Document of The World Bank Report No: ICR0000718 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-34540 IDA-3454A) ON A PROPOSED CREDIT IN THE AMOUNT OF SDR 39.2 MILLION (US$ 50.0 MILLION EQUIVALENT) TO THE REPUBLIC CAMEROON FOR A MULTI-SECTORAL HIV/AIDS PROJECT April 2008 Fragile States, Conflict and Social Development Unit (AFTCS) Cameroon Country Department Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective December 2007) Currency Unit = CFA Franc 1 CFA Franc = US$ 0.00223763 US$ 1.00 = 446.898 FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Defense Syndrome ARV Antiretroviral (Drugs) BBC British Broadcasting Company CNLS HIV/AIDS Committee COSA Local Health Committee DHS Demographic and Health Survey DOTS Directly Observed Treatment Strategy EMP Environmental Management Plan GDP Gross Domestic Product GTC Central Technical Unit HIPC Highly Indebted and Poor Country HIV Human Immunodeficiency Virus IDA International Development Association ISR Implementation Status Report MAP Multi-Country HIV/AIDS Program MDG Millennium Development Goal M&E Monitoring and Evaluation NGO Non Governmental Organization OED Operation Evaluation Department PAD Project Appraisal Document PLWHA People living with HIV STD Sexually transmissible Disease SWAp Sector Wide Approach UNAIDS United Nations Program on HIV/AIDS UNOPS United Nations Operations Support VCTC Voluntary Counseling and Testing Center Vice President: Obiageli K. Ezekwesili Country Director: Mary A. Barton-Dock Sector Manager: Ian Bannon Project Team Leader: Francois Honore Mkouonga ICR Team Leader: Francois Honore Mkouonga ICR primary author: Jerome F. Chevallier CAMEROON Multi-Sectoral HIV/AIDS 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 Graph 1. Project Context, Development Objectives and Design............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 3 3. Assessment of Outcomes............................................................................................ 8 4. Assessment of Risk to Development Outcome......................................................... 11 5. Assessment of Bank and Borrower Performance ..................................................... 11 6. Lessons Learned ....................................................................................................... 13 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 13 Annex 1. Project Costs and Financing.......................................................................... 14 Annex 2. Outputs by Component ................................................................................. 15 Annex 3. Economic and Financial Analysis................................................................. 20 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 21 Annex 5. Beneficiary Survey Results........................................................................... 23 Annex 6. Stakeholder Workshop Report and Results................................................... 24 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR..................... 25 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 41 Annex 9. List of Supporting Documents ...................................................................... 42 MAP A. Basic Information CM-MultiSecal Country: Cameroon Project Name: HIV/AIDS SIL (FY01) Project ID: P073065 L/C/TF Number(s): IDA-34540,IDA-3454A ICR Date: 04/04/2008 ICR Type: Core ICR REPUBLIC OF Lending Instrument: APL Borrower: CAMEROON Original Total XDR 0.0M Disbursed Amount: XDR 38.8M Commitment: Environmental Category: C Implementing Agencies: CNLS (Comite National de Lutte contre le Sida) Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: Effectiveness: 09/28/2001 09/28/2001 Appraisal: 11/06/2000 Restructuring(s): Approval: 01/12/2001 Mid-term Review: 10/20/2003 Closing: 06/30/2007 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Unsatisfactory Quality of Supervision:Moderately Implementing Moderately Unsatisfactory Agency/Agencies: Unsatisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Unsatisfactory Performance: Unsatisfactory i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Yes Quality at Entry None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 12 12 Health 40 40 Other social services 36 36 Sub-national government administration 12 12 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 Primary Primary E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Mary A. Barton-Dock Ali Mahmoud Khadr Sector Manager: Ian Bannon Joseph Baah-Dwomoh Project Team Leader: Francois Honore Mkouonga Jan Weetjens ICR Team Leader: Francois Honore Mkouonga ICR Primary Author: Jerome F. Chevallier David M. Blankhart ii F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) To curb the spread and the impact of the HIV/AIDS epidemic in Cameroon through t he strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implementation of sector specific HIV/AIDS strategies. Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years The HIV/AIDS prevalence rate as evidenced by HDS(2004) is 4.8% in rural Indicator 1 : areas and 8.4% in the urban; it is respectively 2.2%, 7.9% and 10.3% for person between (i) 15-19; (ii) 20-24 and 25-29. Value Initial estimation of 11%, quantitative orbased on ante natal < 5.0% Qualitative) surveillance in limited areas. Date achieved 11/20/2003 06/30/2007 Comments (incl. % achievement) (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Completion or documents) Target Values Target Years Indicator 1 : 5423 local HIV/AIDS committees established and are operational Value (quantitative Not applicable 5,000 7706 or Qualitative) Date achieved 11/20/2003 06/30/2007 06/30/2007 Comments (incl. % achievement) Indicator 2 : 105 Sectoral coordination comittees in place and effective Value (quantitative Not applicable 200 or Qualitative) iii Date achieved 11/20/2003 06/30/2007 Comments (incl. % achievement) Indicator 3 : 300 implementing agencies trained on HIV/AIDS prevention Value (quantitative Not applicable 50% 200 216 or Qualitative) Date achieved 11/20/2003 06/30/2007 06/30/2007 06/30/2007 Comments (incl. % achievement) Indicator 4 : 6335 Community action plans prepared and being implemented Value (quantitative Not applicable 6500 7706 or Qualitative) Date achieved 11/20/2003 06/30/2007 06/30/2007 Comments (incl. % achievement) Indicator 5 : 23 Agreed Treatment Centers and 65 HIV/AIDS care centers in place and functional. Value (quantitative Not applicable 25 and 70 62 and 611 or Qualitative) respectively Date achieved 11/20/2003 06/30/2007 06/30/2007 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 10/11/2001 Satisfactory Satisfactory 0.00 2 12/18/2001 Satisfactory Satisfactory 3.52 3 03/21/2002 Satisfactory Satisfactory 3.90 4 07/30/2002 Satisfactory Satisfactory 4.70 5 12/18/2002 Satisfactory Satisfactory 5.70 6 05/25/2003 Satisfactory Satisfactory 9.29 7 12/08/2003 Satisfactory Satisfactory 15.96 8 05/28/2004 Satisfactory Satisfactory 25.28 9 11/18/2004 Satisfactory Satisfactory 31.52 10 12/01/2004 Satisfactory Satisfactory 31.94 11 06/14/2005 Satisfactory Satisfactory 39.72 12 12/20/2005 Satisfactory Satisfactory 46.90 iv 13 06/09/2006 Satisfactory Satisfactory 51.21 14 01/04/2007 Moderately Satisfactory Moderately Satisfactory 54.09 15 05/01/2007 Moderately Satisfactory Moderately Unsatisfactory 55.21 H. Restructuring (if any) Not Applicable I. Disbursement Profile v 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. In 2000, Cameroon was recovering slowly but steadily from the 1986-93 depression. In the period 1998-2000, annual growth was on average 4.5 percent. Despite this growth, however, per capita income in 2000 reached only two thirds of its peak pre-depression level. Social indicators had not improved, with some of them deteriorating even further. Large primary fiscal surpluses of about 6 percent of GDP were devoted to paying external debt service. Good progress was made in the reform program, particularly on financial, economic and structural issues, but little was done in improving governance and reducing poverty. With an unsustainable debt service burden, high poverty level and a satisfactory three-year track record of implementing reforms, Cameroon was declared eligible for the enhanced Highly Indebted and Poor Countries (HIPC) initiative. A Poverty Reduction Strategy Paper (PRSP) was under preparation and was expected to be completed in early 2002. 2. A Country Assistance Strategy (CAS) progress report was prepared in 2000. It recommended to complete implementation of the program set out in the 1996 CAS and use the enhanced HIPC initiative and PRSP process to support second generation reforms and to address poverty reduction issues more rapidly and effectively, with particular emphasis on governance, fighting corruption and the social sectors, including HIV. The Government strategy was to use HIPC debt savings on seven priority sectors, including health, education, HIV/AIDS, social affairs, rural development, basic infrastructure and governance. 3. Cameroon's first AIDS case was reported in 1986. In 2000, the HIV prevalence rate among the sexually active population was estimated at 11 percent, from a sentinel survey among pregnant women, and the infected people at 937,000, out of a total population of about 15 million. In 1986, Cameroon established the Committee to Fight HIV/AIDS (CNLS). Four short- and medium-term plans were designed and implemented with mixed results due, in particular, to insufficient coordination among the various stakeholders and the scarcity of human and financial resources. As indicated in the Project Appraisal Document (PAD), progress was achieved in sensitization to HIV/AIDS, particularly in urban areas, where 89 percent of youths were aware of the pandemic and 57 percent had used condoms. 4. In September 2000, the Government launched its 2000-2005 National Strategic Plan for the Fight against AIDS. Preparation of the plan involved most line ministries, the private sector, the civil society and donors. 1.2 Original Project Development Objectives (PDO) and Key Indicators 5. The objective of the project was to curb the spread of the HIV/AIDS epidemic and to mitigate its impact for all those who are infected or affected by HIV/AIDS through the strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implement of sector specific HIV/AIDS strategies. 6. A series of output, process and impact indicators (about 18 in total) were listed in the Project Appraisal Document (PAD). Four high level impact indicators were proposed: the decrease in HIV prevalence rate among pregnant women (age 15 to 19), the military (age 18 to 24) and commercial sex workers (age 15 to 24), and the percentage of tuberculosis patients having 1 completed Directly Observed Treatment Strategy (DOTS). A value was set for the first (less than 10 percent) and the last (60 percent) indicators, but no baseline was provided. There was no value, either at project appraisal or at project end, for the other two impact indicators. 1.3 Revised PDO and Key Indicators, and reasons/justification The PDO was not revised; the Key indicators were not revised. 1.4 Main Beneficiaries 7. As stated in the PAD, the general population, especially youth, women and vulnerable groups, were the main beneficiaries of the reduction in the spread of HIV/AIDS. Improvement of care and support to people living with HIV/AIDS (PLWHA) would benefit close to one million people. The increased capacity to deal with the HIV/AIDS crisis would benefit the communities involved, decision makers, managers and staff in various sectors. HIV/AIDS Committees at national, provincial and local levels would benefit from increased capacity for policy and strategy formulation. Finally, communities, savings and credit organizations and financial institutions would benefit from streamlined procedures for transfer of resources to communities 1.5 Original Components 8. The project included five components: support to local response, support to health sector response, support to the design and implementation of sector strategies, capacity building and coordination. 9. Support to local response. Under this component, local communities would prepare their action plans with the help of agencies and non governmental organizations (NGOs) and submit these plans to communal committees and receive matching grants to their own contributions in cash or in kind. Participation methods, which were being implemented in the IDA-financed Agricultural Extension and Research Project, were to be adapted to various settings. 10. Support to health sector response. This component would support establishment of voluntary testing and counseling centers, improvement of blood banks, increase in the availability of drugs to treat opportunistic infections, distribution of equipment and materials for home care of the sick, support to private companies, and training of traditional healers and birth attendants in prevention and medication. 11. Support to the design and implementation of sector strategies. This component would support focal points in key sectors to design sector strategies. 12. Capacity building. This component would include training for facilitators, HIV/AIDS committee members, focal points, staff of financial institutions, and managers. 13. Coordination. This component would include support to small implementation and coordination units at the national and provincial levels and to the operations of one staff in every commune and HIV/AIDS committees at national, provincial and communal levels. 2 1.6 Revised Components 14. The components were not revised. 1.7 Other significant changes 15. N/A 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 16. Soundness of background analysis. The analysis of the HIV/AIDS situation in Cameroon in the PAD was insufficient. The PAD provided valuable information on the most vulnerable groups and progress made in sensitizing the population in urban and rural areas. It indicated that condom availability was a major problem, particularly in rural areas, and suggested that the Government would undertake studies to clarify where the bottlenecks were. The 1998 Demographic and Health Survey (DHS) was ignored, and no mention was made of any local studies in the project file (Annex 8 of the PAD). 