Document of The World Bank Report No: ICR0000650 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-35570 IDA-3557A IDA-H1600) ON A CREDIT AND GRANT IN THE AMOUNT OF SDR 20.7 MILLION (US$ 27 MILLION EQUIVALENT) TO BURKINA FASO FOR A HIV/AIDS DISASTER RESPONSE PROJECT December 20, 2007 Human Development I Country Department AFCW1 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective May 22, 2001) Currency Unit = Franc CFA 731 FCFA = US$1.00 US$0.0137 = 100 FCFA FISCAL YEAR January -- December ABBREVIATIONS AND ACRONYMS ACTAfrica AIDS Campaign Team for Africa MAP Multi-Country HIV/AIDS Program AIDS Acquired Immuno-Deficiency Syndrome M&E Monitoring and Evaluation API AIDS Program Effort Index MIS Management lnformation System ARVT Anti-retroviral Therapy MOH Ministry of Health BSS Behavioral Surveillance Survey NGO Non-governmental Organization BCC Behavioral Change Communication PAD Project Appraisal Document CAMEG Central Procurement Unit for Essential Drugs PA-PMLS HIV/AIDS Disaster Response Project and Medical Supplies PDO Project Development Objective CAS Country Assistance Strategy PHRD Population and Human Resources Development CISSE Health and Epidemiologic Surveillance Center PMU Project Management Unit CMLS Ministerial Committee of Fight Against AIDS PLWHA People Living with HIV and AIDS CNLS-IST National Council for the Fight Against PADS Health Development Support Program HIV/AIDS/STI PMTCT Prevention of Mother-to-Child Transmission CPLS Provincial AIDS Committee PNGT2 Second Community Based Rural Development CVLS Village AIDS Committee Project CWIS Core Welfare Indicators Survey PPLS Population and AIDS Control Project DAF Directorate in charge of Administration and PRSC Poverty Reduction Support Credit Finances PRSP Poverty Reduction Strategy Program DCA/DGA Development Credit Agreement/ Development QAG Quality Assurance Group Grant Agreement QER Quality Enhancement Review DHS Demographic and Health Survey SP/CNLS-IST Permanent Secretariat of the National DMP Department of Preventive Medicine HIV/AIDS/STI Council DOTS Directly Observed Treatment Short-term SP/CONAPO Secretariat of the National Population Council DRS Regional Health Directorate STI Sexually Transmitted Infection FM Financial Management TAP Treatment Acceleration Program GAMET Global Monitoring and Evaluation Team TB Tuberculosis HIV Human immunodeficiency virus TTL Task Team Leader HSSMAP Health Sector Support and Multi-Sectoral AIDS UGF Unité de Gestion Financière (PMU) Project UNAIDS Joint United Nations Programme on HIV/AIDS HTA High Transmission Area UNGASS UN General Assembly IAPSO Inter-Agency Procurement Services Office VCT Voluntary Counseling and Testing IEC Information, Education & Communications ISR Implementation Status Results and Report KAP Knowledge, Attitudes and Practices KPI Key Performance Indicators Vice President: Obiageli Katryn Ezekwesili Country Director: Ishac Diwan Sector Manager: Eva Jarawan Project Team Leader: Tshiya Subayi-Cuppen ICR Team Leader: Johanne Angers BURKINA FASO HIV/AIDS DISASTER RESPONSE PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Profile 1. Project Context, Development Objectives and Design................................................... 1 2. Key Factors Affecting Implementation and Outcomes................................................... 5 3. Assessment of Outcomes..................................................................................... 12 4. Assessment of Risk to Development Outcomes........................................................... 16 5. Assessment of Bank and Borrower Performance......................................................... 16 6. Lessons Learned............................................................................................... 19 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners......................... 20 Annex 1. Project Costs and Financing......................................................................... 22 Annex 2. Outputs to Components.............................................................................. 23 Annex 3. Economic and Financial Analysis.................................................................. 29 Annex 4. Bank Lending and Implementation Support/Supervision Processes........................... 32 Annex 5. Beneficiary Survey Results.......................................................................... 34 Annex 6. Stakeholder Workshop Report and Results........................................................ 35 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR................................. 36 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders.................................. 47 Annex 9. List of Supporting Documents...................................................................... 48 Annex 10. Project Development Objectives (PDOs) Achievements...................................... 51 MAP A. Basic Information HIV/AIDS Disaster Country: Burkina-Faso Project Name: Response IDA-35570,IDA- Project ID: P071433 L/C/TF Number(s): 3557A,IDA-H1600 ICR Date: 11/28/2007 ICR Type: Core ICR Lending Instrument: APL Borrower: BURKINA FASO Original Total XDR 17.3M Disbursed Amount: XDR 19.9M Commitment: Environmental Category: C Implementing Agencies: National AIDS Council (SP-CNLS) Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 09/12/2000 Effectiveness: 03/04/2002 03/04/2002 02/04/2003 Appraisal: 03/26/2001 Restructuring(s): 06/02/2005 12/29/2006 Approval: 07/06/2001 Mid-term Review: 06/18/2004 Closing: 12/31/2005 06/30/2007 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Moderately Satisfactory Quality of Supervision: Moderately UnsatisfactoryImplementing Agency/Agencies: Moderately Satisfactory Overall Bank Overall Borrower Performance: Moderately UnsatisfactoryPerformance: Moderately Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Performance Indicators any) Rating Potential Problem Project at No Quality at Entry (QEA): Satisfactory any time (Yes/No): Problem Project at any time Quality of Supervision No Satisfactory (Yes/No): (QSA): DO rating before Moderately Satisfactory Closing/Inactive status: D. Sector and Theme Codes Sector Code (as % of total Bank financing) Original Actual Central government administration 15 15 Health 74 74 Other social services 6 6 Sub-national government administration 5 5 Theme Code (Primary/Secondary) Gender Secondary Secondary HIV/AIDS Primary Primary Health system performance Secondary Secondary Participation and civic engagement Primary Primary Population and reproductive health Secondary Secondary E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Ishac Diwan Hasan A. Tuluy Sector Manager: Eva Jarawan Rosemary T. Bellew Project Team Leader: Tshiya Subayi-Cuppen Miriam Schneidman ICR Team Leader: Johanne Angers ICR Primary Author: Johanne Angers Peter Bachrach F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) To assist the government in implementing the 2001-05 HIV/AIDS strategic plan, in order to slow the spread and mitigate the impact of the HIV/AIDS epidemic. Specific objectives are to: (a) Scale up, expand and improve preventive activities in an effort to lower the risks of transmission; (b) Strengthen capacity to provide care, treatment and support to those infected or affected by the epidemic; and (c) Mitigate the socio-economic impact on affected households and communities. Revised Project Development Objectives (as approved by original approving authority) No change of PDO. (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Target Completion or documents) Values Target Years Decrease the percentage of non-married individuals who report having 2 or more sexual Indicator 1 : partners. - Females - Males Value quantitative or Females: 4% Females :2% Females: 1.6% Qualitative) Males : 13% Males: 10% Males: 4.9% Date achieved 03/31/1999 12/31/2005 06/30/2007 Comments (incl. % Source: CWIS 2007. achievement) Indicator 2 : Increase the percentage of men who report having used condom in the past 12 months Value quantitative or 13% 17% 24.6% Qualitative) Date achieved 03/01/1999 12/31/2005 06/30/2007 Comments (incl. % Source: CWIS 2007. Indicator eliminated during the Grant approval in 2005. achievement) Increase (by 20%) condom utilization rates at previous high-risk sexual contact - Females (15-45) - Males (15-45) Indicator 3 : - Females (15-24) - Males (15-24) - Female sex workers - Truckers - Miners Females (15-45) : Females (15-45) : Females (15-45) : 59% 75% 64% Males (15-45) : 42% Males (15-45) : 60% Males (15-45) : 73.6% Value Females (15-24): 77% Females (15-24): Females (15-24): quantitative or Males (15-24): 79% 80% 66.3% Qualitative) Female sex workers: n.d. Males (15-24): 90% Males (15-24): 70% Truckers: n.d. Female sex workers: Female sex workers: Miners: n.d. 60% n.d. Truckers: 70% Truckers: n.d. Miners: 90% Miners: n.d. Date achieved 03/01/1999 06/30/2007 06/30/2007 Comments Source: CWIS 2007; Doc. provided on female sex workers; truckers; and miners were (incl. % taken from a 2005 survey and cannot be considered as a measure of results in 2007. The achievement) surveys were carried out to establish a baseline for Comp. 3. Indicator 4 : Decrease by 20% the number of persons living with HIV/AIDS and have had declared cases of discrimination and stigmatization. Value quantitative or n.d. n.d. n.d. Qualitative) Date achieved 03/01/1999 12/31/2005 06/30/2007 Comments (incl. % Though negotiated under the original credit, this outcome indicator has never been achievement) monitored. (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Target Completion or documents) Values Target Years Increase the percentage of sexually active individuals who know that they can avoid Indicator 1 : contracting HIV by using a condom: Females Males Value (quantitative Females: 24% Females: 50% Females: 88.6% or Qualitative) Males: 57% Males: 80% Males: 90% Date achieved 03/01/1999 12/31/2005 06/30/2007 Comments (incl. % Source: CWIS 2007. achievement) Increase percentage of sexually active individuals who know that a person who looks well Indicator 2 : can be infected by HIV: Females (rural/urban) Males (rural/urban) Value (quantitative Females: 42/78% Females: 60/90% Females: 63.9/87.1% or Qualitative) Males: 67/88% Males: 75/92% Males: 70.7%/90.8% Date achieved 03/01/1999 12/31/2005 06/30/2007 Comments (incl. % Source: CWIS 2007. achievement) Indicator 3 : Increase by 20% the number of sexually active population receiving voluntary testing and counseling. Value (quantitative 610 732 199,767 or Qualitative) Date achieved 03/01/1999 12/31/2005 06/30/2007 Comments (incl. % Source: Secrétariat Permanent. Conseil National de Lutte contre le SIDA (SP-CNLS). achievement) Bilan Général 2006; Indicator eliminated during the Grant approval in 2005. Indicator 4 : Increase the number of pregnant women sero-positive who receive treatment to prevent mother-child transmission Value (quantitative n.d. 1000 1134 or Qualitative) Date achieved 06/02/2005 12/31/2006 06/30/2007 Comments (incl. % Source: SP-CNLS. Bilan général 2006. New indicator added during the Grant Approval in achievement) 2005. Indicator 5 : Increase the number of HIV infected people receiving ARV treatment. Value (quantitative 1000 5000 12,842 or Qualitative) Date achieved 06/02/2005 12/31/2006 06/30/2007 Comments (incl. % Source: SP-CNLS. Bilan général 2006. New indicator added during the Grant Approval in achievement) 2005. Increase by 25% the number of orphans who receive care and support: Indicator 6 : a) ministries b) in 13 provinces c) national Value Ministries: 1500; Ministries: 27.589; (quantitative n.d. In 13 provinces: In 13 provinces: or Qualitative) 40,000; 48,829; National: 100,000 National: 142, 418 Date achieved 12/31/2001 12/31/2006 06/30/2007 Comments (incl. % Source: Unité de gestion financère (UGF). for Ministries data, 2007; SP-CNLS. Bilan achievement) général 2006. New indicator added during the Grant Approval in 2005. Indicator 7 : Increase the number of subprojects by Community-based Organization (CBO) on HIV/AIDS awareness and prevention Value (quantitative 603 5000 13,135 or Qualitative) Date achieved 06/02/2005 12/31/2006 06/30/2007 Comments (incl. % Source: SP-CNLS. Bilan général 2006. New indicator added during the Grant Approval in achievement) 2005. Indicator 8 : Increase the number of HIV/AIDS awareness activities carried out by Ministries. Value (quantitative n.d. 5300 9872 or Qualitative) Date achieved 06/02/2005 12/31/2006 06/30/2007 Comments (incl. % Source: SP-CNLS. Bilan général 2006. New indicator added during the Grant Approval in achievement) 2005. G. Ratings of Project Performance in ISRs No. Date ISR Actual Disbursements Archived DO IP (USD millions) 1 10/15/2001 Satisfactory Satisfactory 0.00 2 01/22/2002 Satisfactory Satisfactory 0.00 3 05/06/2002 Satisfactory Satisfactory 1.00 4 11/07/2002 Satisfactory Satisfactory 2.05 5 12/17/2002 Satisfactory Satisfactory 2.10 6 02/25/2003 Satisfactory Satisfactory 3.14 7 05/27/2003 Satisfactory Satisfactory 4.69 8 11/26/2003 Satisfactory Satisfactory 9.12 9 05/26/2004 Satisfactory Satisfactory 11.46 10 08/11/2004 Satisfactory Satisfactory 13.56 11 03/19/2005 Moderately Satisfactory Moderately Satisfactory 19.09 12 08/24/2005 Moderately Satisfactory Satisfactory 21.88 13 03/09/2006 Satisfactory Satisfactory 25.65 14 01/10/2007 Satisfactory Satisfactory 28.30 15 06/29/2007 Moderately Satisfactory Moderately Satisfactory 28.17 H. Restructuring (if any) ISR Ratings at Amount Restructuring Board Restructuring Disbursed at Reason for Restructuring & Key Date(s) Approved PDO Change Restructuring in Changes Made DO IP USD millions Amendment of the DCA with 02/04/2003 N S S 2.92 extension of the closing date from December 2005 to December 2006 Agreement amending the DCA to reflect the supplemental Grant No. 06/02/2005 N MS MS 19.94 H160-BUR of SDR 3.4 million (US$5.0 million equivalent) and to change the results framework 12/29/2006 N S S 28.30 Closing date extended from December 2006 to June 2007 I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. At the time of project preparation, the most reliable available data suggested that Burkina Faso had the second highest HIV/AIDS infection rate in West African sub-region (after Côte d'Ivoire) and was in the generalized phase of the epidemic. HIV prevalence was estimated at 7.2% in the general population and between 3.8% and 8.4% in pregnant women. Other limited data on infection rates from studies, surveys and sentinel sites indicated: disproportionate geographical distribution (linked to heavy internal and external migratory flows) and large gender disparities in HIV with HIV prevalence rates among young women 15-24 more than twice as high as among their male counterparts; rapid increases among pregnant women, from less than 2 % in the mid 1980s to over 7 % a decade later, with some rates as high as 9-10 %; very high rates among vulnerable groups: commercial sex workers: 15-60 %; Sexually Transmitted Infection (STI) clinic patients: 16-42 %; TB patients: 34 %; and infection rates among infants born to HIV+ mothers as high as 20-25 % at the Banfora Regional Hospital Center in the Comoé Province. 2. The cumulative number of reported AIDS cases had reached about 17,000 in 2000, and this number was believed to represent only a fraction of the actual cases because of serious underreporting and the general stigma associated with the disease. Finally, the rapid rise in HIV infection rates was paralleled by a worsening TB epidemic with approximately 16,000 new cases each year and an estimated annual new TB case rate (140 per 100,000) similar to that of Kenya and Uganda. 3. Though clearly in imminent danger, Burkina Faso also had several advantages in organizing its response at the time: Quickly recognizing the gravity of the HIV/AIDS epidemic since the emergence of the first AIDS cases in 1986, the Government had: (i) prepared with UNAIDS assistance a diagnosis of the situation (Epidémie du VIH/SIDA au Burkina Faso: Diagnostics et réponses opérationnelles); (ii) drafted a strategic plan (Cadre stratégique de lutte contre le VIHISIDA et les IST 2001-05); (iii) adopted norms for treatment of STIs and for blood transfusion among others; and (iv) taken measures to establish the National AIDS Council (Secrétariat Permanent-Conseil National de lutte contre le SIDA, SP-CNLS). Through previous experiences with several Bank-funded projects (Health and Nutrition, and Population and HIV/AIDS), the Government had: (i) tested a number of potential strategies; and (ii) established an effective implementing unit at central level and mechanisms for providing decentralized funding. According to the 1999 Demographic and Health Survey (DHS), knowledge of HIV was virtually universal in the population (96 % of men and 87 % of women stated that they either knew of or had heard about the disease), though action lagged far behind (19.3% of men and 3.4% of women indicated that they had begun to use condoms for protection against infection). 4. With demonstrated Government commitment, an agreed-upon national strategy and coordinating structure, existing modalities to ensure rapid project implementation, and a population demanding a more active role in the fight against HIV/AIDS,1 Burkina offered positive conditions for accessing the 1See the Aide-Mémoire: Examen du Portefeuille des Projets IDA et Renforcement de la Lutte Contre le VIH/SIDA (June 2000), para. 5. 