Document of The World Bank Report No: 36119 IMPLEMENTATION COMPLETION REPORT (IDA-34580) ON A LOAN/CREDIT/GRANT IN THE AMOUNT OF US$ MILLION TO THE GHANA FOR A AIDS Response Project (GARFUND) June 29, 2006 CURRENCY EQUIVALENTS (Exchange Rate Effective as June 29, 2006) Currency Unit = Cedis 1 Cedis = US$ 0.00011 US$ 1 = 9193.36 Cedis SDR 1 = US$ 1.49 FISCAL YEAR January 1 December 31 ABBREVIATIONS AND ACRONYMS CAS Country Assistance Strategy CBO Community Based Organization CCM Country Coordination Mechanism CDD Community Development Driven CSWs Commercial Sex Workers DAs District Assemblies DACF District Assembly Common Fund DCA Development Credit Agreement DPRME Directorate Policy, Research, Monitoring and Evaluation DRIMT District Response Initiative Management Team DRI District Response Initiative FBO Faith Based Organization GAC Ghana AIDS Commission GARFUND Ghana AIDS Response Fund GOG Government of Ghana GDHS Ghana Demographic Health Survey GSMF Ghana Social Marketing Foundation HIV Human Immuno Deficiency Virus IAs Implementing Agencies IEC Information Education Community IDA International Development Association MDAs Ministries, Departments and Public Agencies M&E Monitoring and Evaluation MOE Ministry of Education MOF Ministry of Finance MOH Ministry of Health MMWG Multi-Sectoral Working Group MLGRD Ministry of Local Government and Rural Development NACP National AIDS Control Program NCTE National Country for Tertiary Education NGO Non-Governmental Organization NSF National Strategic Framework PDO Project Development Objectives PLWHA People Living With HIV/AIDS OVC Orphans and Vulnerable Children RACs Regional AIDS Committee STD Sexually Transmitted Diseases SWAP Sector-Wide Approach TA Technical Assistance USAID United States Agency for International Development VCT Voluntary Counseling and Testing Vice President: Gobind T.Nankani Country Director Mats Karlson Sector Manager William Experton Task Team Leader/Task Manager: Aissatou Diack GHANA AIDS Response Project (GARFUND) CONTENTS Page No. 1. Project Data 1 2. Principal Performance Ratings 1 3. Assessment of Development Objective and Design, and of Quality at Entry 2 4. Achievement of Objective and Outputs 5 5. Major Factors Affecting Implementation and Outcome 14 6. Sustainability 16 7. Bank and Borrower Performance 17 8. Lessons Learned 19 9. Partner Comments 22 10. Additional Information 35 Annex 1. Key Performance Indicators/Log Frame Matrix 37 Annex 2. Project Costs and Financing 39 Annex 3. Economic Costs and Benefits 41 Annex 4. Bank Inputs 42 Annex 5. Ratings for Achievement of Objectives/Outputs of Components 45 Annex 6. Ratings of Bank and Borrower Performance 46 Annex 7. List of Supporting Documents 47 Project ID: P071617 Project Name: AIDS Response Project (GARFUND) Team Leader: Aissatou Diack TL Unit: AFTH2 ICR Type: Core ICR Report Date: June 29, 2006 1. Project Data Name: AIDS Response Project (GARFUND) L/C/TF Number: IDA-34580 Country/Department: GHANA Region: Africa Regional Office Sector/subsector: Health (85%); Central government administration (10%); Other social services (5%) Theme: HIV/AIDS (P); Population and reproductive health (S); Participation and civic engagement (S); Gender (S) KEY DATES Original Revised/Actual PCD: 09/29/2000 Effective: 05/08/2002 05/08/2002 Appraisal: 10/19/2000 MTR: 03/26/2004 03/26/2004 Approval: 12/28/2000 Closing: 06/30/2005 12/31/2005 Borrower/Implementing Agency: GOVERNMENT OF GHANA/GHANA AIDS COMMISSION Other Partners: DFID, USAID STAFF Current At Appraisal Vice President: Gobind T. Nankani Callisto E. Madavo Country Director: Mats Karlsson Peter C. Harrold Sector Manager: Alexandre V. Abrantes Rosemary Bellow Team Leader at ICR: Aissatou Diack Eileen Murray ICR Primary Author: Aissatou Diack; Kofi Amponsah 2. Principal Performance Ratings (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely, HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: S Sustainability: L Institutional Development Impact: SU Bank Performance: S Borrower Performance: S QAG (if available) ICR Quality at Entry: S S Project at Risk at Any Time: No 3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective: The objective of the Project was to intensify multisectoral activities designed to combat the spread of HIV infection and reduce its impact on those already affected by HIV/AIDS, by financing interventions outside the Ministry of Health's (MOH) mandate. Specific objectives of the Project were to: (i) provide resources that would enable the Government of Ghana (GOG) to implement a balanced, diversified multi-sector response, engaging all relevant government sectors, non-governmental organizations (NGOs) and grassroots initiatives; (ii) to expand contributions made by the Ministry of Health (MOH) to engage the civil society in the fight against AIDS; and (iii) to finance eligible activities conducted by civil society organizations including NGOs, community-based organizations (CBOs), faith-based organizations (FBOs), trade and professional associations, associations of People Living With HIV/AIDS (PLWHAs), districts, and line ministries to ensure a rapid multi-sector scaling up of HIV prevention and care activities in all regions of the country and at all administrative levels. The objectives of the project were consistent with the Bank's Country Assistant Strategy (CAS), which underpinned the need to continue to provide sector-wide support to the health sector in Ghana and the urgent need to address the spread of HIV/AIDS through a multi-sector approach. 3.2 Revised Objective: The objectives were not revised. 3.3 Original Components: The project had four components: Component 1. Prevention and Care Services ($21.00) This component was to finance governmental (excluding health) and civil society entities to provide a broad spectrum of prevention and care activities at national, regional and local levels. Seventy percent of project funds were allocated to these activities, out of which $15.0 million were earmarked for non-governmental and community-based initiatives. The prevention activities were designed to reduce high risk behaviors and exposure to risk, to reduce the vulnerability of those who were unaware of their risk by raising their awareness, and to de-stigmatize the disease so as to increase access to prevention and care. The project sought to reduce the vulnerability of families affected by HIV/AIDS by financing services to protect their rights, income generation activities, care for orphans and home-based care for the ill. The project provided access to funds through three windows for financing of proposals that were categorized under three groups. The first group (Window A) included proposals from the line ministries to finance activities for internal and external clients. The second group (Window B) included financing for proposals for civil society organizations including NGOs, CBOs, FBOs, trade and professional associations, associations of PLWHAs, districts, and NGO affiliation networks (umbrella organizations). The third group (Window C) provided seed money for activities conducted by small CBOs and associations. - 2 - Component 2. Strengthening Public/Private institutions for HIV/AIDS Control (Capacity Building) (US$2.40) This component was intended to improve skills and strengthen structures to help achieve the GARFUND's objective of scaling up the national HIV/AIDS response. The aim was to enhance both the technical and managerial capacity of implementing entities to implement projects as well as sustain the process of scaling up the HIV/AIDS response. The project provided support through technical assistance (TA) to specific projects and training to groups of implementing entities. In addition to some TA identified in the proposals of implementing entities, the project was expected to identify additional needs through project supervision and the entity's experience in the implementation of subproject activities. Training was subcontracted to NGOs, line ministries, or pre-qualified training providers with expertise on HIV/AIDS. To monitor the services provided, the beneficiaries would provide feedback on a regular basis and the Ghana AIDS Commission (GAC) could undertake random site visits. Component 3. Knowledge Management (US$1.40) This component was to set up and maintain information clearing house database on HIV/AIDS relevant to implementing entities to improve their effectiveness. The purpose was to provide implementers with the latest information on HIV/AIDS prevention and care, best practice examples from other countries, research results, and any other reports that would be useful to them. Additionally, the project provided a forum for information sharing and experience exchange by implementing entities, as well as access to technical information on the project itself. Information was to be disseminated in the various media, including newsletters, copies of published papers, coordination meetings and via the internet. It was expected that umbrella organizations could have a key role as vehicles of information. Once the regional AIDS committees were all established, they would serve as a focal point for dissemination. Financing of this component was expected to strengthen the impact of activities financed under component 1. Component 4. Project management and Monitoring and