.---,,-,--",,---,---,,-,,~ !Comments (incl. % I e target was achieved. All 303 CRD implemented at least one subproject and 487 of 575 subprojects !..chiev~~ent) _._ !disbursed ~~ le~_~~% ~ftheir bu~get and aC~"y~d their p~cipal objectives. . J Indicator 13 : IDGA (2003): Data for outcome and impact indicators are collected regularly from all main line ! __._._"______ ~inistries., regio~!.. non:.gove~enta1 o~ganizations (NGOs) and~ommUility p~ojects. i Value (Quantitative onitoring and Evaluation "&E system I M&E system partly operational I or Qualitative) M&E) system not operational perational _I ,,1(2008: Acces 2008., pp. 34-35) 1 ~=~ :':;~~:~=e~=S~2=~~::"~~wereJ iIndicator 14 : ~ GA (2003): Increase by at least 1500 the number of orphans who attend school regularly as of2004. Value (~titative 00 1500 "I ;1295 I lor Qualitative) 2003: SElCNLS) (2004: SElCNLS) I f~:~~Y(~CC% rn': :;~~3~ils partiallY-achieved, til(;;gh mlmber oforphans attend~~~:~~~~:cre8sed siSniflcarttly. -~ :achievemerit) _ _-..J iIndicator 15 : GA (2007): 10 million male and 50,000 female condoms distributed. I ~iIo:m)tBti;' ,~-·-·------·---------"T----"-- r.:~l~:~ggggo ~~:I::O;ci~gg----------------! lor ve I (2006: SE/CNLS) i ! 1(2008: SE/CNLS) I Date achieved ----.--.---- ~~~~2°1?.~_ _T-"-"---.---.--i-------_,,--._J-.----,,_---.__..".~12~3112~.08 __, __,,_,,______._____._1 iComments (incl. % The target was partially achieved; 91% of the targeted acquisition of condoms occurred in 2007 and I iachievement) 2008. . . ~~~~;!ij2ipref~have.at1east""!~~~~~C:;!~ ~~ Indicator 16 : -"._._------,,--- Value (Quantitative pro Qualitative) !Date achieved ''2006: SElCNLS) 12/3112006 -----r (2008: SElCNLS) -j1N1I200-8--·------_·---I I lComments (incl. % The target was achieved. ~~~!!!~~~enQ__. Indicator 17 : DGA (2007): 15 voluntary counseling and testing centers are operating. Value (Quantitative 10 15 ;11 (CDV: 10; CTA: 1) lor Qualitative) 2006: UNGASS 2010, p. 43) K2008:SElCNLS) I !Date _______ 12/3112006 •__._M.achieved .---. ___I ---- --------~--- ~12/3112008 -.----~..-. I iComments (incl. % "/The target was partially achieved. !achievement) -L-- _._____ iIndicator 18 : OOA (2007): 18 youth information centers are equipped. !Comments (incl. % e target was partially achieved. . :achievement) viii !Indicator 19 : DGA (2007): 26 public sector organizations supported and total amount of funding. ! Value (Quantitative 0 !1~26 IOn average 33 per year i lor Qualitative) /US$ 7.3 million I _ K2008: SElCNLS, AGF) , I i-Oa-te-;Cit-ie-v-ed---+1-2-/3-11-2-oo-2----------'------- -1------------1----------:12/3112008 - ---------1 \Comments (incl. % !The target was achieved for 2003-05; an average of33 organizations a year (23 ministries and-10 public I iachievement) Isector organizations) received project support. Project advances to these organizations during these years I - ere used to finance activities through the end of 2007. ~::::!:v~CI. o/~~~ ~i~!w~-parti~ly achie;;d. Action-piw-f~i-8-regio~~-;-e;~~;{:~~~0;004-:05-With adv~~s------i !achievement) lused to finance activities in all regions in 2006-07 and in a single region in 2008. Overall, of an expected i - , ~otal of 35 plans, 31 (or 8~%) were fInanced b~ the e..~iect._____.___,____ ,___~ !Indicator 21 : f A (2007): 268 Civil Society Organizations supported for subprojects (includes NGO, CBO, FBO) and I :- ' Value (Quantitative 0 otal amount offundin~_.__ l 'F ,_.. 180 orgs/132 projlFGN 3.4 billion J , :r QualitatiV~_.1- IOa~e achieved " 11213112003 ___ ____ ±,____, ~--.--,-------~;.O~C~~~ ~~; ~o~ I ~12/31t2008 __ _,_ iComments (incl. % !The target was achieved, though information is incomplete,: 80 organizations (representing 132 sub !achievement) projects) were fInanced directly, while 909 OeB sub projects were fmanced indirectly through the action I !plans of the 303 Rural Development Committees (CRD) and 38 Urban Development Committees (CU). ~ !The amounts for the directly fmanced sub projects are known, while the indirectly financed projects are ! included in the CRD and CU expenditUres~ !Indicator 22 : ~A (2007): 75% of National AIDS Coordinating Authority that report annually on at least 75% of the indicators in its national HN M&E framework and that disseminates the report to national-level leaders in at least three public sector organizations, national civil society leaders and business leaders in the private sector. --------,----,-- - ' - - - - ' - - - - - - - - -.. ~--.-----~----- .. Value (Quantitative ~ 10r~itativ~L___, 75.0% !95.3% (61 out of 64 indicators) K2008: SElCNLS) r---'-------'--------- -'-----------,--r----------------.--------,----------- I iDate achieved 12/3112006 12/3112008 iComments (incl. % The target was achieved. !achievement) !Indicator 23 : DGA (2007): Send yearly a cohort of 7000 orphans to school. - ----i Value (Quantitative 2933 ----- 17000 ;2007: 10097 -J , I lor Qualitative) '2006: SE/CNLS, p. 6) i(2008: SE/CNLS) Date achieved 12/3112006 :12/3112008 _.------ iComments incl. % The tar et was achieved durin the onl school ear covered b the ro .ect after the restnicturin ix ·~:';:~~O::U~~;I~;~~I;~i7W~::=~~~~_~i I lor Qualitative). _ 12008:12291 i :2007 (UNGASS 08, pp. 21, 45) i 12008 (Acces 08, . 39) I 1 02/21103 Satisfactory Satisfactory ,-~-.--------+-. ---- 2 05/29/03 Satisfactory Satisfactory 3 11126103 Satisfactory Satisfactory 9 06/29/06: Moderately Satisfactory Satisfactory ! 10 01119/07: Moderately Satisfactory Satisfactory 11 08/07/07 Satisfactory Moderately Satisfactory 14.17 12 01124/08 Satisfactory 'Satisfactory_: __ 17.91 _. 13 08/08/08.! Satisfactory Satisfactory --------r~-= 21.49 ___ 14-: _ 1~~~~MOd!~telY_S8:~!!actoryt= Satisfac~ry ____ _--==c= ~-2.-96-_-~-: H. Restructuring - !Revised indicators to eliminate mv 09/05/2007 Yes 14.17 revalence and focus on vulnerable groups IfPDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: -nut"~Ritf";~i"· Moderately Satisfactory Satisfa'?tory Moderately Satisfactory x I. Disbursement Profile xi 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Country context. For most of the decade prior to project appraisal, Guinea suffered from a variety of problems contributing to a deteriorating mv/AIDS situation, including: • dramatic poverty with UNDP's Human Development Index ranking Guinea as the poorest country in the world between 1992 and 1994 and 16200 of 174 in 2000; • regional strife in Liberia and Sierra Leone resulting in an influx of nearly half a million refugees as well as the internal displacement of a similar number of Guineans; • domestic political instability with frequent charges of electoral irregularities and a rapid turnover among the political leadership; and • poor. performance on key social indicators (health, education, water, etc.) even in comparison with other Sub Saharan Africa countries. 2. HlV/AIDS ~ituation. Guinea anticipated the seriousness of mv/AIDS by creating the National AIDS Commission in January 1986, more than a year before the official notification of the first cases.2 But its overall response was somewhat slow and uncoordinated; three short-term plans to combat the epidemic were subsequentlyimpleniented (with donor assistance) emphasizing the following interventions: • 1987-90: (i) raising awareness and training to improve hospital capabilities in Conakry (at the two university teaching hospitals) and in the mining areas (Fria .and Kamsar); (ii) strengthening prevention (via blood transfusion and mother-to-child transmission); and (iii) improving diagnosis and biological surveillance of AIDS cases3 • Epidemiological surveys of mvIAIDS in 1989 and 1990 estimated prevalence in Conakry and in rural towns at 0.96% and 1.78% respectively. • 1990-95: (i) the syndromic care in basic health facilities for patients with sexually-transmitted diseases; and (ii) the· mobilization of social groups, especially young people at school and sex workers. • 1995-99: (i) recognizing the long-term nature of the epidemic and the need to establish an organizational framework; (ii) adopting a national strategy to include a political dimension to the technical approach used previously; and (iii) envisioning future possibilities for the treatment of persons infected by the disease. 3. Although these plans addressed a number of the future Multi-Sectoral mvIAIDS Program (MAP) elements, they did not succeed in reducing prevalence; the frrst national survey undertaken in J~ly 2001 showed that the mv prevalence rate was much higher than previously estimated. The prevalence rate among pregnant women had reached 4.4% in the urban areas throughout the country, with even higher rates in Conakry (5%) and in the forested region of Eastern Guinea (7%). In addition to the increasing extent of the epidemic, the survey showed two other alarming trends: (i) a change in the gender ratio of mv-infected paqents from 8 men to 1 woman (in the late 80's) to 2 women for 1 man (in 2000); and (ii) a decrease in the average age of AIDS cases from 39 years old (in 1989) to 26 years old (in 1999). Finally, the survey found mv to be particularly prevalent within specific groups, including: sex workers, people suffering from a sexually transmitted infection or tuberculosis, truck drivers, the military, and mine-workers. 4. The publication of the results of the 2001 survey had a profound effect on policy makers, key social players and development partners, and the population as a whole. Discussion of the epidemic focused on: (i) the factors contributing to the spread of the disease (inadequate knowledge and inappropriate attitudes, sexuality at an early age, high prevalence of risky behavior, subOrdinate status and lack of empowerment 2 Concurrently, beginning in the l~ 1980's, Guinea initiated several important reforms in the delivery of primary health care, including decentralization, cost recovery, and essential drugs. 3 Considered a proxy for the population as a whole, given the absence of national population data. 1 among women, importance of mining and trucking activities, and large numbers of refugees and displaced people); and (ii) the weaknesses of the health service delivery system. . 5. Beginning in 2002, the country critically analyzed the Government's response to the AIDS epidemic and initiated several important measures to strengthen the response and qualify for MAP n financing. Specifically the country: • formu~ated a multi-sectoral strategy in the fight against AIDS over the period 2002-2006, which: (i) emphasized seven priority areas; and (ii) highlighted the specific needs of the most wlnerable groups such as the young, the military, inhabitants of zones with a high concentration of refugees· and prostitutes, and mobile populations; and • strengthened the structures to coordinate the fight against IllY/AIDS by: (i) replacing the National Commission to Fight AIDS (chaired by the Minister of Health) with a multi-sectoral National AIDS Commission (CNLS) l,lDder the leadership of the Prime Minister; and (ii) establishing focal points for AIDS activities in most central ministries as well as at regional, prefectoral, and district levels. 6. Further, by recruiting an Executive Secretary for the CNLS, deciding to select an independent agency to oversee financial management, and agreeing to fund activities undertaken by the private sector, civil society organizations, including religious groups, local associations, and communities, Guinea met the eligibility conditions for MAP. 7. Country Assistance Strategy and Rationale for Bank Involvement. Among Bank strategy documents, the 1997 CAS noted the country's significant efforts to decentralize health services, provide essential drugs, and involve local communities in financing and managing health services, but IllV/AIDS was not mentioned until 2000, initially. in the interim Poverty Reduction Strategy Paper (IPRSP) and subsequently in the CAS Progress Report (July 2001)4. The IPRSP emphasized the need to address the ''urgent emerging" AIDS threat through medical and non-medical means by: (i) stabilizing or reducing the incidence ofIllV/AIDS; and (ii) controlling its socioeconomic impact. 8. The Multi-Country IllY/AIDS Program for the Africa Region established the epidemic at the center of the development agenda and argued that curtailing the spread of IllY was pivotal for the achievement of human and overall development goals in the region and· in countries such as Guinea. According to Bank analysis,Guinea's progress in moving from a state-controlled to a market-based economy, in focusing on poverty issues and strategies, and in improving the delivery of basic services to the population would not be sustainable if strong efforts, backed by the international community, were not made to help Guinea implement its IllV/AIDS program. The Bank further noted that donors had expressed interest in supporting the program and indicated that Bank involvement was essential for its success. 9. The CAS Progress Report recommended the preparation of an IllY/AIDS project under the MAP operation, suggesting that: (i) the Bank retrofit its ongoing operations to include and/or strengthen IllV/AIDS components; and (ii) the Government use the decentralized structures and systems being strengthen~ in other programs as an innovative approach for the proposed project to tackle IllV/AIDS. The PAD itself did not list any alternatives considered, though the project concept document review notes three which might have been considered: a ministry of health-based project, an IllV component in a Health SWAP, or a part of a broader communicable disease control project. 10. Bank support for Guinea's efforts to fight IllV/AIDS· was justified by insufficient donor funding' for the response and inadequate resources to scale up existing and proposed interventions. Overall, the Project 4IDAIIMF, Joint Staff Assessment of the Interim Poverty Reduction Strategy Paper (Report No. 21402) (November 2000); World Bank, Country Assistance Strategy (Report No: 22451) (July 2001. S In addition to the traditional UN agency support, bilateral support included USAID and KfW (social marketing of condoms) and GTZ and Canada (treatment of STI). A number of national and international NGOs were also providing services. 2 Appraisal Document (PAD) estimated that Bank funding would essentially double the financial resources available to fund the country's response. Further, it was expected that Bank support to the Strategic Plan, together with its ability to ensure an appropriate fiduciary architecture and to attract donor interest would catalyze a coherent, multi-sectoral, and well-funded response to HIV/AIDS in Guinea. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 11. As presented in the PAD, the overall objective of the project is to limit and reverse the trend of the epidemic by preventing new infections. In addition, the project was expected to contribute to building capacity for HIV/AIDS prevention, care and treatment, and mitigation activities6• . 12. More specifically, the PAD stated that the project would: (i) assist the Borrower in implementing the National Plan against HIV/AIDS (PNLS) for the period 2003-06 and promoting civil society and community initiatives for prevention and care put forward by beneficiary groups so as to prevent the spread of HN/AIDS; (ii) expand People Living with HIV and AIDS (PLWHA)'s access to treatment, care and support; and (iii) support civil society and community initiatives for HIV/AIDS prevention and care. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 13. The original PDOs were formally revised in May 2007 as part of an umbrella restructuring of eight MAP projects which, among other things, eliminated HN prevalence as a PD~, proposed a more strategic management of the epidemic, and recommended modifications in institutional arrangements. As restructured, the overall development objectives of the Project were to: (i) increase HIV/ AIDS knowledge and promote low risk behaviors; and (ii) improve the coverage and use of HIV/AIDS prevention, care, treatment, and support services. 14. Data on the original and revised key outcome and intermediate outcome indicators are presented in Section F of the Data Sheet and discussed in more detail in Section 3.2 and Annex 2. 