1 Multi-Country HIV/AIDS Program for the Africa Region, which had been approved by the Board on July 6, 2001. 5. In addition to meeting the eligibility criteria established for the MAPs, the project supported other strategic orientations in the country, including: the Poverty Reduction Strategy Program (PRSP) (2000) which focused inter alia on: (i) increasing access of the poor to basic social services, including health; and (ii) strengthening the ability of the health system to cope with HIV/AIDS, given the disease's prominence in the country's epidemiological profile; and the Country Assistance Strategy (CAS) (2000, updated in 2003 and 2005) which identified the following strategies for supporting the government: (i) mainstreaming HIV/AIDS activities into all areas of IDA assistance; (ii) continuing policy dialogue with authorities to ensure that HIPC funds are targeted for critical HIV/AIDS activities; (iii) ensuring that funds from the on-going Population and AIDS Control Project are effectively used for priority interventions; and (iv) preparing the HIV/AIDS Disaster Response Project on a fast track. No instrument other than a Specific Investment Loan (SIL) was considered at the time. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 6. As indicated in the Development Credit Agreement (DCA), the overall Project Development Objective (PDO) is to assist the Borrower to implement its HIV/AIDS Strategic Plan for 2001-05, in order to slow the spread, and mitigate the impact, of the HIV/AIDS epidemic through a multi-sectoral approach by: (i) the expansion nationwide to youth, women of childbearing age and other vulnerable groups2 of access to HIV/AIDS prevention, care and treatment; and (ii) the strengthening of the capacity of public, private and community institutions to design, carry out and monitor Subprojects and Work Programs. The Project Appraisal Document (PAD) presents the specific objectives somewhat differently to: (i) Scale up, expand and improve preventive activities in an effort to lower the risks of transmission. (ii) Strengthen capacity to provide care, treatment and support to those infected or affected by the epidemic. (iii) Mitigate the socio-economic impact on affected households and communities. 7. The PAD identified outcome and output indicators linked to prevention and to care and miti- gation; the following outcome indicators to measure project performance were agreed on in the DCA: (i) Decrease from 1998/99 to 2004/05 the percentage of non-married individuals who report having 2 or 3 partners: Females-from 4% to 2%; Males-from 13% to 10%. (ii) Increase from 1998/99 to 2004/05 the percentage of men who report having used condoms during the past 12 months from 13% to 17%. (iii) Increase of 20 percent in condom utilization rates among priority groups. (iv) Decrease of 20 percent in proportion of PLWHA reporting discrimination and stigmatization. 8. PDO indicators and Intermediate Outcome indicators3 are presented in the Data Sheet; additional 2In addition to youths and women of childbearing age, the other vulnerable groups included in the results framework were PLWHA, orphans and vulnerable children, widows and other poor women, sex workers, truckers, migrants, and miners. See Annex 1 of the PAD. 3There were no intermediate outcome indicators in the PAD or DCA, only outcome and output indicators. 2 indicators in the results framework of the PAD are discussed below and presented in Annex 10. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 9. Though substantial changes were introduced in the DCA in February 2003 to add a sub- component (to place 850 persons under ARV treatment, including an operational research program for 400 persons) the PDO were not revised. In June 2005, the DCA was amended to incorporate a supplemental grant financing (SDR 3.4 million or US$ 5 million equivalent) and included both minor and major changes in the Key Performance Indicators (KPIs): (i) Decrease from 1998/99 to 2004/05 the percentage of non-married individuals who report having 2 or more sexual partners: Females: from 4% to 2%; Males: from 13% to 10%. (ii) Eliminated. (iii) Increase (by 20%) condom utilization rates at previous high-risk sexual contact for: females (15-45), males (15-45), females (15-24), males (15-24), female sex workers, truckers, and miners. (iv) Eliminated. 10. As indicated in the Supplemental Grant Document, "the revised performance indicators (were intended to) reflect the addition of new project activities (particularly Anti-retroviral therapy treatment and prevention of mother to child transmission) and modifications of a few output indicators to be consistent with the national HIV/AIDS monitoring system." 1.4 Main Beneficiaries 11. The PAD devotes considerable attention (see Figure 6, PAD) to identifying priority target groups (considered the core transmitters of HIV), such as commercial sex workers and their clients, uniformed services, and highly mobile workers for scarce public resources but concludes that the generalized nature of the epidemic requires that other sexually active groups, such as women, youths, civil servants, private sector employees be addressed as well. 12. Thus, though a "primary target group" is not explicitly identified in the PAD, a wide range of potential beneficiaries are indicated in the discussions of the components; these include: line ministry staff and their families to promote preventive activities and to support those infected and affected by the disease (Component 1); Ministry of Health to finance identified program gaps and to expand care and treatment for those infected by the disease (Component 1); national and provincial authorities to strengthen planning and coordinating activities (Components 1 and 2); local communities to empower them to better cope with the HIV/AIDS epidemic and its effects (e.g., PLWHA, orphans and vulnerable children, etc.) (Component 2); and targeted vulnerable groups (e.g., youth, women of reproductive age, commercial sex workers, prisoners, truck drivers, migrant workers) to curb the spread of the pandemic (Component 3). 13. The Supplemental Grant Document broadly identifies the "beneficiaries" as the "population of rural and urban areas," and mentions the same groups as in the PAD (including a few others such as PLWHA receiving ARV treatment and pregnant women), and more specifically indicates quantified objectives for reaching these beneficiaries. 3 1.5 Original Components 14. Component 1. Line Ministry Work Programs (US$ 10.60 million equivalent) continued IDA financing from the Population and AIDS Control Project to support the multi-sectoral response by helping: 13 line ministries4 to prepare and implement annual work plans involving policy development, preventive interventions, psycho-social counseling, and capacity building; the Ministry of Health to develop HIV treatment and care activities (including ARV by focusing initially on formulating guidelines and strengthening health services); and the Permanent Secretariat of the national HIV/AIDS/STI committee (SP/CNLS) to strengthen oversight and policy formulation capabilities by: (i) planning, programming and coordinating national activities; (ii) organizing technical assistance and training; (iii) facilitating decentralization of program activities; and (iv) monitoring progress and facilitating exchange of best practices. 15. Component 2. Provincial Activities and Community Sub-Projects (US$ 5.10 million equivalent) built on Burkina's decentralization process, including IDA-funded experiences with management of health district plans (Health and Nutrition Project) and with community organization of HIV/AIDS activities (Community-Based Rural Development Project) to: support provincial authorities (in 13 of 45 provinces) to plan and coordinate HIV/AIDS activities; screen, approve and monitor community sub-projects; and build capacities of communities and associations to carry out sub-projects; and finance local community sub-projects focusing on: (a) awareness, advocacy, peer education and condom promotion; (b) home-based care and support for those infected and affected by the disease; (c) care of orphans; and (d) income-generating activities. 16. Component 3. Targeted Interventions (US$ 4.20 million equivalent) built on international experience with contracting for services and on the results of the Norwegian grant accompanying the IDA-funded Population and AIDS Control Project to recruit NGOs with specialized expertise and abilities both to carry out targeted interventions aimed at those groups critical to curbing the spread of the disease (e.g., youth, women of reproductive age, commercial sex workers, prisoners, truck drivers, migrant workers) and to serve as umbrella organizations for assisting smaller organizations which may not necessarily have the capacity to prepare projects for submission receive. 17. Component 4. Coordination, Monitoring and Evaluation (US$ 3.60 million equivalent) was intended to finance: a comprehensive monitoring and evaluation system for the national program; and a Project Management Unit to work closely with the SP-CNLS on technical issues and to be responsible for the administrative and financial management aspects of the project. 1.6 Revised Components 18. At the time of project design, antiretroviral therapy (ARVT) was not eligible for IDA support, but this policy was changed shortly after project effectiveness. At Government's request, intensive work began almost immediately to revise Component 1 to allow for care and treatment activities, including ARVs. By November 20025, (i) a three-pronged approach (involving both urban and rural service delivery models and a prospective two-year clinical trial through the Centre Muraz) had been agreed on; 4The list of the original thirteen ministries and the subsequent eight additional ministries may be found in Annex 2. 5See especially Annexes 7 and 8 of the Aide-Mémoire of November 2002. 4 and (ii) OPCPR had confirmed that national drug procurement and distribution agency (CAMEG) had the capacity to import ARV drugs in conformity with IDA procedures. Arrangements were finalized in January 2003 in discussions with IDA and WHO, and IDA agreed in February 2003 to the Government's request to amend the Credit to add a subcomponent to Component 1 to place 850 persons under ARV treatment, including an operational research program for 400 persons. 1.7 Other significant changes 19. Amendment of the DCA. In February 2003, an amendment was proposed with three objectives: (i) facilitate the introduction of a comprehensive care and treatment sub-component, including the financing of anti-retroviral drugs; (ii) simplify procedures to allow authorities to respond more rapidly to the epidemic; and (iii) extend the closing date by one year (from December 2005 to December 2006) to avoid interruption of treatment and allow for a smooth transition to a new IDA operation under the MAP framework. Since there were no changes in overall project objectives, the amendment was approved by the Regional Vice President. 20. It should be noted that the measures agreed on prior to amending the DCA contributed to the Government's readiness to rapidly expand treatment with resources from: (i) the Global Fund (beginning in 2003); (ii) the IDA-funded Treatment Acceleration Program (from 2005); and (iii) a number of other agencies (eg., Esther, Médecins Sans Frontière, Tan Aliz, etc.). 21. Supplemental grant. A supplemental grant (P088879) was approved on May 3, 2005 in the amount of SDR 3.4 million (US$5.0 million equivalent) and became effective on November 29, 2005. Though partly the result of rapid disbursement by the project, the supplemental was justified under OP 13.20 based on: (i) fall in the US dollar, which resulted in a loss of US$2.6 million relative to prevailing exchange rates during implementation; (ii) the Bank's decision to retroactively classify the project as "category B" and to require implementation of a proposed $1.8 million medical waste management action plan not foreseen during project design; and (iii) conflict in Côte d'Ivoire, together with rising international oil prices, which increased the cost of transport and materials in Burkina by more than 20%. 22. Other DCA amendments. In addition to February 2003 amendment, a reallocation of the project proceeds was granted in November 2004. After approval of the supplemental grant, a reallocation and a two-month extension of the closing date was granted in December 2006 to February 28, 2007 and subsequently extended to June 30, 2007. A final request for reallocating project funds was agreed on in June 2007. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 23. Following an IDA portfolio review identifying pertinent HIV/AIDS actions (June 2000), project preparation was carried out from September 2000 to July 2001 and involved: two preparation missions (September and December 2000), a Quality Enhancement Review (January 2001), an appraisal mission (April 2001), project negotiations (May 2001), and Board approval (July 2001). 24. Project preparation was informed by the Bank's strategic approach to HIV/AIDS (Box 3 in the PAD) and benefited from: (i) background analysis and existing documentation available in Burkina; and (ii) prior experience from Burkina's two previous IDA-financed projects (Health and Nutrition and Population and AIDS Control Projects) (Boxes 2 and 4 in the PAD). In addition, a number of preparation studies were financed by the Population and AIDS Control Project and by a PHRD grant. 5 25. Background analysis in the PAD included: (i) an overview of the HIV/AIDS situation in Burkina (and elsewhere in Africa) and a more detailed epidemiological annex containing additional information on STIs, TB, and blood transfusion; (ii) estimates of the potential economic costs of the epidemic (though the annex addressing the economic justification for the project refers only to the overall MAP justification); and (iii) a summary of the Government's evolving strategic response to HIV/AIDS and discussion of the main issues of effective targeting and scaling up of multi-sectoral approaches. 26. Project preparation benefited from prior implementation experience: (i) the Health and Nutrition Project's innovation allowing a disbursement category to fund annual work programs, which became the basis for financing line ministries and decentralized authorities (Component 1); and (ii) the Population and AIDS Control Project's piloting (in 2000-01) of a community driven scheme, which subsequently provided a model to be scaled up under the new project (Component 2). In addition, the PHRD grant funded studies which addressed targeting (geographical and socio-cultural) and vulnerable populations (laborers and orphans) and which served as a basis for the targeted interventions (Component 3).6 Finally, the PHRD grant also financed preparation of the project implementation manual (which was one of the conditions for effectiveness). 27. Preparation included dialogue and consensus (with the Government and other partners) on the basic principles of the proposed project (an integrated multi-sectoral approach, capacity building at all levels, and decentralized resources with both flexible procedures and appropriate controls) and on institutional arrangements leading to the strengthening of the SP-CNLS. 28. Finally, the PAD included some specific annexes in response to the QER and the Decision Meeting requests for more details about: the mechanics for how the project would operate (Annex 15 of the PAD) and the principles and procedures for how the funds would flow (Annex 6 of the PAD); a detailed first year program emphasizing the steps needed for this project to reach what the QER characterized as "a state of true readiness" (Annex 12 of the PAD); the subcontracting arrangements (including criteria for judging proposals) for channeling support to line ministries, provincial and community actions, and targeted interventions through NGOs (Annexes 2d and 13 of the PAD); and monitoring and evaluation in general and specific studies addressing key issues (e.g., orphans, migrant workers, etc.) in particular (Annex 11 of the PAD). 29. In sum, the preparation: (i) carried out appropriate background analysis based on the Bank's strategic directives and comparative advantages; (ii) efficiently incorporated lessons from previous projects and prepared detailed annexes indicating modalities for implementing the proposed project; (iii) effectively promoted the institutional arrangements best suited for the implementation of the project; and (iv) involved the different partners. Thus, while the project was based on the standard MAP design, it was significantly further advanced than similar MAPs in other countries at the time of approval.7 6This may have been the first MAP to include a specific component (Component 3) for reaching high risk groups and core transmitters as recommended in Martha Ainsworth and A. Mead Over, Confronting AIDS: Public Priorities in a Global Epidemic (Oxford 1997). For a recent description of the methodology, findings, and conclusions used in this exercise, see Maria Khan, et al., "HIV-Related Sexual Behavior in Urban, Rural and Border Areas of Burkina Faso," AIDS Behavior, 10 (September 2006), 607-617. 