58604 v. 1 Document of The World Bank Report No: PROPOSED PROJECT RESTRUCTURING PAPER OF THE SECOND MULTISECTORAL HIV/AIDS PROJECT CREDIT 4290-BEN TO THE REPUBLIC OF BENIN November 22, 2010 Africa Region Health, Nutrition and Population (AFTHE) ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Anti-Retroviral treatment CBO Community-based Organization CCLS Communal HIV/AIDS Control Committee CDLS Departmental HIV/AIDS Control Committee CNLS National HIV/AIDS Control Committee CSO Civil Society Organization DHS Demographic and Health Survey EA Environmental Assessment GOB Government of Benin HIV Human Immune Deficiency Virus IDA International Development Association IEC Information Education and Communication IP Implementation Performance ISR Implementation Status and Results Report M&E Monitoring and Evaluation MoH Ministry of Health MTCT Mother-to-Child Transmission MTR Mid-Term Review MWMP Medical Waste Management Plan NEIA National Environmental Impact Assessment OVC Orphans and vulnerable children PAD Project Appraisal Document PDO Project Development Objective PIU Project Implementation Unit PLWHA People living with HIV/AIDS PNLS National HIV/AIDS Control Program PSI Population Services International SDR Special Drawing Right SGASS Second Generation STI/AIDS Surveillance Survey SP/CNLS Permanent Secretary of National HIV/AIDS Control Committee UNGASS United Nations General Assembly Special Session on HIV VCT Voluntary Counseling and Testing Regional Vice President: Obiageli Katryn Ezekwesili Acting Country Director: Madani M. Tall Sector Manager / Director: Eva Jarawan Task Team Leader: Ayité-Fily D'Almeida 2 BENIN SECOND MULTISECTORAL HIV/AIDS PROJECT P096482 CONTENTS Page A. SUMMARY 4 B. PROJECT STATUS 4 C. PROPOSED CHANGES 6 ANNEX: RESULTS FRAMEWORK AND MONITORING 8 3 BENIN SECOND MULTISECTORAL HIV/AIDS PROJECT RESTRUCTURING PAPER SUMMARY 1. The Project Development Objective (PDO) of the Benin Second Multisectoral HIV/AIDS Project ("Project") is to contribute to: (a) strengthening access to and increasing utilization of prevention services for vulnerable groups (women, youth) and high-risk groups such as commercial sex workers and staff of some key ministries; (b) improving access to and utilization of treatment and care services for HIV/AIDS-infected and affected persons, notably those living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVC); and (c) consolidate the coordination, management, and monitoring and evaluation (M&E) of the national response to HIV/AIDS to ensure its sustainability. 2. The proposed changes, the subject of this restructuring paper, aim to: (a) revise some of the outcome indicators baseline and end-of-Project target values to take into account new data and reflect changes which occurred during the past 32 months of implementation; and (b) reallocate the Credit proceeds. At the time of the Project preparation, data for the baseline values of Project outcome indicators reported in the results framework were either not available or estimated on a provisional basis. On another hand, given higher than planned spending in the Vehicles and Equipment category, due in large part to the higher than anticipated cost of acquiring two mobile HIV/AIDS testing laboratories and its operating costs, the Government of Benin (GOB) has requested a reallocation of the Credit's proceeds to cover overdrawn categories, and to allow the Project to move forward smoothly until the closing date. The reallocation does not entail changes in activities, and project cost is not affected. All expenditures will continue to be financed at 100%. PROJECT STATUS General status of the Project 3. The Project's mid-term review (MTR), held from January 18-29, 2010, found that the Project remains both highly relevant and feasible. The review showed that it has been making steady progress towards the achievement of the PDO and was rated Satisfactory. Given the good progress made up to the date of the MTR, achieving the PDO by project closing was considered very likely. The Implementation Performance (IP) was also rated satisfactory in the Implementation Status and Results Report (ISR) approved on October 4 22, 2010. The Project is in full compliance with all legal covenants. As of November 22, 2010, 35 months after effectiveness, 56% of the Credit amount has been disbursed. This rate is somewhat satisfactory if one considers the difficult environment that surrounded the implementation of the Project's activities, such as the social unrest with recurrent strikes observed within Benin's civil service, particularly in the health sector. 