Evaluation (US$3.00) The project was placed under the authority of GAC, which was to be in charge of the definition of broad priorities for action, the selection of eligible proposals (through a technical subcommittee) and the monitoring of project performance. The GAC includes high level representatives of all line ministries which should play a role in the fight against HIV/AIDS, religious, occupational, NGO affiliations, women's associations, students' organizations and other interest groups. The Secretariat of GAC was tasked to implement GAC decisions and was responsible for financial and administrative aspects as well as overall monitoring and evaluation (M&E) of the project. In addition, the Secretariat was to provide support to entities awarded contracts under the project with basic training in financial management and procurement in order to ensure compliance with Bank procedures. It was also responsible for preparing and administering contracts to selected executing agencies, as well as monitoring their technical and financial performance. Finally, the Secretariat was to provide financial and technical reports on quarterly basis to the GAC, prepare annual reports for financing agencies, and ensure that annual audits were carried out in accordance with agreements with International Development Association (IDA), to ascertain that - 3 - funds were used following procedures agreed upon with IDA in the Development Credit Agreement (DCA) and the operations manual. - 4 - 3.4 Revised Components: The components were not revised. 3.5 Quality at Entry: The quality at entry is rated as moderately satisfactory. The project development objectives (PDO) were relevant to the sector related CAS overall goal of reducing the spread of HIV/AIDS through a multi-sectoral approach, and the GOG's health sector priorities. The project design incorporated lessons learned from similar operations in Africa as well as other parts of the world. In particular, several design features of successful AIDS/STD programs in Africa and other regions were reflected in the design. Moreover, risk factors such as, inadequate response from the Ministry of Health (MOH), low capacity at the grassroots level, which could hamper strong community response, and lack of implementation experience by the Secretariat were thoroughly assessed and mitigation measures were proposed. The project also built upon a strong government ownership and supported the national program, which was expected to enhance sustainability by building institutional capacity at national and local level. Finally, the project design benefited from a series of consultations with key development partners, including DfID and USAID. However, major design flaws were noted in the project preparation. First of all, the use of HIV prevalence as the golden indicator set in the PDO, against the written statement in the overall MAP I project document and the QK advisor, was not appropriate as it could not have been affected by a four-year project. Prevalence could even have increased as a result of successful project implementation because of increased reporting of HIV cases resulting from greater awareness raising and reduction in stigma and discrimination. The increased utilization of antiretroviral therapy, though supported by the Global Fund and WHO, could decrease mortality of PLWHA and thus increase HIV prevalence. Secondly, it was an error to exclude the Ministry of Health (MOH) from project implementation and funding, based on the assumption that the health SWAP would meet all the funding needs. This decision limited the GARFUND's capacity to contribute to and be accountable for increased utilization of HIV-related health services such as VCT, PMTCT, medical care and antiretroviral care, while unmet needs were clearly documented. Finally, in the context of a concentrated epidemic, the project design should have focused more on high risk groups, such as sex workers, prisoners and men having sex with men (MSM). 4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective: Overall project outcome is rated as satisfactory. The project was designed to achieve two main objectives: (i) to intensify multisectoral activities designed to combat the spread of HIV infection, and (ii) to reduce the impact of HIV/AIDS on those affected and their families. (i)PDO 1: To intensify multisectoral activities designed to combat the spread of HIV infection: The project likely contributed to noticeable changes in sexual behavior and increased demand for HIV-related health services, by strengthening the national response to HIV/AIDS. The Ghana Demographic Health Survey (GDHS) reported that the proportion of people in union using condoms at their last intercourse, increased from 15 to 45% for men and from 6 to 35% for women. The median age at first intercourse has also increased from 17 to 18.3 - 5 - years for females and from 17 to 20.2 years for males indicating a noticeable improvement. The national response to HIV/AIDS was greatly expanded through funding for approximately 3,026 subprojects in all communities across the country. GARFUND has been successful in expanding the community response to HIV/AIDS by increasing the proportion of funds awarded to CBOs which constitute about 72% of funded organizations. Furthermore, 71 ministries and departmental agencies (MDAs) and all the 110 districts in Ghana implemented annual plans to address HIV/AIDS from 2003 to 2005. Finally, GARFUND resulted in unprecedented government ownership of the response to HIV/AIDS and was characterized by fast track implementation of new and pilot interventions. - 6 - The HIV prevalence among pregnant women remained well below 6% at the end of project. Analysis of trend data from HIV/AIDS Sentinel Surveillance Surveys indicate that the median HIV prevalence rate among pregnant women in Ghana was reduced from 3.4 % in 2002 to 2.7 % in 2005, though significant regional variations in HIV prevalence rates remain (1.2 % in the Northern Region to 4.7 % in the Eastern Region). The Ghana Demographic Health Survey (GDHS) published in 2003 showed a national HIV prevalence among 15 to 49 years old women of 2.7%, which is well below the targeted 6%. However, the HIV prevalence among those women is much higher than among 15 to 49 years old men (1.5%). It is lowest among the 15-19 years age group (0.5%) compared to older women (4.7% among 35-39 years). However, the ICR team could not document the link between project interventions and a reduction in the spread of HIV infections as national HIV incidence data are not available in Ghana. The HIV prevalence among pregnant women 15 to 19 years old could be used as a proxy indicator to measure incidence of new HIV infections and has greatly decreased from 2.3% in 2002 to 0.8% in 2005. No rate is available for the proportion of men and women who have reduced their sexual partners in response to perceived risk. Data on female commercial sex workers showed mixed results as HIV prevalence decreased among seaters, while it increased among roamers, in both Accra and Kumasi. HIV prevalence among seaters decreased from 76% in 2001 to 52% in 2006 in Accra, and from 45% in 2002 to 39% in Kumasi. On the other hand, there has been an increase in HIV prevalence among roamers from 23% in 2002 to 37% in 2006 in Accra, and from 15% in 2002 to 24% in 2006 in Kumasi. (ii) PDO 2: To reduce the impact of AIDS on those affected and their families: Through the care and support interventions, the project has provided support to PLWHAs, Orphans and Vulnerable Children (OVC). The project has provided substantial home-based and community-based care services for more than 30,000 PLWHAs nationwide through 15% of funded NGOs. The project has helped scaling up the Orphans and Vulnerable Children (OVC) program, using the innovative Manya Krobo model whereby support was channeled through the traditional leadership structures (chieftaincy). Approximately 17,500 orphans have benefited from different kind of support ranging from payment of school fees, provision of nutritional supplements, and medical assistance. 