17. More importantly, the PAD did not discuss the serious issues besetting the health sector. The Health, Fertility and Nutrition operation approved in March 1995 was rated as unsatisfactory for both project implementation and development objective at the time of the preparation of the project under review. The health project was eventually rated as highly unsatisfactory by the Operation Evaluation Department (OED) in 2001. The project was overly complex and risky in an environment of low government commitment and capacity, and poor governance. 18. The four lessons learned and reflected in the project design included the need to (i) scale up HIV/AIDS initiatives; (ii) sub-contract activities to private organizations; (iii) enhance community participation for behavioral change; and (iv) transfer resources to communities. With the exception of the second one, these lessons were drawn from broader African experience, not from Cameroon. 19. The rationale for the Bank's intervention was strong, but poorly articulated in the PAD. The PAD mentioned the Multi-Country HIV/AIDS for the Africa Region (MAP), and indicated that the preparation team endeavored to ensure that the operation would be truly multi- sectoral and focus heavily on the empowerment of communities in the fight against HIV/AIDS. The PAD indicated that IDA was well placed to help the Government make this fight truly multi-sectoral and field oriented, because of its experience with supporting large operations, such as the ongoing National Extension and Research Project. The team leader for the operation under review was indeed closely associated with the agriculture project, which was eventually rated as satisfactory in the Implementation Completion Report issued in December 2004. Also, as an active member of the UNAIDS group, IDA was expected to help mobilize additional support from other donors. 20. Project design. The objective of the project, which was to curb the spread of the HIV/AIDS epidemic in Cameroon, was clear, but its design was overly complex. It included five components, involving a multitude of organizations, both in the public and private sectors, and at the national and local levels. It was expected that 5,000 rural and urban communities would have designed and implemented their HIV/AIDS action plans, with the help of sub- 3 contracting agencies and NGOs; 300 communes (out of 339) and 10 provinces would have established HIV/AIDS councils; and staff in 100 implementing agencies, 8 focal points at the national level and 80 at the provincial level, and managers and staff in the coordination units at the national, provincial and local level would have been trained. At least 13 ministries were to design specific HIV/AIDS strategies. 21. When the project was designed, a small number of NGOs had experience on participatory processes and the authorities were not used to working with the civil society. 22. As was the case with other MAP projects, additional grant resources were expected from other donors to complement the IDA credit, but without any details. The PAD also indicated that HIPC resources and budget allocations would be made available. 23. The handling and disposal of HIV-contaminated material were considered as the most significant environmental issues. The Environment Management Plan (EMP), which, according to the PAD, was to be developed prior to credit effectiveness, would address these issues. However, the effectiveness conditions included in the credit agreement did not mention the EMP, and preparation of the plan was much delayed. The Government made repeated promises it would prepare one, but the EMP has not yet been formulated. 24. Two social issues were mentioned in the PAD: the involvement of PLWHA in the design and implementation of the operation and the inclusion of highly vulnerable groups. The first category of the population participated in the design of the operation. As concerns the vulnerable groups, research was planned to adapt participatory methodologies developed in Cameroon to their specific requirements. It was carried out during the first year of project implementation. 25. The PAD indicated that, after modest government commitment to the fight against HIV/AIDS, a change took place in April 2000, when the Government initiated the preparation of its Strategic Plan, with the help of UNAIDS. The 2000 budget of the Ministry of Health was increased by CFAF 2 billion (about US$2.6 million) to address the HIV/AIDS crisis. Many initiatives were undertaken to sensitize the population to its impact. The eligibility criteria for access to the Multi-country HIV/AIDS Program (MAP) were met, including the evidence of a strategic approach to HIV/AIDS, the existence of a high level coordinating body, appropriate implementation arrangement, use and funding of multiple implementation agencies, and existence of a communication strategy. 26. The risk of the operation was assessed as substantial. A number of risks were mentioned, including 10 from outputs to objective and 4 from components to outputs. In the first category, 4 risks were rated as substantial. They had mostly to do with the transfer of resources to communities in a timely and transparent fashion and the low capacity of financial sector institutions and coordination units. Weak governance leading to inappropriate use of resources was considered as a high risk, which was to be mitigated by strong control and audit mechanisms. No mention was made, however, of the risk that improved knowledge would not result in behavioral change, or that the AIDS stigma would impede support to people living with AIDS. 27. The financial management of the project was complex, with two special accounts, each subdivided into ten sub accounts, one for each province. Private accounting firms were to be recruited by the central and the ten provincial implementation units. Payments were expected to be made to 13,000 villages and end-users, but because of their dispersion across the 4 country, accounting and reporting would be minimal. Supporting documentation held by communities would be audited by external auditors on a random basis. 28. The major risk of the operation was adequately assessed, but the mitigation of the most critical risk, the inappropriate use of funds, was not up to the challenge. 2.2 Implementation 29. The project had a slow start. The credit became effective in October 2001, almost nine months after Board approval. The selection of a private accounting firm to help with the financial management of the program took longer than expected. Eventually, a firm was selected, but its involvement in the project was minimal in the early years. Its role was reinforced in 2004, following the mid-term review of the project in October 2003. 30. The financial management specialist of the project unit was not up to the task and had to be replaced, but this took more than one year to be done. Procurement was poorly managed. The procurement plan for 2002 was not available during the supervision mission of February 2002, and agreed-upon procedures were not followed. The National Secretariat in charge of project management (GTC, the Central Technical Group) was weak and needed a considerable amount of assistance from Bank missions. In mid 2002, the Permanent Secretary of the National HIV/AIDS Committee (CNLS) was replaced. 31. The delays in project start and the inefficiencies in project management had negative consequences on disbursements, which were considerably delayed. By the end of FY03, before the Mid-term Review, an amount of about US$9 million had been disbursed against a total of US$30 million envisaged in the PAD. 32. A key component of the project was to help local communities prepare and implement their HIV/AIDS action plans. By the end of the project a total of 5000 communities were expected to have implemented their action plans, but at the end of the first project's year, only 123 community groups had been involved. To accelerate the process, CNLS decided to outsource it to NGOs and local associations. In 2007, it was reported that 7,706 local communities had an action plan. Most of these plans were similar, however, raising doubts as to the real involvement of local communities. Over 12 percent of the plans were discarded by the National Secretariat because some communities existed only on paper or were not operational. 33. The central and provincial offices (GTC and GTP) were overstaffed. There was 138 staff working in these offices, including 59 at the national level in 2006. Yet oversight of provincial offices by the central office was minimal. The monitoring by provincial offices of the preparation and implementation of action plans by local communities was ineffective. Controls over how resources were used by communities were lax. Under these conditions, it is difficult to assess the results achieved. 34. The project was intended to support a multi-sectoral response to the HIV/AIDS challenge, even though the government strategy launched in 2000 was mostly focused on health sector interventions. The Minister of Health continued to provide leadership to the program. The Minister was the President of CNLS and was closely involved in running the program. In 2002 the 10 provincial technical offices were put in place. They were all headed by staff from the Ministry of Health. By the end of 2002, doubts were expressed on whether the CNLS, which was controlled by the Minister of Health, would be able to provide the support required to all actors engaged in the fight against HIV/AIDS. During the Mid-term Review in 5 October 2003, it was agreed that medical staff who were not able to manage resources, would be replaced. Five provincial coordinators were replaced in early 2004. 35. The Ministry of Health was late in preparing its own sectoral strategy and plan. The plan was eventually approved in 2003. Project activities under the health component were carried out by GTC, until responsibility for the component was transferred to the Ministry of Health in 2003-04. 36. The Mid-term Review of the project took place in October 2003. The review focused on the report prepared by external consultants COWI on the institutional aspects of the project in August 2003. This report raised a number of issues, such as the lack of oversight by the national and provincial HIV/AIDS committees, the overbearing importance of the Minister of Health in the decision making process, the overstaffing high administrative cost and bureaucratic nature of the national and provincial offices, and the lack of monitoring and evaluation. 37. In 2004 a Demographic and Health Survey (DHS) was carried out, with partial support from the Bank. It provided detailed information on the HIV/AIDS situation in Cameroon. The prevalence rate in the adult population was estimated at 5.5 percent (6.8 percent among the female population). This rate was estimated to be consistent with the rate drawn from the 2000 sentinel survey (10.75 percent among young pregnant women), which did not cover rural areas where the prevalence rate was lower than the national average. 38. The Credit Agreement was amended in early 2004 to increase allocations for health equipment and drugs. Inadequate counterpart funding for the project was a recurrent issue. Eventually, the Bank agreed to finance 100 percent of project cost, as part of the decision to change the country financial parameters in May 2005. 39. In 2004, Cameroon became eligible to the Global Fund resources, and received a grant of US$75.991 million, of which US$33.465 million has been disbursed. 40. In May 2007, the Government decided to distribute antiretroviral (ARV) drugs free of charge and to reduce by half the cost of testing to CFAF 500 (a little over one dollar). Availability of drugs remains a serious problem, however. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 41. Monitoring and evaluation (M&E) has been consistently neglected throughout project preparation and implementation. The main text of the PAD did not discuss M&E arrangements. It did not provide baseline indicators. A rather theoretical annex on M&E was added to the PAD. 42. During project implementation, little was done to establish a system for M&E. The deficiencies in M&E were noted by supervision missions in their aide-memoires. The second and third ISR gave an unsatisfactory rating on M&E. The rating was upgraded to satisfactory in the fourth ISR (July 2002) to take account of progress made, including the establishment of a general framework for M&E, the finalization of the terms of reference for the baseline studies, and the decision to include behavioral aspects in the DHS planned for 2004. From then on, and until January 2007, all ISRs gave a satisfactory rating to M&E, despite the absence of a reliable system. 6 43. Efforts were made, including the recruitment of ten statisticians, one for each province, in early 2006, but without sufficient guidance from the central level, not much was accomplished. Different systems were put in place for the collection and processing of data by the donors providing assistance to the national program, resulting in confusion. 44. In 2004, a report card system was introduced, whereby local communities would make a self evaluation of their HIV/AIDS situation and efforts to fight against it. After adjustments, the system was further tested in 2005, but there was no follow up. It is a promising tool for improving accountability of local committee members. 2.4 Safeguards and Fiduciary Compliance 45. The inappropriate use of funds was a major project risk. In the last Implementation Status Results and Report (ISR) of May 1, 2007, procurement was rated as unsatisfactory and financial management as highly unsatisfactory. In all previous ISRs, these critical aspects of project management were rated as satisfactory, despite the problems mentioned in the previous section. In December 2006, the BBC radio criticized the management of HIV/AIDS funds in Cameroon for lack of transparency, and a local newspaper accused the Minister of Health of conniving with the firm in charge of internal audit of the project for the embezzlement of funds. The Integrity Department of the Bank was kept informed of these allegations. The National Audit Body carried out an audit on the use of project funds, but the Government has not yet made available its report. 