7In hindsight, the non inclusion of impact measures or of any likelihood of attribution to the project seems to have been a prudent design decision which anticipated later Bank thinking (e.g., with respect to HIV prevalence targets). 6 30. In three areas, however, the overall high quality of the preparation (and its relatively seamless continuation of the previous project) turned out to be deficient: the assessment of risks and adequacy of the risk mitigation measures seem oddly discordant (e.g., with respect to communities), incomplete (e.g., the components to outputs analysis), and misjudged (e.g., absorptive capacity of line ministries, local authorities and communities, the acceptance VCT, the availability of drugs); neither the PHRD studies nor the extensive efforts to operationalize monitoring and evaluation in the PAD (and its importance for a project based on "learning by doing") were effectively integrated into project implementation; and the difficulties of formalizing arrangements for national AIDS coordination and for project implementation at central level (predicted at the QER) were greater than anticipated by the preparation team. 31. Two other issues not treated during preparation later involved substantial additional work during project implementation: (i) the introduction of ARVs (mentioned in the PAD but addressed in greater detail in the minutes of negotiation); and (ii) medical waste management (recognized subsequently to have been incorrectly omitted based on the original project classification). 32. Finally, minutes of the negotiations identify two issues not resolved during preparation and only addressed (sometimes with difficulty) during implementation: decentralized and flexible procedures as presaged by the disagreement over whether to domicile the special account in the Central Bank or in a commercial bank; and institutional arrangements as indicated by the maintenance of the National AIDS Secretariat (SP-CNLS) within the Presidency, the existing Project Management Unit (Unité de Gestion Financière or UGF) within the Ministry of Finance, and the commitment to merge UGF within the SP-CNLS by January 2004 at the latest. 2.2 Implementation 33. The original credit was approved by the Board on July 6, 2001 for an amount of SDR 17.3 million (US$ 22.0 million equivalent) and became effective on March 4, 2002, with delays due mostly to the difficulties of recruiting personnel for the SP-CNLS. 34. Though based on demonstrated approaches from previous projects and using the experienced personnel from the PMU of the Population and AIDS Control Project (through retroactive financing), initial implementation of the project began slowly and exhibited problems, some of which (as noted in the ISRs8) persisted throughout the implementation period, as summarized by component below: Component 1/Line ministries: a lack of standardization in presenting and measuring the results of the annual work programs, delays in approval, and variable efficacy and efficiency among ministries particularly with regard to the cellules relais at decentralized levels; Component 1/Ministry of Health: modest interest, a separate (and parallel) planning process for both the central CMLS-Health and the districts (with submission and approval coming sometimes as late as October), and slow disbursement despite repeated urging to move quickly on care and treatment, which was followed by improved disbursement after the introduction of the district funding mechanism (Programme d'appui au développement sanitaire, PADS); 8Because of a glitch in migrating information in the ISRs, the same issues and actions appear in all fifteen ISRs; as a result, the identification of issues was done retrospectively by the ICR team. 7 Component 1/SP-CNLS: concerns expressed in the early years of the project about weak capacity and inadequate program coordination; Component 2/Provincial and Community activities: ambitious capacity building in the 13 provinces followed by rapid scaling up and disbursement of project funds; Component 3/Targeted interventions: persistent delays in organizing the tender, evaluating the offers, and awarding the contracts; Component 4/Monitoring and evaluation: constant consultant missions (including five missions from the Global Monitoring and Evaluation Team (GAMET)) with very limited results and no discernible use of data for management. Component 4/Project coordination: generally satisfactory with some occasional weaknesses noted in financial management and procurement. 35. The project moved essentially at two speeds, with the line ministries, the provincial/community sub-projects, and the project coordination sub-components quickly scaling up and disbursing rapidly while the other sub-components advanced much more slowly. The ISR ratings did not make this distinction; summary ratings for PDO and IP were almost uniformly "satisfactory" throughout with: (i) a minor recalibration upon the introduction of the new ratings system in 2004; and (ii) a single divergence between the PDO and IP in 2005. A more accurate rating should probably have downgraded the PDO more substantially from 2004 on and maintained the IP at MS (which is where it finished).9 36. A major theme emerges from the various documents describing project implementation. Within nine months of effectiveness, the project was considered a "relatively well disbursing MAP operation" and within eighteen months, disbursements (particularly for Ministry plans including care and support, introduction of ARVs, and community subprojects) were such that the Task Team was signaling the need for a supplemental or a follow-on project. Contributing to the increasing pace of disbursement was the suggestion from high level Bank management that resource availability should not be considered an issue and that unplanned but justified activities (e.g., the pilot project in Samnatenga ) should be initiated rapidly. 10 From November 2003 on, insufficient resources became a preoccupation for project management and the Task Team. 37. With increasing disbursements and a non-functional management information system, the Task Team expressed concern (backed up by an analysis of expenditures indicating an abnormally high proportion of expenditures on travel and per diems) about the linkage between disbursements and results. 38. While the mid-term review, scheduled for June 2004, should have provided the occasion to examine these concerns, the ISRs for the period indicate that institutional tensions were noted between PA-PMLS (the Bank's project) and SP-CNLS (the overall Government program). SP-CNLS strongly recommended that a project review not be done separately from the mid-term review of the national strategy, but PA-PMLS proceeded with a number of evaluation studies, which were deemed to be of dubious quality by the Task Team (and are not cited among the project's documents). The Task Team meanwhile carried out a project MTR in June 2004 with a number of specialists and participated in the strategy MTR in November 2004. 9The other ratings were also satisfactory (with the exception of issues related to counterpart funds and a qualified audit). Monitoring and evaluation was downgraded from S to U in June 2004, rose back to S in June 2006, and finished (appropriately) at MU in June 2007. 10Aide-mémoire. Mid-term Review. June 2004 8 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 39. Annex 11 of the PAD premised the design of the proposed monitoring and evaluation system on the need to monitor progress in implementing both the project (based on the establishment of a management information system) and the program (the national response based on a series of national surveys such as DHS and other BSS, periodic studies following on the PHRD studies, and routine Ministry of Health reporting). In its proposed approach, the Bank contributed resources from GAMET and worked in collaboration with UNAIDS and the Measure/Evaluation Project (among others) to establish the M&E system. 40. In practice, there were problems with both the selection of indicators and the means used to measure their achievement. With respect to the selection of indicators, considerable effort was made with project staff during the ICR mission to trace indicators and results at the beginning, mid-point, and end of the project. As summarized below, the outcome and intermediate outcome indicators followed four scenarios: (i) those consistently used throughout the project and measured at the beginning and the end; (ii) those measured (or measurable) at the beginning and the end, but which were eliminated at the time of the Supplemental Grant in 2005 ; 11 (iii) those introduced in the Supplemental Grant but usually without baseline data; and (iv) those included in the original DCA but without baseline data and either eliminated in the Supplemental Grant or not really monitored in any systematic manner. 41. The four scenarios for monitoring the outcome and intermediate outcome indicators are presented in the table below with the corresponding indicators (See Annex 10 of ICR for cross-reference): Availability of baseline and final data Available Not available A1: Non-married individuals who report having two B4: Pregnant, HIV positive women receiving or more sexual partners treatment to prevent mother to child transmission A3: Condom utilization rates at previous high risk B9: Orphans receiving care and support sexual contact IndicatorsB1: Sexually active individuals knowing that B10b: HIV/AIDS awareness activities carried out by used contracting HIV can be avoided by using a condom Ministries B2: Sexually active individuals knowing that a well- looking person can be infected by HIV Systematic B5: HIV infected people receiving ARV Treatment monitoring of B10a: Villages and CBO carrying out HIV/AIDS indicators subprojects A2: Men who report having used condoms in past 12 A4: PLWHA declaring having been victims of months discrimination and stigmatization B3: Sexually active population receiving voluntary B6: Infected people treated for opportunistic Indicatorstesting and counseling infection in participating provinces not used B7: PLWHA who are receiving home-based care in participating provinces B8: Communities providing orphan care and support in participating communities 42. With respect to the development of means to measure achievement, despite considerable additional resources mobilized by the Task Team (from GAMET12 and other sources) to assist the PMU and the SP- 11The QAG assessment concluded that the Task Team should, at the mid-term review, agree with the Government on a smaller and simpler set of indicators for measuring project progress, but there is no indication that this was done. 12GAMET's support for the development of M&E capabilities deserves more study to determine why the component was not satisfactorily implemented; the ICR team cannot say whether the proposals were too complex, lacked adequate incentives, fell victim to evolving institutional arrangements, etc. 9 CNLS, the management information system for the national strategic framework, which incorporates the project indicators, was never fully operational and only a few of the proposed surveys and studies were actually implemented: the DHS was repeated in 2003, seems to have had some comparability problems with the 1999 DHS (and was only sporadically referred to in the Aide-mémoires and ISRs), and was replaced by the 2007 CWIS as the source of data for comparison purposes. The project contributed US$100,000 to the cost of the CWIS, which required doubling the number of enumerators because many questions were gender sensitive; the Behavioral Surveillance Survey (BSS) was intended to be carried out every two years but was not repeated nor were the initial beneficiary assessment (2001) or the mapping exercise (2001) for which a methodology (in Tenkodogo) was developed during project preparation. 43. Additional studies of orphans and migrant workers were conducted in 2005 at the start of the targeted interventions but were considered as limited baseline exercises rather than follow-up studies on the PHRD work. 44. However, with strong support from the Task Team, DECRG carried out a remarkable number of operational research studies, including: (i) a survey of health facilities delivering ARV treatment (2006); (ii) the addition of questions related to treatment to the 2007 CWIS; (iii) a survey of HIV/AIDS patients and their households (ongoing); (iv) an analysis of the HIV/AIDS data in the Burkina Faso DHS 2003; and (v) an impact evaluation on cash transfers to orphans (baseline survey scheduled for early 2008). Preliminary results of (i) and (ii) have been presented in Burkina Faso and Ghana (January and July 2007), and further analysis is ongoing. The analysis performed under (iv) has been published in two World Bank Policy Research Papers (WPS # 3844 and # 3956) and one journal (Population and Development Review); it has been disseminated in Burkina Faso (2006) and at various international conferences as well. Data collection under (iii) and (v) is either ongoing or scheduled for the near future. 45. In sum, the M&E sub-component of the project never completely achieved its objectives at the outcome, output, or process levels; at the same time, however, SP-CNLS was: developing a comprehensive monitoring and evaluation framework (comprising 18 impact indicators, 25 results indicators, and more than 100 process and input indicators); producing (at least for 2004 and 2005) the UNGASS country report on the HIV/AIDS situation in Burkina Faso; and consolidating large quantities of data from disparate sources for presentation (2002 through 2007) at the annual meeting of contributors and participants in the fight against HIV/AIDS. While the documentation for the annual meeting was cumbersome to produce (comprising some 250 pages) and not especially useful for management decision-making on a regular basis, the information provides the only comprehensive overview of the national response. 2.4 Safeguard and Fiduciary Compliance 46. Environment. At the time of appraisal, the project's environmental category was "C" and thus did not need an environmental assessment, though the PAD noted there were concerns about hazardous waste and proposed (in an action plan produced in November 2002) to address these concerns by incorporating criteria (for disposal, IEC, and training) into the selection of sub-projects for communities and of work program agreements of line ministries. As indicated in the supplemental grant document (April 2005), the project was retroactively classified as environmental category "B"; a waste manage- ment plan was prepared, reviewed and found satisfactory by the Bank, and disclosed to the InfoShop on March 30, 2003. 10 47. The proposed action plan for medical waste management had an originally estimated cost of 900 million CFA (about $1.8 million). Though the costs of implementing the plan were not foreseen in the project design, the project did finance some preparation activities and training for hospital staff, and the supplemental Grant was intended to finance initial implementation of the Action Plan. In April 2005, a supervision mission recommended a series of legislative, regulatory, and technical actions; two years later, the final supervision mission concluded that none of the recommendations had been followed up and that they be deferred to the new project. 48. Procurement, Disbursement, and Financial Management (FM). Early supervision missions were satisfied with the directives established in the manuals and PMU's compliance with them, and an extensive review of financial management procedures in November 2002 suggested only modest improvements (linked mostly to the information systems). In June 2004, subsequent review affirmed the basic elements (including systems and personnel), and suggested: (i) better coordination and supervision among the financial managers in the ministries and provinces; and (ii) increased efforts to initiate quarterly Financial Management Reports (FMRs). A final FM review in April 2007 contained a dozen or so shortcomings and recommendations for project budgeting, accounting systems, internal controls (for equipment, vehicles, gasoline, etc.), supervision of the financial management component, use of technical and financial audit results, and inadequate FMRs. The April 2007 review rated FM as moderately unsatisfactory due to significant shortcomings on internal controls, in particular those related to budget control and analysis. 49. Conversely, despite repeated recommendations to improve procurement (e.g., updating of the procurement plan, insufficient quality of the tender documents, disproportionate use of sole-sourcing, etc.), the project was consistently rated Satisfactory. 50. Review of the DCA/DGA. Except for an early supervision mission (November 2002), there is no evidence that the Bank systematically reviewed the DCA/DGA; however, the PMU provided a final analysis (October 2007)13 which concluded that all of the clauses were fulfilled except for the mid-term review, which was combined (with Government concurrence) with a mid-term review of the overall national strategy. 