4.2 Outputs by components: Component 1: Prevention and care services (21.0=actual project cost) This component is rated as satisfactory. It facilitated a nation-wide mobilization against the epidemic through a broad range of partners. Through the project's intensive IEC campaigns, there have been tremendous improvements in creating an almost universal awareness on HIV/AIDS among men and women of reproductive age. It is estimated that 96% of women and 98% of men believe that there is a way to avoid the virus which causes AIDS. The project's prevention interventions have also contributed to increasing the percentage of males and females who know they can avoid HIV by using condoms from 40% to 86% for males and from 22% to 77% for females. According to GDHS (2003), 95% of males and 90% of females now know they can avoid HIV by sticking to one unaffected partner, compared to 60% of males and females at - 7 - baseline. In the area of care and support, 35% of the 110 districts have organized care for AIDS orphans and 50% have conducted community-based care for PLWHAs. The project also provided support to several organizations for the benefit of 17,500 orphans and vulnerable children (OVCs). - 8 - The component was designed to operate through three windows: Window A for the public sector, Window B for non public sector organizations, and Window C for small community-based organizations (CBOs). A total number of 3,026 sub-projects were funded in various areas of interventions through four calls for proposals. About 82% of those subprojects were fully completed. Besides, through a parallel funding mechanism, DFID supported training and technical assistance to beneficiaries with a grant of 20 million pound sterling. Major areas of GARFUND under this component interventions include: (i) HIV/AIDS in the workplace programs; (ii) advocacy and counseling; (iii) condom promotion; (iv) information, education and communication (IEC) and peer education; (v) behavior change promotion for commercial sex workers (CSWs); (vi) voluntary, counseling and testing (VCT); and; (vii) care and support for PLWHAs and OVCs. The project recorded that, through the first call for proposals, 91% of subprojects effectively implemented and met their stated objectives. Analyses were not made for subsequent calls for proposals. Compared to other organizations, the private sector received funding for only 21 subprojects, of which four were completed. The low funding of the private sector was due to its late involvement in the GARFUND project, only from the fourth call for proposals. The project allowed implementation of a wide range of community HIV/AIDS interventions that covered the whole country. Recent data on project activities and statistics of beneficiaries are illustrated in the table below: Activity Number of people who have benefited from or utilized services Medical care and psychosocial 482,526 support Counseling 638,495 Peer education 2,984,183 Condom distribution 7,334,295 IEC 3,360,683 Advocacy and community 4,251,922 mobilization Capacity building and training 587,379 Voluntary Counseling and 210,000 Testing Prevention of Mother to Child 60,000 Transmission Anti Retroviral Treatment 3,800 - 9 - The distribution of condoms has been very effective, with condoms generally sold at affordable prices without supply disruptions. Throughout the life of the project, more than 7 million condoms were distributed by the implementing partners. With DFID and USAID support, condom sales by Ghana Social Marketing Foundation (GSMF) have grown by 30% per annum. Flexibility of funding allowed the implementation of community HIV/AIDS control initiatives that can be considered as best practices. A remarkable accomplishment of the project is the "Condom Purse" program of the Police Service, aimed at attaining 100% condom use for casual sex among its work force. Police officers were portrayed to be equipped with a life jacket against HIV, with a slogan "Condom Wallet, Your Life Jacket". Another example was the targeted activities of the Prisons Service supported by the project. The program dubbed "AIDS is real, clean the face of your HIV/AIDS infected friend" aimed to further improve awareness of the reality of the disease and to support members of the prison community who have been infected. A special focus was put on IEC, but its links with behavior change are unclear. The project supported the production of several IEC materials and major radio, television, and music productions that were used to raise awareness of the general population on HIV/AIDS prevention and care issues. A special focus was put on awareness raising in rural areas, and 45% of subprojects have developed IEC material meant for rural communities. To induce greater emphasis on behavior change interventions, GAC produced national IEC/BCC strategy towards the end of the project. Despite these achievements, several shortcomings hampered smooth implementation of component 1 activities: (i) insufficient targeting of high risk groups and priority areas with higher HIV prevalence that received relatively low funding during the first rounds of proposals, while disproportionately high amounts of funds were allocated to general population awareness raising; (ii) inability of ministries to provide the required counterpart fund (10% but later reduced to 5%) because they had no line items in the ministerial budgets for this purpose; (iii) low commitment toward HIV/AIDS prevention and care in some ministries, which resulted in inadequate staffing and lack of operational resources for their HIV/AIDS secretariats; (iv) slow disbursement of funds to the benefiting organizations for the second and third installments, due to lengthy processes for approval of their reports that tended to be incomplete; (v) insufficient information on district referral systems between home-based and institution-based care; and ; (vi) insufficient number of institutionalized NGOs umbrella organizations, which explains the low level of funds disbursed for their support to smaller civil society organizations. Component 2: Strengthening Public/Private Institutions to control HIV/AIDS (US$1.4m ) This component is rated as satisfactory. Extensive capacity building activities have been completed for NGOs, CBOs, MDAs, DAs, FBOS and the private sector. GAC has produced a technical manual on HIV/AIDS related issues, organized leadership training for beneficiary organizations, and trained its field investigators on supervision, research and analysis. Focal persons in 74 MDAs have been trained to prepare and implement HIV/AIDS plans and all line ministries have provided adequate HIV/AIDS training for their trainers at the district level. More than half of the MDAs have received support and training in preparing their strategic plans and - 10 - civil society institutions received training in budgeting and accounting. Proposal development workshops were conducted in all regions to orient NGOs and CBOs on the types and format of information required and the criteria to be met to access project funds. The private sector, however, received little training because of its late involvement in the project. The DFID-SIPAA project provided parallel financial support to organizations to assist in the preparation of subprojects of GARFUND. The GHANET network benefited from DFID-SIPAA capacity building activities, which enabled them to provide better oversight of their registered NGOs involved in HIV/AIDS. - 11 - The Education Sector implemented the most comprehensive HIV/AIDS in the workplace program and numerous capacity building activities, because it benefited from DfID co-financing. Through this component, the sector developed and implemented an HIV/AIDS policy and programs targeting its employees; set up a full time secretariat, an HIV/AIDS task force and a steering committee to oversee implementation. The curriculum Research and Development Division (CRDD) has integrated HIV/AIDS information into the primary and secondary school curricula, and regional and district Directors of Education have been trained in HIV/AIDS competence. The project also provided training to about 28,000 teachers at primary, junior secondary and senior secondary school levels, including private school teachers. Furthermore, the universities have developed institutional HIV/AIDS policies, and the National Council for Tertiary Education (NCTE) has implemented a program for distribution of condoms. Finally, the ministry and its NGO partners have rolled out an unprecedented amount of prevention activities in most schools, including tertiary level universities. Care and support was a new and important focus of training for civil society organizations to improve the quality of life of PLWHAs and OVCs. Several training sessions focused on strengthening local capacity in the areas of care and support. A psycho-sociological course intended to strengthen the capacity of master training counselors was organized. Training needs assessment activities were carried out with greater involvement of PLWHAs and scaled up their involvement in the implementation of the National Response. This was coupled with peer counseling and education activities for PLHWAs as well as similar regional activities. Nine regional PLWHAs networks were created and strengthened by capacity building programs supported by GARFUND and other partners in the areas of program coordination and management. Component 3: Knowledge Management (0.5m) This component is rated as satisfactory. Numerous research projects and studies were completed and disseminated and all districts regularly received information on best practices of HIV/AIDS interventions. In close collaboration with development partners, the GAC has developed a policy framework and guidelines for OVC program, targeting children in difficult situations. Other key studies completed and disseminated are: (i) a situational appraisal of the HIV/AIDS activities in Ghana, (ii) a study on orphans and vulnerable children (iii) a study on home-based care and research on associations of PLWHAs; (iv) a study on HIV, HCV, TB and Syphilis among prisoners; (v) a review of HIV seroprevalence among health workers; and; (vi) a study on knowledge, attitudes and perception of traditional healers on HIV/AIDS. Component 4. Project Management (1.4m) This component is rated as satisfactory. (i)Policy and coordination GAC has achieved substantial successes in the areas of institutional arrangements, policy and coordination. A National HIV/AIDS Strategic Framework 2001-2005 was