46. In spite of efforts made by the Bank team during project implementation to reinforce procurement and financial management, serious problems persisted in these areas throughout the project's life. Procurement plans were not updated. Bidding documents were poorly prepared. Splitting contracts was used to avoid competitive tenders. Tender board members were not well prepared to discharge their duties. Provincial offices were poorly supervised by the CNLS Secretariat. Long delays occurred between contract approval and signing for major tenders. Records were poorly kept, despite the large number of staff in central and provincial offices. Important delays were encountered in providing accounting data and justifying requests for special accounts replenishment. 47. The PAD mentioned that an Environment Management Plan (EMP) would be developed prior to credit effectiveness to address the handling and disposal of HIV-contaminated material. The Plan was expected to provide health facilities with equipment for that purpose. It would also provide for the training of health and municipal staff in charge of waste disposal. As indicated above, preparation of the Plan was much delayed. Supervision missions kept mentioning that the plan was being prepared. They also indicated that health staff was being trained on waste disposal procedures. Eventually, an inventory of waste from hospitals was carried out. Despite the delays in the formulation of the EMP, compliance with the safeguards policy concerning the environment was constantly rated as satisfactory, until the end of 2004, when the ISR format was changed and the rating on environment compliance was no longer required. 2.5 Post-completion Operation/Next Phase 48. In March 2006, the Government launched its National HIV/AIDS Strategic Plan for 2006- 2010. The Plan aims to (i) reduce the number of new infections in the general population; (ii) achieve universal treatment and care for PLWAs; and (iii) reduce the impact of HIV/AIDS on 7 orphans and vulnerable children. This is to be achieved by actions in seven priority areas: voluntary counseling and testing, prevention and management of sexually transmitted diseases (STDs), promotion of condom use, blood safety, scaling up HIV prevention among youths, prevention of new infections among women, and scaling up prevention of mother to child HIV transmission. The Plan was reviewed by donors, who suggested that a Sector-Wide Approach (SWAp) be used. A program is under preparation. 2.6 Expected Next Phase/Follow-up Operation 49. A follow-up operation is envisaged, but within the context of a larger Health project. Before moving ahead with its preparation, however, the country team would like to come to closure with the corruption allegations and better analyze what worked well and not well under the project under review. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 50. The objectives of the project were highly relevant at the time of credit approval and are still now. The HIV prevalence rate seems to have stabilized. Nevertheless, the average national prevalence rate of 5.5 percent is high enough for HIV/AIDS to be classified as a generalized epidemic in Cameroon. This epidemic runs the risk of further undermining health outcomes, which have deteriorated dramatically in past decade. Cameroon is seriously off track for reaching its Millennium Development Goals (MDGs), particularly those related to health, including HIV/AIDS. The Government has updated its HIV/AIDS Plan and the Bank has prepared an Interim Strategy Note (ISN) in November 2006. Fighting against HIV/AIDS remains a core priority in the ISN. A follow-up operation to the project under review is proposed in the ISN. It would emphasize community-based responses in coordination with other partners and with harmonized implementation arrangements. 3.2 Achievement of Project Development Objectives 51. The HIV prevalence rate increased steadily in the 1990s. In 2004, as indicated by the DHS, the HIV prevalence rate had stabilized, which is a major achievement. On the other hand, the incidence of tuberculosis has continued to increase from 156 per 10,000 people in 2000 to 174 per 10,000 people in 2005. According to national surveys, in 2005, the HIV prevalence rate among pregnant women aged 15 to 19 was 2.2 percent, among military aged 18 to 24, 6.7 percent, and among commercial sex workers aged 15 to 24 it was 26.4 percent (this figure is for 2004). In 2005, the percentage of tuberculosis patients, who had completed directly observed treatment strategy (DOTS), was 74 percent 52. The project has contributed to raising awareness. The 1998 DHS reported that 78 percent of the population had heard of HIV/AIDS. In the 2004 DHS, this percentage was 98 percent for females and 99 percent for males. Knowledge remained limited, however. Only 20 percent of women had a complete knowledge of HIV (reject the two most common local misconceptions about AIDS transmission or prevention, know that a person in apparent good health can carry the HIV virus, and correctly identify three ways to prevent AIDS); for men this percentage was higher at 28 percent. More troublesome is that for young people (15-19) the rate is only a little higher (24 percent) for young women and (30 percent) for young men. The project has 8 also contributed to raising the demand for testing, but the supply is still inadequate to meet demand. 53. The demand for condoms has considerably increased, and the project has contributed to making them available to the general population. The 2004 DHS reported that 58 percent of women aged 15 to 49 used a condom the last time they had sex with non-regular partner. This percentage was 64 percent for men. These percentages were respectively 16 and 31 percent in the 1998 DHS. The contraceptive rate has also increased. Between the two demographic and health surveys of 1998 and 2004, the contraceptive rate (percentage of married women aged 15 to 49 who use a modern method of contraception) increased from 7 percent to 13 percent. 54. It is impossible to assess whether the project made a contribution to mitigating the impact of the epidemic on those who are infected or affected by HIV/AIDS because the implementation of community action plans was not adequately monitored. There are signs, however, that progress was made at the local level in providing support to families affected by HIV/AIDS. A large number of mutual assistance funds have been established at the local level, and field observations, as well as data from surveys, point to a decline of the stigma attached to HIV/AIDS. Three quarters of the adult population believe that people with HIV/AIDS should continue to work. 3.3 Efficiency 55. The project implementing agencies did not endeavor to make the most effective use of resources provided. Control over resources was lax. The monitoring of local activities was inadequate. The performance of the personnel of the central and provincial offices of CNLS was not evaluated. Overhead cost was high. In a context of weak governance and lack of accountability for results, pressures to disburse led to inefficiencies in the use of resources. 3.4 Justification of Overall Outcome Rating Rating: Moderately Unsatisfactory 56. The outcome is rated as moderately unsatisfactory. Substantial efforts were made and progress was achieved on several fronts, including on stabilizing the HIV prevalence rate, but, in the absence of an adequate monitoring and evaluation system, it is impossible to measure the direct impact of the project. The results on the ground are not solid enough to justify a higher rating. It is also difficult to link IDA-financed activities to results, as other funds were available in the fight against HIV/AIDS. 3.5 Outputs by Component 57. Support to local response. Reports prepared by GTC, the central project unit, indicated that by end-2006, 7706 local communities had established HIV/AIDS councils, including 1015 health committees (COSA). At end of 2004, however, about 12 percent of these councils had been found to be non existent or inactive. In the absence of a reliable M&E system, it is difficult to assess the effectiveness of these councils. It is clear, however, that without project assistance, a large number of these councils would not have provided services to their members. 9 58. All communes, with the exception of the two largest cities (Douala and Yaounde) have established local HIV/AIDS councils. These councils have supported local activities, but were not much involved in supervising actual implementation of these activities. These councils remain highly dependent on project support. 59. A total of 216 sub-contractors have been hired to help local communities prepare and implement their action plans. About 1000 people working for these organizations have benefited from training sessions supported by the project. Doubts have been raised as to the integrity of many of these organizations, however, following the observations that almost all the local work plans were similar. 60. Support to health sector response. Drugs for the treatment of STDs, tuberculosis and opportunistic diseases were to be made available in 90 percent of health facilities in participating communes. These drugs are reportedly available in close to 50 percent of district hospitals. The project was expected to establish 30 Voluntary Counseling and Testing Centers (VCTCs). With assistance from the Bank and other donors, 91 district hospitals provide testing, in addition to 12 mobile units. Early on, the cost of testing was a disincentive, but this was corrected in the past two years. The 2004 DHS reported that 21 percent of adult women and 16 percent of adult men tested for HIV/AIDS at least once in their lifetime. The number of people tested was multiplied by about 3 over the 2002-2006 period from 21,247 to 74,499. The prevention of mother to child HIV transmission took off in 2006. In 2002, 499 HIV positive pregnant women received ARVs. This number increased to 2,514 in 2005 and 4,780 in 2006. 61. The management of blood banks has not improved. The epidemiological and behavioral surveillance of HIV prevalence in the general population has not been regularly conducted in the 30 sentinel sites, contrary to expectations in the PAD. This has made monitoring of the epidemic impossible. Distribution of condoms has considerably increased from about 1 million in 1989 to about 13 million in 2000 and 33 million in 2006. In 2006, 28,403 persons benefited from ARVs, or about 6 percent of the infected population. 62. Support to sector strategies. Twenty one teams have helped prepare and implement plans in the public sector and 77 teams have done the same in private enterprises. From project reports, however, it is not clear how these plans have been implemented and what results they have brought about. 63. Capacity building. A large training program has been implemented for the benefit of all people who have helped local communities, communes, ministries and enterprises prepare and implement their action plans. 3.6 Overarching Themes, Other Outcomes and Impacts 64. One of the project's overarching theme was to empower local communities, to give them the resources they needed to fight HIV/AIDS. Some empowerment took place, as a number of communities were actively involved in the preparation and implementation of their action plans. Little oversight on how resources were spent was clearly not conducive to genuine empowerment, however. (a) Poverty Impacts, Gender Aspects, and Social Development 10 65. Women at all ages are more affected by the HIV/AIDS epidemic, even though they are much less likely to have multiple partners than men. In 2004, the HIV prevalence rate among women was 6.8 percent and 3.9 percent among men. The 2004 DHS reported that 39 percent of men had multiple partners. This was the case for only 8 percent of women. Women are less informed than men about HIV/AIDS. For instance, 43 percent of women identified the use of condom as a means of protection against HIV infection, while this was the case for 63 percent of men. (b) Institutional Change/Strengthening 66. The project contributed to strengthening a number of local communities. There is anecdotal evidence that some of these communities continue to provide services to their members. A large training program was implemented. Local institutions supported under the project were mobilized to promote activities for the benefit of their members. The availability of condoms across the country has considerably improved. The voluntary testing program has demonstrated its usefulness and has continued after credit closing. 4. Assessment of Risk to Development Outcome Rating: Significant 67. The fight against HIV/AIDS has been scaled up, but has not yet reached a strong enough momentum to continue without external support. The apparent stabilization of the HIV prevalence rate is fragile. Knowledge about the epidemic has increased, but behavioral change has been limited. The health sector remains weak and may not provide the support required for preventing and mitigating the epidemic. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Satisfactory 68. The project's objective was highly relevant. It was a key element of the country assistance strategy. The epidemic was a major threat to Cameroon's development and was undermining both the economic gains made after the end of the depression in 1994 and the efforts made by Government to improve social indicators, which had badly deteriorated during the depression. 69. The technical, economic, institutional and social analyzes for this project could have been stronger. The understanding of the local HIV/AIDS situation was limited. The dynamics of decentralization and local community empowerment were not analyzed. The government's commitment was too much taken at face value. The bases for establishing a monitoring and evaluation system were not in place. The proposed mitigation of environmental issues was inadequate. The risk analysis rightfully pointed out that inappropriate use of resources due to poor governance was a high risk, but measures for mitigating this risk were inadequate. 