2.5 Post-completion Operation/Next Phase 51. During project preparation and for much of project implementation, institutional arrangements for coordinating the national strategy and the project were slowly worked out, principally among SP- CNLS (Presidency), UGF (or the PMU of PA-PMLS housed initially in the Ministry of Finance), and the line ministries (especially the Ministries of Health and Social Affairs). The final step was the merger of PMU within SP-CNLS in April 2005, about 15 months after the date agreed on at negotiations. As a result, both the institutional arrangements and the management capacities have been strengthened for the future. 52. In July 2005, a second strategic framework (2006-2010) was adopted and reaffirmed the need to continue the multi-sectoral approach of the previous strategic framework. In addition, the strategic framework emphasized the principle of the "three ones" (common funding, harmonized procurement and financial management procedures, and shared monitoring and evaluation indicators and practices). In line with these principles (and in addition to the PRSC), the Board approved the Health Sector Support and Multi-sectoral AIDS Project (HSSMAP) on April 27, 2006 for SDR 33 million (US$ 47.7 million equivalent). The PAD argues, as a rationale for Bank participation, its ability to: 13SP/CNLS-IST, Respect des clauses de l'Accord de Crédit (October 2007), pp. 5-19. 11 encourage harmonization among donor partners, including for HIV/AIDS, health programs, and community interventions; promote institutional reforms and finance key priorities essential for MDGs, including funding for community and nongovernmental organizations, and strengthening monitoring and evaluation-and to pilot reforms that are later integrated into national systems (such as performance contracting); manage the risks associated with decentralization and budget support, including capacity- building and financial management (especially, continued difficulties with liquidity). 53. The new project was declared effective in August 2007 and will support a sector wide approach and provide flexible financing through a pooled funding mechanism for the HIV/AIDS strategic plan. Very similar component activities (as well as the TAP's interventions) and a number of the performance indicators for the HIV/AIDS project have been included in the HSSMAP. 3. Assessment of Outcomes 54. As part of the ICR mission's objective of sharing the methodology for and preliminary results of the ICR, the following section (and the accompanying table in Annex 10) was originally included in the Aide-Mémoire and discussed with Government authorities and other stakeholders during the wrap-up meeting of the ICR mission which visited Burkina Faso in October 2007. The text has subsequently been translated into English and the conclusions modified to take into account subsequent comments, discussion, and decisions from the review meeting. 3.1 Relevance of Objectives, Design and Implementation 55. The relevance of the project's overall strategy and components as well as its specific activities are rated satisfactory14 from the perspectives of the Bank's objectives and Burkina's priorities in the fight against HIV/AIDS. 56. With respect to the Bank's policies and strategies, the Project's Development Objectives (PDOs): support the Country Assistance Strategy (CAS) adopted in 2000, updated in 2003, and revised for the period 2005-09; and correspond to the original intent of the Multi-Country HIV/AIDS Program for the Africa Region in their modification and anticipate many of IEG's recommendations in its evaluation of the "first generation" projects.15 57. With respect to Burkina's priorities, the Project's Development Objectives (PDOs): support two of the four priorities of the Poverty Reduction Strategy adopted in 2000 and updated in 2005: (i) access of the poor to social services and especially to prevention, care, treatment, and control of HIV/AIDS; and (ii) promotion of good governance through strengthening capacity at decentralized levels; correspond to the National Strategic Plan to Fight HIV/AIDS both for the period 2001-2005 and for the revised plan for the period 2006-2010; and contribute to the achievement of the Millennium Development Goal 6 which aims to halt the spread of HIV/AIDS and begin to reverse the current trends. 14Though IEG uses a four point scale for rating relevance, efficacy, and efficiency, ICRR guidelines (OPCS, June 2007) do not provide similar explicit ratings scales. For consistency's sake, the ICR team used the six point scale which is mostly used throughout Annex A of the ICRR guidelines to orient its considerations. 15See OED, Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (2005), pp. xvii-xviii. 12 58. Finally, it should be noted that, in analyzing the key sector issues, the current Health Sector Support and Multi-sectoral AIDS Project has built on no less than six areas addressed during the implementation of the HIV/AIDS Disaster Response Project (see the HSSMAP PAD, paragraph 9). In other words, the project's concerns were relevant in 2000, continued to be relevant in 2007, and are expected to be relevant through the HSSMAP closing date in 2010. The project's relevance would have been rated highly satisfactory except that the design did not sufficiently develop strong and coherent links between inputs, outputs, and outcomes either within the individual components or between the components and the overall expected impact. To be rated highly satisfactory would have required a clearer operationalization of the project's key words noted in Para. 6 (e.g., scale up, capacity, mitigate) combined with a more robust M&E system and systematic use of the results. 3.2 Achievement of Project Development Objectives 59. Achievement of the PDOs was rated as moderately unsatisfactory. As shown in the accompanying table (Annex 10), two of the four outcome indicators included in the original DCA were eliminated from the amended DGA and only partial data were available for the remaining two. Moreover, assessment of the PDOs must take into account two additional elements which increase the number of outcome indicators for consideration: the new ICR format automatically reclassified the DCA's output indicators as intermediate outcome indicators, and in the ICR Team's estimation, three should be considered as such in determining the overall outcome rating while the others are simply outputs; and the restructuring of the project requires that "separate outcome ratings (against original and revised objectives) be weighted in proportion to the share of the actual disbursements made in the periods before and after approval of the revision."16 On the basis of 14 potentially quantifiable outcome/intermediate outcome indicators, the ICR found that 8 were achieved, 3 were not (with 2 missing their objectives badly), and 3 had no data (and thus considered not achieved).17 Whether using the strict outcome results or the combined outcome/intermediate outcome results, the project must be rated as moderately unsatisfactory. 60. Achievement of the output indicators was rated as moderately unsatisfactory as well, due in part to the lack of achievement (for those in the original DCA) and in part to the weighting formula (for those in the amended DCA). 61. Finally, though not directly attributable to the project, there are data which indicate an improvement in the situation prior to and during the project period: a time trends review from individual surveillance sites shows a sharp drop in prevalence (including among women aged 15-24), which began in the late 1990s through early 2000s, suggesting reduced incidence in addition to increased mortality (see Annex 3); the 2003 DHS provided the first national level HIV estimates, which resulted in a significant downward revision of prevalence levels (2% nationally), largely because earlier models overestimating the HIV prevalence in rural areas, and most of the sentinel surveillance sites were urban based; 16ICRR Guidelines (June 5, 2007), Appendix B, p. 42. 17Subsequent to the ICR mission, the Government has provided data for commercial sex workers, truckers, and miners, but the data is from the initial studies of the NGOs involved in the targeted interventions and should probably be considered as baseline information rather than end results. 13 results from the sentinel surveillance correspond closely with the findings on urban prevalence levels in the DHS (e.g., about 4% in 2003). While these results represent the combined efforts of both the Government and its technical and financial partners, the project did contribute to undeniable progress in several important areas: · organizing and strengthening the public response for prevention and care and treatment at both central and decentralized levels; · increasing the geographical coverage of VCT and PMTCT services and consequently the number of persons tested and the number of mothers receiving treatment to prevent transmission of the disease to their children; · increasing the number of PLWHA receiving treatment with ARVs; and · based on data from the expanded number of sentinel sites, decreasing the rates of new infections. 3.3 Efficiency 62. Project efficiency was rated as moderately unsatisfactory based on a consideration of: (i) the inherent inefficiencies introduced by the MAP strategy; (ii) the role of the MAP in financing the national strategy modalities used to implement the different components; and (iii) the financial management practices of the PMU. These considerations are addressed in more detail in Annex 3. 63. As one of the earliest MAP operations, the HIV/AIDS Disaster Response Project conformed to the recommended structure and (to a lesser extent) resource allocations with certain consequences for overall efficiency. First, while there was discussion of targeting and priorities, the potential efficiency of Components 1-3 were not yet known. Second, as the Task Team Leader pointed out in one ISR, there was a tendency for the components to operate somewhat vertically, both among themselves and between the MAP activities and those of other partners. Third, there was a preoccupation with rapid start-up and disbursement, and this project (with its good disbursement record) was perhaps encouraged: (i) to spend too rapidly on previously tested but still unproven interventions; and (ii) to expand components or to add activities in the name of flexibility but to the detriment of efficiency. 64. Further, over time, the MAP financed a decreasing proportion of the overall program. New partners (Global Fund, private sector, etc.) and new projects (TAP, AfDB) focused on more specific interventions such as VCT, or treatment while the MAP continued to focus more generally on prevention and care and support. At the same time, analysis by the Task Team (and by AfDB during its project preparation) showed that: (i) expenditures for line ministry activities included disproportionate amounts for per diems, fuel, etc.; (ii) unit costs for the community projects were relatively high; and (iii) projected budgets for the targeted interventions were substantially higher than expected. There was also concern about the costs of Component 2, given its coverage and likely impact since: (i) provinces were selected on the basis of their population rather than their prevalence rate; and (ii) the vast majority of the sub-projects were in rural areas where prevalence was estimated at less than 1%. 65. Finally, weak planning and budgeting practices (with the resulting need to review priorities, correct unit costs, negotiate reduced budgets, etc.), consistently late approval of annual work plans (in March or April thus effectively reducing the time for executing activities and budgets to 8-9 months), and constant concerns about insufficient funds (accompanied by amendments to the DCA/DGA to reallocate funds among categories) contributed to inefficiencies during project implementation. 14 3.4 Justification of Overall Outcome Rating Rating: Moderately unsatisfactory 66. Though the project can legitimately claim to have been and continue to be satisfactory for its relevance, this rating cannot overcome the greater importance of and the moderately unsatisfactory ratings for efficacy and efficiency. The overall outcome rating is moderately unsatisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 66. The final external evaluation18 identified a number of the project's positive contributions with respect to gender and social development: Targeting and involving women are essentials to lead the social mobilization effort in general and particularly in the case of pregnant women to sensitize others and to accompany them to be tested. Using appropriate communications channels to reach youths (clubs, peer educators, performances, etc. in secondary schools). While decentralizing structures and capacity to the village level is important, these structures must deal with a variety of local issues in addition to HIV/AIDS. The multitude of structures (NGOs, associations, village organizations, etc.) at decentralized levels can sometimes provoke political problems and personality clashes which weaken their impact and make them less able to respond adequately to outside pressures (from political powers, donors, etc.). (b) Institutional Change/Strengthening 67. While the institutional arrangements and financing for the national strategy (mentioned before) were strengthened for the long-term within the project, institutional arrangements within the ministries and at provincial levels remain precarious. Though line ministry coordinating committees at central and decentralized levels (CMLS and the Cellules Relais) have a legal status, seats remain unfilled and budgeted resources are mostly non-existent (though the Ministry of Finance has generally provided some funds and several ministries are including very modest funding in their 2008 budget submissions). In the 13 (of 45) provinces supported by the project, there was a very positive impact on activities related to HIV/AIDS, but the PMU's final evaluation asks whether the motivation of the provincial coordinating committees (CPLS) will fade with the lack of funding. The Government has initiated studies on this issue,19 and the new IDA-funded project will allow time for additional reflection. 68. Weak financial management impacted on institutional development in at least two ways. First, the project's efforts to establish the annual planning and budgeting process were significantly disrupted by the lack of funds at critical moments; thus, while the structures were primed to function, they were 18Impact Plus / Idea International. Evaluation Finale du Projet d'appui au Programme National Multisectoriel de Lutte contre le SIDA et les IST (PA-PMLS) (June 2007), see pp. 94-95. 19SP-CNLS. Méthodes de financement innovantes pour l'accès universel aux soins du VIH/SIDA (Sept 2006-June 2007). 15 often forced to slow down or stop. Second, efforts by the project to strengthen financial management capacity within the line ministries and facilitate project expenditures by recruiting financial managers had a decidedly negative impact not anticipated during preparation, which engendered: (i) costs not commensurate with the amounts being managed; and (ii) conflict with the existing line ministry financial staff (Administrative and Financial Directorate, DAF). (c) Other Unintended Outcomes and Impacts (positive or negative) 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Not applicable 4. Assessment of Risk to Development Outcome Rating: Moderate 69. Government's commitment to fighting HIV/AIDS and the institutional and strategic measures described previously constitute the major risk mitigation factors in achieving the development outcomes. Since 2001, the Government has systematically: (i) promoted institutional arrangements (at central, provincial, and community levels); (ii) developed consistent and coherent national strategies; (iii) adopted appropriate program policies and procedures (for testing, care and support, and treatment); (iv) mobilized significant amounts of financing (from public, private, and donor sources); and (iv) improved absorptive capacities (through harmonized procedures among sources and modalities for decentralized spending). 70. Particularly significant progress has been made in enhancing surveillance, expanding testing and counseling, acknowledging (and slowly reducing discrimination against) PLWHA, and providing PMTCT and ARV treatment. No significant progress was recorded on introducing measures for waste management. 71. Despite these impressive gains, controlling (and potentially reducing) the spread of HIV/AIDS depends on inculcating (and sustaining) behavioral change, on which Burkina has encountered many of the difficulties faced by other countries. In this particular area, both prevailing international experience and Burkina's project results require rating the risk to development outcome as moderate. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory 72. Despite the fact that both the QER (in comments not included in the official panel report) and the QAG assert that "the project was not ready to be implemented when it was approved" (particularly with respect to M&E and FM), the ICR rates preparation as satisfactory given the relevancy of the project's objectives, the urgency with which it was prepared, and the mostly successful efforts made to respond to reviewers' concerns. 