developed and support - 12 - was provided to key government ministries and agencies to elaborate their 2002-2006 HIV/AIDS Strategic plans. In 2004, GAC successfully organized a joint review of the national strategic framework implementation which brought together all stakeholders, including its development partners, and provided recommendations for improvement of the national HIV/AIDS response. This process has significantly strengthened collaboration among the various partners. GAC has also demonstrated strong commitment to improving communication and networking with its partners. In this regard, GAC has received work plans of key partners and incorporated them into composite annual workplans. In resource mobilization, GAC has had a series of discussions with District Assemblies (DAs) to adhere to government directives for the DAs to allocate 1% of the District Assembly Common Fund (DACF) to HIV/AIDS. Over 50% of the DAs have made efforts to release fund for HIV/AIDS. - 13 - However, while the GAC is well respected and its mandate appears to be well-understood by all key stakeholders the concern was raised by various partners that the GARFUND management had absorbed a disproportionate amount of its time and may have diverted its attention from policy formulation, strategic planning and coordination of overall response to HIV/AIDS. In addition, GAC did not strengthen its dialogue with the health sector to use HIV surveillance data as key criteria for resource allocation community interventions. The standardized funding mechanism which lacked flexibility during project implementation constituted a lost opportunity to build an evidence-based HIV response after the first calls for proposals. Finally, little attention was paid to quality of interventions as field investigations targeted only 20% of funded organizations and focused more on control and financial accountability than on outputs and outcomes of community interventions. (ii)Procurement GAC has made significant progress in complying with procurement procedures. The April 2003 audit report indicated that procurement was carried out in accordance with procedures defined in the Development Credit Agreement (DCA). A 2003 Procurement assessment found that for contracts below the prior-review threshold, signed between January 2002 and April 2003, agreed procedures were generally followed. GAC has maintained a standard procurement office, and its records are classified according to bid packages. However, the last Bank mission showed that several challenges remained in procurement and should be addressed during implementation of future projects. They are mainly related to: (i) procurement filing with documentation of contracts frequently mixed up with unrelated processes; (ii) insufficient involvement of procurement manager in monitoring the procurement aspect of subproject implementation that was solely carried out by external auditors, GAC field investigators and the GAC internal auditor; and; (iii) unclear definition of procurement manager duties and responsibilities. (iii) Monitoring and Evaluation GAC has demonstrated strong commitment to Monitoring and Evaluation (M&E), and significant progress has been made on M&E of national response. A national HIV/AIDS monitoring and evaluation plan for 2001 and 2005 has been established, and annual reports were regularly produced throughout the life of the project. Focal Points were identified at regional and district levels to facilitate monitoring and develop simple reporting formats for use by GARFUND beneficiaries. By 2004, the reporting rates among the districts had already reached 70%. Financial audits of subcomponents complemented this effort. The National AIDS Control Program (NACP) has improved biological surveillance and the reports were regularly published on a yearly basis. NACP also analyzed the preliminary report of the Ghana Demographic and Household Survey (2003) to provide a clear picture of the status of the HIV/AIDS epidemic in Ghana. Systems to collect second-generation biological and behavioral surveillance data are functional. - 14 - Despite these commendable efforts, GAC failed to systematically document relevant information and collate quantitative statistics to assess the project's achievements; provide feedback to regions; districts and beneficiaries that provided the data; and take timely decisions to improve project performance. In addition, there are independent monitoring and evaluation reporting systems which do not feed into the district, regional, and national HIV/AIDS response, and this may have led to inadequate knowledge about the response at various levels. Furthermore, except for Commercial Sex Workers (CSWs) in selected regions, miners and the Police; there is limited surveillance among high risk groups; and due to the limited involvement of the private health sector, AIDS cases are underreported. Finally, GAC focused solely on process data (disbursement, inputs) and relied on external partners to regularly collect important output and outcome information that could have provided a clearer picture of HIV-related behavior trends in the country. Thus, it did not have any leverage to influence the timing of data collection, and was not able to avoid the delayed availability of BSS data, for example. (iv) Financial Management GAC has developed sound financial systems, which allowed adequate financial monitoring. The external annual audits conducted during project implementation affirmed that GAC's financial procedures were in compliance with internationally accepted standards. GAC has set up different internal controls to ensure that funds are used for intended purposes and are accounted for before subsequent disbursements are made to project beneficiaries : (i) recipient CBOs and NGOs were required to provide regular financial support; (ii) independent field officers conducted annual financial reviews of 20% of all beneficiary organizations; (iii) focal points at the district level regularly monitored recipient community organizations; (iv) NGOs and CBOs were required to provide regular progress report on their activities; and; (v) Ernst and Young was selected to conduct an investigation of 20% of projects funded under the first round, which triggered greater transparency and accountability and can be considered as a best practice. GAC field investigators conducted about 300 random and unannounced visits to a sample of beneficiary organizations to verify that disbursed funds were used for the intended purposes. The field visits helped ascertain the existence of NGOs and CBOs; interviewed beneficiaries and other community members for information about the relevance of the sub-projects; as well as obtain some basic M&E data and inputs from beneficiaries. Some cases of irregularities in use of funds were reported, further investigated and corrective measures were taken. The key challenges reported in financial management was the lengthy GOG disbursement procedures, mainly because of the review by the Accountant General's office that precedes the deposit of funds into the recipients' bank account, and weak internal controls within some beneficiary organizations. 4.3 Net Present Value/Economic rate of return: Not applicable 4.4 Financial rate of return: Not applicable 4.5 Institutional development impact: - 15 - Institutional development impact of the project is rated as satisfactory. The project has strengthened GAC to become a viable multi-sectoral and multi-disciplinary body, which serves as a lead agency for policy development and coordination of the national response to the pandemic. Through GAC, the project has strengthened the capacity of MDAs, NGOs, CBOs FBOs, and private sector organizations to effectively deal with the fight against the HIV/AIDS in Ghana. GAC has effectively championed the process for the preparation of 2006-2010 National Strategic Frameworks by bringing together all stakeholders, and ensuring effective stakeholder consultations. This framework, among other things, will adequately deal with issues such as voluntary counseling and testing (VCT), anti-retroviral treatment (ARVs), prevention of mother to child transmission (PMTCT), care and support of OVCs and gender. - 16 - The project has also been successful in building decentralized structures at district levels. At decentralized levels, a concerted effort has been made to integrate and mainstream the HIV/AIDS response in the regional and District Assemblies (DAs) work plans to ensure ownership and not to set up parallel structures. The HIV/AIDS committees are thus comprised of a subset of representatives of the respective assemblies at the regional and district levels. Representatives of these structures have benefited greatly from various training programs (see component 2). The project has also strengthened the capacities of Focal Points to adequately implement HIV/AIDS awareness programs in the MDAs. Except for the 28 newly created districts, all of the other 110 districts have a multi-sectoral District AIDS Committees. Within the committee, a District Response Initiative Management Teams (DRIMT) monitors HIV/AIDS programs and provides technical assistance to CBOs, FBOs, and NGOs. To monitor HIV/AIDS activities implemented by various stakeholders, each District Assembly has appointed a district monitoring and evaluation focal person. Some districts also have focal persons responsible for monitoring HIV/AIDS activities implemented by sectors such as social welfare and health. Unfortunately, the project, right from the design phase, did not make allocation to provide any support to the National AIDS/STD Control Program (NACP), which is primarily responsible for the provision of care and support, including treatment of opportunistic infections and antiretroviral treatment (ART). The NACP is also responsible for monitoring the epidemic through HIV sentinel surveillance and behavioral surveys. Furthermore, the GAC did not set up a regular consultation mechanism with NACP that should have been systematically involved in the approval and monitoring of NGOs proposals of HIV/AIDS-related health services (VCT, PMTCT, Care); to ensure their compliance with guidelines developed for the delivery of quality health services. 