4. The Project has ensured so far, among other things, the financing of social mobilization and HIV prevention services carried out by civil society organizations (CSOs) and community-based organizations (CBOs). A total of more than 800 sub- projects have been financed for information, education and communication (IEC) activities and for direct support to people living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVC) to mitigate the impact of HIV. To improve access to treatment, care and impact mitigation services, the Project has begun rehabilitating laboratories, constructing incinerators in the country's departments, and providing medical equipment, anti-retroviral (ARV) treatment, drugs to manage opportunistic infections, reagents, and other medical consumables. The proceeds of the Credit have also been used to support training for more than 1,000 traditional healers and religious leaders in the Vaudou convents, and an estimated 500 health personnel to effectively manage opportunistic infections and ARV regimes. Specific issues singled out during the Project MTR 5. The MTR was an opportunity for primary stakeholders involved in HIV/AIDS control to discuss the main issues concerning project implementation. 6. The first issue of concern was the low progress achieved with regard to the environmental safeguards. The Environmental Assessment (EA) was rated Moderately Satisfactory (MS) after the MTR due to the delay experienced by the Ministry of Health (MoH) to acquire medical waste management equipment for health centers at the national level. The MTR mission recommended a number of measures to strengthen the medical waste management sub-component of the Project, including outsourcing key activities to civil society and private actors to allow the national medical waste management agency to 5 focus on the oversight, supervision and technical support for these activities. Over the six months following the MTR, progress achieved under this subcomponent is deemed to be satisfactory: On the Government side, the necessary equipment, the additional materials and training expenses related to medical waste management are covered through the Ministry of Health Budget and through the IDA Credit proceeds; an environmental health specialist of the Ministry of Health has been appointed as responsible focal point for following up the MWMP recommendations during project implementation; the proceeds of the Credit have been used to: (i) procure small equipment distributed to health facilities for collecting and destroying medical waste; (ii) prepare technical documents used for the training of health staff in charge of medical waste management; (iii) construct incinerators in 20 health facilities; (iv) recruit a communication agency to design sensitization materials in the field of medical waste management. From the Bank side, the project is being supervised by a Sr. Environment Specialist based in Abidjan who is following up on issues concerning : (i) the model and placement of incinerators; (ii) training; and (iii) the distribution of equipment at health centers. To date, safeguards implementation is satisfactory 7. A second issue of concern discussed at the MTR was the status of counterpart funds. While the full amount pledged by the GOB to pay supplementary allowances to civil servants working on the Project has been received by the implementing agency, the rating has been downgraded from Moderately Satisfactory (MS) to Moderately Unsatisfactory (MU). This is because the inter-ministerial decree ­ outlining the specific allowances to be paid to the various categories of staff to allow utilization of the counterpart funds ­ has still not been finalized. After the MTR, the issue was discussed at length with the Ministry of Finance and has now been solved in accordance with the national policy provisions on allowances to be granted to civil servants. 8. The third issue raised during the MTR concerned the Project's monitoring and evaluation (M&E). The MTR includes detailed discussions on this subject, recommending that a new results framework be prepared in order to clarify some project indicators and better tie indicators to project activities, taking into account the data provided by the Second Generation STI/AIDS Surveillance survey carried out in 2008. 