73. From the initial portfolio review through negotiations, the Bank's preoccupations were clear and clearly transmitted to the Government: (i) establish intervention priorities focusing especially on contact points (geographical, socio-cultural, etc.) where the disease was most likely to be spread; (ii) determine 16 how to scale-up these priority interventions for prevention and care and treatment; and (iii) define and strengthen institutional relationships to ensure effective implementation. The PHRD studies contributed to the first; the results of the previous IDA-financed projects contributed to the second; and dialogue with the Government throughout the preparation (and in negotiations) contributed to the third. 74. The QER (January 2001) noted the progress in developing the project on a very fast track and the many positive elements of project's design, including: (i) its consistency with the Bank's emerging cross-sectoral approach to supporting the establishment of an institutional framework for community action in Burkina; (ii) the appropriateness of the proposed emphasis on a flexible and demand driven response to the HIV/AIDS epidemic in Burkina; and (iii) the clarity of the monitoring and evaluation activities to be developed in the project. 75. While supporting as appropriate the "learning by doing" character of the project design, the Panel stated that "flexibility should not come at the cost of accountability" and urged the Task Team to: (i) manage expectations (acknowledging that this first operation will itself likely only begin the process of reversing the growth in the incidence of the disease); (ii) phase the "ambitious" set of outputs and outcomes to establish realistic benchmarks for newly established institutions requiring satisfactory completion of initial capacity-building efforts; and (iii) prepare a detailed plan for the first year of the project to ensure that the project gets off to a quick start. As indicated previously, the Task Team responded adequately to each of these concerns. 76. In three other areas noted by the QER (and cited by the QAG), the Task Team was less successful in providing: clearer links between the proposed project and ongoing or planned efforts to strengthen the "biomedical response" to HIV/AIDS; greater specificity on the project design and particularly on the management of funds for the community sub-projects and the targeted interventions; and more specific modalities for using the results of the M&E system in decision-making about the flow of resources. (b) Quality of Supervision Rating: Moderately unsatisfactory 77. The QER, Panel noted that, as for other MAP projects, success will require intensive Bank support during project implementation and urged management to assure that adequate resources be available. At the Decision Meeting, a further recommendation was made that the Task Team get agreement from management on a supervision strategy and resource level for reference in the project file. Annex 16 in the PAD did this and sought $150,000 for FY02. For FY02-04, the Bank allocated almost $500,000 for supervision of which $450,000 was actually spent. 78. Initially, the project benefited from frequent supervision missions (three per year in 2002 and 2003) and from field-based supervision beginning in September 2003. In August 2004, the Quality Assurance Group (QAG) reviewed the project and rated the quality of supervision to be "satisfactory" (2 on the QSA6 rating scale). The QAG noted a number of strengths (e.g., adequate/complementary staffing and substantial budgets, detailed and candid ISR reporting, etc.) and positive results on handling weaker aspects of the preparation (e.g., environmental issues, institutional development, etc.). The QAG noted that: (i) the ISRs could be shorter and more strategic; and (ii) "ratings occasionally appear to have been disconnected from actual project progress or not clearly enough explained" (especially for the M&E and FM ratings, which were "sometimes overestimated"). 17 79. After the QAG, the quality of supervision declined. Between early 2005 and September 2006, TTL responsibilities for the ISRs and for the supervision missions seem to have been shared; in September 2006, full responsibility was transferred to a fourth TTL based in the field. Between May 2005 and May 2007 (as pointed out in the final supervision mission Aide-mémoire of May 2007), no formal supervision missions were conducted. In fact, beginning as early as June 2004, supervision missions dealt with several projects simultaneously (the HIV/AIDS Disaster Response and the Supplemental Grant, the Treatment Acceleration Program, and the Health Sector Support and Multi- sectoral AIDS Project), and the emphasis on the start-up of the TAP and the preparation of the HSSMAP may have reduced the amount of time the Task Team could devote to the MAP. 80. Perhaps more significant than the somewhat uneven approach to supervision at different stages of project implementation was the Task Team's inability (despite dialogue and proffered Technical Assistance) to solve the problems of a project whose components (as pointed out by the QAG) were advancing at very different speeds. Rapid expansion and high disbursements for line ministry work plans (Component 1) and community sub-projects (Component 2) stand in stark contrast to the long delays and inadequate results produced by the pilot Burkinavi treatment program (Component 1), the targeted interventions (Component 3), and the development of M&E (Component 4). Based on a reading of the ISRs, it may be (and the QAG suggests this as well) that the Task Team could have focused more on outcomes and less on components to draw attention to this unbalanced implementation.20 (c) Justification of Rating for Overall Bank Performance Rating: Moderately unsatisfactory 81. ICR guidance states that when the rating for one dimension is in the satisfactory range (in this case for quality at entry) and the other is in the unsatisfactory range (for quality of supervision), the rating for overall Bank performance normally depends on the outcome rating, which was moderately unsatisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately satisfactory 82. Within the overall context of MAP implementation and based particularly on: (i) government's ownership and commitment to achieving the development objectives; (ii) progress in developing the enabling environment (politico-institutional, technical, financial, and administrative); (iii) strengthened implementation capacity at central, provincial, and community levels; (iv) productive relationships with donors, partners, and other stakeholders; and (v) the adequacy of transition arrangements, the project might well earn a satisfactory rating. However, persistent weaknesses in (i) financial management and procurement; (ii) arrangements for monitoring and evaluation (especially the use of such information in decision-making and resource allocation to improve efficacy and efficiency); and (iii) lack of progress on waste management require that the rating be reduced to moderately satisfactory. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 20The ISRs should, at some point, have reflected different ratings for PDO and IP rather than being (with one exception) identical. 18 83. It was agreed that the PMU (Unité de Gestion Financière, UGF) be integrated from the Ministry of Finance into SP-CNLS at the time of negotiations and the transfer be effective before January 2004. The PMU was finally integrated in February 2005 at which time it ceased to be an implementing agency. Both prior to and subsequent to the integration of the PMU, however, its performance is rated as moderately satisfactory. Despite the presence of an experienced unit, the weaknesses noted above in procurement, financial management, and especially project (as opposed to program) monitoring and evaluation diminished the quality of the unit's performance. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately satisfactory 6. Lessons Learned 84. Lessons can be learned from each of the three major "story lines" which emerge from examining the preparation and implementation of this project. 85. First, though an early MAP (with the inherited weaknesses of the original design), this project differed from other MAPs by relying on previous project experience (and a well-trained PMU) to introduce some innovative elements (e.g., Component 3's targeted interventions) and a number of fairly sophisticated approaches (e.g., for monitoring progress and measuring achievement). In fact, this created a project which worked at two different speeds (see paras. 35 and 83): Those things which the project knew how to do from previous experience it did well (Components 1 and 2), and those things it knew less well (and for which there were perhaps insufficient incentives to do better) it did less well. 86. How to balance effective implementation of well-mastered processes with appropriate capacity- building and incentives for innovative approaches constitutes a continuing challenge for TTLs and Bank management. The enormous delays in recruiting the NGOs already active in HIV/AIDS to implement the targeted interventions in Burkina was due to the Bank's limited flexibility to use civil society structures for project implementation and resulted in long delays and very limited success in addressing these high risk groups. 87. Second, though the project was in many respects exemplary in its inherent relevance to Bank policies and country strategies and its ability to respond to the evolving national needs, the indicators chosen to measure this response did not keep pace. Indicators were selected and eliminated, measured (or not) haphazardly, and generally ignored as a management tool throughout much of the project period (at least by the project)(see para. 41). Though not a new lesson, this project illustrates once again the need for: (i) objectives and performance indicators to be carefully selected; (ii) an adequately designed M&E system to exist at the start of project implementation; and (iii) appropriate structures to be in place to ensure that information is used strategically for decision-making. 88. Third, though the decision to move from a series of projects (Population and AIDS Control, HIV/AIDS Disaster Response and the Supplemental Grant, and Treatment Acceleration) to a more programmatic approach (Health Sector Development) to address Health and HIV/AIDS was almost certainly appropriate, the period from 2004-2006 was probably both confusing for the Government and distracting for the Task Team (see para. 82). With two complementary but complex projects addressing the HIV/AIDS epidemic, the preparation of the Health Sector Development Program should probably have been delayed. 89. Each of these areas has implications for ACTAfrica specifically and Bank management more generally. Given the generally similar components of each MAP, ACTAfrica should have been providing counsel from its experience across the range of MAP interventions and drawing the Task 19 Team's attention to the need for better measurement and more balanced implementation. There is nothing in the record (supervision mission reports, ISRs, MTR, etc.) to indicate that ACTAfrica played any such role in the implementation of this project. 90. Finally, the broader issue of institutional relationships within the Bank for oversight of the MAP projects should perhaps be examined in more detail: The complexities of (i) coordinating the different concerns of DC and field-based management; (ii) juggling administrative requirements for current project implementation while developing a future program; (iii) organizing technical inputs from a number of Bank agencies, including the Global AIDS Program, ACTAfrica, GAMET (hosted by the Bank but a service of UNAIDS), DECRG, etc. are such that true project management may be beyond the ability of any single TTL; and (iv) ensuring that adequate supervision resources is allocated to the task team. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: See Annex 7 By letters of December 20, 2007, (no. 2007-0016941/MS/CAB and no. 2007-1384/PRES/CNLS-IST/SP), the ICR team received Borrower's comments on the draft French version of the ICR dated December 6, 2007. While most of the comments not related to the translation into French have been taken into account, the ICR team would like to highlight the following: With respect to the information in the data sheet: Point A (Basic Information): These data are system generated and stored in the World Bank project database. Point B (Key dates): In view of the system's constraints, the Borrower's reference to the dates of Grant effectiveness is mentioned in paragraphs 21 and 33. Point F (Results Framework Analysis): The original Target Value date should correspond to the original credit closing date: December 31, 2005 or the amended closing date at the time of the supplemental Grant: December 31, 2006. With respect to the other comments: Paragraph 1: The information related to the prevalence rates comes directly from the Project Appraisal Document, paragraph 1.4. Paragraph 3: The report cited was written in 2000 when UNAIDS existed. Paragraph 32, point 1: The ICR does not state that the issue was not resolved, but that agreement at negotiations was implemented with some difficulties thereafter. Point 2: The English version of the ICR does not contradict the point made by the Borrower. Paragraph 33: The Borrower is correct that the supplemental Grant was delayed by the legal opinion; but an ISR indicates that the original credit effectiveness was delayed due to the recruitment issues. Paragraph 34: These points were made in the ISRs and concern particularly the early years of the project. Paragraph 38, point 1: The ISRs indicate differences of opinion between the Task Team, PA- PMLS, SP/CNLS-IST at the time of the mid-term review. Point 2: The ICR does not state that the SP/CNLS-IST refused to carry out a project mid-term review, but rather recommended that it be integrated into the review of the strategic framework. The information is taken from the ISRs. Point 3: The ICR does not state that the studies were not agreed to by the Bank, but rather argued that (based on the conclusions of the Task Team in the ISRs) their results were of dubious quality. 20 Paragraph 62: Financial management practices are noted in paragraphs 48, 65, and 68 and are addressed in Annex 3. A qualified audit, among other documents consulted, suggests that there were issues in this area throughout the project. Paragraph 64, point 1: A table that shows these amounts was provided to the ICR team. Not only perdiem are mentioned, but also a range of other operating costs. Point 2: The sub-projects were implemented in rural areas. Annex 10: The Borrower's point is made in paragraph 61 of the ICR; accordingly target indicator must therefore not be overly ambitious. The Project overall outcome rating remains at moderately unsatisfactory. (b) Cofinanciers: Not applicable (c) Other partners and stakeholders: Not applicable 21 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Components Appraisal Estimate Percentage of (USD millions) Estimate (USD millions) * Appraisal Line Ministries Work Program 12.1 12.8 106% Provincial Activities and Community Sub-projects 6.1 4.9 80% Targeted Interventions 6.3 4.5 71% Coordination, Monitoring and Evaluation 4.2 7.9 188% Total Project Cost 28.7 30.1 105% * As of end June 2007 (b) Financing Appraisal Actual/Latest Source of Funds Type of %age of Cofinancing Estimate Estimate (USD millions) (USD millions) Appraisal Borrower 1.50 1.60 106% Local Communities 0.20 0.22 110% International Development Association (IDA) 27.00 28.28 105% Total Project Cost 28.70 30.10 105% * As of end June 2007 22 Annex 2. Outputs by Component Component 1: Line Ministry Work Programs. The component financed three interventions: (i) capacity-building of the SP/CNLS-IST; (ii) support for the Ministry of Health; and (iii) strengthening of line ministry structures and financing work plans at central (CMLS) and decentralized levels (CR). SP/CNLS-IST strengthening. In addition to contributing to the operations of the SP/CNLS-IST (planning and coordination, personnel salaries, etc.), the project financed the construction and equipment of new offices. Support for the Ministry of Health. In addition to the Ministry's own work plan for its CMLS, the project directly supported expansion of PMTCT (in seven health districts) and the Burkinavi operational research study which included ARV treatment for some 290 PLWHA). Indirectly, the project contributed to an overall program which scaled up services during the period of the project as indicated in the table below: Scaling-up of services over the project period 2002 2003 2004 2005 2006 Sites offering: VCT 51 93 116 PMTCT 9 14 44 152 211 ART 3 24 49 62 Diagnosis and treatment: VCT (tests) 11 038 57 550 153 366 199 767 PMTCT (tests) 19 661 29 010 ART (treatment) 1 514 3 867 8 136 12 842 Source: Bilans généraux, 2005 and 2006. Strengthening of line ministry structures and annual work plans. Though initially targeting 13 ministries, project records (which are incomplete) indicate that in 2006, 27 ministries and 6 institutions had participated in this sub-component (either by doing a situation analysis, or by preparing an action plan, or by