5. Major Factors Affecting Implementation and Outcome 5.1 Factors outside the control of government or implementing agency: The impact of factors outside the control of the government and the implementing agency has been substantial. First, the project was slightly delayed by a change of government following presidential elections in December 2000. In the transition between governments, the coordination between the Ministry of Finance (MOF) and the Multi-Ministerial Working Group (MMWG) which was in charge of project preparation weakened. Second, logistical issues confronted field monitoring, supervision, and investigation teams, especially at the regional level. Inadequacy of logistics was repeatedly emphasized by various reviewers, but GAC could not do anything about it since expenditure on logistics was ineligible. Third, working practices of some development partners were said to be partly responsible for weaknesses in coordination of the national response, as they did not work in accordance with the structures established by the National Strategic Framework (NSF). Some partners were even reluctant to declare funds and their different funding and reporting arrangements made it difficult to monitor resource flow and allocations. 5.2 Factors generally subject to government control: The impact of factors subject to government control has been substantial. The high level of - 17 - political leadership provided by the President, the Vice president, Members of Parliament (MPs) positively influenced project implementation. The government's unflinching support for GAC also paved the way for smooth implementation of the activities. Moreover, the Act of Parliament, which established GAC provided an enabling environment for implementation. However, the emergence of tensions between GAC and the MOH during the early stages of project implementation did not create a favorable atmosphere for project operations. The MOH did not feel fully empowered by the project to expand the fight against HIV/AIDS, especially in the areas of care and support where unmet needs were lingering. Assisting the MOH through its own SWAP would, in theory, have been advantageous in terms of integrating HIV/AIDS activities into public health priorities; but, in practice, it was not well suited for addressing program specific needs. The SWAP resources could not be earmarked for HIV/AIDS from the outset and the Bank-funded Treatment Acceleration Project is still in the early stages of implementation. It was fortunate that, through dialogue and facilitation by external partners, a memorandum of understanding that clarifies roles of MOH and GAC was signed towards the end of this project and will guide the implementation of M-SHAP. In addition, difficulties emerged between GAC and the Ministry of Local Government and Rural Development (MLGRD) with respect to the leadership of the District Response Initiative (DRI). The DRI was a bottom up initiative aimed at building AIDS competent communities. Moreover, with the exception of the education sector, MDAs did not provide sufficient human resources to champion the fight against HIV/AIDS and support focal points that were sometimes overwhelmed by their other tasks. Finally, MDAs had difficulty in providing the requisite 10% contribution (counterpart funds) for their action plans. The percentage was temporarily reduced to 5%, but even then a substantial number of MDAs were unable to start the program, while the GOG could have made the funds available as a proof of its commitment to HIV/AIDS control. 5.3 Factors generally subject to implementing agency control: The impact of factors subject to implementing agency control has been substantial. The project's proposal review and disbursement processes were lengthy and bureaucratic. Reports from recipients of GARFUND support indicated that it took between two to three months for proposals to be approved. After approval, further delays were observed before the release of funds. The delays were mainly due to the Secretariat's own internal processes, external processes at the Controller and Accountant General's Department, and the banking system. This situation slowed down implementation by grant recipients particularly at the initial stage of the project, but led to greater accountability of funds. Many implementing partners also lacked the capacity to provide quality reports as even very new NGOs and CBOs could access funding. - 18 - The planning process seldom brought together stakeholders' action plans into a common framework. Departmental staff within the ministries had little knowledge of the internal response that was developed by Focal Points. This situation could have been improved if the GAC Secretariat, which was designed to be a small unit of about 10 staff, contracted out some key functions such as M&E. The interim review of the GARFUND also called for a more strategic approach to a multisectoral HIV/AIDS response that promotes the involvement of all key stakeholders of key geographic areas to build a common response to the epidemic and avoid duplication within and between sectors, but all stakeholders agreed to wait the second phase of the project to implement this approach. 5.4 Costs and financing: The estimated total project cost as reported in the PAD was $US27.8 million. The actual project cost over the entire life of the project totaled US$ 26.5 million. Total IDA credit allocation at appraisal was 19.6 million SDR equivalent to US$25.0 million. The credit was fully disbursed. Outstanding withdrawals, after December 31, 2005 to April 30, 2006 amounted to US$0.3 million A grant amount of 20 million pound sterling was provided by the DFID to support activities carried out under component 1. At the end of the project, the government had contributed a total amount of US$1.7 million. IDA and the GOG combined disbursed a total amount of US$26.5 million. The table below illustrates actual and cumulative disbursements as reported by the borrower throughout the project. Year 2002 2003 2004 2005 2006 Total Actual(US$ 2.46 9.20 9.67 6.22 0.12 27.97 million)* Cumulative 2.46 11.67 21.63 27.85 27.97 27.97 *Sum of all components Source: Ghana AIDS Commission (GAC) 6. Sustainability 6.1 Rationale for sustainability rating: Overall sustainability of GARFUND is likely due to strong government commitment, increased capacity, increasing donor support and continued institutional and managerial strengthening of GAC, NACP and other stakeholders. The GOG, has demonstrated strong political commitment to the national response and is likely to provide support to the fight against the epidemic. Even though support in programmatic planning and strategic focus should be strengthened, GAC has the technical capacity to effectively coordinate, supervise and harmonize all HIV/AIDS programs. Donor support is also likely to - 19 - continue in the implementation of future HIV/AIDS programs, which could sustain several project achievements. For instance, (i) funding of subprojects under prevention and care component is likely to benefit from funding by the DfID and M-SHAP; and; (ii) gains in institutional capacity of GAC and NACP with respect to skills, experience, equipment, management and recognition are likely to continue in future. Social sustainability, that relies heavily on behavior change outcomes, is likely as the project was able to influence the adoption of positive behaviors and attitudes towards HIV/AIDS by regional authorities, central government officials, civil society representatives and community members. However, the sustainability of GAC will depend on the commitment of the Ministry of Finance and Economic Planning (MOFEP) to finance the GAC's operating cost from 2006 and staff salaries from 2008, and provide funding for MDAs financial contribution to their subprojects. The Project's sustainability will also depend on the ability of GAC to: (i) focus on quality and effectiveness by implementing the recommendations of the 2003 GARFUND interim review and 2004 joint HIV/AIDS Program Review; (ii) shorten the lengthy and cumbersome disbursement process where approved funds had to pass through many channel members ( GAC Secretariat, MOF, Controller and Accountant General's Department, and the Bank) to get to the final beneficiaries; (iii) harmonize the wide variations in program implementation expertise of various NGOs; and (iv) strengthen its monitoring, evaluation and supervision procedures by focusing more on outcomes than on processes. In future programs, GAC should track project achievements through regular reporting on quantitative indicators and make necessary changes as needed. 