1.4 Main Beneficiaries and Benefits 15. Though national in scope, the project was expected to reach about 50% of the country's population through one or several of the proposed interventions (e.g. information and awareness, condom distribution, voluntary testing and counseling, STI diagnosis, blood safety, etc.). Coverage of targeted groups was expected to be higher, specifically for: (i) youths, women, and high-risk populations (sex workers, truck drivers, military, and miners) meriting prevention programs7; (ii) people currently infected by HIV and their immediate families benefiting from improved care and support; and (iii) orphans and families headed by children targeted for educational and other types of assistance. The PAD also indicated that project implementation would monitor benefits to ensure that communities were not left behind and that high- powered groups do not get disproportionate support from the project. 16. The project was expected to have a number of positive benefits, including: (i) reducing the costs associated with Guinea's current burden of disease (STIs, tuberculosis, and other opportunistic infections) and future expenditures for treatment and care; (ii) lowering child mortality related to the number of HIV- infected newborns; and (iii) extending the productive lives of people infected with HIV/AIDS and mitigating the economic and social impact of AIDS particularly for vulnerable populations affected by HIV/AIDS. In addition, public, private, and community institutions were expected to benefit from the project's contribution 6 The PD~ are phrased as follows in the Development Grant Agreement (DGA): The objective of the Project is to support the Recipient's multi-sectoral efforts to limit and contain the spread of the HIV/AIDS epidemic through: (1) implementation of 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 mvI AIDS; and (2) promotion of civil society and community initiatives for mvIAIDS prevention. 7 The project made a conscious decision not to address refugees as they were targeted by several NGOs. 3 to strengthening the technical, financial, and managerial capabilities of the various implementing agencies involved. 1 ..5 Original Components 17. Component 1: Support to community-based initiatives (USS 10.00 miUion). By providing grant resources to support a broad range of community, civil society and private sector initiatives, the component intended to empower communities to address lllVIAIDS prevention, care, mitigation, and support. Building on existing IDA-fmanced initiatives in health and social development and especially on the participatory approach used by the Projet d'Appui aux Communautes Villageoises (PACV) project, the project intended to rely on two main typesofNGOs: (i) those that help local communities cany out their participatory diagnosis; and (ti) those that are specialized in and provide certain services to the communities. The project supported: (i) the assessment and registration ofNGOs based on their experience. and capabilities; (ii) the participatory diagnoses by NGOs to raise community awareness and stimulate demand for information and services, (iii) the preparation of community action plans for approval and financing by the governing rural development committee (CRD) or urban commune (CU); and (iv) the implementation and supervision of a small grants program administered by the CRD/CU for the benefit of the successful communities. 18. Component 2: Support to the public sector (USS 5.94 miDion). This Component was intended to: (i) improve the capacity of all line ministries (both central and regional) to respond to the lllV/AIDS epidemic by integrating lllVIAIDS activities into ongoing operations and activities; (ii) provide ministerial staff and their dependents with lllV/AIDS and STI education, training, and care-related support; and (iii) develop AIDS-related activities emphasizing prevention and care for those constituencies falling within their mandate. Though all ministries were eligible to receive support for their annual action plan, ten ministries and their constituencies were considered priority: Health; Education (in-school youths); Youth, Sports and Culture (out-of-school youths); Social Affairs (persons living with lllVI AIDS and orphans); Interior (uniformed services); Transport and Public Works (truckers and transporters); Tourism (sex workers); and Mines, Geology and the Environment (miners). The Ministry of Communication was also included for its contribution to advocacy, information, and marketing. 19. Among the priority ministries, the Ministry of Health was designated to receive the largest share of fmancing for core activities related to: (i) prevention (condom distribution, blood screening and transfusion, management of sexually transmitted infections, voluntary counseling and testing, mother-to-child- transmission); (ii) care and treatment (at both primary and referral levels); and (iii) national sentinel surveillance. Antiretroviral therapy (ARn was only to be established on a pilot basis for 150 patients after the conditions ~or buying ARV drugs were in place. 20. In addition, the project supported efforts to manage hazardous waste including: (i) the development of disposal methods (acquisition of incinerators, burial, etc.); and (ii) the training of health workers in handling lllVIAIDS hazardous materials. 21. Component 3: Capacity buUding (USS 1.66 mllUon). This component was intendedto.fmance: (i) updating of the national lllV/AIDS Strategy and Action Plan; (ii) strengthening of public and private institutions in lllV/AIDS prevention and care through technical assistance; (iii) cross-cutting support (training, communication, procurement, etc.) for Components 1 and 2; and (iv) studies and surveys for monitoring and evaluation purposes. In particular, the component envisaged contracts to private entities with the demonstrated capabilities: (i) to expand lllVIAIDS services more quickly and to regions not yet covered; and (ii) to contribute to the professionalization and sustainability of the fight against lllV/AIDS. 22. Component 4:. Project Coordination and Facllitation (USS 2.70 miUion). This component was intended to support the operations of: (i) the National Commission against lllVIAIDS (CNLS) located in the Prime Minister's Office; (ii) the Executive Secretariat responsible for adminiStrating, coordinating, and facilitating project implementation; and (iii) the regional, prefectoral, and sub-prefectoral committees responsible for supervising the implementation of action plans and proposals at local levels. This component also financed the recruitment of an independent financial management agency. 4 1.6 Revised Components 23. The restructuring of the project did not alter the original four project components. 1.7· Other significant changes 24. During implementation, the original Development Grant Agreement (DGA) was amended to: (i) modify implementation procedures;· (ii) revise project outcomes; (iii) reallocate the proceeds of the project; and (iv) extend the closing date. 25. Revisions ofproject implementation procedures were approved: (i) in August 2003 to correct the procurement threshold for small works to reduce the proportion of subproject co-financing by the beneficiary from 20% to 10%; (ii) in October 2005 8 to permit project fmancing of the previously omitted regional AIDS committees (CRLS),to assign the CRLS the responsibility of approving the CRD/CU action plans, and to further reduce the beneficiary co-fmancing requirement from 10% to 5% either in cash or in kind9; and (iii) in August 2007 to incorporate revised thresholds for procurement. 26. Revisions of project outcomes were approved in July 2007 as part of the umbrella restructuring of theMAPsIO. 27. Reallocations of project proceeds were approved: (i) in October 2005 to replace counterpart funding requirements for categories 3 (20%) and 7 (10010) with the Government's proposal to waive duties and taxes on all items used for the fight against lllV/AIDSl1; (ii) in March 2006 to increase the amounts for goods and training and decrease the amount for sub grants; and (iii) in March 2007 to further increase the amounts for goods, consultants, and training and further decrease the amount for sub grants. 28. Revision of the initial project closing w~ approved in February 2008 to extend the closing date from July 31,2008 to December 11; 2008 (to take into account the length of the Bank's suspension of operations . during the months of civil strife). 29. The delay in producing the ICR, originally scheduled for June 2009 and subsequently extended several times (ultimately to June 2011) was the result of the coup d'etat and the subsequent application of the OPIBP 7.30, suspending Bank missions to Guinea until December 2010 when they resumed. 2. Key Factors Affecting Implementation and Outeomes 2.1 Project Preparation, Design and .Quality at Entry 30. Project preparation. An initial "pre-identification" mission was conducted in May 2001 to discuss an lllVIAIDS project, but concerted project preparation began in January 2002. Bank preparation of the project emphasized: (i) the eligibility conditions for the MAP and the broader lessons learned from earlier projects; (ii) an appreciation of the specificities of the Guinean situation (and the previous national program) and the experiences of on-going IDA funding for the health project, including: the Projet Population Sante Genesique (pPSG), the Projet d'Appui aux Communautes Villageoises (pAcV), and the Programme de Renforcement des Capacites Institutionnelles (pRCI); and (iii) a participatory approach involving the full range of potential actors able to contribute to a multi-sectoral approach. Like many of the MAP project preparations, this one was marked by periods of intense activity (to agree on technical components, identify activities, etc.) and lengthy delays (to sort out implementation arrangements). 8 The Government actually requested this amendment in June 2004, but it was not approved by LEGAF until September 2005. 9 The intention was to harmonize and align MAP and Global Fund procedures. . 10 In August 2006, following the mid-term review, the project requested changes in the PD~; this request was never formally acted upon, but it was referred to by the Bank when it formally communicated (in September 2008) its approval of the restructured project indicators approved in May 2007. I Counterpart financing for Category 7 had previously been reduced from 20% to 10% during negotiations. 5 31. Project preparation was supported by a Japanese Trust Fundl2 to contract consulting services to: (i) carry out assessments (of NGOs, Traditional Healers); (ii) formulate strategies (Mother-to-Child transmission, a 100% condom strategy for target groups, an orphans strategy, a private sector strategy); (iii) develop plans (communications, waste management Plan; and (iv) prepare for project implementation (Manuals of Operation, design ofa management training program). The work fmanced under the trust fund in 2001 was used to finalize the National Strategy for 2003-07, which had previously been prepared with UNAIDS assistance l3 . 32. The Project Concept Document (PCD) was reviewed in March 2002 and addressed three key issues: (i) the Government's reluctance to contract out the fmancial management of project funds to the non-state sector; (ii) the implementation arrangements and incentives for a minimum number of core implementing staff; and (iii) the need to focus the project more on prevention than on care and more on target groups (specifically, commercial sex workers, men-having-sex-with-men, truckers, miners, and the military) rather than on the general population, except in those parts of the country where the epidemic had started to spread. 33. Based on the experience with other MAPs, the PCD review was also concerned about the sequence and timing of project appraisal to ensure that the Bank approval process (with a tentative Board date prior to June 30, 2002) did not get ahead of the requirements to adopt regulations, appoint necessary staff, agree on acceptable fmancial management arrangements, conduct specifi,c studies (including the waste management plan), etc. 34. A Project Preparation Facilityl4 in the amount of $700,000 was approved on April 12, 2002 and was expected to fmance: (i) the capacity strengthening and logistics needs of the CNLS, as well as essential consultancies during the remaining phase of project preparation; and (ii) the launching of pilot and other activities both under the public sector and local response components. Disbursement from the Project Preparation Facility (PPF) wasvery slow, utilizing just $70,000 of the total advance as of the original closing date. IS ' 35. An initial pre-appraisal mission was conducted in March-April 2002, and a subsequent pre-appraisal mission was conducted in May 2002. The Decision Meetings of June 3 and June 20, 2002 retroactively considered the second pre-appraisal mission ,as the appraisal mission. While a number of agreements were in place as of May 2002 (establishment of the national committee, technical agreements with existing projects to supervise key activitie&, etc.), several important actions were identified, including fmalizing: (i) project operations and fmancial management manuals; (ii) monitoring and evaluation arrangements; and (iii) baseline data surveys. In addition, the mission emphasized the need for the Government to contribute to counterpart fmancing as a condition of negotiationsl . 36. Several modifications were incorporated into the project design to keep the project on what the decision meeting called a ''fast track". These included: (i) reducing the number of effectiveness conditions; (ii) agreeing on grant initial procedures for funding the community projects}'; and (iii) modifying first year plans and'expected expenditures. Delays in meeting the required conditions (especially fiduciary) postponed 12 Signed in April 2001 with an original closing date of October 30, 2002, the Japanese PHRD grant (TF026713) was subsequently extended to December 3, 2002 and then to March 28, 2003 when the project became effective. Of the total amount ofUS$383,900, US$254,294 (66%) was disbursed. . 13 The January-February 2002 aide memoire lists 6-7 studieslconsultancies to be financed by the PHRD, but the results for only half of these are listed in the document file and/or were available in the field. 14 Signed on April 29, 2002, the PPF (p073378) was closed on March 28, 2003 when the project became effective. Of the total amount ofUS$700,000, US$511,306 (73%) was disbursed. , IS The' original closing date of September 25, 2002 for the PPF was subsequently extended to March 31, 2003 to coincide with expected effectiveness date of the project. 16 The original amount of the counterpart contribution of 800 million GNF was reduced at negotiations to 300 million GNF with an additional 375 million GNF to be deposited six months after effectiveness. 17 It was always intended to modify these arrangements based on the experience gained during implementation. 6 negotiations until October 2002, ~d the Board approved the project on December 13, 2002. While there were subsequent Government delays in ratifying the DGA and approving the project operations manual, the project became effective March 28,2003, slightly less than three months after the signing of the development grant agreement. 37. Project design. The PAD presents a standard MAP design based on considerations of the Bank's experience with MAP 1 and broad participation in planning Guinea's proposed response. It builds on Guinea's'strengths, described in the National Strategy 2003-07, in responding to·the lllV/AIDS epidemic: (i) reasonable data on the evolution of the epidemic by region and by population group; (ii) successful interventions in several key areas, including social marketing of condoms, treatment of STDs, and tuberculosis; and (iii) the mapping of existing partner agencies within an organizational framework for coordinating the technical and fmancial response. 38. While the PAD offers a detailed description of activities to be fmanced, it does not provide much technical justification for the selection of the activities and virtually no data on the numbers of or approaches for reaching the target populations. In addition, the design somewhat arbitrarily established limits for the project by arguing that the project would: (i) not support policy reform in any sector (though the multi- sectoral approach, the reliance on decentralization, and the use of public-private partnerships each seem to require some support); and (ii) only allow for the treatment of an initial 150 PLWHA. 