6 9. Finally, the MTR concluded that the proceeds of the Credit should be reallocated to cover overdrawn categories and allow a smooth implementation of the Project until the Closing Date, scheduled for December 31, 2011. PROPOSED CHANGES 10. There are not any changes proposed for the original PDO, the Project three components, nor in the activities outlined for each component. All institutional and implementation arrangements as originally set-up in the Project Appraisal Document, Financing Agreement and detailed in the Project Implementation Manual will remain unchanged. The restructuring does not entail an extension of the Credit's Closing Date, scheduled for December 31, 2011, which will leave sufficient time for the remaining SDR 10.2 million to be fully disbursed. The Medical Waste Management Plan (MWMP), as disclosed in-country and to the Bank's Info Shop prior to appraisal, is unchanged. The total Project cost remains the same and the Project will continue to be implemented in conformity with the MWMP. The Project Safeguard category remains unchanged, and no Safeguard Policy is triggered. 11. The only changes requested in this Restructuring Paper concern the Project results indicators and the reallocation of the proceeds of the Credit. Results and indicators 12. The MTR made recommendations to prepare a new results framework to clarify the baseline and end-of-Project target values of some indicators. The MTR specifically recommended that the PDO-level results indicators and the intermediate results indicators that were agreed upon during Project preparation and negotiations be adjusted based on the results of the Second Generation STI/AIDS Surveillance Survey carried out in 2008, on achievements at the MTR. The values of the indicators should be either provided (baseline) or adjusted (end-of-Project targets) to reflect achievements over the past 35 months of implementation. These revised indicator values are reported in the Annex (Results Framework and Monitoring) of this document. After thorough discussions between the Bank team and the Benin counterparts, it was agreed to use year 2008 data provided by the Second Generation STI/AIDS Surveillance Survey (SGASS) as baseline values for the Project. The rationale is that the SGASS is the main data source for several core indicators of the Second Multisectoral HIV/AIDS Control project, especially those related to the behavioral aspects. As the project became effective in 2008 and started its activities that year, the Bank team and the Benin counterparts agreed that it is more appropriate to retain the SGASS 2008 data as baseline data and for the basis of the monitoring of the project performance, instead of relying on those of 2005 released in 2006, which were outdated and would definitely give a biased picture of the project performance since the situation has drastically changed in 2008, the 7 year of the beginning of the project. The end-of- project targets values have also been revised to a more realistic level to take into account progress achieved during the past 34 months of project implementation. Reallocation of Credit proceeds 13. The request for the reallocation submitted by the GoB is essentially based on the fact that the Project Implementation Unit (PIU) was confronted to higher levels of spending for rehabilitation works, equipment, consultant services, training and operating costs than originally planned. To face this situation, funds under some of the concerned categories were overdrawn with the view of not hampering the smooth implementation of the Project, while awaiting the MTR to request a reallocation of the Credit's proceeds among existing categories. As regards specifically equipment, related funds under Category 2 were overdrawn due to the fact that, at the Project preparation stage, the costs of some medical equipment were underestimated, as were also the needs in equipment (motorcycles, computers and related office equipment) of the beneficiary entities, especially at the decentralized levels, such as the departmental and communal HIV/AIDS committees in charge of providing support and assistance to local communities engaged in the fight against the epidemic. The Government requests therefore that the funds under Category 2 be increased not only to cover the overdrawing but also to procure goods that have already been planned. It is also requested that funds under Category 5 (Operating Costs) be increased given that costs of expenses incurred locally were much higher with the depreciation of the US Dollar against the CFA Franc in 2008-2009. Funds under Category 4 (Grants to CBO and Line Ministries) are reduced in the reallocation request, to avoid overlap as these beneficiary entities benefit massively from the assistance of other donors. 