6.2 Transition arrangement to regular operations: In order to scale up and ensure continuity of the national response to the HIV/AIDS, a follow-up project Multisectoral HIV/AIDS Program (M-SHAP), has been approved by the World Bank and will be effective by end of March 2006. The development objectives of M-SHAP are to: (i) reduce the new infections among vulnerable groups and the general population; (ii) mitigate the impact of the epidemic on the health and socio-economic systems as well as infected and affected persons; and (iii) promote healthy life-styles, especially in the area of sexual and reproductive health. M-SHAP aims to further pursue, strengthen and consolidate some of the activities initiated under GARFUND, which include, among other things, policies to protect the rights of PLWHA; coordination and management of the MDAs and Regional AIDS Commissions (RACs); activities directed towards vulnerable social groups; interventions aimed at bringing about behavior change among at-risk groups; and scaling up anti retroviral therapy, VCT, and management of sexually transmitted infections. M-SHAP has put all the required inputs in place for effective operation. It has also relied on lessons learned from GARFUND. Concerns were raised, during GARFUND supervision missions, about the lack of priority given to activities targeting groups with high risk behaviors and communities that live in high prevalence geographic areas. The fourth call for proposals attempted to address this situation and extensive discussions were held during appraisal of M-SHAP to reverse the trend during its future implementation. 7. Bank and Borrower Performance Bank 7.1 Lending: Bank performance at identification, preparation, and appraisal is rated as moderately satisfactory - 20 - because of the design flaws discussed in the quality at entry section. The Ghana MAP I main body of the PAD did not include prevalence reduction as an indicator of project performance whereas Annex I of the Ghana MAP I PAD did. It was the responsibility of Bank management and advisers to ensure consistency within the PAD and with the overall MAP concept approved by the Bank's Board of Executive Directors which clearly indicated that reduction in HIV prevalence was not an objective of the first phase of MAP financing. A technical launch of the project took place early 2003, which afforded the GAC and Bank staff the opportunity to: (i) ensure that key stakeholders had a good understanding of GARFUND's objectives, and modalities for accessing funds (including procurement and disbursement issues); (ii) assist in identifying priority activities that would be funded; (iii) discuss modalities for the further involvement of district authorities using as a basis the Community Driven Development (CDD) approach; and monitoring and evaluation plans. 7.2 Supervision: Bank performance during supervision is rated as satisfactory despite insufficient reporting and implementation support during early stages of the project. Subsequently, supervision greatly improved through the posting of the TTL in the field, which led to a turn around in project performance. Bank staff embarked on consistent supervision missions, and sufficiently reported implementation progress in the key project documents (aide-memoires, PSRs/ISRs etc.). The Bank staff maintained good rapport with GAC and government advising and directing GAC about how things could get done on timely basis. Consistent efforts were made to include senior management and ACT Africa in meetings and reviews aimed at sustaining GOG ownership, involving key DPs and supporting project implementation. An interim review was organized with the involvement of all key DPs in HIV/AIDS and some of the lessons learnt were implemented to improve project performance. Notwithstanding these efforts, the Bank's supervision team could not track quantitatively project output indicators to obtain concrete figures, at each stage of implementation. The key performance indicators matrices at the end of most PSR/ISRs are generally blank. 7.3 Overall Bank performance: In the light of the discussions in sections 7.1 and 7.2 above, the overall bank performance is rated as satisfactory. Borrower 7.4 Preparation: The Borrower's performance at preparation is rated as satisfactory. The government engaged in intensive negotiations with Bank team and championed all stakeholder consultations through GAC at the preparation stage to ensure smooth take off the project. However, government's inability to meet two key effectiveness conditions (the recruitment of the executive secretary of GAC and the recruitment of auditors), delayed project effectiveness. The original effective date, which was scheduled for late 2001, had to be postponed to May 8, 2002 . The biggest impediment to effectiveness of the project was the delay in parliamentary approval of credit effectiveness documentation, which was out of the control of the government. In spite of the delay in project effectiveness, the GAC initiated numerous contacts with potential beneficiaries so they could start implementation once the operation was declared effective. The GAC also held consultations with - 21 - all stakeholders (NGOs, CBOs, and the civil society) to explain the operating modalities of the project and solicit subproject proposals. This helped to offset the initial delay and put the operation back on track. 7.5 Government implementation performance: The government's implementation performance is rated as satisfactory. The government provided an enabling and conducive atmosphere for GAC to do business without interference. Furthermore, the relationship between GAC and government was highly cordial, with GAC officials collaborating effectively with top government officials. However, there were delays in the release of government's counterpart fund contribution. Moreover, as indicated in section 4.2, MDAs had difficulty in providing the requisite counterpart funding, because the central government made no budgetary provision for their HIV/AIDS activities. 7.6 Implementing Agency: The implementation agency's performance is rated as satisfactory. In April 2002, GAC organized a Project Launch Workshop which brought together all stakeholders including line Ministries, NGOs, CBOs, civil society, district authorities for intensive discussions on implementation. GAC's intensive effort to bring together all stakeholders resulted in over 500 proposals prepared by NGOs, CBOs, districts, line ministries and other civil society groups to obtain funding for HIV/AIDS related interventions even before the technical launch of the project. Though disbursement was slower at the beginning of the project, GAC has effectively managed the project to a 100% rate of disbursement (see figure 1 in section 5.4). As indicated in section 4.2, GAC has demonstrated high level of commitment to implementation resulting in significant progress. Finally, GAC contribution to the development of midterm review and implementation completion reports was optimal with sufficient attention to timeliness and quality. However, GAC staff could not make monitoring information readily available for decision making until the last call for proposals, and several planned studies needed to evaluate project outcome were not completed, including behavior surveys and the process evaluation. 7.7 Overall Borrower performance: Taking into consideration the discussions in sections 7.4, 7.5, and 7.6 above, the overall borrower performance is rated as satisfactory. 8. Lessons Learned 8.1. The use of HIV prevalence data, though an excellent monitoring tool for the epidemic in countries, should not be a measure of success of a Bank funded HIV/AIDS project. In a mature or maturing epidemic where mortality due to HIV/AIDS becomes a significant factor in determining prevalence rates and in a country that embarks on a rapid ART scale-up, prevalence cannot be regarded as a valid indicator to measure success or failure. 8.2. The decision to design the project without and MoH component was not appropriate. In follow-up MAP operations, it is needed to include a health component with dedicated funding mechanisms to fully empower the MOH in delivering key health related HIV prevention and care services that will respond to increased demands of communities induced by civil society interventions. - 22 - 8.3. Mainstreaming HIV/AIDS in the formal education sector was effective for comprehensive targeting of at-risk youth who reported reduction in number of partners and increased use of condoms. 8.4. Contracting out an international auditor to assess the use of funds by civil society organizations contributed to a balance between implementation facilitation and fiduciary responsibility. 8.5. Decentralization of HIV/AIDS response is very successful in Ghana as demonstrated by the strong ownership of GARFUND by provinces and districts. It proved that the monitoring and evaluation functions in large scale financing of civil society organizations are well served by a functional decentralized set-up, when issues related to capacity building including time allocation for focal persons are adequately addressed. 