18 Finally, very limited attention is paid to voluntary counseling and testing (VCT) and prevention of mother to child transmission (PMTCT). 39. . The design did take advantage of the Government's increased acceptance ofNGOs (and the growth of associations of PLWHA) and the NGOs' improved capabilities to implement activities addressing lllV/AIDS. The design also benefited from Government's concern about the fiduciary performance of the country portfolio in general and the ongoing health project in particular. As a result financial management was contracted out, a financial operations manual prepared, and fmancial management software installed. 40. The PAD could have benefited from: (i) more detailed analysis in several sections (including health sector issues, the economic and social analyses, and the environmental analysis; (ii) more emphasis on the importance of existing Bank-financed projects (PPSG, PACV and PRCI) as well as other projects for the success of the MAP; and (iii) better discussion of the Bank's added value. The risk. assessment and mitigation measures were generic and perfunctory. 41. Project design emphasized a number of lessons learned from the MAP 1 projects. Many were well known, includirig the need for political leadership and commitment, a multi-sectoral approach, community participation, and effective monitoring and evaluation. The Guinea design sought to counter the tendency for MAP projects to lose momentum after Board approval by using: (i) the Policy and Human Resources Development Fund (PHRD) grant to sensitize representatives of public sector and civil society organizations, establish program coordination and implementation mechanisms, and train community development agents; and (ii) the PPF to start pilot operations prior to effectiveness. 42. In July 2007, Guinea was among the countries which agreed to amend their Development Grant Agreements by modifying the Key Performance Indicators (KPI) and extending the closing from July 31, 2008 to December 31, 2008. 43. Quality at Entry. No Quality Enhancement Review (QER) was conducted, but comments on the PAD summarized problems related to the monitoring and evaluation framework (and particularly the lack of baselines and targets), the weaknesses of the procurement and disbursement sections, and the lack of an environmental action plan. A Quality Supervision Assessment (QA7) (September 2006) summarized several conclusions on quality at entry, noting: (i) the Government's lack of capacity and uneven commitment; and 18 Both the PCD and the PAD reviews also noted that the project did not address refugees llIld internally displaced persons,.but the preparation team argued that other, more appropriate organizations (e.g. UNHCR and Medecins Sans Frontieres) were working with these groups and that the number of refugees in Guinea was decreasing. 7 (ii) the PAD's weak ·presentation of the results framework. The assessment concluded, however, that "in retrospect, it seems unlikely that the remaining steps for readiness could have been achieved in time for a prompt project start, and that moving to implementation (with the enhanced resources and expectations of delivery entailed) most probably accelerated completion of key steps." 2.2 Implementation 44. Disbursement overview. The original Development Grant Agreement (H014 GUI) in the amount of SDR 15.4 million (US$20.3 million equivalent) was signed on December 30,2002, became effective on March 28, 2003,19 and was expected to close on July 31, 2008. The borrower was expected to finance US$2.0 million equivalent bringing the total project cost to US$22.3 million equivalent. 45. As the following table shows (see the disbursement profile as well in Section I of the Data Sheet), actual disbursements tracked the PAD's planned disbursements to a remarkable extent: Table 1: Comparison of planned and actual disbursements (cumulative) Disbursements 2003 2004 2005 2006 2007 2008 Amount ('000 USD) Planned (PAD) 3098 6519 10893 16071 20368 0 Actual 2239 6024 11634 15993 20270 23262 Percentage Planned (PAD) 15.2% 32.0% 53.5% 78.9% 100.0% Actual 11.0% 29.6% 57.1% 78.5% 99.5% 114.2% Source: AGF (KPMG), Analyse de la perfonnance (Janvier 2009). 46. Given the important additional resources which became available after project effectiveness (from mPC, the Global Fund and bilateral projects including among others Kreditanstalt fUr Wiederatifbau, Reconstruction Credit Institute· (KFW), Gesellschaft fUr Technische Zusammenarbeit (German Agency for Technical Cooperatioil-GTZ), and United States Agency for International Development (USAID), the disbursement would seem to be even more remarkable. 47. Implementation overview. Despite the measures initiated under the PPF, the project began slowly as noted by the initial supervision missions. The implementation of the capacity-building component was a particular concern since the preparation of materials and the organization of training were late. By November 2003, the Implementation Status Report (lSR) indicated that significant activity was underway in all of the components. A year later the ISR (November 2004) described more mixed results (particularly with respect to the community-based initiatives), but rated both implementation progress and achievement of the PDOs as satisfactory. With minor changes in the ratings, this pattern of satisfactory (or intermittently moderately satisfactory)performance on both the PDO and the IP continued throughout the duration of the project. 48. Somewhat obscured by the smooth disbursements and consistent ratings are: (i) the country's continuing political instability particularly during the period 2005-07; and (ii) the modest nature of the project's ambitions and fmancing. On the one hand, though political instability resulted in reduced government commitment and fmancing as well as physical destruction of project assets (for instance, computers and other equipment to monitor the project were looted or destroyed in 5 of 8 regions during the events of January and February 2007), project commitments for the local and sectoral initiatives proceeded rapidly, reaching 75% by early 2005 and more than 90% by early 2006. 49. On the other hand, the project's ambitions were perhaps overly modest as shown, for example, by the project's: (i) insufficient staffmg for project implementation at national and especially at regional levels, 19 Despite the delays noted previously, the Guinea MAP was the first MAP to become effective within 90 days of the signature of the grant agreement. . where the lack of staff handicapped project implementation; (ii) inability to respond to demands for additional subproject funding more than two years before the project's original closing; (iii) limitations on the number of patients eligible to receive ARVs (150 PLWHA); and (iv) the small project contribution to the expansion of VCTIPMTCT sites (5 completed at the beginning of a period from 2006-2009 which saw the number of sites increase from 4 to 74). Three potential reasons for this timidity can be advanced: (i) fear of overpromising and under-producing which characterized a number of the previous MAPs; (ii) the recognition of the large role that the Global Fund would play; and (iii) the Bank's desire to move to a health sector funding approach, for which preparation began during the period of the MAP. 2.3 Monitoring aod Evaluation (M&E) Design, Implementation and Utilization 50. M&E design. Neither the National Strategic Framework (NSF) 2003-07 nor the PAD provide much guidance for the design of monitoring and evaluation.2o The NSF proposes a number of broadly defmed indicators to be collected at different intervals depending on the administrative level. The PAD identifies three mechanisms: supervision, surveillance (epidemiological and behavioral), and surveys, with all three essentially under the responsibility of the Ministry of Health assisted by external technical assistance (TA), and especially GTZ and the University of Montreal for the project zones, for surveillance and surveys. The PAD also, of course, identifies outcome and intermediate outcome indicators which are only generally related to those in the NSF. 51. Between project appraisal and effectiveness in March 2003,·the Trust Fund fmanced three technical assistance missions. The first two were intended to: (i) better define the project·indicators and the methods for calculating them; (ii) describe the activities, roles, and responsibilities of M&E personnel; and (iii) draft an M&E manual. The third mission was expected to: (i) collect baseline information for the project indicators; and (ii) train relevant personnel on the use of the M&E manual. In addition to these technical issues mentioned above,·pre-effectiveness reviews of the M&E system expressed concerns about the issue of . ownership and the need to establish an effective process for training and involving contributors/recipients of project data at all levels. It is not clear from the documentary record whether. any of these efforts were fmalized. 52. At the outset, there were some small discrepancies: (i) between the PAD's discussion of the PD~ and the KPI and the proje~t design summary (Annex 1); and (ii) between the KPI in the PAD and those in the Development Grant Agreement. In addition, there were problems with a number of the proposed project indicators: (i) several were poorly formulated and difficult to' measure; (ii) baseline data were not available for all of the indicators; and (iii) some targets could not be disaggregated to show the project's contribution. 53. The indicators were reviewed and clarified in 2006 after the mid-term review by: (i) eliminating prevalence and five other indicators for various reasons (e.g. achieved, unmeasured or un-measurable); and (ii) reformulating three other indicators (due to the lack of clarity or data). These revisions were incorporated into a restructured project in 2007 as part of the umbrella MAP restructuring.21 54. Implementation. Progress in implementing monitoring and evaluation was limited in the year following effectiveness, but accelerated in 2004: (i) in March, the Bank fmanced technical support to fmalize the M&E manual and propose tools for routine field data collection; (ii) by September, an operational plan for monitoring and evaluation had been validated by a UNAIDS technical working group and adopted; and (iii) by December, the Monitoring, Research and Evaluation Unit had been established within the SElCNLS, an M&E specialist recruited, c.omputers procured for focal points required to submit reports,· management 20 In comparison, the M&E framework, formally adopted in October 2008 as part of the revised National HIVIAIDS Strategy, was a very complete presentation. . 21 The umbrella restructuring revised indicators to eliminate HIV prevalence and to focus on vulnerable groups. The restructured project also incorporated the revised Bank procurement guidelines (of October 2006) and altered procurement thresholds of the aggregate amount for some procurement methods. 9 information software adapted for the project (using GTZ's SIDAPES), and quarterly reporting underway .with guidelines and forma~2. 55. . Specific progress had been achieved on: (i) physical and financial monitoring, with the Financial Management Agency (FMA) monitoring all contractual arrangements between the project and the beneficiaries of project funding; (ii) project monitoring, with the SElCNLS following the principal project indicators; and (iii) surveillance, with the Ministry of Health conducting .a number of surveys and studies, with support from GTZ and the University of Montreal operating initially in Mamou and Labe and subsequently in N'zerekore and Kankan. 56. Physical and financial monitoring. As discussed below, the FMA's financial monitoring and contract management systems worked well from the beginning and provided timely and accurate information. Financial Monitoring Reports (FMR) and annUal external audits were regularly submitted by the project and routinely analyzed and commented on by the Bank. In addition, a technical audit was conducted in December 2005 in the context of the mid-term review. The audit covered project operations for 2003-04, but it is not possible to determine the extent to which the comprehensive fmdings and recommendations were incorporated into the project restructuring, which occurred in 2007. 57. Project monitoring. Project M&E was consistently rated satisfactory or moderately satisfactory during project implementation 23 for the following reasons. First, the M&E unit produced: (i) regular summaries of the status of project outputs (see Annex 2); (ii) consistent overviews of the progress in meeting the PDOs and intermediate outcome indicators for the different supervision missions; and (iii) informative annual reports. Second, a number of studies were carried out on a variety of subjects such as: (i) the fmancing of local associations and community radios to increase information coverage among rural populations; (ii) an evaluation of the use of antiretroviral drugs; and (iii) assessments of the medical waste management program. Third, with the technical support of UNAIDS in particular, much of the necessary data to monitor Guinea's progress was assembled periodically. These included: (i) the UNGASS reports of 2006, 2008, and' 2010; (ii) reports on progress toward universal access (2008) and on the state of the epidemic nationally and in the Forest Region (2009). Somewhat surprisingly, given the amount ofIDV/AIDS funding and the important involvement of UNAIDS, no periodic assessments of national IDVIAIDS expenditures were carried out in Guinea during the period of the project. 58. Surveillance and research. Outcome data from the 2001 DHS provided adequate baseline data fora number of indicators, and the 2005 DHS provided the basis for revising some of the indicators at mid-term, but the lack ofDHS data from after 2005 represents a weakness in the implementation of the M&E strategy. Two other surveys also provided useful information: (i) behavioral surveys conducted in 2001 and repeated in 2008; and (ii) sentinel surveys organized in 2004 and repeated in 2008 (both with project fmancial support). 59. Utilization. The availability and use of information were reviewed during the mid-term review, and the following weaknesses were noted: (i) insufficient collaboration between the SElCNLS and the Ministry of Health, which' reduced the interest of a principal provider and user of the information; (ii) inadequate M&E capabilities within SElCNLS and a lack ofM&E personnel at regional levels, which may have reduced the credibility of the information produced; and (iii) irregular meetings of the national institutions, which eliminated the obvious settings for disseminating results. Despite these weaknesses, the regular fmancial information provided by the FMA, the project management information, and especially the epidemiological and behavioral surveys were of importance for making certain programmatic decisions. 22 As mentioned, most of the equipment (computers, photocopiers, etc.) provided to the ministries and regions was destroyed in 2007. . . . 23 The indicators used to measure M&E performance (Data Sheet Indicators 13 and 22) showed thilt one was achieved and oile was partially achieved. 10 60. M&E is rated substantial, based on the Independent Evaluation Group (IEG)'s criteria for assessing the design, implementation, and utilization of the data as they are applied to the epidemiological, financial, and implementation results data produced by the M&E system. Based on the detailed operational plan for monitoring and evaluating the National Strategic Framework 2008-12, the M&E system will certainly be sustained, though many of the specific project-related indicators will be eliminated and replaced by others. 2.4 Safeguard and Fiduciary Compliance 61. Environment. The environment category of the project at the time of appraisal was B, with risks related to the handling and disposal of HIV/AIDS-infected materials with the potential to affect health personnel in hospitals, health centers and municipalities who handle waste; families whose income is derived from the triage of waste, and the general public if the waste is not disposed of properly. 