14. The reallocation would not entail changes in any activities. Total Project cost would not be affected. All expenditures would continue to be financed at 100%. However, the Task Team has amended the withdrawal schedule submitted by the Government with regards its proposed reallocation for Category 6-PPF refinancing; the actual disbursed amount is XDR 90,251.38 while the proposed allocation in the request is only for XDR 89,000. The new withdrawal schedule amended by the Task Team is as follows: Allocation % of Financing Category of Expenditure (expressed in XDR) (inclusive of Taxes) Current Revised Current Revised Current Revised (1) Works -- 670,000 758,000 100% -- (2) a) Vehicles, Motorcycle and -- 740,000 1,029,000 100% -- Equipment 8 b) Medical Equipment, Drugs, Tests, -- 7,200,000 7,536,000 100% -- and Reagents (3) Consultants -- Services, Audits and -- 3,700,000 4,413,000 100% Training (4) a) Grants to CBO -- -- 2,350,000 1,540,000 100% b) Grants to CSO -- -- 4,200,000 4,897,000 100% c) Grants to Line Ministries -- 1,000,000 451,000 100% -- (5) Operating Costs -- 2,100,000 2,785,748.62 100% -- (6) PPF -- 330,000 90,251.38 (7) Unallocated -- 1,210,000 0 TOTAL 23,500,000 23,500,000 9 ANNEX Results Framework and Monitoring SECOND MULTISECTORAL HIV/ CONTROL PROJECT D=Dropped Cumulative Target Values** Responsi- Data Source/ Core PDO Level Results C=Continue Unit of Baseline 2011 Freque bility for Indicators* N= New Measure (2008)*** 2009 2010 (Propose ncy Methodology Data R=Revised d) Collection Indicator One: C 21.5% -- Available 45% Bienni Second MoH, Percentage of young (Second by early al Generation CNLS women and men aged Generation 2011 STI/AIDS 15-24 who both STI/AIDS Surveillance correctly identify ways Surveillanc Survey of preventing the sexual e Survey ­ transmission of HIV 2008) and who reject major misconceptions about HIV transmission in the last 12 months (UNGASS, IDA 14) CORE INDICATOR Indicator Two: C 49.5% -- Available 65% Bienni Second MoH, Percentage of young (Second by early al Generation CNLS women and men aged Generation 2011 STI/AIDS 15-24 reporting the use STI/AIDS Surveillance of a condom during last Surveillanc Survey sexual intercourse with e Survey ­ a non-regular or non- 2008) cohabiting partner in the last 12 months (UNGASS). C 79.7% -- Available 90% Bienni Second MoH, Indicator Three: by early al Generation CNLS Percentage of sex (Second Generation 2011 STI/AIDS workers who report Surveillance using a condom with STI/AIDS Surveillanc Survey their most recent client (UNGASS) e Survey ­ 2008) Indicator Four: C Adults: Adults: Available Adults: Annual Health Sector MoH, Percentage and number (52.7%) (65.8%) by early 19000 Program CNLS of people with 11308 15087 2011 Monitoring advanced HIV infection Reports, Children: receiving antiretroviral UNGASS Children: (81.0%) Children: combination therapy reports (UNGASS). CORE (57.8%) 1084 2000 INDICATOR 770 Indicator Five: C 52.8% 56,8% Available (70%) Annual Health Sector MoH, Percentage and number (1447) (1703) by early 2689 Report, CNLS of HIV-infected 2011 UNGASS pregnant women Country receiving a complete Report course of antiretroviral prophylaxis to reduce risk of MTCT - CORE INDICATOR 11 Indicator Six: Number C 175 086 Year Available 375,000 Annual Health Sector MoH and Percentage of (87.7%) 2009: by early Reports persons aged 15 and 106211 2011 older who undergo HIV voluntary counseling and testing in the last Cum: 12 months and know 281 297 the results (89.2%) Indicator Seven: C _ _ 2 4 Annual Joint review CNLS Annual joint program report and reviews and work annual work planning exercise by all plan CNLS donors (under the report coordination of SP/CNLS INTERMEDIATE RESULTS Intermediate Results (Component One): Social Mobilization and HIV Prevention Services Revised Intermediate Results: No revision