implementing an action plan). The following table summarizes the participating ministries (though it should be noted that there was a reorganization of ministries in 2006) and the number of civil servants who were involved to some degree in the activities organized by the different ministries: 23 Ministries and civil servants involved in implenting the annual action plans 2002 2003 2004 2005 2006 Total 38 694 55 745 57 966 59 261 62 961 Min. de l'action sociale et de la solidarité nationale MASSN 1 167 1 264 1 497 1 602 1 812 Min. de la promotion de la femme MPF 94 91 127 137 167 Min. de la défense MD na na na na na Min. de l'enseignement de base et de l'alphabétisation MEBA 31 472 41 515 41 515 39 449 38 889 Min. de l'administration territoriale et de la décentralisation MATD 1 435 1 435 1 435 1 435 1 435 Min. de l'environnement et du cadre de vie MECV 1 199 1 190 1 045 1 055 933 Min. de l'agriculture, de l'hydraulique et des ressources halieutiques MAHRAH 2 346 2 906 2 914 2 930 2 930 Min. des ressources animales MRA 981 970 1 050 893 863 Min. de l'économie et du développement MEDEV 447 447 463 518 Min. de l'information MINFO 899 899 899 899 Min. de la sécurité MSECU 4 061 4 153 5 027 5 323 Min. de la justice MJUS 967 1 023 1 027 1 027 Min. des finances et du budget MFB na na na 3 680 Min. des mines, des carrières et de l'energie MMCE 1 861 1 850 1 850 Min. des postes et de la télécommunication MPTIC 2 420 2 552 Min. de la promotion des droits humains MPDH 74 83 Min. de l'enseignement secondaire, supérieur et rech. scientifique MESSRS Min. des sports et loisirs MSL Min. de la culture, des arts et du tourisme MCAT Min. de l'emploi et de la jeunesse MEJ Min. de la santé MS MT, MHU, MAE, MTSS, MID, MCPEA, MRP, MFP/RE MTSS Source: Bilan général, 2006. Of these civil servants participating in the activities of the ministries, the number (and proportion of total ministry staff) who participated directly in the CMLS or the CR is presented in the following table: Number of CMLS and CR members 2002 2003 2004 2005 2006 Total 2 408 2 970 4 680 4 891 4 871 CMLS/CR members as a proportion of Ministry civil servants 6% 5% 8% 8% 8% Source: UGF Based on information available through UGF, the amount of money expended by the line ministries by type of activity is as follows: Summary Ministry expenditures by type of activity (FCFA) 2002 2003 2004 2005 2006 Total Total 895 256 223 1 347 223 915 2 593 266 697 747 219 056 438 509 321 6 021 475 212 Capacity building 895 256 223 1 265 484 991 927 248 092 101 848 283 171 640 848 3 361 478 437 Prevention 0 75 000 512 832 755 517 868 994 57 942 345 1 088 719 094 Care and support 0 0 1 125 046 000 127 501 779 193 466 128 1 446 013 907 Surveillance 0 81 663 924 28 139 850 0 15 460 000 125 263 774 Source: UGF Overall, capacity building activities constituted approximately 60% of expenditures, while prevention and care and support account for 17% and 21% respectively. A summary of line ministry outputs by type of activity is presented in the following table: 24 Summary of Ministry activities by type of activity 2002 2003 2004 2005 2006 Total Capacity building Establishment of CMLS 13 19 0 27 28 Equipping of CMLS 0 15 0 6 0 21 Financing work plans 12 12 12 21 21 Establishment of CR 143 278 421 Training of CR 1 410 2 147 434 359 0 4 350 Prevention IEC activities 737 3 746 5 336 53 0 9 872 Sensitization supports 17 7 771 11 900 1 500 0 21 188 Production of kits 0 683 368 19 0 1 070 Video cassettes 0 0 1 469 20 0 1 489 Press articles 0 0 95 26 26 147 Care and support Training of Social Affairs 683 270 310 0 0 1 263 Home visits 0 763 2 261 862 156 4 042 Support for infected persons 0 240 690 920 927 2 777 Support for affected persons 0 307 1 059 13 897 16 242 31 505 Source: UGF The following table shows the component's results in terms of encouraging staff to determine their HIV status and providing support to HIV+ colleagues. Given the preponderance of Ministry of Education staff, specific details are provided on these cadre. Diagnosis, care and treatment among Line Ministry Staff 2002 2003 2004 2005 2006 Total number of Ministry personnel (except Defense) 38 694 55 745 57 966 59 261 62 961 % personnel belonging to Ministry of Education 81% 74% 72% 67% 62% Number of staff having determined their HIV status 1 491 1 277 1 974 5 818 6 859 % of staff having determined their HIV status (except Defense) 4% 2% 3% 10% 11% % of Ministry of Education staff having determined their HIV status 0% 0% 0% 0% 3% Number of HIV+ staff 291 423 500 643 780 Number of HIV+ staff receiving socio-economic support 0 393 468 542 651 % of HIV+ staff receiving socio-economic support 0% 93% 94% 84% 83% Number of HIV+ staff receiving medical support 150 286 418 487 619 % of HIV+ staff receiving medical support 52% 68% 84% 76% 79% Source: UGF Component 2: Provincial Activities and Community Sub-Projects. This component financed two major interventions: (i) strengthening of the local (public and private) response; and (ii) community sub- projects. In addition, the project financed three NGOs which provided regional assistance to community groups intending to prepare and implement sub-projects. Strengthening of the local response. The following table summarizes the project's outputs in terms of the establishment and strengthening of the local response. 25 Summary of Support for Strengthening of decentralized structures 2002 2003 2004 2005 2006 Total Establishment of decentralized structures No. of Provincial Committees (CPLS) 21 45 45 45 45 No. of CDLS / CCLS 125 324 362 409 No. of CSCLS 170 214 393 372 No. of Village Committees (CVLS) 3 527 4 678 6 735 8 409 No. of associations 800 1 500 1 000 1 000 500 Training of decentralized structure members 15 942 No. of Trainers trained 1 033 No. of Provincial Committees (CPLS) 310 310 No. of CDLS / CCLS 1 374 1 374 No. of CSCLS established 12 036 12 036 No. of Associations 1 189 1 189 Source: UGF Community sub-projects. The following table summarizes the number of sub-projects submitted and approved as well as the allocation of expenditures by type of activity. Summary of Support for Community Sub-Projects 2002 2003 2004 2005 2006 Total Number of projects Submitted 4 491 3 868 4 674 (4674)* 13 033 Approved 2 496 2 773 3 392 2 114 10 775 Expenditures 448 796 101 558 451 504 184 706 439 304 399 456 1 496 353 500 Prevention 310 683 133 329 802 974 129 712 636 170 216 674 940 415 417 Care and support 119 536 770 211 092 181 50 443 803 113 477 782 494 550 536 Monitoring 9 476 198 12 306 349 0 13 005 000 34 787 547 Operations 9 100 000 5 250 000 4 550 000 7 700 000 26 600 000 Source: UGF. Due to lack of funds, only a proportion of projects approved in 2005 received their remaining allocation in 2006 The table on the following page summarizes the number of beneficiaries reached (by category of beneficiary) and the number of activities conducted (by type of activity). 26 Summary of Beneficiaries Reached and Results of the Community Sub-Projects 2002 2003 2004 2005 2006 Total Beneficiaries 2 968 898 1 907 430 1 024 000 1 006 195 7 219 325 Prevention 2 321 000 1 605 672 769 894 950 361 5 646 927 Youths 804 344 749 704 263 741 273 146 2 090 935 Women 843 913 570 367 330 778 327 445 2 072 503 Men 672 743 285 601 175 375 336 000 1 469 719 Miners 13 200 13 200 Sex workers 570 570 Care and support 647 898 301 758 254 106 55 834 1 572 398 Widowers and widows 35 97 938 220 000 70 000 6 836 394 809 Children 501 151 250 665 250 665 0 1 002 481 OVC 150 48 809 70 000 7 320 48 829 175 108 PLWHA 10 329 500 50 160 1 049 Activities 500 000 2 664 932 2 021 569 1 028 725 1 514 081 7 729 307 Prevention 500 000 2 658 831 2 011 953 1 018 682 1 509 036 7 698 502 Discussion groups 5 652 5 944 13 568 6 342 31 506 Video projections 3 934 2 972 3 392 580 10 878 Theatre 1 967 2 972 1 696 2 114 8 749 Theatre forum 13 39 13 0 65 Radio/TV broadcasts 13 26 13 0 52 VTC sensitization 500 000 2 647 252 2 000 000 1 000 000 1 500 000 7 647 252 Condom promotion 90 000 900 000 1 280 000 1 500 000 1 000 000 4 770 000 Condoms demonstrated 70 000 200 000 350 000 135 000 330 000 1 085 000 Condoms sold 20 000 700 000 930 000 1 365 000 670 000 3 685 000 Care and support 6 101 9 616 10 043 5 045 30 805 School costs, food, clothes 200 1 260 3 243 2 883 7 586 Psycho-social support 3 934 2 972 3 408 1 114 11 428 Home visits 1 967 5 384 3 392 1 048 11 791 Source: UGF Component 3: Targeted Interventions. This component financed interventions by five NGOs for the following target populations: (i) youths; (ii) women; (iii) orphans and vulnerable (OVC); (iv) sex workers; (v) itinerant miners; and (vi) associations. The results may be found on the following page. Component 4: Coordination, Monitoring and Evaluation. This component financed coordination activities, monitoring and evaluation, and project management. 27 Summary of support provided to targeted populations Youths Women OVC OVC Sex Workers Sex Workers Miners Miners Associations Total FDC FDC CECI IPC Pop. Council CCISD CECI CCISD AIFAM Contract amount 235 528 553 132 592 277 204 306 000 490 484 860 323 121 138 206 970 193 188 196 300 260 627 587 129 312 000 2 171 138 908 Investment 57 025 211 37 142 711 24 500 000 46 170 000 44 785 600 46 094 900 34 050 000 38 968 980 18 080 000 346 817 402 Operations 162 275 765 86 772 333 163 460 000 403 922 600 253 032 307 146 250 266 140 133 000 201 507 825 101 120 000 1 658 474 096 Mangement costs 16 227 577 8 677 233 16 346 000 40 392 260 25 303 231 14 625 027 14 013 300 20 150 782 10 112 000 165 847 410 Target zones Regions 4 4 5 Provinces 7 6 15 Health Districts 2 Cities 2 5 13 Strategies and results Strengthening local partnerships Clubs 248 60 8 316 Associations 26 19 5 5 1 48 104 RALIS 226 226 OBC 582 10 161 753 Health / Testing facilities 11 10 21 Other (CDLS/CVLS, COGES, etc.) 10 2 12 Training Local personnel Project strategies 60 n/a 59 131 44 n/a 30 324 Mngt/Imp of micro-projects 953 90 1 323 n/a 38 86 n/a 134 2 624 Prev., social mobilization, BCC 13 096 225 n/a 14 302 143 54 n/a 291 28 111 Managing lifestyles and risks 13 748 10 920 24 668 Health personnel Diagnosis and treatment of STIs n/a n/a n/a n/a n/a 47 20 26 22 115 Counseling and testing n/a 88 n/a n/a 50 40 56 30 n/a 264 Laboratoy, CD4, niverapine, ARV n/a 110 n/a n/a n/a n/a n/a n/a n/a 110 Sensitization 130 566 64 510 15 300 1 691 50 725 21 894 4 939 1 686 15 729 307 040 Distribution of condoms Male condoms 46 060 3 490 n/a n/a 130 621 51 148 1 800 8 784 n/a 241 903 Female condoms 510 3 162 1 858 85 5 615 Testing and follow-up Testing 5 805 1 745 n/a n/a 3 185 n/a 91 n/a 72 10 898 PMTCT Tests 597 597 Follow up of HIV+ women 12 12 Care and support Treatment kits MEG n/a 11 3 14 OI n/a 600 341 941 STI n/a 5 400 2 566 16 522 2 619 22 27 129 STI cases treated n/a n/a n/a n/a n/a 951 811 566 22 2 350 PLWHA 26 21 47 OVC 3 830 68 015 96 n/a n/a n/a 895 72 836 Psycho-social / Health support 61 066 616 Socio-economic / Prof. support 6 949 279 Source: CERAC, Evaluation des performances et appréciation des résultats des interventions ciblées par les ONG et les associations (Mai 2006). 28 Annex 3. Economic and Financial Analysis Two major weaknesses in the design and implementation of the project constrain any attempt to analyze the economic and financial implications of the project. First, the conservative (and probably realistic) results framework is essentially incomplete since it: does not address lives saved (through reduced incidence or decreasing prevalence) or lives extended (through treatment); only partially addresses the linkages between inputs, knowledge and behavior; and does not sufficiently address the linkages between inputs, coverage, and utilization of services. As a result, expectations for what was supposed to occur as a result of expenditures on Components 1 and 2; and to a lesser extent Component 3 are not clear, and the use of existing positive data on the evolution of the epidemic (as shown below) cannot really be used. PREVALENCE 4,5 3,9 4 3,6 3,5 3 2,5 2,5 2,3 2,2 2 2 2,1 1,5 1 0,5 0 2000 2001 2002 2003 2004 2005 2006 ANNEE Evolution of HIV prevalence between 2000-2006 among pregnant women aged 15-24 Second, as has been mentioned several times in the text, the lack of an effective M&E system within the project makes linkages between project data and program data difficult. This analysis follows on IEG's evaluation of the first generation MAP projects21 which bases the project's economic and financial results on the counterfactual of no assistance and on its contribution to: (i) deepen political commitment to controlling the epidemic; (ii) expand and strengthen national and sub- national AIDS institutions for the long-run response; (iii) enlist NGOs in the national response and reinforce their capacity to provide access to prevention and care among the high-risk groups most likely to contract and spread the infection; and (iv) enhance the efficiency of national AIDS programs. Increased political commitment. In addition to expressions of commitment embodied in the MDO's, the national strategy, and the statements of the President, the periodic UNGASS reports for 2004 and 2006 contain one potential measure of the project's contribution to political commitment, as expressed by the policy index, which increased from 71% in 2003 to 77% in 2005.22 Two additional measures should also be considered: (i) increased Government financing of HIV/AIDS through its own resources; and (ii) Ministry commitment to devote 1% of their own budgets to supporting the line ministry actions. With respect to Government financing, the amounts have increased 21OED, Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (Washington, 2005), p. xv. 22The UNGASS Report for 2007 will be preapared in 2008. 29 significantly over the past five years though usually with a lag between the increases from other sources and the Government's response. Amounts and shares of HIV/AIDS financing (in millions of FCFA) 2001 2002 2003 2004 2005 2006 Total Amount Government 1099 1556 1 368 1 037 1 158 1 832 8 050 Bank 0 1 200 4 027 4 641 5 741 5 149 20 758 Total 3903 8 624 14 247 16 137 21 605 20 405 84 921 Proportion Government 28.2% 18.0% 9.6% 6.4% 5.4% 9.0% 9.5% Bank 0.0% 13.9% 28.3% 28.8% 26.6% 25.2% 24.4% Source: Methodes de financement, op cit., Annexe 2, p. 59, citing the Bilan Général, 2005. With respect to the 1%, while none of the line ministries were able to achieve the 1% budget line item for HIV/AIDS, SP/CNLS-IST's annual report for 2006 shows that ten ministries did finance activities.23 Expanded and strengthened national and sub-national AIDS institutions. The project contribu- ted directly to expanding and strengthening national and sub-national institutions, as indicated by the chart below, summarizing project support to political and administrative structures through Components 1 and 2. 2002 2003 2004 2005 2006 Total Line ministries Establishment of CMLS 13 19 0 27 28 28 Financing work plans 12 12 12 21 21 21 Establishment of CR 143 278 421 Training of CR 1 410 2 147 434 359 0 4 350 Decentralized structures No. of Prov. Committees (CPLS) 21 45 45 45 45 No. of CDLS / CCLS 125 324 362 409 No. of CSCLS 170 214 393 372 No. of Village Committees (CVLS) 3 527 4 678 6 735 8 409 No. of associations 800 1 500 1 000 1 000 500 Though other partners provided financial and technical support, the project was probably the most important source of financial support. Enlist and reinforce NGO capacity to provide services among the high-risk groups. The project attempted to do this in one of its most innovative approaches for: (i) developing principles for mapping populations and targeting interventions; (ii) recruiting NGOs already present and working in Burkina; and (iii) accompanying the interventions with rigorous operational research methods. That this intervention was delayed by a series of procurement difficulties and encountered financial constraints (linked both to the costs proposed by the NGOs and to the expenditures of other components) meant that the project was really not able to demonstrate the effectiveness of this approach. Enhanced efficiency. Throughout the implementation period there were concerns about the project's efficiency and particularly the kinds of activities and the amounts and types of expenditures for Components 1-3. A posteriori (and without a detailed analytical accounting), it is difficult to reach a judgment about the project's efficiency. With respect to the kinds of activities, it can be noted from the tables presented in Annex 2 is that: 23Secrétariat Permanent. Conseil National de Lutte contre le SIDA (SP-CNLS), Bilan Général 2006, Table 40, p. 109. 