62. A draft medical waste management plan was prepared by the Government and approved by the· Bank in June 2002. Among its recommendations, the plan proposed that all of the national and regional hospitals have medical waste disposal facilities. Since the plan called for the use of incinerators, the Bank requested the Government to provide in the plan for adequate management and maintenance skills and for monitoring of the potential risk for dioxin production. The Waste Management Plan was subsequently revised and finally approved by the relevant national ministries in January 2003. 63. In May 2004, a supervision mission noted that: (i) certain hospitals had begun to construct incinerators to the proposed standards; (ii) personnel had been trained in preventive measures and management of bio~medical waste; and (iii) equipment had been planned and ordered. In December 2004, the Bank approved the procurement of 13 incinerators for 9 prefectures (Montfort) and 4 regional hospitals (Turbo 2000). 64. An evaluation of the management of medical waste, carried out in 2006 (prior to the mid-term review), assessed practices in 2 national and 9 regionallprefectoral hospitals. Unfortunately, the quality of the evaluation was deemed inadequate, and a subsequent evaluation in 2007 (by the author of the original waste management plan) concluded that: (i) both knowledge of and commitment to the plan were insufficient; (ii) implementation of the plan was inadequate due to the absence of an appropriate institutional framework; and ' (iii) none of the regulatory initiatives had commenced. The implementation of the originally planned activities was judged to be uncoordinated and ineffective. The project budget of US$200,000 was partially disbursed, essentially for training and equipment noted above. Disagreement about the choice of incinerators delayed their procurement, and political unrest delayed installation. Ultimately, incinerators were installed in the 4 regional hospitals in 2008, and it was agreed that the Bank health project would fmance incinerators for the prefectures. 65. The QSA7 concluded that the task team considered waste management as a priority issue and was effective in having the Borrower recognize this priority as well, but without the necessary technical support and government commitment, progress )Vas slow. 66. Procurement, Disbursement, and Financial Management. As with all of the MAPs, there were difficulties during the initial stages of project implementation in conforming to accepted Bank procedures for procurement and fman~ial management. Unlike virtually all of the other MAPs, financial management was never rated less than satisfactory throughout project implementation, and procurement was never rated less than moderately satisfactory. 67. Procurement. Early supervision missions (2003-04) emphasized the need to respect the conditions established by the DGA, keep accurate and updated procurement plans, submit adequately prepared requests for non-objections, and organize the records generated during the procurement process. These efforts were hampered by inconsistencies between the PAD and Legal Agreement which were not fully corrected by the August 2006, when the switch to new guidelines occurred for the final phase of the project. In addition, as the QAG pointed out, it was not clear whether the procurement arrangements and the associated procedures, manuals, etc. (especially on the community sub-grants component) had been updated and staff trained in order to correctly apply them. Finally, there were unresolved tensions throughout the project concerning: (i) 11 whether the threshold amounts were too high or too low; (ii) whether procurement was overly centralized (within SElCNLS) or not; (iii) how much of the procurement should be done with prior or post review. 68. Financial management. Financial management was contracted to KMPG and was characterized overall by adequate accounting methods and tools (specifically, the accounting program SUCCESS-RSF), the submission of accurate withdrawal requests and timely Financial Monitoring Reports, and unqualified audits. The FMA also helped monitor contracts for the sub-projects. KPMG had periods of staff turnover, but responded in an adequate and timely manner to Bank supervision requests to ensure sufficient,· qualified personnel. Periodic reviews of the FMA contract were generally positive. 69. The respective roles of the FMA and the SE/CNLS in aspects of fmancial management (e.g., in verifying receipts for expenditures, which was eventually delegated to the FMA) were a continuing concern. Relations between the two structures improved over time, in large measure due to the Bank's mediating role. In addition, three problems were cited by the FM specialist during project implementation: (i) the implementation of an accurate and timely budgeting system; (ii) the timely submission of Statements of Expenditure (SOEs) by SElCNLS and the .line ministries24 to ensure the replenishment of the sub-accounts; and (iii) the mobilization of counterpart funding. The first two were resolved satisfactorily over time by the project and the FMA. The third was resolved by amending the DGA to accept the non-payment of import duties and taxes by the project in lieu of counterpart funding. 2.5 Post-eompletion Operation/Next Phase 70. The major issues affecting the post-completion phase of the operation generally concerned the government's uneven commitment (at least prior to the political changes which occurred in 2009) and specifically: (i) the continuing debate over the roles and responsibilities of the institutions leading the fight. against IllV/AIDS; and (ii) the need to ensure adequate fuiancing from various sources to share the burden of program expenditures. 71. From an institutional perspective, the task team made a significant effort throughout project preparation and implementation to work with UNAIDS to promote coordination between the SElCNLS, the Ministry of Health, and their partners. A technical working group within UNAIDS (headed by the Executive Secretary of CNLS) was set up and expected to meet quarterly to examine the implementation of the annual operational plans. In addition, the task team urged the various actors to increase collaboration within the framework of ''the three ones2S ." 72. In practice, (essentially) parallel structures were initially established between SElCNLS and the Bank on the one hand and the Ministry of Health, the Country Coordinating Mechanism (CCM), and the Global Fund on the other. As one of the last supervision missions noted, with the MAP accounting for more than 90% of the operational costs of the SElCNLS, a number of the critical functions (including monitoring and evaluation) were at considerable risk after the end of the project. Similarly, activities for ministries (other than health) and communities were almost totally dependent on MAP support. By their nature, the private sector activities were less at risk. The project was urged to prepare a plan describing how those activities at risk would be continued in the absence of the project, but such a plan does not seem to have been submitted to the Bank. 73. From a financial perspective, with the MAP and the Global Fund assuming the major proportion of IllV/AIDS funding, continued financing was·an obvious concern: external financing over the period 2006- 20~8 constituted about 98% of total fmancing, with the MAP accounting for 24%. In June 2008, the Ministry of Economy and Finance formally requested Bank fmancing in the amount of USSSO million for a MAP 2. The letter noted the positive developments under MAP I particularly with respect to civil society, but argued for additional funding to address a number of other areas defined in the Second Poverty Reduction Strategy 24 The outstanding amounts were progressively reduced from $763,037 in October 2005 to $261,038 in June 2006 to $US·ll,599 in October 2008. 25 One AIDS action framework, one national AIDS authority, and one M&E system. 12 and the revised National mv/AIDS Strategy 2008-2012. In July 2008, the Bank responded negatively, urged the Government to successfully complete the project to encourage other development partners to contribute, and provided a list of potential sources of funding. 74. As the proposal for the Global Fund Round 10 shows, even with significant additional government funding (which has increased from around US$200,000 in 2009 to US$1.5 million in 2011), private sector funding (estimated at about US$750,000 per year), and external funding (including Global Fund funding from Round 6 and subsequently from Round 10), Guinea has a significant financing gap When compared with the planned activities in the National Strategic Plan for 2008-2012. 3. Assessment of Outcomes 75. To facilitate the assessment of outcomes, the following discussion is linked both to the summary of ratings by PD~ in Table 10 (the Overall Outcome Ratings) and to the specific results of the PDQ indicators and Intermediate Outcome indicators in the Section F of the Data Sheet. ,3.1 Relevance of Objectives, Design and Implementation 76. The relevance of the project's development objectives, components,and specific activities is rated Substantial for the original and Substantial for the restructured credit based on consideration of the project's: (i) adherence to the basic objectives of the PRSP, the CAS and the principles of the MAP . approach; (ii) support for Guinea's international and regional obligations as well as its national policies and directives 26 ; and (iii) contribution to the combined programmatic response of the various technical and fmancial partners. 77. The original project: (i) adopted as PD~ the objectives of the interim Poverty Reduction Strategy Paper to stabilize or reduce the incidence of mY/AIDS and control its socioeconomic impact; and (ii) followed the recommendation of the CAS Progress Report to use the decentralized structures and systems being strengthened in other programs as innovative methods for the MAP to implement mY/AIDS activities. The subsequent 2003 CAS (covering the period 2004-06) reiterated the operational principles of the MAP, but concluded that "the strategy could strike a better balance between treatment and prevention27 ". The Second PRSP (2007) sought to: (i) reduce mY/AIDS prevalence rate to 1.5 percent; (ii) provide adequate and comprehensive case management of persons living with mv/AIDS and persons affected, in particular orphans and vulnerable children; and (iii) reduce the socio-economic impact of mY/AIDS infection on infecte4 or affected persons, on society and on the country as a 'whole. While the restructured MAP project eliminated (i) from the PDOs, it continued to address (ii) and (iii). 78. The original project fully supported the National Strategy 2003-07, which was based on strategies aimed at: (i) the population as a whole (communication and behavior change, social marketing of condoms, treatment of STDs, blood safety, etc.); (ii) specific target populations (youths, women, and mobile populations including sex workers, armed forces, truckers, miners, etc.); (iii) persons infected by and affected by the epidemic (and particularly PMTCT); and (iv) management, coordination, monitoring and evaluation. The restructured project, which reflected the reduced funding and evolving role of the MAP, also adhered to the priorities of the National Strategy 2008-12, which: (i) reduced the focus on the population as a whole in favor of priority groups; (ii) increased the emphasis on treatment, care, and support of persons infected and affected by the epidemic; and (iii) maintained the priorities related to management, coordination, and monitoring and evaluation. 26 See in particular Cadre Strategique National 2003-07, pp. 30-31. 27 I.e., with somewhat more emphasis on testing and treatment. See 2003 CAS, p. 13. 13 3.2 Achievement of Project Development Objectives 79. As shown in the overview below, 80% of the project's objectives were completely or partially achieved; of those not achieved, three result from the lack of DHS information to confirm achievement: Table 2: Summary of the achievement of project objectives Indicators Achiewment PDO 10 No. %oftotaI Achieved 1,4,5,9, II 5 2,5,9, 10, 12, 16, 19,21,22,23,24 II 16 45.7"10 Partially achieved 2, lO 2 4,6,8, II, 13, 14,15,17,18,20 10 12 34.3% Not achieved 3,6,7,8 4 1,3,7 3 7 20.0% Source: Data Sheet 80. Project efficacy is rated as Moderately Satisfactory, based om (i) the project's overall results shown in the Data Sheet, in Annexes 2a and b, and in the following paragraphs; and (ii) the project's weighted results as, a proportion, of actual disbursements at restructuring and at closing, as shown at the end of this section. - 81. ' Project Development Objective 1: Increase HIV/AIDS knowledge and promote low risk behaviors. While certain KPI results were positive, overall the project made a Modest contribution ''to limit and contain the spread of the lllV/AIDS epidemic" prior to restructuring and to "increasing mY/AIDS knowledge and promoting low risk behaviors" after restructuring. . 82. Both prior to and after restructuring, the PDOs focused on interventions for the general population, for youths, and for targeted, higher risk populations. Among the targeted, higher risk PQPulations, the results were evaluated by behavioral surveillance surveys in 2001 and 2007. The results are presented below: Table Y. Use of condoms among the targeted, higher risk population Results Orig. Rev. Results Indicators 01 target target 07 Army personnel (pDO 1) 33.0% 55.0% 65.2% Sex workers(pDO 1, PD~ 4) 72.0% 55.0% 95.0% 99.8% Truck drivers (pDO 1, PD~ S) 32.0% 55.0% 60.0% 73.3% Miners (pDO 1, PD~ 6) 50.0% 55.0% 75.0% 49.7% ,Sources: ESSIDAGUI (2001); ESCOMB (2007). 83. Excepting miners, the project achieved the original and revised objectives for the higher risk groups. For truck drivers, the rapid increase in the number of truck stops offering an lllV/AIDS prevention program (10 2) was certainly a contributing factor. 84. Among youths, the results are presented in the following table, but ambiguous indicators and incomplete data complicate the interpretation of these results: 14 Table 4: Knowledge and risk behavior among youths aged 15-24 Resuhs Orig. Results Rev. Results Indicators· 01 target 05 target 07 % of youths aged 15-24 years having knowledge of sexually transmitted diseases (STDs) ND 85.0010 and of ways to prevent HIV/AIDS (10 3) Males with knowledge of male STDs 63.9% Females with knowledge offemale STDs 65.9% Males .with knowledge of ways to prevent HIV/AIDS 35.4% Females with knowledge of ways to prevent HIVIAIDS 39.4% % of men and women aged 15-24 who have had sexwith more than one partner in the last 12 months (poo 7) Males 37.2% 55.0010 ND Females 25.8% 40.0010 ND % of youths using a condom during their last sexual encounter (poo 1) 29.0010 55.0010 Males 68.1% Females 62.0010 Sources: EDSQ.II (1999), ESSIDAGUI (2001), EDSQ.IIl (2005), and ESCOMB (2007). As shown in the table, only PD~ 1 offers clear and clearly positive results, while 103 was not achieved and PD~ 7 would seem to be incorrectly stated. 85. Among the general population, the results were not systematically measured because the EDSG-IV, scheduled for 2009-10 was delayed until 2011. The situation is presented in the following table: Table 5: Knowledge and risk behavior among the general population Results Orig. Results Rev. Results Indicators 99 target 05 target 07 At least 50% of people who are aware of AIDS have used a condom with a partner other than their regular partner in the last 12 months (pDO 2) Males 27.0"/0 50.0"/0 37.2% ND Females 17.6% 50.0"/0 25.8% ND Decrease by at least 20"/0 the % of women and men not imowing any means to prevent transmission of the mv or having erroneous imowledge from the 99 level of Males 29.5% 10.0"/0 ND ND Females 29.8% 10.0"/0 ND ND % of men and women aged 15-49 who have had more than one sexual partner in the past 12 mos reporting use of a condom during their last sexual intercourse (pDO 8) Males 32.1% 55.0"/0 ND Females 26.1% 40.0"/0 ND Sources: EDSG-II (1999) and EDsG-m (2005). Indicators for PD~ 2 show some improvement although the target was not achieved. Results for the other two indicators are incomplete. 