70. The project was part of a broader program for sub-Sahara Africa ­ the Multi-Country AIDS Program (MAP) - and, as for many other countries in the sub-continent, it was deemed that an 11 urgent response was required in Cameroon and considered important to launch a process of learning by doing as rapidly as possible. Without delaying action, however, project preparation should have been more thorough. (b) Quality of Supervision Rating: Moderately Unsatisfactory 71. The focus of supervision has been mostly on processes, not enough on development impact. It was more concerned with the number of participating organizations than on the content of their action plans and their effective implementation. Bank missions did their best to get a large number of activities launched throughout the country. They could not verify the quality of these activities, however, in the absence of adequate monitoring by the local project teams. 72. Bank supervision missions made considerable efforts to address never ending procurement and financial management issues, but these efforts were not up to the task. Monitoring and evaluation was not a priority. Satisfactory ratings for implementation progress ­ when there was a large disbursement gap ­ and for the fiduciary aspects and monitoring and evaluation were not justified. While there is the need to build on the project's achievements, adequate transition arrangements have not been put in place. (c) Justification of Rating for Overall Bank Performance 73. The Bank performance is rated as Moderately Unsatisfactory. The priority given to quick delivery of the operation made all supervision efforts more difficult. The lack of focus on results and development impact however, justifies the overall Bank performance rating. 5.2 Borrower Performance Rating: Moderately Unsatisfactory 74. The Government prepared its National Strategic Plan for the Fight against HIV/AIDS, and agreed that it would be continuously improved, including making it truly multi-sectoral. It increased the 2000 budget of the Ministry of Health by CFAF 2 billion (about US$2.6 million). During project implementation, however, the program has remained under the close control of the Minister of Health. 75. The project implementation institutions (technical groups at the national and provincial levels) have promoted community participation to fighting HIV/AIDS through the signing of over 7,000 contracts with local communities. Preparation and implementation of action plans by local communities has not been adequately supervised, however, resulting in serious doubts as to the effectiveness of these plans. 76. Project management was less than satisfactory. Overhead was too high (about 20 percent of project cost versus 7 percent estimated at appraisal). Despite the larger than expected number of staff in the project implementation institutions, supervision, monitoring and evaluation of program implementation were not emphasized. There has been a persistent lack of compliance with fiduciary agreements. 12 6. Lessons Learned 77. Fighting HIV/AIDS when it reaches epidemic proportions, as was the case in Cameroon in 2000, is a top priority. The urgency of the fight would justify accelerating procedures, but not lessening the rigor of analysis and ignoring basic operational principles. 78. The Multi-Country AIDS Program (MAP), developed in 2000 and aimed at enabling African countries to scale up their programs against the devastating epidemic, was focused on speed, flexibility, learning by doing and reliance on multiple implementing partners. Scaling up promising activities makes much sense, but these activities must be clearly defined and the justification of providing vastly increased resources clearly made. 79. Implementing organizations have a tendency to become oversized, particularly when the project involves a large number of activities and partners. This tendency should be checked from the very beginning and constantly until the end of the project. 80. Providing grants to a multitude of local organizations is a risky business everywhere and particularly in a context of poor governance. It was clear from the outset that the risks of misuse of funds were high. Extraordinary precautions should have been taken to mitigate these risks and reduce the vulnerability of a key Bank-financed operation to corruption. 81. Pressure to disburse in a context of weak governance and lack of accountability for results leads to inefficiencies in the use of resources. 82. A monitoring and evaluation system must be put in place at the outset of an operation. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 83. The Borrower's observations are in Annex 7 (Summary of Borrower's ICR). (b) Cofinanciers 84. There were no cofinanciers for CNLS. (c) Other partners and stakeholders 85. Several development partners (multi and bilateral agencies) that were working in the HIV/AIDS domain at the same time as CNLS actively collaborated with the project. Their views are summarized in Annex 8: Comments of Cofinanciers and other Partners/Stakeholders. 13 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Estimate Actual/Latest Components Percentage of (USD millions) Estimate (USD millions) Appraisal SUPPORT TO LOCAL RESPONSE 30.00 30.53 101.7 SUPPORT TO HEALTH SECTOR RESPONSE 3.43 5.95 173.4 SUPPORT TO THE DESIGN AND IMPLEMENTATION OF SECTOR 2.30 3.04 132.1 STRATEGIES CAPACITY BUILDING 4.80 7.80 162.5 COORDINATION 8.40 11.10 132.1 Total Baseline Cost 48.93 58.42 119.4 Physical Contingencies 0.38 0.53 Price Contingencies 0.69 1.05 Total Project Costs 50.00 60.00 Front-end fee PPF 0.00 0.00 Front-end fee IBRD 0.00 0.00 Total Financing Required 0.00 60.00 (b) Financing Appraisal Actual/Latest Source of Funds Type of Percentage of Cofinancing Estimate Estimate (USD millions) (USD millions) Appraisal Borrower 7.50 0.00 .00 Local Communities 2.50 0.00 .00 International Development Association (IDA) 50.00 0.00 .00 14 Annex 2. Outputs by Component Project Development Objective The objective of the project was to curb the spread of the HIV/AIDS epidemic and to mitigate its impact for all those who are infected or affected by HIV/AIDS through the strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implement of sector specific HIV/AIDS strategies. to curb the spread of the HIV/AIDS epidemic and to mitigate its impact for all those who are infected or affected by HIV/AIDS 1. Decrease in HIV prevalence rate among pregnant women (age 15 to 19) 2. Decrease in HIV prevalence rate among military (age 18 to 24) 3. Decrease in HIV prevalence rate among commercial sex workers (age 15 to 24) 4. Percentage of tuberculosis patients having completed Directly Observed Treatment Strategy (DOTS) Annual result of HIV prevalence surveillance and HIV/AIDS vulnerability mapping were not provided regularly throughout the project life span. Component 1: Support to local response. Under this component, Local communities would prepare their action plans with the help of agencies and non governmental organizations (NGOs) Local communities which have prepared their action plan would submit these plans to communal committees and receive matching grants to their own contributions in cash or in kind. Implementing agencies will be trained and contracted to facilitate participatory processes at the community Voluntary Counseling and testing Centers will be established 1. Number of Communities which have opened an account and received funding from MAP. 2. Number of implementing agencies contracted to facilitate participatory processes at the community level 3. Number of staff in implementing agencies trained to support the participatory development of action plans 4. Provincial HIV/AIDS committees established Component 2: Support to health sector response. This component would support establishment of voluntary testing and counseling centers, improvement of blood banks, increase in the availability of drugs to treat opportunistic infections, distribution of equipment and materials for home care of the sick, support to private companies, and training of traditional healers and birth attendants in prevention and medication. 15 Support to health 1. Availability of gloves and basic Sector response equipment for home care of terminal HIV/AIDS patients of front line health facilities 2. Percentage of health institutions with drugs available for treatment of STD, tuberculosis, and other opportunistic diseases 3. Number of Voluntary Counseling and testing Centers established 4. Availability of medication to prevent 462 sites put in place and mother to child transmission in 50% of functional in partnership with Elisabeth Glaser natal clinics; Foundation , Glaxo Smith Kline, Plan International, UNICEF and private Sector 5. Systematic screening of blood in 60% Data not available of blood banks; (Current blood transfusion structures in Cameroon are not up to international safety standards) 6. Increase from 30% to 60% in covering Data not available of demand for condoms 7. Number of Traditional healers and 1419 Traditional birth attendants were trained Component 3: Support to the design and implementation of sector strategies. This component would support focal points in key sectors to design sector strategies. Support to Sector 1. Number of action plans prepared by response public sector(*) and private sector(**) 2. Number of action plans elaborated by sector Focal Points to develop sector specific strategies with the involvement of all public, private and semi-private agencies and organizations in the sector 3. Amount of resources re-allocated by sectors to support the implementation their specific strategies (use of HIPC resources, re-allocation of public resources, retro-fitting of donor financed projects) Component 4: Capacity building. This component would include training for facilitators, HIV/AIDS committee members, focal points, staff of financial institutions, and managers. 1. Number of staff in implementing agencies trained to support the participatory development of action plans Component 5: Coordination. 16 This component would include support to small implementation and coordination units at the national and provincial levels and to the operations of one staff in every commune and HIV/AIDS committees at national, provincial and communal levels. 1. GTC* and GTP** in place and fully operational Outcome of VCT per Year 80000 70000 le 60000 eopp 50000 No. of people tested of 40000 erb 30000 No. of people tested muN positive 20000 10000 0 2002 2003 2004 2005 2006 Year Evolution of PMCTC 100000 90000 Number of pregnant women 80000 tested 70000 Number of women tested rebm 60000 positive 50000 Nu Number of women tested 40000 positive having received 30000 ARV 20000 Number of children having received ARV 10000 0 2002 2003 2004 2005 2006 Years 17 RESULTS AND OUTCOME Status of agreed outcomes indicators: Indicators Measurement Baseline Value Progress To Date End-of-Project Target Value Number or text Date Number or text Date Number or text Date Observations PDO Indicator The objective of the project was to curb the spread of the HIV/AIDS epidemic and to mitigate its impact for all those who are infected or affected by HIV/AIDS through the strengthening of communities' capacity to design and implement action plans for HIV/AIDS and through support to the design and implement of sector specific HIV/AIDS strategies. 1. The HIV prevalence rate Initial 11/20/2 2.2 % (DHS 06/30/20 < 10.0% 06/30/20 Annual result of HIV prevalence among young women ( age 15 estimation of 003 Survey 07 07 surveillance and HIV/AIDS vulnerability to 19) should be under 10% 11%, based on Nationwide mapping were not provided regularly ante natal 2004) throughout the project life span surveillance in limited areas. Intermediate outcome indicator(s) 1. Increase in functioning Not applicable 5000 06/30/20 7706 06/30/20 The number of local committees put in HIV/AIDS Council at community 07 07 place reflects great enthusiasm among levels with well established work population at the grassroots level but, programs the quality of work plans produced is still questionable. Very little specificity and sense of innovation was recorded. In August 2005 suspension of funding of these committees occurs due to a lack of justification of their performance and efficiency. Above all, significant number of fictitious or irregular committees was recorded 2. Increase in implementing Not applicable 200 06/30/20 216 06/30/20 During the first phase of the project, agencies contracted to facilitate 07 07 number of Associations and NGOs were participatory processes at the recruited and their personnel trained on community level participatory approaches. After the second year of implementation they were left out in the cold for non satisfactory implementation rate and poor results in monitoring of communities' work. Project staff gradually replaced contracted associations and NGOs. 2.1. Number of staff in Not applicable 100 06/30/07 1000 06/30/20 The project gave the opportunity to train implementing agencies trained 07 more than 1000 "pair éducateurs" but to support the participatory unfortunately they have not been development of action plans optimally utilized in terms of follow up work. 2.2. Implementing agencies will Not applicable 5000 2004 3,500 Implementing agencies `work was have facilitated the participatory committees put characterized by a rush for creating new design and implementation of in place but no committees without putting enough community action plans against evidence of emphasis on the quality of communities HIV/AIDS effective work work plans. Most of the plan did contain plans the same set of activities without reference to sociological characteristics of various communities impacting on the epidemic. 