8.6. Development Partner collaboration and co-financing was successful and should be promoted and expanded. Performance of capacity building interventions were optimized by the collaborative effort established between the MAP operation, which has primarily funded sub-projects, USAID which has supported project start up activities, and DFID which has supported training and technical assistance to potential beneficiaries and to the GAC through parallel funding. 8.7. An effective monitoring and evaluation system is essential for optimal effectiveness of the MAP "learning by doing" strategy. The M&E system should have been strengthened by: (i) developing a standard program activity monitoring form for all recipients to enable effective aggregation of data at all levels that allows the regular flow of data for decision making; (ii) ensuring systematic epidemiological surveillance of vulnerable groups and use data to better understand HIV transmission dynamics and critical intervention opportunities; (iii) developing a results-oriented approach to the financing of NGOs/CBOs/FBOs and the private sector. The project M&E design also needs to plan for the collecting of key indicators at mid-term and prior to project closure, to facilitate evaluation of the project. 8.8. There is an urgent need to strengthen the focus on strategic management of the epidemic and tailor the multisectoral approach to Ghana's contained and relatively stable epidemic. Priority should be given to emerging issues with regards to antiretroviral treatment, orphans and other vulnerable children, voluntary counseling and testing, prevention of mother-to-child transmission, and prevention activities among high risk groups (CSW and their clients, discordant couples, prisoners, and MSM). Furthermore, future interventions should focus more on quality and effectiveness of civil society interventions rather than on quantitative criteria such as number of projects and disbursement rates. 8.9. The private sector as an engine of growth should be more largely and systematically included in the implementation of the MAP projects. Future interventions should build on its existing interventions within and outside of the GARFUND project and on the private sector's potential to substantially contribute financially to prevention efforts. The private sector can also - 23 - support the adoption of sustainable strategies for financial support of PLWHA by providing them with work and reducing stigma in the workplace. 8.10. The financing of salaries through donor funds should be considered with caution where it concerns the financing of institutions that need continued and sustainable financing beyond the scope of projects. - 24 - 9. Partner Comments (a) Borrower/implementing agency: Government's contribition GHANA AIDS COMMISSION "working actively and in partnership to combat HIV/AIDS" GARFUND IMPLEMENTATION COMPLETION REPORT Submitted to: Implementation Support/Implementation Completion (ICR) Mission March 31, 2006 - 25 - - 26 - TABLE OF CONTENT 1. PROJECT OBJECTIVES, DESIGN AND IMPLEMENTATION MECHANISMS 1 1.1 Project Goals and Objectives 1 1.2 Project Design, Components and Strategic Approach 1 1.3 Implementation Arrangements 3 1.4 The Environmental Context 3 2. OPERATIONAL EXPERIENCE AND COVERAGE 4 2.1 Regional Projects 4 2.2 Ministries, Departments and Agencies (MDAs) 5 2.3 Private Sector 5 2.4 Monitoring and Evaluation 5 2.5 Information, Education and Communication 5 2.6 Research 6 3. FINANCIAL PERFORMANCE 6 3.1 Disbursement 6 3.2 Replenishment 6 3.3 Accounting 6 3.4 Monitoring and Supervision 7 4. PROCUREMENT 7 4.1 Objective, Processes and Guidelines 7 4.2 Key Issues 7 5. CAPACITY BUILDING ACTIVITIES 8 6. EVALUATION OF BANK'S PERFORMANCE 8 7. EVALUATION OF GOVERNMENT'S PERFORMANCE 9 8. LESSONS LEARNT AND RECOMMENDATIONS 9 APPENDICES: Appendix 1: Number of GARFUND Projects by Year & Region Appendix 2: Research Activities Supported Under GARFUND Appendix 3: National Monitoring & Evaluation Indicators, 2001 ­ 2005 Appendix 4: Publications & Reports Appendix 5: IEC Materials Produced Appendix 6: TV Productions Appendix 7: Radio Programs Appendix 8: Music Productions Appendix 9: National Level Capacity Building Activities Covered Under GARFUND Appendix 10: District Level Capacity Building Activities by Region & Activity/Course Appendix 11:GARFUND Disbursements & Withdrawals Appendix 12:Project Disbursement by Procurement Method - 27 - Appendix 13:GAC Professional Staff - 28 - 1. Project objectives, design and implementation mechanisms 1.1 Project goals and objectives The overall goal of GARFUND was to support implementation of the government's national strategy to reduce the spread of HIV/AIDS and its impact on persons already infected and affected. The specific objectives as articulated in the government's "National HIV/AIDS Strategic Framework, 2001-2005 included: (i) to reduce new HIV infections by 30% by 2005; and (ii) to improve service delivery and mitigate the impact of HIV/AIDS on individuals and families. The project objectives corresponded to a crucial need identified by the Government of Ghana to undertake a comprehensive national response to prevent, control and manage the impact of the HIV/AIDS epidemic in Ghana. Progress made as at the end of the project toward the Project Development Objective is assessed overall as fully satisfactory. The most recent reports from biological surveillance, including the HIV Sentinel Survey (2004 Report) indicated that the median level of HIV/AIDS in Ghana was 3.1%. This is somewhat lower than the level estimated at the time the World Bank's Project Appraisal document (PAD) was prepared, but higher than the levels estimated in 2000 and 2001 which were only 2.5% and 2.8%. The 3.1% prevalence recorded for 2004 represents an approximate decrease of 14% over the prevalence recorded in 2003 (3.6%). This decrease does not necessarily represent an overall decline of HIV infection in the country although it indicates a leveling or stabilization of the epidemic. (Results of the 2005 Sentinel Survey Report are yet to be released). The project objective, namely "to reduce new HIV infections by 30% by 2005" as stipulated in the National Strategic Framework, was a bit ambitious in the light of the existing implementation capacity then for its achievement. 1.2. Project design, components and strategic approach GARFUND was designed to enable the Government implement a balanced, diversified multi-sector response to the epidemic, engaging all relevant government sectors, non-governmental organizations, the private sector and grassroots initiatives to undertake HIV/AIDS intervention activities throughout the country. The multi-sectoral and developmental approach adopted was strategic and beneficial in that it has contributed significantly (i) in promoting acceptance of the project by various stakeholders at all levels of society; and (ii) in eliciting positive responses from all parties who have come to acknowledge that the project is of major concern to them and that their participation is necessary. The project was designed to cover four (4) components as follows: Component 1: Prevention and Care Services: This component financed governmental (excluding health) and civil society entities to provide a broad spectrum of preventive and care activities at national, regional and local levels. It supported a wide-range of activities aimed at raising awareness, reducing high-risk sexual behavior, mitigating the impact on those affected and promotion of income-generating activities. It was designed to provide funds to public and civil- - 29 - society entities at all levels of society undertaking such intervention activities. Total funding allocation for this component was US$21 million and represented nearly 76% of the total GARFUND. Total amount disbursed at the end of the project was US$21.971 million. Component 2:Strengthening Public/Private Institutions for HIV/AIDS Control and Care Giving. This component supported training and technical assistance for public and private-sector institutions on technical and practical aspects of working with HIV/AIDS. Total funding allocation for this component was US$2.4 and at the end of the project total amount disbursed was US$1.554 million. This component has empowered the local structures with financial and decision-making authority and strengthened capacities at the local level. Component 3: Knowledge Management. This component provided support for the establishment of systems for collecting, organizing, and disseminating up-to-date information on HIV/AIDS prevention and care, best practices of existing projects, research results, and any reports that would be useful to implementing entities. It also financed activities that aimed at promoting sharing of experiences among organizations as well as collaboration with research institutions and support to traditional medicine centers for testing of herbal preparations. A total of US$1.4 million was allocated to this component and at the end of the project, the total amount disbursed was US$505,886. Disbursement under this component was low because supplementary funding was obtained from the GAPP Project (DFID) and the SIPAA Project (Action Aid). Component 4: Project Management. This component covered funding for design and establishment of systems for managing implementation of the project. A key aspect of the component was a monitoring and evaluation system established to monitor GARFUND activities and assess progress on the basis of targets defined in the National Strategic Framework. Also covered under this component was financial and procurement monitoring. Technical audits on a sample of 20% of sub-projects were carried out on annual basis as well as special audits and field investigations of operations of project beneficiaries. Total allocation for this component was US$3.0 million and at the end of the project US$2.5 million had been disbursed. Management and co-ordination of the project have been fully satisfactory throughout the operational period. Management of the GAC Secretariat has maintained a high degree of commitment and professionalism in managing the project. The Secretariat was woefully understaffed throughout the period. With only ten (10) professional staff, however, significant achievements were made. (See Appendix 13: Professional Staff of GAC Secretariat). A joint review of the national response was successfully undertaken and it provided useful inputs to the design of more effective strategies for strengthening implementation of the next phase of the national response. 