86. Though IllY prevalence was discarded after restructuring. HIV prevalence among urban pregnant women between ages 15 to 24 years old was estimated to be below 5% in 2004 (4.2% in Conakry) but had risen to 5.7% in 2008 (pDO Indicator 3). This is partially the result of the scale-up of treatment, but it could also be an increase in incidence (new cases per year). 15 87. Project Development Objective 1: Improve the coverage and use of HIV/AIDS prevention, care, treatment and support services. Though its contribution to many of the inputs required for the expansion of care, treatment, and support was limited, the project did contribute throughout to rehabilitation, equipment, and provision of goods and supplies. Overall; the project made Substantial contributions to a number of important services. 88. Condom distribution. The project used two mechanisms to acquire and distribute condoms: • During the early ye~s of the project, funds were provided to NGOs and community groups to purchase condoms locally at stores supplied by PSI. In 2004, 10 4 to ensure a continuous supply of condoms in 90% of all sale points was met. In 2005-06, 81% of sale points had no stock-outs; and in 2007, PSI replaced its retail approach with a wholesale approach so data are unavailable. • Subsequently, the project contributed to the national condom supply and, in 2007-2008, procured more than 9 million male condoms and 80,000 female condoms (10 15). From 2003-2008, the project provided 20% of all condoms procured. 89. Blood transfusion. With project support, 100% of blood units in hospitals were regularly and adequately screened by 2005 (10 5), and, though there was a decline to 52% in 2006, the project achieved 100% screening in 2007 and 2008: 90. Treatment of STDs. Over the period of the project, services .for STD treatment expanded to all of the 38 prefectures in the country exceeding the 30 established as the project target (10 16). The project fell short, however, in its objective to train 80% of health personnel involved in the treatment of sexually transmitted infections and opportunistic infections by 2006 (10 6). In fact, only 48% were trained. 91. Service Quality. All national and regional-level public hospitals were expected to have facilities to dispose of hospital waste and use them regularly (10 9); this objective was achieved, although the MAP only contributed incinerators to four regions. Private sector service delivery points were expected to increase by 5% per year and receive a logo indicating the quality of the services offered (10 8), but only 3 services were awarded a logo. 92. Voluntaty counseling and testing. The project contributed early to the operations of VCT centers (1017), but the subsequent expansion of these centers was financed by other sources (especially the Global Fund) and the project's contribution declined, as shown in the following table: Table 6: Expansion'ofVCT services Indicators 200S 2006 2007 2008 Annual number of testing sites 10 0 16 43 Cumulathe no. of testing sites 10 10 26 69 MAP contnbution I Numer 10 10 11 II MAP contnbution I Proportion 1000/0 1000/0 42% 16% Sources: UNGASS (2010), p. 43; SF/CNLS. 93. Data on the numbers of persons tested were not available, but the behavioral survey of 2007 noted that 10.6% of persons aged 15 and older received counseling and testing for lllV as well as their test results (PD09). 94. The project also contributed to counseling and testing by: (i) equipping 12 (of 18 planned) youth centers which served as sources of information on STDs and lllV/AIDS (10 18); and (ii) training 325 (of 250 planned) traditional healers in lllV/AIDS prevention and counseling (1010). 95. Treatment of PLWHA. Treatment services for men and women living with lllV/AIDS expanded rapidly over the last 2-3 years of the project as shown by the results presented in the following table: 16 Table 7: Treatment services for PLWHA Jndcators 2004 2005 2006 2007 2008 Treatment sites Curmlative no. of treatment sites 4 8 11 22 33 Pregnant 1W)men li~ng with HIVIAIDS Annual no. receiving ARV 70 59 281 1145 652 Curmlative no. receiving ARV . 70 129 410 1555 2207 PLWHA % treated for STIs 49.0010 % treated for TB 61.3% Annual no. treated with ARV 500 1196 4699 5228 12650 Curmlative no. receiving ARV 715 1911 6610 11838 24488 MAP contribution I Numer 150 150 720 MAP contnbution / Proportion 2.3% 1.3% 2.9% Sources: UNGASS (2005,2010); Acces 2010. 96. The cumulative number of treatment sites increased significantly, but the project objectives were not achieved: (i) the cumulative number of pregnant women living with mY who received antiretroviral drugs to reduce the risk of MTCT (pDO 10) was 49% of the target; and (ii) the proportion of PLWHA benefiting from STI and TB treatment (10 7) was 49.0% and 61.3% respectively. Finally, while the MAP exceeded the project target for ARV treatment (pDP 11), the number of patients treated constituted only a small proportion of the total number placed on treatment. 97. Support for OrPhans and vulnerable children. The project's contribution to the support of orphans and vulnerable children is summarized in the following table: . Table 8: Support for OVC Jndcateurs 2003 2004 2005 2006 2007 2008 Curmlative no. of households benefiting 2062 2980 6800 12291 ~nnual no. receiving educational aid 200 1095 571 2933 10097 18185 Curmlative no. receiving educational aid 200 1295 1866 4799 14896 33081 MAP contribution I NUm)er 200 1295 1866 4799 MAP contribution / Proportion 100010 100010 100010 100010 Sources: UNGASS (2008, 2010); Acces 2008. 98. Over the first few years, the project made a significant contribution to school assistance for Orphans and Vumerable Children (OVC): while the objective of 1,500 orphans by 2004 (1014) was not achieved, the number of households (10 24) and OVC (10 23) benefiting from project support increased steadily, and the objectives were achieved in 2008. 99. Other Outcome and Intermediate Outcome Objectives. The remaining PD~ and 10 do not fit easily into the restructuredPDOs but constitute important contributions in that they successfully: (i) promoted a multisectoral approach; (ii) decentralized responsibility for implementing mY/AIDS activities; and (iii) expanded accountability for results to communities and local authorities, thus expanding the national capability from central level to a range of public and private sector entities at regional and local levels. Project achievement of these objectives is rated substantial. 100. Support for public sector ministries and local authorities. Both prior to and after restructuring, the project aimed to involve key ministries and other public sector organizations in the fight against mY/AIDS. 17 The number of projects and amounts awarded for fIrst line (priority) and second line ministries '(10 11) as well as for other public sector organizations (10 19) are shown in the following table:- Table 9: Public sector support for the fight against HIV/AillS Indicateurs 2003 2004 2005 2006 2007 2008 Total First-line Ministries No. receiving project support 7 7 7 8 7 7 43 Ant. allocated COOO USD) 964 1058 1369 113 0 0 3504 Second-line Ministries No. receiving project support 13 15 20 13 12 5 78 Amt. allocated COOO USD) 324 660 1299 36 0 0 2320 Other poliic sector organizations No. receiving project s~ppCirt 4 5 6 4 2 2 23 Ami:. allocated COOO USD) 47 60 174 0 0 0 282 Total No. receiving project support 24 27 33 2S 21 14 144 Ant. allocated COOO USD) 1335 1778 2843 150 0 0 6105 Sources: SF/CNLS; AGF. NB. Several ministries/organizations spent amounts allocated in previous years during the later years ofthe project. 101. Plans adopted by the regions to fIght mv/AIDS as well as the activities included in the plans adopted by the local urban and rural authorities (CU and CRD) (10 20 and 10 12) were also fmanced by the project. The fl1,nnber of projects and amounts awarded are shown in the following table: Table 10: Support for Regional, Urban and District Plans Indicateurs 2003 2004 2005 2006 2007 2008 Total CRl8 pans No. receiving project support 0 8 8 8 6 1 31 Ant. allocated COOO USD) 0 548 786 0 0 0 1334 CUpans No. receiving project support 10 21 30 8 4 0 73 No. of projects financed 12 21 31 9 4 0 77 Ami:. allocated ('000 000 FGN) 284 456 1026 449 217 0 2432 CRDpans No. receiving project support 2S 154 2S9 114 0 0 552 No. of projects financed 2S 155 276 119 0 0 575 Ant. allocated COOO 000 FGN) 220 1662 4493 2725 0 0 9100 Sources: SF/CNLS; AGF. - 102. All 38 CU and 303 CRD received multiple funding and, according to estimates, fInanced more than 900 small project grants for community-based projects submitted by the various groups and associations. 103. Sup,port for civil society and private sector organizations. In addition to the community-based groups, more formal civil society organizations also received funding from the project (1021) as shown in the following table: 18 Table 11: Support for civil society, private sector, and other plans Indicateurs 2003 2004 2005 2006 2007 2008 Total NGOs No. receiving project support 11 30 30 30 11 3 115 No. of projects financed 13 32 41 31 12 3 132 Amt. allocated ('000 000 FGN) 136 428 477 817 1085 485 3428 Priwte sector No. receiving project support 1 2 0 0 0 4 Amt. allocated ('000 000 FGN) 65 18 510 0 0 0 592 Labor unions and other No. receiving project support 2 4 6 3 0 0 15 Ant. allocated ('000 000 FGN) 77 228 588 463 0 0 1356 Sources: SFJCNLS; AGF. 104. Overall achievement result. Based on the restructured project's revised indicators and the ICR guidelines (requiring separate outcome ratings weighted in proportion to the share of actual credit disbursements made in the periods before and after formal restructuring), the following table assesses the project's overall efficacy rating is Moderately Satisfactory.28 . Table 12: Combined overaU project achievement ratings / Efficacy Against· Against Original Restructured Considerations PDOs PDOs Overall 1 Rating MS S 2 Rating value 3.82 4.48 3 Amount disbursed 12.13 3.27 15.40 4 Weight (% disbursed 79% 21 % 100% . before/after PDQ change) 5 Weighted value (1 x 3) 3.01 0.95 3.96 6 Final rating (rounded) MS Source: OPCS, ICRR Guidelines (rev. November 2010), Annex B, pp. 42ff. In other words, the ICR argues that, while support for plannjng and implementing activities to increase IllV/AIDS knowledge and promote low risk behaviors (pDQ 1 and Other) was substantial in creating the demand for services, the. project's response in supplying services (pDO 2) was essentially modest. 3.3 Efficiency 105. As noted in Annex 3, the PAD for the Guinea MAP, like most other MAPs in the region, referred to the economic analysis carried out in previous reports and did not carry out a cost-benefit analysis. As a result, an assessment of the overall efficiency of the project before/after and with/without comparisons is not . possible for either direct (savings from treatment costs) or indirect benefits (gains made from reductions in disability and death and associated economic productivity).). Annex 3 summarizes the arguments advanced by MAP 1 and MAP 2 and the extent to which the project addressed the most effective and efficient 28 The worksheet detailing the calculations leading to these results is available from the Project Files. 19 interventions given the prevailing epidemiological situation in the country. In addition~ the following paragraphs focus on the project's internal effici~mcy and assess its success in economizing on scarce capacity and prioritizing activities29 • . . 106. MAPs are in some respects inherently inefficient at start-up since they must: (i) adapt the specific components (and allocations) and the suggested institutional arrangements to the local context, (ii) improve planning and budgeting to avoid consistently late approval of annual work plans (due to reviews of priorities, unit cost corrections, potential duplication of activities, etc.); and (iii) invest the necessary resources to strengthen management systems and train personnel at central, regional, and district levels. The Guinea MAP was no exception, but it varied from other MAPs in two important ways: (i) it disbursed the project proceeds in a timely manner and as planned (with the exception of the training category which was quickly exhausted); and (ii) it employed several strategies to increase efficiency. 107. First, recognizing the lack of implementation capacity, the project relied on contracting out specific services to five large agencies already involved in service delivery in Guinea to ensure efficient and effective implementation. These included four contracts for service delivery (condom distribution, behavioral change capacity, STI treatment, and sentinel surveillance and counseling) and one for fm~cial management services. In addition, the behavioral change communication (BCC), STI, and mv interventions were limited initially to three regions (Kindia, Labe,.and Mamou). Performance on these contracts was evaluated at mid- term, and the contracts were renewed on the basis of these results. Subsequently, other contracts were signed for: (i) specific groups (fishermen, informal miners, OVC); and (ii) specific services (PMTCT in Conakry and treatment in Kankan and N'zer6kore. 108. Second, the project addressed the public s~tor by distinguishing between first and second tier ministries, focusing initially on the former. Third, the project recognized the potential problems of providing small grants to NGOs and local organizations and proceeded to: (i) conduct initial screening. and 'periodic assessments of these groups to ensure their capacity to deliver the required services; and (ii) use procedures developed by a companion Bank project (PACV) as the basis for assisting the CU and the CRD to award small project grants. Fourth, though targeting preventive interventions for vulnerable groups was part of the initial design, the project increased the emphasis on specific target populations (high risk groups, high, prevalence regions, and underserved rural areas) after restructuring, but the M&E system does not allow for an assessment of this trend. 109. Finally, with Bank support, the project was constantly looking at administrative measures to eliminate constraints and increase the pace of funding for activities, though not all of the proposed measures were ultimately accepted (e.g. the use of a single selection committee for approving subprojects fmanced by the MAP and the Global Fund). 110. Based on this combination of ' technical and administrative measures to improve the project's efficiency in achieving the PDO's, efficiency is rated as Modest for the project as a whole. 3.4 Justification of Overall Outcome Rating 111. Based on considerations of the various ratings criteria and indicators and disbursement prior to and after project restructuring, the following table presents the overall outcome rating for the project as Moderately Satisfactory. 29 Operations Evaluation Department, Committing to Results: Improving the Effectiveness oflflV/AIDS Assistance (2005), see especially Table 4.1, p. 45. 20 Table 13: Summary ratings by Project Development Objective** Criteria I Indicators Relevance Efficacy Efficiency Outcome Increase HIV/AIDS knowledge and Moderately Substantial Substantial Modest promote low risk behaviors satisfactory Improve the coverage and use of Moderately Substantial Modest Modest HIV/AIDS prevention, care, treatment unsatisfactory Moderately Other lOs Substantial Substantial Modest satisfactory Overall Project Outcome Rating Moderately Substantial Substantial Modest satisfactory OVERALL RATING MODERATELY SATISFACTORY ** The worksheet is available from the TTL 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 112. Poverty. Though an integral part of the government's poverty reduction strategy, the project did not explicitly target an impact on poverty. Revenue-generating activities,. for instance, were not included. However, to the extent that the project promoted free care for those in need of services, financed consumables for diagnosis and drugs for treating 150 patients, and supported educational assistance for children affected by the epidemic, the project did contribute to poverty reduction. 