2.3. Communities will have Not applicable 5000 7706 Opened At beginning, the financial sector did not opened accounts and received their accounts provide adequate institutional capacity funding from MAP. to accommodate several thousands of accounts for communities. The project had to negotiate with Micro finance institutions in order to facilitate transactions at the grassroots level. In fact only MFI could ensure national coverage. 3. Percentage of health Not applicable 50% 06/30/20 47% 06/30/20 The implementation of the Health sector institutions with drugs available 07 07 HIV/AIDS strategy as far as information for treatment of STD, availability is concerned suffered from tuberculosis, and other lack of Collaboration and coordination opportunistic diseases between the Ministry of health monitoring system and Communal / Provincial HIV/AIDS Committees. Their relationship was subject to some tensions, resulting in poor quality information. 3.1 Voluntary Counseling and Not applicable Not applicable 611 testing Centers established and operational by end of project; 3.2 Availability of medication to 50% 462 sites put in The follow-up of drug availability for the 18 prevent mother to child place and treatment of STD and tuberculosis and transmission in 50% of natal functional in opportunistic diseases as well as other clinics; partnership with activities conducted such as VCT, Elisabeth Glaser availability of medication to prevent Foundation , mother to child transmission has not Glaxo Smith been an easy task at the level of health Kline, Plan centers and clinics due to staff turnover International, and resources spread too thinly across UNICEF and multiple project objectives and clinics. private Sector The CNLS had to develop a parallel 3.3 Systematic screening of .60% Current blood system for data collection. blood in 60% of blood banks; transfusion structures in Cameroon are not up to international safety standards 3.4 Increase from 30% to 60% in 60% covering of demand for condoms; 3. 5 Availability of gloves and 50% of front basic equipment for home care line health of terminal HIV/AIDS patients of facilities front line health facilities 3.6. Toolkit will be available and 1419 Traditional traditional healers and healers and traditional birth attendants will Traditional birth have been trained on HIV/AIDS attendants were prevention and mitigation. trained, but no follow-up in their daily activities was organized. 4. Number of action plans Not applicable 12 and 60 06/30/20 21 and 77 06/30/20 prepared by public sector(*) and 07 respectively 07 private sector(**) 4.1. Elaboration of action plans 80 in both 98 Most of actions plans prepared by public by sector Focal Points to public and sector contain the same set of activities, develop sector specific strategies private sectors without any reference to sector with the involvement of all specificities. public, private and semi-private agencies and organizations in the sector 4.2. Sector strategies address Not applicable Most of public sector strategies prevention and mitigation elaborated are not specific enough to among staff working in the address the identified challenges in the sector and their families, the sector. public being served by the sector The private sector ones seems to be more and adequate communication adequate to their needs. In general strategy geared to the sector communications aspects should be specific needs reinforced to help promote real 4.3. Re-allocation of available Not applicable ownership. resources to finance implementation of sector specific strategies (use of HIPC resources, re-allocation of public resources, retro-fitting of donor financed projects) 5. Number of agreed Treatment Not applicable 06/30/20 62 and 611 06/30/20 In the public sectors, this opportunity Centers (*) and HIV/AIDS care 07 07 has not been used. The private sector centers (**) in place and through few companies had to re- functional. allocate their own resource to implement their strategy (AES-SONEL, ALUCAM, ...) This indicator was introduced during implementation to strengthen emphasis on treatment in addition to awareness raising 19 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) Separate economic and financial analyses are not applicable to MAP projects. 20 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/ Specialty Lending Supervision/ICR Jan Weetjens Lead Knowledge & Learning Off. HRSLB Project TTL at Appraisal Jean Delion Sr. Operations Officer AFTCS Project TTL during implementation All aspects related to Nicolas Ahouissoussi Sr. Agriculture Economist AFTAR local response and civil society Michel Bakuzakundi Consultant AFMCM All aspects related to sectors response Jean Delimard Consultant AFTPC Fathma Diana Jalloh Junior Professional Associate All M&E aspects Kouami Hounsinou Messan Procurement Specialist. AFTPC All aspects related to procurement Francois Honore Mkouonga Rural Development Specialist AFTAR All aspects related to local response Helene Simonne Ndjebet Yaka Operations Analyst AFMCM All related aspects to disbursement All aspects related to Fridolin Ondobo Financial Management Specialist AFTFM Financial management Pooshpa Muni Reddi Program Assistant MNSED All secretarial aspects Anselm Schneider Human Development Specialist AFTH3 All aspects related to health Miriam Schneidman Sr. Health Specialist. AFTH3 All aspects related to health Ousmane Seck Sr. Rural Development Specialist AFTAR Related aspects to operations 21 (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 34 161.53 FY02 13 64.54 FY03 0.80 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 FY08 0.00 Total: 47 226.87 Supervision/ICR FY01 0.00 FY02 9 70.01 FY03 36 142.23 FY04 34 198.75 FY05 55 174.19 FY06 59 195.27 FY07 33 120.47 FY08 7 12.65 Total: 233 913.57 22 Annex 5. Beneficiary Survey Results No beneficiary survey was conducted for this operation. 23 Annex 6. Stakeholder Workshop Report and Results There has been no Stakeholder workshop for this project. 24 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Introduction Cameroon's response to the HIV/AIDS epidemic was early with the establishment of the National AIDS control Programme as early as 1986. Up till 1999, the action embarked upon was set out in several components, in the long and short runs developed and implemented by the Ministry of Public Health. Unfortunately, the inadequacy of resources and the heavy concentration of the control effort on only the health sector and the insufficient involvement of the other sectors of national life did not make it possible to curb the spread of the disease. In the face of increased HIV-prevalence, the President of the Republic, expressing an unprecedented political will, made the control of this disease one of the national priorities and urged the government to take up the challenge. A National AIDS Control Strategic Plan aiming to strengthen the response within the framework of the National Strategy for the Control of this pandemic was developed for the 2000- 2005 period with the support of development partners. This plan was presented to the national and international community on 4 September 2000 by the Prime Minister, Head of Government. From that time on, AIDS was identified as a development problem and as such, the control thereof is part of one of the priorities of Cameroon's Poverty Reduction Strategy Paper. The 2000-2005 Strategic Plan aimed to reverse the trend of HIV prevalence and to reduce the socio- economic impact of the epidemic in Cameroon, incorporating therein all sectors of national life. It included an operational plan in 6 intervention areas and a 2000-2002 emergency plan. The priority intervention areas included: - prevention of HIV/AIDS and transmission of STIs through behaviour change; - prevention of HIV transmission in hospitals by blood contamination; - provision of clinical and home-based community care for persons living with HIV/AIDS; - definition of an ethics, legal and human rights framework for persons living with HIV/AIDS; - strengthening of HIV/AIDS and monitoring programme; - programme management and coordination. The emergency plan on its part targeted high-risk population groups (men in uniform, students, sex workers, prison population and truck drivers and focused on three points: - use of condoms (male and female); there was talk then of the 100% condom - strategy; - voluntary counselling and testing (VCT); - promotion of behaviour change among youth of between 15 and 24 years. The 2000 -2005 strategic plan, by opening up to others (Ministries other than Health, the private sector and NGOs), is part of the national poverty reduction strategy. To achieve these goals, Cameroon and the World Bank in March 2001 signed a US$50 million grant agreement within the framework of MAP funding, which supported the 2000-2005 NSP in five components: - support to local interventions: this centered on assistance to communities in their efforts to prevent and reduce the effects of the pandemic; - support to the development and implementation of sector strategies; - support to health response interventions; - capacity building for stakeholders involved in the control effort in the public, - private and civil society sectors; and - coordination. 25 At the end of the period of implementation of the 2000-2005 National Strategic Plan, it is necessary to draft a general end-of-project report with the purpose of bringing out the accomplishments and achievements and lessons learnt during the operationalisation of MAP 1 the initial objective of which was to curb the spread of the AIDS epidemic in Cameroon and cushion its effects on those infected and affected by HIV/AIDS. The lessons drawn from this shall make it possible to build on the strengths and correct weaknesses in the development and implementation of a similar project. I. Description of the Institutional HIV/AIDS Control Framework HIV/AIDS and STI control is carried out within the framework of the National AIDS Control Programme (NACP): - The National AIDS Control Committee (NACC): This advisory multidisciplinary organ chaired by the Minister for Public Health is tasked with defining the general AIDS control policy in Cameroon. - The Joint Monitoring Committee (JMC): It provides advice and ensures - evaluation and control of the activities of the Programme. - The Central Technical Group (CTG): This is the executive organ in charge of coordinating, managing and implementing the activities of NACP. Under the authority of the Permanent Secretary, assisted by a deputy Permanent Secretary, the Central Technical Group comprises: o A Planning, Monitoring and Evaluation section; o A Contracts Award Section; o An Administrative and Financial Management section; o A Health Sector Support section; o A Sector Response and Partnership Section; o A Local Response Section; o A Communication for Behaviour Change and Social Marketing Section; o Support executives and staff. - The Provincial AIDS Control Committee (PACC): These are multi-sector o teams at the level of each province. They are tasked with ensuring the o coordination of AIDS control activities in the province. - The Provincial Technical Group (PTG): It is the executive organ at the level of each province. Under the authority of a Coordinator, it executes AIDS control activities in the province under the supervision of the Provincial AIDS Control Committee (PACC). It comprises: o A Planning, Monitoring and Evaluation unit; o A Local and sector response unit; o A Communication for Behaviour Change and Social Marketing unit; o An accountant and support staff. - The Communal AIDS Control Committee (CACC): It coordinates AIDS control activities within the council. Chaired by the Mayor, this committee has broad and multi-sector representation. - The communal correspondent: He is the executing agent of the Communal AIDS Control Committee. - The Local AIDS Control Committee (LACC): It is charged with carrying out AIDS control activities in a village, neighbourhood, a group of villages or neighbourhoods. This institutional framework makes it possible to consolidate the multi-sector nature of control both in the central and peripheral levels. As an illustration, NACC is made up of 12 26 representatives of various ministries and 2 MOH representatives, 14 members of the Civil Society (PLWHA, Employers' Association, Churches, NGOs, etc.) and representatives of donors involved in HIV/AIDS control. The institutional framework makes for great decentralization of the control effort in the communities with CACC found in villages, in neighbourhoods both in rural and urban areas. However, the weaknesses noted in the functioning and management of CACC were behind the reorientation of community mobilization with the use of existing local grassroots organizations. This process has been ongoing with the decentralization of funding to the level of parishes since 2006. It will continue with decentralization to the basic structures of the sectors as nearly all ministries have AIDS control units. There are no provincial breakdowns of these structures. II. Presentation of Outcomes by Component II.1. Local Responses 1. Objectives of local responses The "local response" component was not taken into account at the time of development of the strategic plan in September 2000. It is subsequently in the course of 2001 that the country embarked on the implementation thereof. The objective of Local Response was to elicit the response of grassroots communities through assistance provided to the latter by the Programme in their efforts to prevent and reduce the effects of the AIDS crisis. Specifically, focus was on: o Developing and adapting methodological tools on participatory approaches adapted to the various target groups in order to elicit local response; o Providing support to subcontracting structures in the implementation of the process of community participation in AIDS control in the communities; o Developing ways and means of transferring resources towards the communities to support the execution of Community AIDS control Action Plans (CAP) drawn up to this effect and the rational use of the resources transferred; o Facilitating, monitoring, supervising and controlling the execution of agreements, contracts and conditions of contract drawn up with subcontracting agencies; o Preparing the contractual framework for collaboration and implementation of local response strategies. 