30 for Component 1, the evolution indicated in the summary of Ministry activities seems reasonable: from capacity building in years 1-3 to prevention in years 2-4 to care and support in years 3-5; for Component 2, the evolution of activities does not seem nearly so clear-cut, perhaps because the project: (i) was more directive with the Ministries and (ii) respected the demand-driven nature of this component; and for Component 3, it is impossible to discern any trend since the interventions only lasted a year or so. With respect to the amounts of the expenditures, the results are somewhat different: for Component 1, there seems to be very little relationship between annual activities and expenditures; for Component 2, comparing unit costs for prevention and for care and treatment in terms of beneficiaries and activities can only be indicative, but not surprisingly, care and treatment is more costly (particularly on an activity basis); and for Component 3, management costs were fixed at 10% of operating costs and there are not comparable units (not even the number of beneficiaries, which would seem to be a particular weakness of the approach used). Some evidence has been collected along the way (though not systematically), which may justify somewhat the monies used by the project: for Component 1, the Ministries of Defense and Security showed, based on a study of 2640 soldiers and police recruited between 1999-2001 (all HIV negative) and re-examined again in 2004, that intensive prevention campaigns can work: only 3 had become HIV positive; for Component 2, an evaluation in 199924 showed a significant difference between areas covered or not by sensitization efforts: in covered zones, 79.4% said that they had changed their behavior as a result of being reached while in uncovered zones only 59.7% said they had change their behavior; for Component 3, the recent work by Khan, Brown, et al. cited in the ICR demonstrates the need to focus on core groups and to tailor prevention strategies to their specific characteristics. Overall, the project certainly enhanced Government's commitment and allowed it to expand and strengthen its strategy at national and sub-national levels. It was not able to build effectively on the existing NGO capacity to provide services among the high-risk groups though this capacity still exists and may well be continuing with other sources of financing. And though perhaps not the most efficient operation, there is evidence to suggest that it was on track in several regards and, in any case, filled a gap in the comprehensive program that allowed other partners to focus on more efficient interventions. 24Rapport d'évaluation de l'impact des interventions financières par le fonds de population et de SIDA (September 1999). 31 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/ Specialty Lending Supervision/ICR Bepio C. Bado Sr Operations Off. AFTPR William Dakpo Procurement Spec. AFTPC Nicole Fraser-Hurt Consultant HDNGA Timothy A. Johnston Sr Health Spec. EASHD Pierre Joseph Kamano Sr Education Spec. AFTH2 Djibrilla Karamoko Sr Health Spec. AFTH2 Harounan Kazianga E T Consultant DECRG Amadou Konare Sr Environmental Spec. AFTEN Luc Lapointe Consultant AFTPC Ibrahim Magazi Sr Health Spec. AFTH2 Oumar Ouattara Consultant AFMBF Aguiratou Savadogo-Tinto Operations Officer AFTTR Abdoul-Wahab Seyni Social Development Spec. AFTCS Bintou Sogodogo Program Assistant AFMBF Gaston Sorgho Sr Public Health Spec. WBIHD Mamadou Yaro Sr Financial Management Specia AFTFM (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle No. of staff weeks USD Thousands (including travel and consultant costs) Lending FY01 56 153.92 FY02 4 4.24 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 FY08 0.00 Total: 60 158.16 Supervision/ICR FY01 0.00 FY02 26 80.51 FY03 54 165.02 FY04 41 167.68 FY05 35 127.34 32 FY06 21 55.56 FY07 7 25.13 FY08 1 3.02 Total: 185 624.26 33 Annex 5. Beneficiary Survey Results Not applicable 34 Annex 6. Stakeholder Workshop Report and Results Not applicable 35 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Annex 7a: Summary of Borrower's ICR PRESIDENCE DU FASO BURKINA FASO ------------- Unité ­ Progrès- Justice NATIONAL AIDS/STI COUNCIL ------------- PERMANENT SECRETARIAT 03 BP 7030 Ouagadougou 03 Tel: (226) 50.30.66.22/50.31.67.85 Fax: (226) 50.31.40.01 / e-mail: spcnls@fasonet.bf ----------------- FINANCIAL MANAGEMENT UNIT SUMMARY OF THE REPORT ON THE COMPLETION OF THE NATIONAL MULTISECTOR AIDS AND STI CONTROL PROGRAM SUPPORT PROJECT (PA-PMLS) ----------- IDA CREDIT 3557-0-BUR/PA-PMLS OF SEPTEMBER 6, 2001 AND GRANT AGREEMENT H 160-0/BUR/PA-PMLS OF JUNE 2, 2005 (JANUARY 1, 2002 to JUNE 30, 2007) OCTOBER 2007 36 INTRODUCTION Burkina Faso is one of the hardest hit countries by HIV/AIDS in the West African sub-region south of the Sahara, with a prevalence rate estimated at 7.17% in 1997. To help combat this epidemic, the Government of Burkina Faso and the World Bank Group's International Development Association (IDA) signed a Development Credit Agreement (Credit Agreement 3557-0-BUR) on September 6, 2001 and a supplemental Grant Agreement associated with Development Credit Agreement 3557-0-BUR (Grant H 160-0-BUR) on June 2, 2005 to achieve the goals of the National Multisector AIDS and STl Control Program Support Project (PA-PMLS). This project marked the World Bank's will to assist the Government of Burkina Faso with the implementation of the HIV/AIDS Strategic Plan (CSLS) for 2001-2005. I. MAIN RESULTS OBTAINED FOR EACH PROJECT COMPONENT 1.1. Component 1: Support for the ministerial AIDS committee (CMLS) action plans: Box 1: Component 1 Goals - Set up sector-based coordination structures (CMLS); - Set up implementation structures (local units) reporting to the CMLS; - Ministry capacity-building: institutional support, training and equipment; - Monitor and evaluate the CMLS; - Finance the annual action plan of the Permanent Secretariat of the National AIDS/STI Council (SP/CNLS-IST); - Socioeconomic assistance to infected and affected persons - Action plans implemented in 21 ministries instead of the 12 initially planned; - 421 local units (cellules relais) set up as implementation structures in all of the 13 regions and 45 provinces; - A database designed and the members of the 21 ministerial AIDS committees (CMLS) trained in using it; - Five ministerial AIDS committees (CMLS) equipped with means of transport (vehicles) and 21 ministerial AIDS committees (CMLS) equipped with computer and audiovisual equipment; - Day-to-day running of 21 ministerial AIDS committees (CMLS) and 421 local units (cellules relais); - 21 managers recruited; - Prevention activities: 4,350 staff trained in IEC,9,872 IEC activities conducted, 1,070 action packs produced, 1,489 video cassettes produced on the activities conducted and 21,171 t-shirts made, 147 articles placed in the press, and 1,618 voluntary screening and counseling campaigns conducted reaching a total of 59,044 people; - A growing interest among staff to have themselves screened; - ARV therapy for 850 patients, 400 of whom in the form of operational research by the Muraz Center in Bobo Dioulasso and 450 by the Ministry of Health and NGO/association structures; - Socioeconomic assistance provided to 2,777 infected persons and 31,509 affected persons (3,920 adults and 27,589 orphans and vulnerable children), 4,042 home visits made, 1,263 welfare officers trained in counseling for psycho-social and economic support for infected and affected persons; - Monitoring and evaluation activities: support to set up 421 local units (cellules relais), 2,118 staff trained in strategic planning and monitoring and evaluation, 408 oversight missions conducted by the ministerial AIDS committees (CMLS), and 77 performance/programming workshops held. 1.2. Component 2: Support for provincial activities and community-based micro-projects Box 2: Component 2 Goals - Decentralize the program activities; - Support capacity-building for the provincial authorities' community-based project planning, selection, approval and supervision, and coordination of AIDS activities; - Build the capacities of the communities and associations to develop, implement and manage AIDS micro-projects; - Finance income-generating activities. 37 - Coordination structures set up: 13 provincial AIDS committees (CPLS), 138 departmental AIDS committees/commune AIDS committees (CDLS/CCLS), 144 sector-based commune AIDS committees (CSCLS), and 3,485 village AIDS committees (CVLS) instead of the 2,000 planned; - Players and beneficiaries involved in setting up the structures: 588 members of the provincial technical advisory frameworks (CCTP), 3,370 local administration officers (RAV), 24,300 people, 1,109 representatives of community-based organizations (CBO), and 79,500 leaders informed and mobilized; - Training: · 15,000 copies of modules, guides and booklets produced; · 1,033 trainer sessions; · 561 committee members trained in micro-project approval, management and monitoring; - Awareness-building for two million people on average per year; - Support to orphans and vulnerable children (OVCs): 50,000 OVCs on average per year; - Capacity-building for communities and associations: 12,036 village AIDS committee (CVLS) and sector- based commune AIDS committee (CSCLS) members as well as 1,189 association members trained; - Micro-project financing Micro-projects financed: over 12,000 applications accepted and financed for a total sum of 1,356 billion; Prevention activities: 74,474; Case management activities: 7,586. 6.2.3. Component 3: Support to targeted interventions: Box 3: Component 3 Goals - Mobilize the provincial players and assist the NGOs and associations with information actions on HIV/AIDS and STIs: infection, transmission, prevention and healthcare for target groups at risk in the project zone; - Identify the specific goals and targets: · Women: raise the level of knowledge of HIV/AIDS/STIs among women aged 15 to 24 years and encourage them to go for voluntary and anonymous screening; · Girls: raise the proportion of those who have one single partner in 12 months; · Boys: raise the proportion of those who see the condom as a means of prevention and take HIV tests; · Gold panners: encourage them to use health services following any sexually transmitted infection; · Commercial sex workers: raise the rate of use of male and/or female condoms in the cities and towns and encourage them to know their serological status; · Encourage each network to develop and implement, in the form of pilot projects, specific care and support activities for orphans, widows and widowers, and PLHIV, and interventions for commercial sex workers, young waitresses, and young people in the informal sector over a period of six months; - Build the capacities of the NGOs and community-based organizations. - Results of the first year: · 19,068 OVCs received support; · 10,981 commercial sex workers and 3,195 clients attended informal talks; · 8,097 gold panners informed and seen in a medical capacity, · 46,800 girls and 58,646 boys informed in the secondary establishments of Ouagadougou. - Building of the management capacities of the of HIV prevention and PLHIV association networks; 1.4. Component 4: Coordination, monitoring and evaluation of activities Box 4: Component 4 Goals - Plan, program and coordinate national activities; - Organize technical assistance and training; - Facilitate the decentralization of program activities; - Monitor progress and facilitate the transfer of skills and best practices; - Conduct behavioral monitoring surveys; - Build the capacities of the SP/CNLS-IST. 38 - Capacity-building: Financial Management Unit (UGF) staff trained in management and Permanent Secretariat of the National AIDS/STI Council (SP/CNLS-IST) staff trained in technical aspects and monitoring-evaluation; - A manager recruited for the SP/CNLS-IST; - Human resources transferred to the SP/CNLS-IST; - The SP/CNLS-IST Head Office built and fitted out. Goods and services purchased for the SP/CNLS-IST and the implementing structures; - PA/PMLS and SP/CNLS-IST supervision missions; - Evaluation mission to analyze the pertinence of targets and intervention zones, chosen strategies, and efficiency of implementation; - Joint supervision missions with the World Bank; - Production by the PA-PMLS of six-monthly and annual reports. II. STRENGTHS, ACHIEVEMENTS, WEAKNESSES AND LESSONS OF THE IMPLEMENTATION OF THE PA-PMLS In addition to the abovementioned results, the implementation of the PA-PMLS enabled Burkina Faso to develop HIV/AIDS and STI prevention and control capacities and capabilities. However, certain weaknesses were found, which gave the players involved useful lessons for the future. 2.1. Strengths and achievements - Existence of regional networks of associations to prevent and control STIs and AIDS (RALIS); - Involvement of management staff from the ministries and institutions via their duties as chairs of the ministerial AIDS committees (CMLS); - Capacity-building via training and the availability of documents on standards for the case management of PLHIV; - Implementation of micro-projects in French and national languages; - National expertise available; - Building of the skills and technical capacities of the SP/CNLS-IST in monitoring and evaluation; - Improvement in the indicators on the different focal points and sectors (see Annex I); - Visibility of the SP/CNLS-IST and the other implementing and coordinating structures. 2.2. Weaknesses - Running of most of the ministerial AIDS committees (CMLS) and their structures, which remains dependent on external financing; - Mobility of the members of the ministerial AIDS committees (CMLS) and the local units (cellules relais) with implications in terms of the loss of institutional memory; - Slow approval and allocation of funds, making it hard to implement annual planning and causing a break in the socioeconomic case management of infected and affected persons; - Absence of formalized management procedures for the funds allocated to the local units (cellules relais) by the ministerial AIDS committees (CMLS); - Too many associations working in the same geographical areas and fields with a resulting fragmentation of actions, which does nothing to facilitate supervision and monitoring-evaluation work; - Absence of strategies for the target groups in all the country's regions, especially gold panners and commercial sex workers, to capitalize on the achievements given the mobility of these targets; - Inaptitude of the structures to sustain the program and probable disappearance of the leadership from certain structures at the end of the project. 2.3. Lessons learned - Set up a mechanism fostering associative action by the structures in a given place; - Introduce mechanisms and/or arrangements for closing the financial year to prevent breaks by the budget estimate for the activities of the first quarter of year Y+1 in the Year Y allocation; 39 - Take up the option of a strategy for target groups at risk (gold panners and commercial sex workers) throughout all the country's regions; - Include decentralized resource management mechanisms in the procedural manuals. III. PROJECT COORDINATION AND MANAGEMENT The Coordinator manages and coordinates the project. He liaises with the Government and the World Bank. He works with the implementing and coordination structures on one side and the other partners on the other. In this regard, he informs the political authorities, the World Bank managers, and the other project implementing players. The management of the PA-PMLS enjoyed: - A good understanding between the IDA and the Government, with the effect that credit reallocations were accorded as they were needed; - The sound involvement of the lead managers of the implementing units in the advisory structures set up. 3.1. Main World Bank decisions furthering the implementation of the project - Renewal of all the Project Coordination Unit (UCP) and SP/CNLS-IST staff contracts financed by the Population and Aids Control Project (PACP) for the management of the PA-PMLS; - Recruitment of managers for the ministries; - Setting up of management tools and instruments (monitoring & evaluation system and accounting and financial management system); - Acceptance of three Credit Agreement extensions (2003, 2005 and 2006); - Acceptance of a Grant Agreement extension (2006); - Acceptance of three amendments to the Credit Agreement resulting in reallocations of funds by category and two resulting in reallocations of funds by category for the Grant; - Raising of the level of the special accounts for credit expenditure; - Signing of a supplemental grant agreement in 2005 for a sum of five million US dollars (CFAF 2.5 billion) in the form of an additional budget to complete the project's goals; - Lifting of the budget limit, which fostered the 100%-financing of the ministerial AIDS committees' action plans. 3.2. Main World Bank decisions hindering the implementation of the project - Frequent changes of contacts, mobility of monitoring staff at the World Bank, and a multitude of people working on the project (consultants recruited by the World Bank and specialized World Bank personnel); - Slow responses to requests concerning procurement contract awards and financial management. 3.3. Main Government decisions furthering the implementation of the project - Compliance with commitments made with the Bank (effective payment of the national counterpart funding, action taken with respect to the recommendations made by the Bank and the evaluation missions, etc.); - Regular updating of the national public procurement regulations; - Provision of personnel; - Existence of texts regulating the operations and organization of the different central and decentralized structures (ministerial AIDS committees and local units). 3.4. Main Government decisions (or lack of decisions) hindering the implementation of the project - No updating of the texts governing project management; - Frequent changes to the staff working in the coordination and implementing structures; - Changes to the senior managers in the ministerial departments, resulting in a high turnover of managers in the coordination and implementing structures. 