113. Gender. Though the feminization of the epidemic was recognized during project preparation, the issue was not explicitly addressed during the early phase of project implementation. Beginning in January 2005, though, Bank supervision missions paid increasing attention, insisting that women's associations be accorded priority by local governments in the selection of community level projects. Consequently, as women were increasingly affected by the epidemic, they received a proportional increase in access to prevention and treatment services (though data from the monitoring system are not adequately disaggregated to demonstrate this). 114. Social development. The project also focused on a range of socially marginalized groups (including sex workers, miners in the informal sector, fishermen, etc.) seeking to raise their awareness about risky sexual behavior, but also to help these populations understand the implications of the disease and its potential impact on their lives. The project made major contributions in three areas: (i) the development of associations of PLWHAs; (ii) the inclusion of an IllYIAIDS component in the school curriculum, which had to overcome considerable opposition within the Parliament; and (iii) the encouragement of a small group of Men who have sex with men (MSM) to organize itself to receive assistance. Though this last initiative was ultimately unsuccessful, the Bank's commitment deserves mention. (b) Institutional Change/Strengthening 115. As in other countries with UN, Bank and Global Fund support, there were tensions about the roles and relationships of the CCM, the SE/CNLS, and the sources of financial and technical support. While the Bank tended to work in close collaboration with UNAIDS (and their technical groups) and the SE/CNLS, the Global Fund worked most closely with the CCM and the Ministry of Health. Working relationships were constantly being revisited and clarified, which slowed the potential development of the different institutions and the acceptance of the "three ones" principles. Efforts to create a Partners' Forum only succeeded after the project was closed. 116. The project was more effective in working with a wide range of public sector institutions to: (i) promote a multi~sectoral response to the epidemic and to mainstream IllYIAIDS activities into the action plans of key sector ministries; (ii) decentralize resources and responsibility for implementing these activities; 21 and (iii) strengthen the management capabilities of a range of civil society and private sector entities to improve results at regional and local levels. 117. Other institutions benefiting from the project included both the public sector (where urban and rural local governments benefited from project financing) and the private sector (where employer associations and labor unions received project financing). The fmal evaluation of the project estimates that more than 130,000 miners were reached through the efforts of the project. The centers for discussion and counseling for adolescents (CECOJE), of which more than 30 were established in the country (about a third with project funding), also proved to be an especially effective institution (particularly in collaboration with AGBEF, the Guinean Family Planning Association which provided adolescent health care and family planning services. 118. A review of the quantitative and qualitative results of Annex 2 indicates the range of public and private institutions which benefited from the project. 119. Guinea's approach for implementing the local iriitiative response included a number of elements of interesf°. First, the project built on the expertise of the PACV, with the intention of jointly reviewing the small projects to be implemented by the two projects in order to increase the efficiency of proposal review and avoid duplicative funding. Second, a capacity assessment of NGOs was carried out, and a roster of .eligible NGOs was established during project preparation and updated regularly thereafter to include those . NGOs receiving training and satisfying the criteria. (c) Other Unintended Outcomes and Iinpacts (positive or negative) 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 120. A beneficiary assessment was not organized prior to the project but was being conducted at the time of this ICR. 4. Assessment of Risk to Development Outcome Rating: Modest 121. At the time of project closing in December 2008, the risk would have been considered substantial or perhaps even high: political instability, reduced financing (with especially negative prospects for many of the activities fmanced by the project), and an uncertain future for the SElCNLS. But there were also some bright spots including: the expressed commitment to continuing the fight as part of the poverty reduction strategy, a revised national strategy for 2008-12 which formed a consensus for moving forward, the continuing presence of several contractors fmanced by the project (including GTZ, DREAM, AGBEF), and ongoing financing of the Global Fund. These elements, as well as a greater fmancial commitment to the SElCNLS, an increased reliance on the decentralized authorities to deliver services, .and success in receiving additional fmancing from the Global Fund (Round 10) have contributed to lower the assessment of risk to the development outcomes to Modest. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 122. No Quality at Entry Assessment was organized by the Quality Assurance Group. The project preparation team made a major effort to avoid some of the ·weaknesses of the MAP 1 preparations, in particular through the use of: (i) the PHRD grant to finalize the 2003-07 national strategy and to anticipate future areas of project concern (capacity assessments of NGOs, condom distribution, orphans, waste 30The experience was written up and published by the SElCNLS, L 'extension de la couverture de la lutte contre Ie VIHlSIDA dans les collectivites locales (2006). 22 management, etc.); and (ii) the PPF to eStablish the SElCNLS, sensitize national and local authorities, and initiate the sub project process. The team also invested significant time in developing a coordinated approach with other agencies to implement the fight against lllV/AIDS. 123. On balance, these efforts to improve the qualitY of the project had mixed results. First, the PAD's conclusions were sound and ultimately correct (particularly with respect to fmancial management) even though it had demonstrable weaknesses (related to use of the preparatory studies, justification of activities, and institutional arrangements, particularly for M&E). Second, the PPF recognized and sought to contribute to project start-up, though ultimately it was not able to anticipate and resolve several important issues related to sub-project selection and implementation, including the need for the project to have a regional presence. Third, the team attempted to collaborate with UNAIDS and SE/CNLS to enhance the program, but the institutional tensions mentioned previously (between UNAIDS and the Global Fund and between SFJCNLS and the Ministry of Health) proved impossible to overcome completely. 124. An attempt to enhance quality through project restructuring was done as part of an umbrella restructuring of eight MAP 1 and MAP 2 projects and intended to realign indicators to national strategies, redirect funds to priority and high impact interventions, and better coordinate institutional arrangements. A Bank issues paper (2006) addressed the challenges and lessons learned from the MAPs and proposed ten potential revisions31 of which Guinea requested three: (i) modification of the PDO; (ii) elimination ~fthe KPI "that are not realistic to measure"; and (iii) adoption of the revised Bank procurement guidelines of October 2006 to avoid implementation delays by removing procurement thresholds of the aggregate amount for some procurement methods. (b) Quality of Supervision Rating: Satisfactory 125. A Quality at Supervision Assessment was organized by the Quality Assurance Group (QSA7) in September 200632 and accorded the supervision a rating of2 (Satisfactory) overall. 126. Over the life of the project, Bank supervision was characterized by: (i) the continuity of the task team (with a single TIL33 and little turnover among the fiduciary team members over the life of the project); (ii) the consistent assessment of project performance34 during supervision; and (iii) the timeliness of the agreements reached, with virtually every aide,.memoire signed by the CNLS, the Bank, and UNAIDS. Intensive early supervision, the quality of the documentation, and the constant follow-up of the recommendations of previous missions were all helpful to the project. 127. The task team's technical and operational contributions to the project were both substantial. Of particular importance technically were the team's actions to support: (i) legislation relating to the inclusion of IllY/AIDS in school curricula; (ii) programs for men who have sex with men; and (iii) greater attention to the issue of gender. Operationally, the team's flexibility in suggesting Or accepting proposals to improve the operations of the different components contributed to increased project efficiency as noted previously. Supervision was particularly effective in ensuring the quality of the mid-term review and the restructuring of project objectives. Finally, the QSA noted the effectiveness of Bank management in assisting the task team. 31 In addition, the Africa Region and the Global IDV/AIDS. Program (HDNGA) proposed an IDV/AIDS results Scorecard for all HIV projects, but this was not used in Guinea. 32 There was also a previous QAG assessment (QA6), but the author was unable to find the results in the IRIS. 33 A previous TTL managed the project preparation phase but was not heavily involved during project implementation. 34 The aide-memoire even periodically reviewed the risks and the DGA agreements, though they never referred to the ISR ratings accorded to the project. 23 128. Supervision has been rated satisfactory (rather than highly satisfactory) due to: (i) inadequacies noted by the QSA with respect to the supervision of procurement and financial management; and (ii) somewhat inflated ISR ratings during the initial years of project implementation3s • (c) Justification of Rating for OveraU Bank Performance Rating: Moderately Satisfactory 129.. Following ICR guidance in.dicating that when the rating for one dimension is in the satisfactory range (for the quality supervision) and the other is in the moderately satisfactory range·(for quality at entry), the rating for overall Batik performance depends on the outcome rating. Bank performance is therefore rated Moderately Satisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately Unsatisfactory 130. As described in the 2003 CAS, Guinea was a Low-Income Country Under Stress (LICUS) confronted by: (i) external constraints due to the instability in the sub-region; and (ii) internal constraints related to governance and a highly centralized public sector. Government commitment to the project at the highest levels was uneven, as early interest gave way to more pressing socio-political concerns and internal strife. From 2002 to 2008, Guinea was headed by six different Prime Ministers who were expected to preside over the National Committee (which in fact met only twice during this period). Further, as mentioned, Government contributions to the counterpart funding were often less than budgeted and arrived late; though in the end all of the Government's fmancial obligations were met. Finally, the Ministry of Health's weak contribution to project implementation demonstrated its lack of commitment to the project, due in part to continuing debate over the roles and responsibilities of the Ministry and SElCNLS, and in part to the availability of Global Fund financing. . 131. Expanding government performance to include other central ministries as well as public sector officials at regional and local levels provides a somewhat different picture of government performance. These entities, especially many of which (including some fIrst and second line ministries as well as the urban and rural local governments) rarely received external assistance to support their annual programs, enthusiastically accepted MAP support to implement activities and used the MAP funding to achieve their objectives and to demonstrate their capabilities to other potential sources offmancing. Though disbursement tended to be slow and justifIcation of expenditures even slower, the authorities interviewed during the ICR mission expressed satisfaction with what they were able to achieve. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 132. Project implementation was shared by: (i) the Executive Secretariat of the CNLS, a public sector entity under the auspices of the Prime Minister, created by decree in March 2002 and responsible for coordinating policy and regulation, mobilizing financial resources, and facilitating program implementation and supervision; and (ii) the Financial Management Agency, a private sector agency recruited by the CNLS and responsible for financial management. While there were sometimes gaps and occasional ambiguities in their respective functions, the division of responsibilities for project ID!plementation and oversight balanced facilitation and fIduciary tasks, and these two agencies collaborated in a relatively harmonious manner. 133. SE/CNLS. The performance of the Executive Secretariat was hindered institutionally by conflicts (with theCCM and the Ministry of Health), and operationally by insufficient staff and counterpart fInancing 35 These ratings were subsequently downgraded following the recommendations of QSA6 but remained somewhat higher than probably warranted. 24 which particularly affected its performance at regional and local levels. Given the range of issues requiring attention, the Executive Secretariat had a tendency to stray into implementation or to substitute itself for the more appropriate technical agency. Several supervision missions had to remind the SE/CNLS of the limits of its role and responsibilities, but both implementation progress (with one exception) and project management were rated Satisfactory by the task team during the entire duration of the project. 134. The SE/CNLS was less successful in carrying out its responsibilities for procurement, with supervision missions pointing out deficiencies in procurement planning, numerous errors in the preparation of tenders, frequent delays in the delivery of goods and the recruitment of services, and poor archiving of documents. The task team somewhat generously rated procurement as Moderately Satisfactory throughout the latter half of project implementation. 135. FMA. The FMA (KPMG) played an important role in the project's success by providing both financial management expertise and an institutional buffer between the SE/CNLS and other political and technical influences. The fmancial results achieved by the FMA were considerable, including the submission of acceptable Financial Management Reports (FMRs) mostly on time, and annual audits always on time. At the same time, its dominance in controlling the fmancial functions (some of which were to be shared with the SE/CNLS), its careful (and slow) processing of withdrawal applications, and the limited training to transfer competencies were all sources of concern for the SElCNLS; and the outstanding advances to community groups (and the inability to audit these groups in a timely manner) were a source of concern for the Bank. Given these weaknesses, the performance of the FMA is rated Moderately Satisfactory. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory 136. The Moderately Unsatisfactory performance of the Government and the Moderately Satisfactory performance of the Implementing Agencies, combined with the overall project rating of Moderately Satisfactory, yield a rating of Moderately Satisfactory for the Borrower. 6. Lessons Learned 137. The Guinea MAP confirms many of the fmdings of previous MAPs, but it offers several strategic and operational lessons which merit consideration. 