2. Local response implementation strategies Local response is developed in five phases: 1. Identification of communities to be mobilized for implementation of AIDS control activities; 2. Participatory development of community action plans with the involvement of all social groups (vulnerable groups: women and youths) and especially Persons Living with HIV/AIDS (PLWHA) in the planning and execution of activities. 3. Capacity building for the stakeholders. This process of capacity building for secondary NGOs (Local Support Organizations) was renewed each year following selection of the latter subsequent to a call for expression of interest. 4. Implementation of the community participation process. Following the identification of communities to be mobilized, the population of the latter formed social/professional sub groups according to sex, age, centre of interest in order to receive technical support from a subcontracting structure in view of developing an annual community AIDS control action plan. This plan includes a set of activities considered by the community among 27 which the following were considered eligible for financing by the Programme: training of peer educators, prevention, promotion of voluntary testing, support to infected and/or affected persons, promotion of condom use, monitoring of activities and functioning of the Local Committee. 5. Financing of Community Action plans (CAP). At the end of the participatory exercise, the community forwards a funding request file through the communal correspondent to the Council AIDS control Committee or failing that to the Provincial Technical Group in order to receive Programme resources for the implementation of its activities. This file comprises : proof of formation of LACC, proof that the community has grouped themselves into a legal entity with legal status, an AIDS control action plan based on which a request is made by the community for the financing of eligible actions, proof of opening of an account in an approved financial institution in the name of the LACC. 3. Outcomes of local responses Local response to AIDS control mobilized 7,706 grassroots communities from 2002 to 2007, for a total funding of 6 766 894 988 CFA Francs. These communities are broken down as follows: Table 1: Number of Communities mobilized and grant funds disbursed by the MACP from 2002 to 2007 per structure Types of communities Number Amount Local Aids control communities 5 739 5 665 662 323 Association of PLWHA 176 464 872 665 Women's associations (Communities 20 9 250 000 Women's Sector) Association of Public Service Staff 101 76 500 000 Association in schools/universities 387 204 900 000 Informal communities 179 17 610 000 Heath District Committees 89 71 250 000 Health area Committees 1 015 256 850 000 TOTAL 7 706 6 766 894 988 4. Strengths and weaknesses of community response Strengths 1. Mass action which affected more than 7 706 grassroots communities in all municipalities 2. Involvement of community members in the analysis of the HIV situation, development and implementation of community action plans 3. Financial support of MAP to the implementation of community action plans 4. Improvement of community knowledge on HIV 5. Training of community volunteers for peer education for behaviour change with respect to HIV 6. Strong involvement of traditional, religious, administrative and local authorities in stimulating behaviour change 7. Increase in availability and use of condom 8. Increase in demand for voluntary counseling and testing services 9. Reduction in stigmatization of PLWHA and acceptance of PLWHA by communities 10. Greater solidarity of communities towards people infected and/or affected by HIV. Weaknesses 28 1. The setting up of local response was not preceded by a situational analysis to identify suitable structures and leaders in the communities that could help define the best community control framework 2. The setting up of special AIDS control management structures in communities sometimes creating conflicts of authority with Community management structures already established there 3. Discontinuation of community activities at the end of financing calls for planning for sustainability from the start of the project by incorporating the control effort in development actions 4. Emphasis was laid on quantitative indicators of project disbursement, instead of qualitative outcome indicators of the project 5. Low involvement of all community groups in AIDS control 6. Instability of Community AIDS control management structures the existence of which is closely related to the existence of the support grant to MAP 7. The context of poverty in which some communities live and which compels them to allocate MAP grants more to poverty reduction actions than to AIDS control 8. Limited blending of AIDS control with concrete poverty reduction actions as the priority of grassroots communities 9. Non transparent management of grants to support community action plans 10. Low involvement of Health sector in Community HIV/AIDS control 11. Inadequate monitoring of Community AIDS control activities 5. Perception of local response by recipients The following points emerged from the provincial interactive meetings organized within the framework of the evaluation of the 2000-2005 strategic plan: o Inadequate training of various personnel at grassroots level and of other local response stakeholders did not facilitate the implementation of local response; o Inadequate time to prepare local committees with very perfunctory training without practice in the field; o Lack of real commitment on the part of municipal authorities resulting in the non involvement of communities in the financing of HIV control activities. o Lack of credibility with regard to the setting up and existence of some local committees; o Difficulty for communities to adapt to extreme standardization of activities to be financed by the PTG with account not taken of the specific realities of each community; o Low level of awareness of some populations with regard to the HIV situation either by ignorance or bad faith; o Instability of Community relays (peer educators) o Unsuitability of communication to local realities (language code in particular); o Lack of cooperation between the PTG and other actors constituting part of the weaknesses for the control effort. II.2. Sector responses and partnership 1. Objectives assigned to sector responses The aim of the sector response and partnership is to push all sectors (public, private and denominational) of national life to get involved in AIDS control with priority to public/private sector partnership for additional concrete actions beneficial to all segments of the population and those at the grassroots level. Public authorities also associate the Denominational Sector to the national response in order to: (a) supplement response to HIV/AIDS with a spiritual dimension which gives pride of place to support and communication; (b) utilize the opportunities provided 29 by religious denominations in school, health guidance and social mobilization; (c) take into account theological aspects in connection with HIV/AIDS and break the damaging silence based on ignorance. 2. Implementation strategies of sector responses A sector is made up of sub-sectors of similar activities or actors that can be public, lay private or denominational. Each sector has the responsibility of working out its own AIDS control strategy. To coordinate this process, contact teams are identified in each sector. The CTG provides support to contact teams in the form of training on the methods of strategy definition and on the problems of AIDS specific to each sector. Members of coordination teams in each sector are selected by consensus and trained by the CTG with the technical assistance of consultants on the methods of definition and implementation of the AIDS control strategy. Each sector identifies a focal point made up of a team of 2 to 3 persons; members of this team are based in their sector and are the interlocutors of the CTG Sector Response Section. Focal teams of the sectors are tasked with coordinating the development of the sector plans. These sector plans ought to specify: (a) Specific actions to be implemented by each of the sub-sector (advocacies, capacity building, mobilization and public awareness campaigns, prevention actions, etc.) and the monitoring indicators of these activities; (b) The terms and conditions of partnership between sub-sectors and mechanisms of integration of their activities); (c) Specific communication actions to be carried out within the sector; (d) Mechanisms of financing the implementation of planned activities. The sector plans is financed by the budget of each sector. For that purpose, funds come from: (a) The reallocation of existing budgets of public and para-public sectors; (b) HIPC Initiative resources; (c) The reallocation of funds for ongoing project and/or new projects financed by various donors. The financing of activities and the procedures of disbursement are clearly defined in the partnership conventions. In fact, activities contained in the conventions are jointly financed by NACC and the private sector (enterprises, Religious Denominations, etc). The relevance of the advocacy carried out by the NACC Chairman made it possible to mobilise significant funds from the following sources: (a) State budget; (b) World Bank IDA Funds; (c) Funds allocated by UNAIDS to support interventions; and (d) Funds accruing from debt relief to the Heavily Indebted Poor countries (HIPC). With regard to the activities financed by NACC, the budget of the action plans is drawn with the participation of Companies on the basis of standards of calculation in force at NACC. Any eligible activity has a work plan and a use of funds plan. 30 3. Outcomes of sector response It was only in the year 2002 that the first conventions were signed with six (6) public administration sectors (Education, Higher education, Defense, Women's, Social Affairs, and Social Administration), 26 with the private sector and 17 with religious denominations. Among these sectors having signed these conventions 23 companies were financed to the tune of 282 million, 15 religious denominations, 254 million and 3 university institutions for more than 11 million in order to carry out the activities of the first six months of 2004. The year 2003 was also devoted to technical and financial support to the development of the sector plans of 14 ministries and the National Assembly and led to the validation of the plans of 6 ministries which had already signed their conventions in the year 2002. Public sector This support was limited to funding the process of development of their control Plans, funding their implementation from the TTL's point of view, ineligible for IDA financing. Religious denominations In 2002, approximately 17 conventions were signed and 15 financed for the first half of the year with religious denominations for a total amount of 253 981 333 CFA Francs. 4. Strengths and weaknesses of sector response Strengths 1. Implementation of the multisector approach strengthening partnership between the various sectors to cope with the pandemic which is a major obstacle to the socio-economic development of the country; 2. Total commitment of the private sector to HIV control in Cameroon; 3. Capacity building of several focal points within each sector, so as to guarantee the permanent availability of skills for the management of sector programmes; 4. Quality of prevention and management of STIs and OIs related to HIV/AIDS and by ARV drugs within health structures of the denominational sector; 5. Management of OVC thanks to financial support from the authorities; 6. Ability of Religious denominational partners of NACC to design, formulate and implement HIV/AIDS control campaigns in denominational settings and to manage crisis situations as regards HIV/AIDS. Weaknesses 1. The process of putting in place focal points, building their capacity and the development of sector plans took much time. Indeed, the process which started in 2001 continued for the first three years before the first sector plans were validated in 2003; 2. Weak commitment of officials at the level of some ministries who have not completed their sector plans and are not mobilizing to seek internal or external funding; 3. Lack of sufficient information with regard to the execution of activities of the private sector, the public sector and religious denominations. 4. Absence of control mechanisms with respect the use of funds granted to the sectors; 5. Inadequate supervision mechanism and technical support to the various sectors to properly ensure the process of development of sector plans; 6. Non compliance with contract clauses by the CTG with respect to certain sectors; 7. Weaknesses, within the CTG and PTG, in the management and technical and financial follow- up of activities of sector response; and 8. Inadequate decentralization of sector response activities. 