40 To sum up, project management enjoyed a good quality of relations between the World Bank and the Government. Similarly, the requests for documents for use for other purposes demonstrate the credibility accorded the coordination activities and the positive performance of the different project players. IV. ECONOMIC AND FINANCIAL EVALUATION OF THE PROJECT The project cost estimated at US$28.70 million (CFAF 19.05 billion) breaks down as follows: - US$22 million (CFAF 15.4 billion) by the IDA, accounting for 80.84 percent of the project cost in the form of a credit initially in 2001; - US$5 million (CFAF 2.5 billion) by the IDA, accounting for 13.12 percent of the project cost in the form of a grant in 2005; - CFAF 910 million in 2001 and CFAF 100 million in 2005, totaling CFAF 1.01 billion, by the Burkina Faso State, accounting for 5.30 percent of the project cost in the form of a subsidy; - CFAF 140 million by the communities, accounting for 0.73 percent of the project cost. 4.1. Summary of initial estimates and actual costs by project component at August 31, 2007 Initial estimates Adjusted Drawdown % N Components (CFAF) estimates (disbursement Disburse o (CFAF) s) -ments (CFAF) 01 CMLS and SP/CNLS-IST 8,390,000,000 7,253,477,715 6,996,004,243 96.5% action plan 02 Provincial activities 4,100,000,000 2,774,634,163 2,707,058,694 97.6% 03 Targeted interventions 3,940,000,000 2,537,679,241 2,438,957,521 96.1% 04 Coordination and M&E 2,620,000,000 4,555,977,947 4,315,965,499 94.7% 05 Total 19,050,000,000 17,121,769,066 16,457,985,957 96.1% The above table presents the overall situation for the four sources of financing (Credit 3557, Grant H 160, Government counterpart funding, and contribution from the beneficiary communities). The sharp drop observed between the initial estimates and the adjusted estimates is due to a combination of the following three factors: - The underlying fall of the US dollar, which lost some 30% of its value over the course of the project's implementation, leading to substantial foreign exchange losses for the project (CFAF 4.242 billion for the Credit and the Grant); - The cancellation, when the adjusted estimates were made, of the beneficiary communities' contribution, initially estimated at CFAF 140,000,000; - The downward adjustment (50.50%) of the Government's counterpart funding following the amendment of the credit agreement, which authorized the 100-percent financing of the CMLS and SP/CNLS-IST action plans from the IDA contribution instead of "90 percent IDA" and "10 percent Burkina Faso State". 4.2. Initial estimates and actual costs by project expenditure category at August 31, 2007 N Expenditure Initial estimates Adjusted estimates Drawdown % o category (CFAF) (CFAF) (disbursements) Disburse- (CFAF) ments 01 Building work 356,069,364 715,690,839 689,893,743 96.4% 02 Materials & 3,923,333,900 1,380,339,264 1,348,742,498 97.7% equip. 03 Consultants 5,213,226,794 5,731,896,953 5,347,391,531 93.3% 04 Sub-projects 3,430,219,313 1,496,013,886 1,454,939,272 97.3% 41 05 Action plan 3,086,509,691 5,139,830,746 5,123,089,544 99.7% 06 Operating 1,616,363,482 1,323,710,113 1,216,913,004 91.9% expend. 07 Not allocated 1,424,277,457 0 0 - 08 Drugs 0 1,334,287,265 1,277,016,365 95.7% Total 19,050,000,000 17,121,769,066 16,457,985,957 96.1% 4.3. Value and level of collection of the Government's counterpart funding N Government Initial Adjusted Level of Drawdown % o counterpart estimates estimates collection (disbursement Disburse (CFAF) (CFAF) from the State s) (CFAF) -ments 01 Counterpart linked 910,000,000 500,000,000 487,000,000 474,801,196 97.5% to Credit 3557 02 Counterpart linked 100,000,000 0 - 0 - to Grant H 160 Total 1,010,000,000 500,000,000 487,000,000 474,801,196 97.5% 4.3. Recurring costs generated by the project, with an impact on the State budget The recurring costs concern the profitability and/or capitalization of the different actions taken: - Running of the structures allocated resources by the PA/PMLS: vehicles, computers, audiovisual equipment, and operating supplies. - Continuation of the socioeconomic case management of persons infected and affected by HIV/AIDS. CONCLUSION The implementation of the project enabled Burkina to make marked progress in controlling and preventing HIV/AIDS and STIs. The project's contribution and the other players' contributions to combating HIV/AIDS and STIs brought about: - An improvement in prevention, especially in terms of the use of condoms wherein the proportion of users rose for both men and women; - An improvement in the treatment of opportunist infections and a growing interest in screening among the population; - An appreciable increase in the number of OVCs managed by community-based organizations; - An upturn in the socioeconomic case management of people by the ministries and the families concerned; - A keen interest in ARV therapy for persons infected by HIV/AIDS (850 people under the Project and 7,908 under the Treatment Acceleration Program (TAP), representing a total of 8,758 for the World Bank out of a national grand total of 15,409 persons receiving ARV therapy at June 30, 2007); - A reduction in the HIV/AIDS prevalence rate in general, which fell from 7.17% in 1997 to 2% at the end of 2005. In addition to these outcomes presented in the annexed table, which do not always reflect the reality due to a lack of reliable statistics at certain levels, the PA/PMLS played an important role in the launch and scaling up of initiatives to control and prevent HIV/AIDS (financing of player activities, implementation of micro- projects, and various activities via targeted interventions). The experience and know-how gained by the PA/PMLS benefited other players such as the projects in progress, financed by the AfDB and Belgium Technical Cooperation (CTB). The PA-PMLS made a substantial contribution to the implementation of the HIV/AIDS strategic plan (CSLS), in which it was a definite catalyst. 42 Annex 7b: Summary of Borrower's Comments on Draft ICR COMMENTS FROM THE GOVERNMENT ON THE DRAFT IMPLEMENTATION COMPLETION AND RESULTS REPORT OF THE HIV/AIDS DISASTER RESPONSE PROJECT 1/ DECEMBER 20, 2007 1/ Some comments may not apply as they referred to the French version of the Report. 43 1. Acronyms and abbreviations should be corrected to read: Acronyms Instead of : Read : BCC BCC CCC Behavorial Change Communication CAMEG Central Procurement Unit for Essential Central Procurement Unit for Essential Drugs Drugs and Medical Supplies PA-PMLS - HIV/AIDS Disaster Response Project CMLS Multi-sectoral Committee of Fight Against Ministerial Committee of Fight Against AIDS AIDS CNLS National HIV/AIDS/STI Council CNLS-IST National Council of Fight Against HIV/AIDS and STI DAF Administrative and Financial Department Directorate in charge of Administration and Finances for the Ministry of Health DEP Planning and Studies Department Studies and Planning Directorate DMP Department of Preventive Medicine Directorate of Preventive Medicine PADS Health Development Support Program Health Development Support Program PNDS National Health and Nutrition Project National Health Development Plan PNGT2 Community Based Rural Development Second Community Based Rural Development Project Project SP/CNLS Permanent Secretariat of the National SP/CNLS-IST HIV/AIDS/STI Council Permanent Secretariat of the National HIV/AIDS/STI Council SP/CONAPO Secretariat of the National Population Secretariat of the National Population Council Council Point A: Basic Information - Revise the project name with Projet d'Appui au Programme National Multisectoriel de Lutte contre le SIDA et les IST (PA-PMLS) ; - Information on the Grant H 160 of June 2, 2005, for an amount of SDR 3 400 000 or US$ 5 million equivalent is not included ; - Revise the name of the implementing agency with Permanent Secretariat of the National HIV/AIDS/STI Council (SP/CNLS-IST). Point B: Key Dates - the effectiveness date for Credit 3577-0 is March 4, 2002 instead of April 3, 2002; - the effectiveness date for Grant H 160-0 is November 29, 2005. Point F: Result Framework Analysis With regard to indicators for objectives a), b), c), d), f) and g), the original and end of project target values are the same: June 30, 2007. The original dates revised and corrected as indicated in approval document should be September 6, 2001 or June 2, 2005 which correspond respectively to the signing dates of the Agreement for Credit 3557/BUR and its amendment by the Grant Agreement H 160. Review and Comments on the Report Paragraph 1 - The first sentence of the first paragraph must be corrected as follows: at the time of project preparation, Burkina Faso was rated second after Côte d'Ivoire as the most affected country by HIV/AIDS in the sub-Saharan region...... the rest remains unchanged; 44 - On the data, the prevalence rate estimate for pregnant women of 2% in mid-80s must be revised as Burkina Faso declared its first cases of AIDS in 1986; - Indicate the data sources for the prevalence rate for children born of sero-positive mother at the hospital of Banfora of Comoé; - Replace hospital of Banfora of Comoé with "Regional Hospital Center of Banfora in Comoé Province". Paragraph 3 - Under point 1: replace UNAIDS with WHO because UNAIDS was not created in 1986; - Under point 3: instead of Demographic Health Survey, read Demographic and Health Survey (DHS). Paragraph 32 The content needs to be eliminated or rewritten: - under point 1: the disagreement was eventually resolved when the Government authorized the opening of the Project special accounts and the second-generation accounts in commercial banks or financial establishments; - under point 2: on the institutional arrangements, the transfer before end 2004 did not involved the entire Project Management Unit (UGF) but only the two staff responsible for Project monitoring and evaluation in order to strengthen the SP/CNLS-IST capacity; the merger of the UGF and the SP/CNLS-IST in April 2005 was a Government initiative supported by the World Bank; this merger was not planned at the time of the negotiations. Paragraph 33 The delay in credit effectiveness was not due to staffing recruitment for the SP/CNLS-IST but due to the delay in obtaining the National Assembly authorization for Project ratification and from the constitutional council for obtaining the legal opinion. Paragraph 34, point 3 There was no institutional assessment of SP/CNLS-IST showing its weak capacity and the Program inadequacy: this statement should be nuanced. Paragraph 38 This is the first time that the notion of tension between the SP/CNLS ­IST and the PA-PMLS has been mentioned. The source of information is not clear; more details should be provided concerning the existence of these tensions. It is not the SP/CNLS-IST who refused to carry out the Project mid-term review, but rather the then task team leader who believed, on the basis of some terms of reference transmitted by the Project Coordination to the World Bank, that the mid-term review was not required. This argument was based on the fact that the mid-term review of the National Strategic Framework was planned for the same period. The Project has co- financed the preparation of some studies for the national review in order to provide background reference for the Project. It is mentioned that the project has prepared studies of doubtful quality. The Project did not work in isolation and all studies have followed the procedures, which require Bank approval. If this information must remain in the report, examples should be given because the Project cannot realize studies on its own. Paragraph 42 Confusion is noted in the footnote; the GAMET special team was directly financed by the World Bank to support the establishment of a national monitoring and evaluation system for the strategic framework and not the Project; the work that has been carried out only refers to the national level, the project indicators were integrated into the national indicators. 45 Paragraph 45 The World Bank has always insisted on the fact that the monitoring and evaluation area should be managed by the Monitoring and Evaluation Department of the SP/CNLS-IST; this is what justified the transfer of the technical staff to the SP/CNLS-IST. Paragraph 52 Instead of the revised strategic plan (2006-2010), the ICR should refer to the second strategic framework for the fight against AIDS 2006-2010. Paragraph 62 Explain the notion of "management practices of the PMU" or eliminate this point. The remark concerning contracts with the same suppliers is not sufficient for referring to management practices (the coordination did explain at that time the situation; it was relative to procurement of fuel where the same supplier total of Burkina Faso is most often the lowest evaluated bidder). In addition, the detailed explanations that were to appear in Annex 3 are not there. Paragraph 64 - the statement relative to the activities of the ministries and in relation to perdiem are those of a World Bank representative during the first year of project implementation, which had been reported in a document without adequate financial analysis; - It must be noted that 13 provinces are largely urban centers; the point in the first paragraph of page 17 is not founded. Paragraph 67 Kindly nuance the statements since decrees that create from the central to the village levels the committees for the fight against AIDS exist. The texts that establish the structures exist and have been updated for the creation of the CSLS 2006-2010. Paragraph 68 The poor management practices are not sufficiently justified; strangely, everyone was in agreement with the capacity strengthening of the ministries with financial management staff recruited under the Project. This recruitment results from an evaluation of the capacity of the structures in procurement and financial management and accounting under the advices of the World Bank. Annex 10 The Project is a support project, which contributes up to 20% of the financing of the strategic framework for the fight against AIDS and STI. It is surprising and particularly inappropriate to attribute the level of achievement of the indicators established for the national plan to such project or to one project. In fact, the achievement of the national political objectives, whichever the areas or sector, cannot be attributed to one project as it can only contribute to national level. Consequently, the classification of the ratings for this Project must be revised for objectivity, equity and common sense. Done in Ouagadougou, December 18, 2007 46 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Not applicable 47 Annex 9. List of Supporting Documents A. Project Implementation Plan - Project Operational Manual - Project Administrative and Financial Procedures Manual B. World Bank Project Appraisal Document, Report No. 21917-BUR, 2001 Supplemental Grant Document, Report No. 32013-BUR, 2005 Development Credit Agreement, Cr. 3557-BUR, 2001 Agreement Amending the Development Credit Agreement, Cr. 3557-BUR, Grant H160-BUR, 2005 Bank aide-memoires/Back-to-Office Reports · Preparation mission; September 2000. · Pre-Appraisal mission; December 2000. · Appraisal mission; March/April 2001, including formal Procurement Capacity Assessments of PMU, Ministries of Health, Basic Education, and Agriculture; agreed action plan for procurement capacity strengthening. · Implementation Support Missions, period: 2002-2007 · PMR-based disbursements: action plan and technical notes. Country Assistance Strategy for Burkina Faso, 2000 Country Assistance Strategy for Burkina Faso, 2005 PHRD Grant Request, January 2001 Costs of Scaling HIV Program Activities to a National Level in Sub-Saharan Africa: Methods and Estimates, AIDS Campaign Team for Africa. November 2000. C. Other Amon J., T. Brown, J.Hogle, J. MacNeil, R.Magnani, S. Mills, E. Pisani, T. Rehle, T. Saidel, C. Sow., Behavioral Surveillance Surveys: Guidelines for repeated behavioral surveys in populations at risk of HIV, Family Health International, 2000. Auregan, et. al. (12 April 2000), Epidémie du VIHISIDA au Burkina Faso: Diagnostics et réponses opérationnelles. Burkina Faso: Poverty Reduction Strategy Paper and Joint World Bank-IMF Staff Assessment of the PRSP, World Bank; June 2000 Cadre Stratégique du Plan National Multisectoriel de lutte contre les IST/VIH/SIDA au Burkina Faso 2001- 2005 (Document provisoire); Ministère de la Sante; Juin 2000 CERAC. Evaluation des performances et appréciations des résultats des interventions ciblées exécutées par les ONG et associations; Banque mondiale, PA-PMLS-SP-CNLS, Mai 2006. CMLS Défense (2004) Bilan d'exécution du plan d'action 2004; 31 décembre. CMLS Défense (2005) Bilan d'exécution du plan d'action 2005; 31 décembre CMLS Défense (2006) Bilan d'exécution du plan d'action 2006; 31 décembre CMLS MASSN (2005) Bilan physique et financier des activités du premier semestre 2005 CMLS. MASSN ; juillet. CMLS MASSN (2004) Bilan physique et financier a mi-parcours 2004 du CMLS MASSN ; octobre. 48 CMLS MASSN (2004) Bilan physique et financier de l'exécution du plan d'action 2004 au deuxième semestre ­ CMLS MASSN ; juillet. CMLS MASSN (2003) Bilan annuel des activités 2003 du CMLS MASSN ; décembre. 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