138. First, Guinea offers an example of where program advances in the fight against HIV/AIDS can occur even where political instability and political leadership (both of which are usually assumed to be prerequisites) are not entirely adequate. To a large extent this was due to the project's ability to find champions among those groups who were committed. In Guinea, these groups were found among: (i) the public sector (especially, some of the "second tier" ministries and local authorities at regional and prefectoral levels); (ii) the private sector (particularly the mining sector and several labor unions); and (iii) communities. Eventually, these private sector and community-level initiatives were able to overcome (at least to a certain extent) uneven government commitment and weak capacity. 139. Correlated with this is the importance of pro-active project supervision (and effective management) to identify opportunities and take advantage 'of them where they occur. 140. Second, by their very nature, MAPs raise provocative issues, and the Bank's role as an advocate for certain vulnerable populations can be a delicate matter. Some are obvious (women, orphans) and pose no problems; and others might seem to raise some potential issues (commercial sex workers), but have tended to be accepted, at least in West Africa; and some clearly demonstrate the potential limits for Bank success. In Guinea, the Bank successfully argued for the introduction of HIVI AIDS instruction in the school curriculum, but it was unsuccessful, despite important efforts, in encouraging organizational efforts by homosexuals. 141. Third, Guinea demonstrates that insufficient attention is paid during project implementation to the risks and risk mitigation measures proposed in the PAD. In the case of the Guinea MAP, three of the four output to objective risks were correctly identified (though perhaps incorrectly rated), but the measures proved to be wholly inadequate to alter the situation. While project preparation cannot be expected to pre-identify 25 all of the potential solutions to pr~blems which might arise, supervision missions should be required to link their recommendations at least in part to the risks so as to track the effectiveness of the mitigation measures for future projects. This would seem to be the Bank's counterpoint to "learning by doiJ;lg." 7. Comments on Issues Raised by BorrowerlImplementing AgeneieslPartners 142. (a) Borrower/implementing agencies: The task team and the Borrower reviewed and agreed on the results of the indicators .reported in the Data Sheef6. The Borrower has prepared a comprehensive fInal evaluation report in French, which did not contain a summary. A summary of the Borrower's fInal report is presented in Annex 7 in English. The Borrower's fInal evaluation report is available from the Project Files. 143. The revised ICRR was sent to the Borrower for comments, which were received on December 21, 2010. The Borrower confirmed that the evaluation was done with rigor, that it reflected the points of view and observations of the National Secretariat, and that there were no specifIc additional comments to add. (b) Co-tinaneing: Not applicable (c) Other partners and stakeholders: Not applicable 36 A technical note was prepared at the completion of the ICR mission and is available in the project file. In addition to the Executive Secretariat has prepared final project evaluation. 26 Annex 1: Project Costs and Financing Sources: Annex 2 of PAD and Client Connection (November 2010). * Increases in total project fmancing also reflect exchange rate fluctuation in the SDR to dollar exchange rate over the project life. ternational Development Association (IDA) 92.4% orrower ~_'H"' ___ ' __ .• _ •• __ .,_. ___ •• "'_" ___ """""' __ "_''''.'H ...... __ ....H."" •• __ ........... _______ ._... __ H••• __ ...... _ •• _____ ... H··· __ ·".m .... . 2.00 1.75 7.0% ocal Communities 0.00 0.13 0.6% ___.____. . _._. __. _. __ ._._. _____ . __. !~~J:~~t~~t._;t!.i.!'_~~~!~_.__._____ ._._.___.__ . _____~_~_~~~_ . ____ . __._. _~~~~! ____ . . !.~_~.~___.___ . . . c .. __ * Increases in total project financing also reflect exchange rate fluctuation in the SDR to dollar exchange rate over the project life. 27 Annex la: Descriptive summary of project outputs Component 1: Support to local initiatives UrbanlRural Development Committees (CU/CRDl • Assistance in carrying out the participatory community diagnosis • Integration of the local response into CRD I CU plans o Training of the heads of the CRD and CU, 300 development agents o Communications kits for 129 CRD to sensitize communities • Funding for the action plans of all 303 CRD and 38 CU in the coUntry Private sector (for profit, not for profit, associations) • Support forNGOs o Inventory of 282 NGOs and associations working in the area ofHIV/AIDS o Training and communications materials in the areas of social mobilization, communication, counseling ofPLWHA, and monitoring and evaluation o Training of 100 national trainers o Training of 500 staff from NGOs and associations • Support for private health services o Contracting with Aboud Amira Laboratory for biological monitoring ofPLWHA • Support for private companies and labor unions o COI}tracting with the Chambre des Mines for the establishment of 3 VCT centers o Studies on HIV's impact on the mining sector and on the attitudes of miners o Monitoring and evaluation materials provided to the largest 2 unions o Funding for 6 action plans of 4 unions • Support for the establishment of networks ofPLWHA (REFEM, REGAP+, AFIAG) Community • Funding for 909 Community-based organizations (OCB) • Support for traditional practitioners and village inidwives o Guides and materials (in local languages) for traditional practitioners in the areas of social mobilization, communication, and counseling ofPLWHA o Training of trainers for 75 traditional practitioners o Training of 176 traditional practitioners in prevention and counseling on HIV • Support for Orphans and Vulnerable Children: o 10,000 OVC received funding for school fees or benefited from academic support o 5,000 OVC received nutritional and academic support from ONG • Development of services for marginal groups o Preparation of a geographic mapping of prostitute sites and vocabulary used o Organization of services for sex workers in 5 sites in the K.ankan region • Distribution of condoms Component 2: Support to the public sector Ministry of Health • Training of health personnel • Equipment, laboratory consumables and drugs for SID testing and treatment, blood supply testing, testing and treatment of PLWHA 28 • Support for expanding service delivery o VCT: Renovation, equipment and support for 7 VCT centers: 5 (with PNPCSP)in Conakry (2), Mamou, N'Zerekore, and Lolan; and 2 (with the University of Montreal) in Mandiana and Kouroussa o PMTCT: Establishment and support for 10 sites: 5 (with PNPCSP) in Conakry (Lambanyi, Koloma, Coleah, Hafia and Mototo) and 5 (with the University of Montreal) in Kankan Region (Kouroussa, Siguiri, Bolibana, Mandiana, and Kerouane) o SID: Support for activities in Kindia (21 CS,3 HP and 1 HR), Mamou (17 CS, 2 HP and 1 HR), Labe (58 CS, 4 HP, and 1 HR), and Kankan (30 CS). o Nutritional and medical support for 551 PLWHA: 350 (with GTZ) in N'Z6rekore and 201 (with the University of Montreal) in Kankan • Support for training conducting studies for epidemiological surveillance • Support for solutions to the problem of hospital waste management Other ministries • General o Training of250 other staff from 16 ministries, other public sector organizations, and the private sector; .0 Training and operational support for key focal point staff from 5 ministries: Transport, Defense, Mines, Agriculture, Education and support for mainstreaming HlV into the sectoral plans o Training and equIpment • Training of3221 members of the ministerial departments (CMLS) and regional coordinating committees (CRLS) • Material support (computers, A V materials, etc.) for the CMLS and CRLS o Support for the implementation of action plans • 90 action plans at national and regional levels were adopted and funded o Sensitization of213,479 persons and their families associated with ministries • First-line Ministries o Ministry of Social Affairs: • Support for orphans and vulnerable children • Support for families ofPLWHA o Ministry of Communication • Installation of community radios in Kerouane, Bissikirima, Siguiri, Kouroussa, Macenta, Dinguiraye and Telimele with 45 technicians and 52 journalists/communicators trained • Financing of communication materials, production and diffusion of key messages o Ministry of Youth, Sports and Culture • Financing of communications materials, training, organization of general sensitization and peer education ' • Equipment and training of 12 CECOJE (Lelouma, Faranah, Kissidougou, Dinguiraye, Fria, Pita, Koubia, Dalaba, Mali, Macenta, Lola and N'Zerekore) o Education • Creation of the chair oflllV/AIDS to promote specialization within the m~dical school 29 • Formulation of the curriculum for instruction in HNIAIDS and training of 5000 teachers in the new curricula for pre-uriiversity, technical, and professional level schools • Establishment of 10 Anti-AIDS clubs at Teaching Training Institutes in Conakry (2), Kankan, Labe, Dalaba, Kindia, Faranah, Dubreka, Boke and N'Z6rekore • Promotion of peer education o Transportation • Inventory of the 29 most important truck stops in the country • Organization of a package of HN prevention services o Defense and Security • Organization of advocacy, peer education, sensitization, voluntary testing, etc. Component 3: Capacity building • Legislation o . Passage ofa law on the prevention ofHIV prevention and the protection ofPLWHA • Strategy development o Support for the evaluation of the National Strategy (2003-07) and formulation of the revised National Strategy (2008-12) o Formulation of a strategy to reduce the feminization of the epidemic o Establishment of a package of services to assist OVC o Formulation of a communications strategy • Formulation of guides, training documents, and other materials • Contracting for technical assistance in testing and treatment, behavior change, and condom procurement and distribution Component 4: Coordination, facilitation, and monitoring and evaluation • Support for establishment, recruitment and training of staff, and operating costs of the Executive Secretariat • Contracting of the Financial Management Agency • Establishment of systems for monitoring and evaluation, and contract management with financing of annual fmancial and periodic technical audits • Organization of the mid-term, final, and beneficiary evaluations • Sentinel surveillance and research o 1ST surveillance: Support for 8 surveillance sites: 3 exisiing and 5 new sites; sero- surveillance testing in these sites (with GTZ support) o Behavioral and biological surveillance survey for high risk groups (ESCOMB) 30 Annex 2b; Summary Quantitative Results ofthe Project Indlc< . " •• «~ •••• , CADRE DE LA REPONSE 11~cn~~~~~1'9~ I! If\jbre d! ministeres benefici~nt~e financement . ,.. .. , . . u . II! lr..1inisteres de Premiere Ii~ne . 7 7 7 8 7 7 43 IfU~l1ill~~~;d~ ~!~~emelig~!, c .... : .. :,...•.. t.... ., .. 13 15 20 13 12 5 78 I ( (~ntant des financements (en '000 USD) II i rMnis~rescie'premi~re"iigne' , ........ , 964 1058 1369 113 0 0 3504 III1. !M;;iS~..es cie deiiiciilmeiigne f ~ i T .>Y . . . . . . . . . . . . "." .~... •• ,- "" •• ' »> • • "• • ' " 324 660 1299 36 0 0 2320 I jilutres institutions !11Nllred'lnstitutions 4 5 6 4 2 2 23 i IrMOntani ciesiina'ncemenis (en ;000 USD) i f.Lrx.T.:.:"·'" "'.:.-" ... ". ,,,». '. ~". ~ "" • ,,, . . . . ". .... ". • • .. , , __ . . . . 25 155 276 119 575 \1 !Montantdes projetsfinances (en million FGN) ~ ~ris~" "'~ Nbd'hommes 93735 11 Nb de femmes I~f;;;";...i d~ ~ ~"""oii.. SA 1218' :I 12981 1604 'f:-~"""",cied.", 15682 ~~l~tl ~~~ltl 25500 14782 99107 Nbre d'unit6s de sang test6es 15682 13388 14782 86995 %d'unii6s tesiites. . . , . Viti LU .. . . pour Ie 100% 53% 100% 88% erN Ifbre de...sjtes fonctionneis (cumuiatiij dontMAP 41 1~ I 1~ I 2~ I 6~ I 7: ~ 74 5 33 Indleateurs 2002 2003 2004 2005 2006 2007 2008 2009 Total % I I~~i~~~:;:. \~m"i~ 2615 7 5985 22457 29 62087 44 5 47786 62 5 40155 81 5 81 5 Nine de FE iestiles 1862 3970 17644 47621 34433' 39893 :It:-'bre ~~. ~ ~ero positives (annuel) 70 149 599 1722., 1033 860 3.8% 3.8% 3.6% 2.2% :1'!~~ FE.:~H~ 3.4.% 3.0% :::. ; : : .... _ . .... _.. ." . " . ¥ .... "" .~'"' _ ...". ~" H" . Nbre de FE sous AAV 70 59 281 1145 652 783 !I~~e ~E+.mises sou~ MV Nbre d'enfants positifs 100.0% 39.6% 46.9% 66.5% 660 63.1% 341 91.0% 264 Nb..e d;eriiants sous AAV prophylaclique 13 52 182 482 266 231 ! 11~ ~ienian~ lTli~ ~()us MV .... . 73.0% 78.0% 87.5% IJ .ll.L................ ET SOINS iTRAlTEMENTS Irr!'!~~!~~j~~~ . . .. ij N~re ~!.~tes fo~clionnels (cumulati~ 1 4 8 11 22 33 46 46 i i jdontMAP I f ' ' : :'::~:. ........ ;~.. . .. ". . .. 1 1 3 3 5 5 5 I , N~re dEt PWlH beneficiant d'lO (an~uel) .I..! •. ,. , .• ........... . . 215 918 150 j Nbre de cas ayant besoin d'AAV (cum ulatif) 14000 16000 18000 23250 24235 26400 I Nb..e de cas sous'ARV{cumuiati6 ... , 215 500 2474 4699 5228 12650 14999 . " ." 111~::::t::e:s 118 382 841 1633 2068 . 2631 2296 2932 5313 7337 5850 9149 I~~~::::~::=:;.:~.. 3'.6% 15.5% 26.1% 22,5% 52.2% 513'.8% 78% 11~~=~v;jMTB imt~s. .1:01lc.Cl111111 i~llt. t~i~ 5404 478 8.8% 5404 335 6.2% iMlTIGAnON IIsOUtieii.Ux P\iViH ii fNbre (jiONQ;asso. c:iiappui auxPwi-i.. _ . l\ldontMAFi" " .".. ... . appuyees ... 6 8 11 15 27 62 84 92 I: ..,£: :;: .. :.. .... ' .............. ' Nbre total d'associations de PWlH (eumulatif) ..... . 6 1 6 2 6 2 7 6 6 12 8 18 22 29 I l~:J'~~'.... ... . . . .. ~ '1 'Y Soutlen aux OBI ,rI$1Wir:_im\.""~! 51313 52123 52435 52172 51426 50305 48880 47171 2980 6800 9300 122.91 5190 5.7% 13.2% 1a.:5~ 25.1% 11.0% 200 1095 571 2933. 10097 18185 200 1295 2500 5000 34 Annex 3: Economic and Financial Analysis 144. Like most other MAPs, the PAD for the Guinea MAP referred to the economic analysis carried out in previous reports for the Africa Region 37 and summarized the main findings as follows: • HIV/AIDS undermines the major determinants of economic growth (physical, human, and social capital) and has a negative effect on productivity levels, domestic savings and overall economic growth. • HIV/AIDS increases health costs and runs the risks of crowding out other key public health programs, such as immunization, maternal and child health, malaria and parasitic diseases. • Care and treatment of AIDS patients imposes high costs on families and reduces their earning capacity. • Family coping strategies may result in children abandoning school or the family cutting other health or social expenditures to unacceptable levels. 145. In the absence of analysis in the PAD, the question is whether the project focused on the most effective and efficient interventions given the prevailing epidemiological situation in the country. The table belo~8 provides estimates on the potential infections averted and the cost per infection averted and suggests that Guinea was focusing on the appropriate interventions, even if a number of them where not the most efficient. Cost per , High infection averted Low MSM Sex Workers « US$ 1,000) Medium Blood safety PMTCT (US$ 1,000- Condom distribution VCT 3,000) Workplace programs High Community (> US$ 3,000) mobilization Mass media STI treatment Education 146. lEG suggests other criteria for assessing the benefits of MAPs,39 including: (i) enhanced political commitment to controlling the epidemic; (ii) expanded and strengthened national and sub-national AIDS institutions for the long-run response; (iii) mobilization ofNGOs in the national response and reinforcement 37 See the "Economic Analysis ofHIV/AIDS" in the Multi-Country HIV/AIDS Program for the Africa Region (MAP) Project Appraisal Document (Report No. 20727 AFT, Annex 5) and the Second Multi-Country HIV/AIDS Program (MAP2) (APL) for the Africa Region (Report No. P7497 AFR). 38 World Bank (2008) The World Bank's Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, March, citing Bollinger and Stover (2007). 39 Committing to Results: Improving the Effectiveness ofHlV/AIDS Assistance (Washington, 2005). 35 of their capacity to provide access to prevention and care among the high-risk groups most likely to contract and spread the infection; and (iv) enhanced the efficiency of national AIDS programs. The ICR notes the extent to which the "with project" scenario has contributed in particular to (ii) and (iii) in Guinea. 