31 II.3. Health Sector Response 1. Objectives assigned to health response The objectives of the Health Response in the implementation of the 2000-2005 NSP were to: o Set up 30 voluntary counselling and testing centres o Improve transfusion safety by testing blood in 60% of health facilities providing blood transfusion services o Increase the availability of drugs for opportunistic infections, STIs, tuberculosis in 90% of existing health structures in councils selected in the project o Make available, at the level of sites, drugs for the prevention of MTCT in 50% of antenatal clinics o Distribute medical equipment for the home-based management of patients in 50% of highly involved structures o Build the capacity of the private sector in HIV/AIDS control o Conduct HIV-prevalence survey or investigations at the level of sentinel sites and produce a vulnerability map each year o Increase by 30% to 60% condom demand coverage 2. Health response implementation process The execution of Health Response activities to attain the objectives of MACP consisted in: o The Setting up, in 2001, of 16 Approved Treatment Centres (ATC) for the comprehensive case management of PLWHA, Voluntary Counselling and Testing activities, which constituted the basis thereof o The rehabilitation and equipment of these centres to make them functional o The development of training tools (Training Guides for comprehensive case management, Guidelines for case and data management, data collection tools, etc.) o The training of medical and para-medical staff in the comprehensive case management of PLWHA and PMTCT. o The provision of ATC with reagents, essential drugs and supplies o The designation, in various sectors of activities, of officials in charge of implementation of HIV/AIDS control activities o The supervision of activities 32 3. Results achieved Voluntary Counseling and Testing (VCT): Outcomes of VCT per year Year No. of people tested No. of people tested Positive 2002 21 247 2 065 2003 56 968 16 071 2004 54 538 13 243 2005 69 212 10 440 2006 74 499 18 991 Two Mobile Units made it possible to carry out testing on 12,536 persons in 2005 compared with 14,524 in 2006. The purchase of 10 Mobile Units in 2006 certainly made it possible to strengthen testing in communities. Prevention of mother to child HIV transmission (PMTCT) The evolution of PMTCT from 2000 to 2007 is remarkable. Starting from a pilot site in 2000, the number gradually moved to 350 sites delivering PMTCT services in 2003, and to more than 600 sites at the end of 2006. Summary table of the evolution of PMTCT from 2002 to 2006 Year # of pregnant # tested positive # of HIV-positive # of children born women tested women having of + mothers and received ARV as put on ARV at prophylaxis birth 2002 23091 2219 499 447 2003 28934 2467 1571 908 2004 36864 3712 1711 676 2005 52163 6014 2514 1873 2006 90238 9308 4780 4315 PLWHA management: In 2002, a pilot management project was developed and adopted. Several training workshops were organized for 164 doctors and 27 nurses making a total of 191 trained medical staff. In the course of the same year, drugs were bought for the therapeutic management of OIs, with support for clinical follow-up of PLWHA by the provision of equipment for CD4-CDB counts. ARV supply activities were strengthened with an extension of case management for 13 ATC targeting 1300 destitute patients following conventions signed between NACC and the ATC. A guide for treatment with ARV was drawn up and translated and about thirty pharmacists followed training on the dispensing of ARVs and OIs to PLWHA. A national strategy for equitable access to ARVs and treatment of OIs was developed and a request was prepared and submitted to the Global Fund. The commencement of the Global Fund programme in January 2005 allowed for the scaling up of treatment with ARVs. From 16 ATC in 2001, the number moved to 23 ATCs and 68 functional management units (MU) in 2006. From 2000 until the end of 2006, more than 2839 doctors and nurses were trained in the case management of PLWHA, 38 laboratories equipped, 309 laboratory assistants trained and 450 community relay workers trained in community support of PLWHA. 4. Strengths and weaknesses of health response Strengths 1. Free provision of ARV drugs started through pilot projects and was generalized in May 1 2007 33 2. Decentralization of HIV management 3. Free treatment of opportunistic infections 4. Free HIV testing for vulnerable populations 5. Recruitment of some PLWHA in HIV/AIDS control hospitals or institutions 6. Permanent availability of ARV drugs at the level of CENAME 7. Systematic testing of any blood donor 8. Building the capacity of central, provincial and some district laboratories in equipment and reagents for two years 9. Application of safety measures by health personnel during the handling of blood products in laboratories and hospital structures 10. Setting up of associations of blood donors 11. Development of standardized STI management modules 12. Lower costs of essential drugs for syndromic case management 13. Systematic proposal for testing pregnant women during antenatal consultations 14. Significant increase in the number of PMTCT sites 15. Inexistence of progress reports on achievements in management or treatment structures Weaknesses 1. Poorly covered nutritional component 2. Insufficient collaboration between NACC and PLWHA management structures 3. Inadequate monitoring of activities of STI prevention and syndromic management or treatment 4. Lack of supervision to assess the level of achievements and the quality of care given to patients 5. Lack of collaboration between the technical coordination groups of NACC and the central, provincial and operational health structures for the effective operationalization of STI prevention and treatment activities in the whole country 6. Insufficient number of prevention of Mother-to-child transmission sites 7. Stock-outs of PMTCT inputs 8. Non involvement of traditional birth attendants in the process (training and sensitization) 9. Insufficient follow-up of mothers during breast feeding II-4. Communication for Behaviour Change 1. Objectives assigned to CBC The Communication for Behaviour Change and Social Marketing component is responsible on the one hand, for facilitating, coordinating and monitoring the implementation of awareness campaign activities targeting the population on the dangers they face in the context of AIDS, and on the other hand, the institutional communication of the National AIDS Control Committee. This Section is responsible for the communication strategy of the National AIDS Control Committee. 2. Process of implementation of CBC activities Communication for behaviour change (CBC) was not really taken into account during the development of the2000-2005 strategic Plan. However, the need for communication was named in the immediate actions to be carried out to guarantee success in the implementation of the 2000- 2003 action plan. CBC activities are implemented based on the communication strategy of the National AIDS Control Programme which is considered as the centrepiece of all CBC activities. This strategy document was available since June 2004, that is to say, three years after the effective start of the Multi-sector AIDS Control Programme. Before this date, CBC activities were implemented based on a temporary communication plan designed thanks to the contribution of the Technical Communication Support Commission (CTAC) set up by decision of the Minister for Public Health, Chairperson of the NACC. This plan built on various aids considered to be key 34 (road posters, folders, bill boards, small posters, radio and TV campaigns, insertion of sensitization messages on books of pupils/students, match boxes, etc). In June 2004, the communication strategy document of the NACC was validated during a workshop that brought together various AIDS control actors. 3. Results of CBC The main achievements of the CBC are as follows: · the 2002 emergency campaign of NACC launched with the use of four components: A radio campaign based on the production of a spot and a bilingual micro programme broadcast more than 6750 times; A TV campaign through close to sixty broadcasts of spots and production of three documentaries on AIDS control in companies, AIDS control by religious denominations and the management of PLWHA; A press campaign written with the insertion of 126 messages in 15 national newspapers which was rounded off in October 2002 with the publication of the "letter from a big brother"; A public posting campaign with 100 road posters measuring 4 X 3 m and 2000 posters stuck up everywhere. · the "AIDS-free Holidays" campaign of the CTG/NACC editions 2001 through 2006. The objective of this campaign was to raise awareness and to reduce HIV/AIDS infection among at least 120.000 school children, university students and youth during holidays. · the "No AIDS 2004" campaign caravan co-financed by the PAF and the World Bank was a success and enabled the information and sensitizing of almost 9000 young pupils and students from 35 schools in 14 towns and 7 provinces. It was particularly appreciated by youth thanks to concerts, in particular rap music and sketches presented by associations of youths living or not with VIH. · the 2005 multi-media "Pinch-unroll" campaign of the Cameroonian Association for Social Marketing (ACMS) was put in place based on the results of a study carried out on 622 persons, following complaints made about condoms which frequently get torn. This study showed that although 7 surveyed out of 10 declared that they knew how to properly use the condom, their aptitude to correctly describe how to use a condom is definitely lower. · Awareness raising by community radios (NACC/UNESCO/UNICEF/UNAIDS): this translates the importance of proximity communication through the setting up and provision of support to private FM radio stations and provincial CRTV stations: to convey messages in several local languages; transmit messages adapted to the various cultural contexts and the various local problems; obtain feedback from the populations concerned; allow the production of programmes with questions to specialists, testimonies; enable a proper targeting of messages etc. This awareness programme by community radios was the subject of a partnership agreement signed between community radios, UNESCO, UNICEF, the Coca-Cola Foundation and NACC. · brochures titled "the snail and dino" by CTG/NACC; "AIDS declared nonstarter" by PMUC and "letter from big brother" by the Minister for Public Health at the start of new school year campaigns. NACC developed and distributed a brochure titled "the snail and dino" which is based on the comparison between the snail which can get back into its shell when the air is too dry and come out once the rains return, and the dinosaur which disappeared because it did not know how to adapt. · the "Cross-Generational Sex" campaign by ACMS/NACC/GTZ/USAID. This initiative stems from the results of the DHS 2004 which revealed that girls between 15-19 years and 20-24 years have a higher HIV prevalence rate than boys of the same age, 2.2% and 7.9% compared with 0.6% and 2.5% respectively. The hypothesis was thus put forth that they were infected by older men with whom they have more or less regular sexual intercourse. This cross-generational sexuality is an old practice in Cameroon, but it was in exchange for money and worsened because of poverty. 35 4. Strengths and weaknesses of CBC Strengths 1. Multiplicity of promising initiatives as regards multimedia campaigns and the quality of tools developed and broadcast 2. Effort of creativity, innovation and targeting in the contents of messages and choice of aids 3. Express will to use all opportunities to develop CBC actions during major gatherings or assemblies of populations (youth festivals or shows, traditional festivals, sports tournaments, celebration of world days, etc) 4. Collaboration between some partners for the production and dissemination of awareness tools 5. Involvement of the private sector in awareness campaigns. Weaknesses 1. Absence of national CBC strategy document until June 2004 to support the other NACP activities 2. CBC strategies contained in the document validated in June 2004 were ill adapted, and do not take into account media and socio-cultural opportunities of the Cameroonian context 3. Insufficient situation analysis as regards predominant behaviour among high-risk target groups 4. Failure to take into account ongoing actions and research results at the level of the other communication partners 5. Intensification of CBC activities in the urban environment to the detriment of rural areas 6. Relative ignorance in the communication strategy of the predominant role played at community level by the traditional chieftainships and under-utilization of the potential offered by the wealth of associations 7. Inexistence, until 2005, of monitoring and evaluation indicators of CBC activities 8. Insufficient information management attributable to the inexistence of progress reports on CBC activities in the provinces II-5. Administrative and Financial Management The Multi-sector AIDS Control Programme (MAP) was financed by the World Bank to the tune of 50 million dollars and counterpart funds of an estimated amount of 7.5 million dollars from the State for the period from September 2001 to June 30 2007. In the project assessment document (PAD), it was agreed that an adequate financial management system was to be set up with the coming into force of the grant. A financial officer was to be recruited and accountancy was to be subcontracted to a private specialized firm. To meet these requirements, an Administrative and Financial Management Section was set up within the Programme under the authority of a Section Head and an accounting and financial assistance firm was recruited by mutual agreement by the World Bank. During the execution of the Project, the missions of this Firm were reinforced to control financial management at the level of Provincial Technical Groups, thus the Firm became administrator in the Provincial Technical Groups. The financial management of the Programme was decentralized according to the organization of control activities in the field. Each Provincial Technical group had autonomy of management over the annual budgets validated by the NACC and approved by IDA The accounts of the Programme were opened and managed by the National Sinking Fund in mutual agreement between the Cameroonian Government and IDA/World Bank. An accounting, administrative and financial procedures manual was put in place and approved by IDA at the start of the Project. MAP set up a disbursement mechanism enabling it to ensure fluid and speedy transfer of funds from the central level (CAA) to the decentralized level. Bank accounts were opened and managed by the National Sinking Fund (CAA) for the management of project funds. The rate of grant disbursement as of 30/06/2007 stands at 97% and taking into account the last commitments already concluded, it will stand at nearly 100%. The Project had problems with 36 mobilizing counterpart funds. Such that on August 26 2005, the World Bank and the Government of Cameroon signed an amendment to Grant arrangements of 100% funding by IDA of all expenditure of the Project. Strengths and