Intermediate Result -- 502 Available 700 Annual Financial And CNLS Indicator One: by early program Reports Number of subprojects 2011 financed targeting vulnerable populations, high risk groups and geographic hot spots Intermediate Result C -- 11 Available 15 Annual indicator Two: Number by early of public sector 2011 organizations supported and implementing HIV interventions 12 Intermediate Result C -- 727, 438 Available 1,500,000 Annual Periodic reports CNLS Indicator Three: by early from sub- Number of persons 2011 beneficiaries reached with community outreach and support of IEC/BCC programs C -- 1,160,347 Available 3,500,000 Annual Condoms PSI Intermediate Result by early distribution Indicator Four: Grantees 2011 records Number of condoms sold/distributed Periodic reports from grantees Intermediate Results (Component Two): Access to Treatment, Care, and Impact Mitigation Revised Intermediate Results: No revision Intermediate Result C Adults: Adults: Available Adults: Annual MoH, CNLS indicator One: Number 11,308 15, 087 by early 19,000 of people with 2011 advanced HIV infection Children Children: receiving ARV : 1,084 Children combination therapy. ­ CORE INDICATOR 770 2,000 Intermediate Result C -- 4,667 Available 8,000 Annual Grantee routine CNLS indicator Two: Number by early monitoring of people with 2011 records and advanced HIV infection reports receiving psychosocial care Intermediate Result C -- 1,934 Available 5,000 Annual Grantee routine CNLS Indicator Three: by early monitoring Number of PLWHA 2011 records and receiving nutritional reports 13 support reports Intermediate Result C 1,447 1,703 Available 2,689 Grantee routine CNLS Indicator Four: by early monitoring Number of pregnant 2011 records and women receiving a reports complete course of ARV prophylaxis to reduce the risk of mother to child transmission of HIV Intermediate Result C -- 1,767 Available 2,500 Grantee routine CNLS Indicator Five: by early monitoring Number of orphans and 2011 records and other vulnerable reports children whose households have received care and support in the last 12 months Intermediate Results (Component Three): Project Coordination, Management, Monitoring and Evaluation Revised Intermediate Results: No Revision Intermediate result C -- 2 Available 4 Annual Grantee routine CNLS Indicator One: Annual by early monitoring joint workplan review 2011 records and and work planning reports exercise by all donors (under the coordination of SP/CNLS) Intermediate Result C -- 6 (100%) Available 6 (100%) Annual CDLS and CNLS Indicator Two: by early Municipal Number and percentage 2011 Committee 14 of CDLS operational Reports Intermediate Result _ 24(30%) Available 48(60%) Annual CNLS Indicator Three: by early Number and percentage 2011 of CCLS operational Intermediate Result C 40,000 57,254 Available 65,000 Annual Project data PMLS2 Indicator Four: by early Number of persons 2011 trained in HIV service delivery Intermediate Result C --- 25 (52%) Available 48 (100%) Annual Project data PMLS2 Indicator Five: by early Percentage and number 2011 of implementing agencies (public sector and civil society) submitting timely quarterly monitoring and financial reports to SP/CNLS. *Please indicate whether the indicator is a Core Sector Indicator (see further http://coreindicators) **Target values should be entered for the years data will be available, not necessarily annually *** Rationale for using year 2008 data as baseline for the Project: After thorough discussions between the Bank team and the Benin counterparts, it was agreed to use year 2008 data provided by the Second Generation STI/AIDS Surveillance Survey (SGASS) as baseline values for the Project. The rationale is that the SGASS is the main data source for several core indicators of the Second Multisectoral HIV/AIDS Control project, especially those related to the behavioral aspects. As the project became effective in 2008 and started its activities that year, the Bank team and the Benin counterparts agreed that it is more appropriate to retain the SGASS 2008 data as baseline data and for the basis of the monitoring of the project performance, instead of relying on those of 2005 released in 2006, which were outdated and would definitely give a biased picture of the project performance since the situation has drastically changed in 2008, the year of the beginning of the project. 15 16 17