36 Annex 4: Bank Lending and Implementation Support/Supervision Processes 37 ._~"'. _ _ • _ _ M _ _ _ '~' _ _ ' -_ _ _ _ . _ •• _ . _ " ' _ . _ ' : . -----------'-~----'--'~--'-'----'---l Salimatou Drame-Bah ogram Assistant 'AFMGN dministrative Support Thiemo Hamidou Diallo isbursement Assistant AFMGN isbursement ' - - ' - - - - - - ' - - . - ,- - (b) Staff Time and Cost Note: Breakdown by fiscal year is not available. SupervisionlICR FY02 7.4 5,088 FY03 28.(J 17,045 FY04 45.6 32,726 FY05 45.(J 37,218 FY06 ~1.(J 32,125 FY07 39.(J 27,701 FY08 37.3 25,153 FY09 19.4 21,522 FYI0 9.5 32,098 FYll 2,531 Total: 262.1 23,320; 38 Annex 5: Beneficiary Survey Results No/applicable Annex 6: Stakeholder Workshop Report and Results Not applicable 39 Annex 7: Snmmary of Borrower's ICR and/or Comments on Draft ICR 147. Evaluation context. The Borrower's final report of the Multi-sectoral AIDS Project includes chapters on: (i) the context, objectives, and methodology of the evaluation; (ii) the components, costs, and justification of the project; (iii) the performance of the different project components; (iv) the management of the fiduciary aspects of the project and a s~mary of project expenditures; and (v) the conclusions and recommendations of the evaluation. The Borrower's report was explicitly considered "qualitative" and intended to "reflect" on the overall results of the project and their implications for the country. 148. Country context. The Borrower's report briefly summarizes the overall characteristics of the country and the current epidemiological situation; it describes in more detail the country's early efforts to respond to the epidemic. 149. Overview of the Project's Outputs. The Borrower's report briefly summarizes the project components and activities; organizational arrangements for implementing the Government's response; and the arguments justifying the necessity of the project including: (i) the prevalence rate in the country, particularly among women; (ii) the efforts made by the Government to organize itself nationally and to benefit from community and non-governmental organizations (including those representing people living with lllV/AIDS); and (iii) the continuing lack of technical and financial resources, despite assistance from UN, bilateral, andNGO partners. The Borrower's report provides both an overall assessment of the project's results and a more detailed presentation by component. 150. Loeal response. The report concludes that while the project's objectives were realistic: (i) the organization of the local response was not sufficiently coordinated with the Bank-fmanced support to Rural Development Committees (CRD) established at commune level; and (ii) the project's fmancial resources were not sufficient to adequately cover the 303 CRD. Despite these weaknesses, the local response component managed, according to those interviewed, to achieve its objectives, notably: (i) an inventory/assessment of local NGOs capable of managing small projects; (ii) support for an effective regional selection process for small projects. In particular, the evaluation cites the following results: • at the commUne level: (i) training of local authorities and integration of the lllV response into ~e local CRD development plans; (ii) support for the implementation of sub-projects by 909 community-based organizations; and (iii) the establishment of local networks of people living with lllV; • at the yillage level: (i) village development agents were trained; (ii) communications equipment was distributed; (iii) traditional healers were trained to provide information; and (iv) condoms were distributed within the context of the Oncho initiative; and • at the level of particularly wlnerable populations: (i) services were established for commercial sex workers; (ii) school fees ~ere paid for some 10,000 orphans and wlnerablechildren; 151. In addition, the project worked closely with the four principal labor unions and fmanced six operational plans which included establishment of three counseling and testing sites for miners. 152. Sectoral response. Similarly, achievement of the objectives·ofthe sectoral response was estimated at 80% even though there were variations itl the level of performance of the ministries. The bulk of the activities focused on the health sector with: (i) training on a variety of topics; (ii) establishing of five counseling and testing sites and five prevention of mother to child transmission sites; and (iii) provision of drugs and consumables. Treatment was fmanced for: (i) persons living with mv/AIDS (350 in N'zerekore in collaboration with GTZ-IS and 201 in Kankan in collaboration with the University of Montreal); and (ii) sexually transmitted diseases in Kindia (21 health centers, 3 district hospitals and 1 regional hospital), Mamou (17 health centers, 2 district hospitals and 1 regional hospital), Labe(58 health centers, 4 district. 40 hospitals and 1 regional hospital) and Kankan (30 health facilities). Surveillance of STDs was also strengthened in collaboration with GTZ-IS. 153. Other government structures received support: (i) at central level, more than 90 operational plans were financed and 5000 teachers were trained in the revised curriculum containing HIV-related material; and (ii) coordinating committee members at regional and district levels received training. The project also promoted: (i) legislative initiatives, policy documents (for orphans and vulnerable children, the handicapped, and program strategies; (ii) youth services centers in 12 districts; (iii) local radio stations in 8 districts; .and (iv) a range of sensitization activities. 154. Capacity building. In addition to producing educational and informational materials, the project successfully introduced HIV/AIDS into the curriculum of the medical and nursing schools. 155. Coordination, facilitation and M&E. Development of monitoring and evaluation capabilities was mixed: Materials and equipment were procured, but inadequate staffmg and fmancing at the regional level as well as the destruction of project property resulting from political strife represented significant handicaps for the project. Sentinel surveillance and behavioral change surveys were conducted and a strategy for communicating the results (including a web site) was implemented. 156. Summary of the Project's Results. The Borrower's report presents the results of the project with respect to the PD~ and intermediate outcome indicators. 157. Assessment of the Implementation Arrangements. The Borrower's report summarized the implementation arrangements for coordination (through the National Committee), for project management (through the Executive Secretariat and the Financial Management Agency) and concluded: • At national level, the National Committee met only twice in six years was not considered effective; at regional and district levels, the committees were never operational due to a lack of financial resources. • Both the Executive Secretariat and the Financial Management Agency were considered very effective in carrying out their responsibilities. This was due to: (i) the effective working relationships built on the existence of an implementation manual; and (ii) the management style of the Executive Secretary. • Within the Executive Secretariat, the volume of work (particularly with the arrival of the Global Fund) was excessive for the existing staff. • Particular weaknesses were noted in the organization of procurement, within the Executive Secretariat, within the different ministries, and at the regional and district levels. • Particular strengths were noted in the organization of financial management and the achievement of its objectives, although there were somewhat different perceptions of its role by the ES and the FMA and debate over the responsibilities of the two agencies in validating expenditures. 158. Estimation of project costs and expenditures. The Borrower's report reviewed: (i) the initial estimates for project expenditures;. (ii) the unsatisfactory performance of the Borrower in meeting counterpart funding obligations (and the subsequent amendment of the DCA to eliminate them); (iii) the procedures used to disburse project funds through each of the respective accounts. A detailed presentation of project expenditures was included as an annex. 159. Conclusions. The Borrower's report cited in particular results achieved in collaboration with: (i) civil society (and the implementation of more than 900 sub projects); (ii) the private sector (and especially the Chambre des Mines); (iii) the public sector (with the expansion of testing and treatment services and youth services centers); and (iv) the Executive Secretariat (through the development of program implementation capacities). 41 Annex 8: Comments of C;o-financing partners and Other Partners/Stakeholders Not applicable 42 Annex 9: List of Supporting Documents National documents Laws. decrees. and regulatOly texts • Loi Ll20001010IAN du _"_portant sur la sante de la reproduction. • Loi Ll200510251AN du 22 novembre 2005 relative a la prevention, la prise en charge et Ie controle du VIHlSIDA. • Ordonnance No. 056120091PRGISGG relative a laprevention. la prise en char~e et Ie controle du VIHlSIDA en Republigue de Guinee. • Arrete 18561PMlCABI2002 du 06 Mai 2002, portant Attributions et Composition du Secretariat Executifdu CNLS • Arrete N'Al2002125611MSPISGG du 03 Juin 2002, portant Attribution et OrKanisation du Programme National de Prise en Char~e Sanitaire et de prevention des ISTIVIHlSIDA Policies and strategic plans • Ministere de I 'economie, des finances et du plan (2007), Document de strate~ie de la reduction de la pauvrete, • Ministere de la Sante et de I 'Hygiene Publique (2003), Plan strategique de developpement sanitaire 2003-2012. • Ministere de la Sante et de I 'HYgiene Publigue (2004), Plan national de develol!J!ement sanitaire 2005-2014. • Ministere des Aifaires Sociales (2007), Politique nationale de l'enfonce integrant la dimension OEY. Program documents Strategic plans • CNLS (2002), Cadre strateKigue national de lutte contre les ISTIVIHlSIDA 2003-2007. • CNLS (2007), Revue du cadre strategique national 2003-2007. • CNLS (2008), Cadre strate~igue national de lutte contre les ISTIVIHlSIDA 2008-2012. • CNLS(2008), Plan Qperationnel du Cadre Strate~igue National (2008-2012). • Bangue Mondiale (2002), Plan national de ~estion des dechets medicaux en Guinee. • CNLS (2004), Strate~ie d'information et de communication. • Ministere des Aifaires Sociales, de la Promotion Feminine et de l'Enfonce (2005), Rapport de l'atelier d'elaboration des strategies d'implication des femmes dans la lutte contre la /eminisation du VIHlSIDA. • Ministere de la Sante et de I'HYKiene Publigue (2007), Plan nationald'extension de laprise en char~e des PVVIn . • Ministere de la Sante et de l'/fygiene Publigue (2008), Plan national d'extension de la prevention de la transmission mere enfant du VIH (PTME) 2008-2012. Normes. strategies. and protocols • MSHPICNLS (2005), Normes et procedures en prevention de la transmission mere enfant du VIH(PTME). • MSHPICNLS (2009), Protocol de prevention et .de prise en charge integrees des victimes de viols et violences sexuelles en Guinee. 43 • CNLSlFaisons Ensemble (2009). Document national des politigues. normes et procedures en. conse;1 et depista~e du VIR • CNLS (2007), Acceleration ver I 'Qc:ces universel pour la prevention, Ie traitement, les soins et Ie soutien. • CNLS (2008). Vers larealisation de I'acces universel aux services de prevention. de traitement. des soins et d'aI!J!ui en Republigue de Guinee. Monitoring and evaluation • Fonds Mondial (2008). Audit du systeme national d'information sanitaire de Guinee. • CNLS (2008). Plan de SuM-Evaluation du Cadre Strategigue National 2008-2012. Studies • Overviews o CNLS (2004). Impact socio-economigue du VIHlSIDA en Republigue de Guinee. o PSSIGTZ (2008), Etude CAP. o CNLS (2009), Cartographie des risques et yulnerabilites, des offres de service et des interventions ,dans Ie cadre de la riposte a I 'epidemie du VIH en Guinee. o PCSIChambres.des Mines (2009). Etude de faisabilite pour I'integration de laprise en char~e medicale et psycho-sociale des malades du SIDA dans 7 sites miniers des trois principales zones minieres. • Discrimination o Mariam Camara (2005), Analyse de la situation des droits humains lies au VIHlSIDA en Republique de Guinee. (ROSEGUUAFRICASO) o CNLSlREGAP+ (2009). Etude sur la stigmatisation et la discrimination des PVVIH en Guinee. • Evaluations o GTZ (2008). Revue a mi-parcours du PMSlPhase 11 a o CNLS (2006), Evaluation mi-parcours du cadre strategique de .Iutte contre Ie SIDA 2003-07. o CNLS (2006), Extension de la couverture de la lutte contre Ie SIDA dans les CRD et cu. . o CNLS (2006). L 'extension de lacouverture de la lutte contre Ie VIHlSIDA dans les collectivites locales. o CNLS (2006). RaI!J!ort de I 'evaluation de la mise sous ARV. o CNLS (7006). RaI!J!ort d'evaluation du systeme de ~estion des dechets medicaux. biomedicaux et du plan national de ~estion en Guinee. Survexs and surveillance • Ministere de la Sante et de I'Hygiene Publique (2004), Rapport de I'enquete nationale de surveillance sentinelle du VIH et de la syphilis. • Ministere du Plan (2005). Enguete Demographigue et de Sante. • Universite de Montreal (2006), Repertoire des environnements prostitutionnels de Gui1Jee. • CNLS (2007). Enguete de surveillance comportementale et biologigue du VIHlSIDA en Guinee. fESCOMB) • Ministere de la Sante et de I'Hygiene Publigue (2008). RaI!J!ort de I'enguete nationale de surveillance sentinelle du VIH et de la syphilis. , • MSHP (2009), Enquete de surveillance de seconde generation (Conakry). • Health Focus (2009), Enquete de surveillance de seconde generation (Co"idor Boke). 44 • CNLS (2007), Rapport annuel du PMS • CNLS(2008), Rapport annuel du PMS • RSF • External audits / Rapports annuels d'audit Monitoring and evaluation documents • West African Consultants (2005), Audit technique du Projet Multi-sectoriel SIDA 2003-04. • CNLS (2006), Revue a mi-parcours du Projet Multisectoriel de.lutte contre Ie SIDA (PMS). . • CNLS (2006). Ral!Port de ['atelier national de la Revue a mi-parcours du Pro;et Multisectoriel de lutte contre Ie SIDA (PMS). • CNLS (2009), Ral!Port d'evaluation finale du PMS. 46 • UNGASS o UNGASS (2005), UNGASS Report. Rapport de situation sur la riposte nationale a I 'epidemie de VIHlSIDA Senegal o UNGASS (2006), UNGASS Report Update. o UNGASS (2008), Rapport UNGASS. o UNGASS (2009), Rapport UNGASS 2008. o UNGASS (2010), Rapport UNGASS. • ONUSIDA o UNAIDS (2004), Epidemiological Fact Sheet. o ONUSIDAIGuinee (2008), Le point sur I 'epidemie du SIDA et de la reponse en Repuhlique de Guinee. o UNAIDS (2008), Fact Sheet Update. • OMS o WHO (2005), Assessment. Project documents Technical and legal • PAD • DGA • Aide-memoire and Implementation Status Reports Organizational documents • Manuel d'operations Implementation documents • Component 1 o CNLS (2006), Repertoire des ONG/Associations de lulte contre Ie SIDA (Vision Consulting Intemational). o CNLS (2007), Evaluation des contrats de performance finances par la composante RIL du PMS. • Component 2 o PMS (2003), Rapport d'evaluation de la capacite de gestion financiere des ministeres de premiere ligne • Component 3 o AGBEF, Guide National pour I 'Education Sexuelle o Ministere de la Communication, Guide national pour la Communication Sociale o AGBEF, Guide pour Ie Conseil et I'appui Psychologique (Counseling) o Projet SIDA 3, Guide pour la prise en charge des 1ST o CNLS, Guide de Mobilisation sociale • Component 4 Periodic reporting • CNLS (2003), Rapport annuel du PMS • CNLS (2004), Rapport annuel du PMS • CNLS (2005), Rapport annuel du PMS • CNLS (2006), Rapport annuel du PMS 45 l 4°W W SO Thi' map """ produced by the Mop De'ign Un;' 01 The World Bank. ¥\..--V'~ The boundaries; colors, denominations and any other information .hown an thi' map do noI imply. an 'he part 01 The world Bank Group, any ;vdgmenl 00 the legal stafus 01 ony ferri/ory, or ony endorsement or occeplonce of such boundaries. / " Nyogossolo r) Ta6amod ~ .l\ "'-t ' ,- -........ "... ,/ / ..""". ) '"L (--' \ \ \ ...... \ .- "'.. ' '1 r ) lOON t;; { ATLANTIC OCEAN l 4°W GUINEA o SELECTED CITIES AND TOWNS ® PREFECTURE CAPITALS ® REGION CAPITALS ® NATIONAL CAPITAL ~ RIVERS - - MAIN ROADS - - RAILROADS z PREFECTURE BOUNDARIES ~ 65 ;,. ~~I----------------------------------------~