weaknesses of the administrative and financial management Strengths 1. setting up an accounting office 2. putting in place and application of the Manual of administrative, accounting and financial Procedures 3. existence of budgetary norms 4. preparation of detailed annual budgetary estimates and budgets by the project 5. execution of financial supervision missions to detect and correct dysfunctions 6. production of financial and accounting statements 7. production of management reports 8. strengthening of the powers of the Accounting firm at the level of PTG (joint management powers) with financial responsibility since 2004 9. development by the project of its own FRR 10. regular drawing up according to periods of FRR by the AFS/FAU with the support of the National Sinking Fund 11. high level of disbursement. Weaknesses 1. at the level of PTGs, the coordinators who are for the most part doctors have not always been trained in financial management and in World Bank disbursement procedures 2. the firm put in place did not master the financial and accounting management of projects in particular new tools such as Financial Monitoring Reports, follow up of fund reimbursement requests (FRR) and expenditure by financial categories. Consequently, the project operated according to treasury accounting and not commitment rules, hence the real problem of following up commitments, and the cost overruns recorded in some expenditure 3. the application of internal control proved inadequate in Provincial Technical Groups for want of capacity building for its officials 4. the TOMPRO software module put in place was not used in all the human resources management modules of the Project. III. Impact of IDA/WORLD BANK Procedures on the Implementation of the Project It was observed all along the implementation of MAP that World Bank Task Team leaders played a predominant role in the setting of priorities and strategies. MAP 1 was a typical example of a project whose true leadership was external to the country and ensured by the World Bank TTL. This lop-sided nature of decision taking power impacted negatively on the overall performance of the project. 1. Choice of ill-adapted strategies of implementation of local and sector responses The aide-memoire of the World Bank supervision mission from 2 to 9 February 2003 stipulates: "Each Grassroots Community (GC) is eligible to a grant on an indicative base of FCFA 1000 per member, with an average of FCFA 1000 000 per year, a maximum of FCFA 1500 000. A GC is understood to mean a village/neighbourhood of 1000 persons on the average or legally registered organizations, organizations of members carrying out activities at the service of their members, 37 non profit making, parish associations, trade unions, associations of company employees, associations of prisoners, parent teacher associations, soldiers in barracks, HC, small PLWHA associations." "Big Communities (BC) are associations which serve more members and organizations which work with orphans, widows of PLWHA. Each PTG can fund some BC per year (maximum 30) and the amounts will vary from FCFA 7 000 000 to FCFA 10 000 000. The contribution stands at 50% per enterprise, 50% maximum by NACC in the form of grants. In the case of other Big Communities, the contribution of the BC shall be at least 15% by the BC and 85% in the form of grants for sub-projects by NACC. In the case of a BC with a broad impact, the maximum amount of the grant as representing CAP can go up to FCFA 25 000 000 per year, still in supplement to a contribution of the enterprise as defined in the handbook of procedures (50% of the total cost)." These clear guidelines of the World Bank mission show that funding was not done on the basis of activities to be carried out, but on the number of individuals living in an area and often without any established solidarity basis. This approach became a source of confusion in the field for it was difficult to determine members of a local committee. The choice of old and experienced organizations would have been a better option. 2. Choice of process and not outcome indicators The aide-memoire of the World Bank supervision mission from 22 April to 1 May 2003 stipulates: "Follow-up of major indicators: - Number of Grassroots Community having received payment of the first installment for the first year - Number of Grassroots Community having received payment of the second installment for the first year - Number of Grassroots Community having received payment of the first installment for the second year - Number of Grassroots Community having received payment of the second installment for the second year; - Number of OAP contracts under execution; - Number of communities prepared with the support of these OPA; - Number of Big Community having received payment of first installment; - Number of Big Community having received payment of second installment; - Amount disbursed on category A." These indicators must be preceded by estimates (number planned), and was collected quarterly in collaboration with M&E and financial services (FAMU, FAS, Firm)". It is obvious that for TTL, what mattered most was the disbursement of funds and not the outcomes of use of these funds in the field. At the end of the project, there were surprisingly no statistics on the concrete achievements of the various actors having been funded. The unilateral nature of the choices made by the bank did not make it possible to have outcome indicators with respect to the services provided to the population. 3. The pernicious effects of the prior "non objections" of TTL The implementation of yearly action plans needs a formal and written "non objection" of the Task Team Leader. This provision made him the real leader in the implementation of the programme. All activities depended on his availability and that of his colleagues tasked with examining the budgetary estimates or the procurement plan. For all these reasons, the annual action plans of CTG/NACC were always approved after the month of March delaying their implementation for at least three months. These "non objection" power wielded by TTL did not allow CTG/NACC to acquire female condoms in spite of their planned procurement since 2003. It was suggested that they should be procured by ACMS, which 38 is an NGO, then by a United Nations agency etc. All these guidelines, falling under the remit of the TTL alone, always ended in impasse. Conclusion The IDA 3454 grant made it possible for the first time to scale up HIV/AIDS control in Cameroon. This funding allowed for the operationalization of the multisector approach to HIV/AIDS control and enabled thousands of communities in the rural and urban areas to become aware of the dangers of HIV/AIDS. Prepared as a matter of emergency, MAP 1 made use of the principle of "learning by doing" for its implementation. This special context should not be forgotten at the time of evaluating the programme. Several activities carried out cannot be highlighted on account of the absence of relevant monitoring indicators and of a potent monitoring and evaluation system. The following actions, however, stood out as best practices within the framework of MAP 1: - Contracting of service provision: (for instance, condom distribution) with local NGOs and associations of PLWHA who played a vital role in the psychological support of infected and affected persons and nutritional support. - De-stigmatisation of the disease marked by open testimonies and increased demand for voluntary counselling and testing services by community members. - The involvement of leaders of certain communities in the dissemination of HIV and AIDS control messages. - The effective involvement of community radio stations in the spread of HIV and AIDS messages. - Ownership of the control effort by community members and a greater solidarity among infected and affected persons through the setting up of solidarity funds in some communities. - Public/private sector partnership was an entry point for local neighbouring communities to prevention, care and treatment services. - The organization of anonymous and voluntary testing campaigns for all staff followed by the case management of sick workers, as was the case with the ALUCAM and HEVECAM ATC. - Maintaining HIV-positive workers in activity in companies contributed to encouraging workers to freely access voluntary counselling and testing. - The availability of condoms in customers' rooms in hotels (IBIS Hotel, SAWA Hotel, for instance). - The facilitation of sharing of experiences and good practices through the pooling of efforts by means of networks and coalitions of companies such as the Plateforme de Coordination Groupes d'Entrepises (PCGE) ­ [Platform of Coordination of Groups of Companies] (Alucam, Brasseries du Cameroun, Camrail, CFAO, Cimencam) are good examples. - The execution of special awareness campaigns during major social events likely to mobilize a great number of persons (Youth Day, International Women's Day, National Day, etc.) with the use of mobile units for general public testing. - Awareness campaigns among students and pupils during holidays referred to as "AIDS- free Holidays" with the use of mobile units for testing youths. - Information and awareness campaign on HIV/AIDS for students (in secondary and high schools) christened Caravane No Sida [No AIDS Caravan]. Here, awareness messages were carried through music shows, poems and sketches. - Popularization of the male condom thanks to the multimedia "Pinch, Unroll" campaign. The aim here is to help the population use the condom correctly. 39 - Support by NACC to relevant communication activities by the civil society (stage arts, books on AIDS, etc.). The objective here is to encourage Cameroonians engaged in AIDS control. - The insertion of HIV/AIDS control messages in some widely distributed industrial products (school exercise books for youths, match boxes for families and households). It is therefore crucial that these activities should continue within the framework of MAP II, with lessons drawn from the experience of MAP I. This MAP II should be prepared in the spirit of the Paris declaration, namely: Ownership, alignment, harmonization, results-based management, and mutual accountability. 40 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Several development partners (multi and bilateral agencies) actively collaborated with the project. This Annex presents the views of UNAIDS, UNESCO, UNICEF, UNDP and French Cooperation. UNAIDS. The UNAIDS representative emphasized the importance of implementing the "three ones"approach, namely that in Cameroon there must be a common HIV/AIDS strategy, common leadership and a uniform monitoring and evaluation (M&E system. UNAIDS has financed the elaboration of a sound M&E manual and consultant support. She also emphasized on the need for establishing a more dynamic collaboration among development partners. In view of the preparation of a follow-up operation of MAP project and subsequent rounds of Global fund, a Memorandum of understanding was prepared. This MOU pointed out six directions to be developed for the future: (a) The ownership of the fight by all the stakeholders; (b) The implementation of harmonized and alignment procedures on government's priorities; (c) To have regular consultation and discussion among development partners; (d) To put in place a common Monitoring and Evaluation system (e) To regularly share with all stakeholders and development partners project's objectives and annual work plans; (f) To put in place a functional mechanism to share/disseminate information UNESCO: UNESCO has been very instrumental in the fight against HIV/AIDS in Cameroon. The UNESCO representative has been the chair person of the technical and financial development partners group involved in the fight against HIV/AIDS in Cameroon. UNESCO also contributed actively to develop and insert in school curricula, modules to inform and promote behavioral change at the level of primary and secondary education in Cameroun. While regretting the fact that this orientation was not strongly developed within the MAP, they express the need to have future operations to emphasize on prevention in school through curriculum development. UNICEF: UNICEF has actively promoted the prevention of mother to child transmission (PMCT) of the virus, as well as the provision of special medication and nutrition programs for infected or affected children through collaboration with CNLS. Although congratulation CNLS for its achievements in the domain of PMCT, UNICEF was dissatisfied with the amount of resources and attention set aside for PMCT program. UNICEF closely collaborated with the World Bank and UNAIDS and fully support the "three ones"approach in Cameroon. UNDP: UNDP has been actively supporting the development of a strategic plan for 2006-2010 in Cameroon, as well as conducting studies to help improve the implementation of the whole HIV/AIDS program in Cameroon. Among the studies conducted, "resource mobilization and utilization for the fight against HIV/AIDS within sector ministries" was one of their major concerns. The study revealed that following Prime Minister's 2004 order to provision resources in various ministries' budget for the fight against HIV/AIDS, though the resources were mobilized, a very limited amount was effectively used for this purpose. The study strongly recommended that in the future the national committee be informed on the resources mobilized and annual work plans of various ministries, in order to ensure appropriate coordination of activities. French Cooperation: They were actively involved in voluntary counseling and testing. Their main complaint for the project has been the need to share information and set up a sound monitoring and evaluation system to improve data reliability. 41 Annex 9. List of Supporting Documents 1. World Bank: Project Appraisal Document on Cameroon Multi-Sectoral HIV/AIDS Project 2. World Bank: Development Credit Agreement on Cameroon Multi-Sectoral HIV/AIDS Project 3. World Bank: Supervision Mission Aide-Memoires 1-16. World Bank Files, 2001-2007 4. World Bank: Implementation Status Reports 1-16. World Bank Files, 2001-2007 42