1.3. Implementation arrangements i. National level: GARFUND was implemented through decentralized structures which afforded the opportunity for participation at all levels of the society. At the national level, a 48-member Ghana AIDS Commission, established by Act 613 of Parliament in 2002 under the Chairmanship of H. E. The President and with membership of H. E. The Vice-President and all key Sector Ministers, civil society and faith-based organizations and the private organizations, provided - 30 - effective leadership and direction in the co-ordination of the national response. ii. Sector level: At the sector level HIV/AIDS Committees have been established in various MDAs to plan and co-ordinate HIV/AIDS activities in those institutions. Key among them is the National AIDS/STD Control Program (NACP) within the Ghana Health Services which has been operating effectively as the technical advisory wing of the Commission and provided treatment, care and support services and monitoring of the epidemic through sentinel surveillance and behavioral surveys. Sector AIDS Committees have also been instituted in many MDAs with Focal persons directly responsible for day-to-day coordination of HIV/AIDS activities. iii. Regional level: Regional AIDS Committees have been established within the Regional Coordinating Councils (RCCs) in all the ten (10) regions of the country. Regional Monitoring and Evaluation Focal Persons have also been appointed to be directly responsible for overseeing activities in the districts. iv. District level: At the district level multi-sectoral District AIDS Committees (DACs) have been established in 110 districts of the country to serve as the pivotal points of HIV/AIDS activities at that level. District Monitoring and Evaluation Focal Persons have also been appointed in each district and are directly responsible for HIV/AIDS activities in the district. 1.4. The Environmental context GARFUND was implemented in a generally supportive environment. A number of laws relevant to the national HIV/AIDS response existed even before the enactment of the National HIV/AIDS Strategic Framework. These include the Constitution of the Fourth Republic of Ghana, which gives every citizen the right to health care and education and outlaws all forms of human rights abuses, including discrimination and dismissal from employment on any grounds. The Ghana AIDS Commission, established as a supra-ministerial and multi-sectoral body, provided the enabling environment for effective implementation of the national response. The location of the Commission within the highest office of the nation, the Presidency, reflects the high-level leadership and politically supportive environment and commitment which have contributed immensely to successful implementation of the project. 2. Operational experience and coverage As at 2005, GARFUND activities had covered over 3,000 implementing entities comprising MDAs/RCCs, DAs, NGOs, FBOs, CBOs and private sector organizations in all regions, districts and communities in the country. 2.1 Regional projects ˇ Ashanti Region: A total of 557 entities were funded to undertake intervention activities that included advocacy, video shows, drama performances, peer education, condom distribution, and counseling. 420 PLWHAs were also trained as peer counselors and liaison between ART sites and the PLWHA associations. - 31 - ˇ Central Region: 257 subprojects were sponsored for prevention, awareness and peer education activities. Formation of youth clubs was a popular model adopted by several CBOs. ˇ Eastern Region: 638 organizations were supported to undertake activities in prevention, awareness and care and support for PLWHAs and OVC through drama, film shows, house-to-house campaigning, peer education, and durbars. ˇ Greater Accra Region: 317 sub-projects were completed with focus on prevention and awareness. Activities included peer education, condom distribution, voluntary counseling and testing, community fora,, care and support of PLWHAs and OVCs as well as provision of microcredit opportunities to those infected and affected. ˇ Northern Region: 207 sub-projects were completed with the focus on prevention. Activities covered mass media campaigning and workshops, condom distribution and peer education. A major challenge faced by CBOs in the region was countering beliefs that HIV/AIDS is a curse from the ancestors, and not preventable. ˇ Volta Region: 289 sub-projects were completed with the focus on prevention and awareness and many activities directed at the youth. Peer education, condom distribution, and dissemination of HIV/AIDS messages on community billboards were among the activities. ˇ Upper East Region: 96 awareness and prevention sub-projects were completed with distribution of condoms as a major activity. Other activities were house-to-house campaigns involving trained peer educators and, among the youth, drama performances. ˇ Upper West Region: 73 sub-projects were completed with focus on awareness and prevention and activities that involved several religious organizations. The activities included peer education, house-to-house outreach, income generating and care and support. ˇ Western Region: 208 sub-projects were completed with the focus on awareness creation. The main target groups were children, the youth, market women, fisherman and fishmongers. Free VCT services were also provided by several districts in the region. ˇ Brong Ahafo Region: 313 sub-projects were completed with the focus on prevention and awareness. Activities included condom distribution, peer education, durbars, care and support and psychosocial support through counseling as well as provision of home-based care services. (See Appendix 1: Number of GARFUND Projects by Year and Region). 2.2 Ministries, Departments and Agencies (MDA) Over the course of GARFUND implementation, a total of 71 projects were awarded to MDAs (See Appendix 1). All of the MDA have HIV/AIDS focal persons responsible for overseeing the implementation of HIV/AIDS activities, including monitoring and evaluation, within their respective sectors. 2.3 The Private sector Under GARFUND, twenty-one (21) private sector organizations were funded to carry out primarily workplace intervention programs. Through this, greater commitment has been realized for participation of private enterprises in the national response. A significant outcome of this engagement is the planning for establishment of the Ghana Business Coalition. - 32 - 2.4 Monitoring and evaluation of GARFUND The national Monitoring and Evaluation (M&E) plan provided the framework for tracking and assessing the implementation and impact of the GARFUND (Appendix 3). Thus far in the monitoring and evaluation process, emphasis was placed on the output indicators of the subprojects. The regional coordinating councils and district assemblies were mandated, as of 2003, to submit bi-annual and quarterly monitoring and evaluation reports which provided an inventory of the number and type of activities undertaken in their jurisdiction. As of 2003, all 10 regions and 110 districts had focal persons trained in monitoring and evaluation. On the whole 27 indicators were used to monitor GARFUND activities.. 2.5 Information, education and communication GARFUND supported many activities that promoted public awareness and media involvement in the national response. Workshops were organized to improve on media reportage on HIV/AIDS. Various partnerships were formed such as with GAMA Films Company to run productions on HIV/AIDS. A National Integrated IEC/BCC strategy was developed and launched in 2005. GAC also sponsored talk shows on HIV/AIDS activities on radio stations country wide (Appendix 7). Bill boards bearing HIV/AIDS Messages were designed, produced and erected in selected districts in the country. The major challenge facing the country is that of behavior change. IEC materials were developed to provide useful HIV/AIDS information to the general public to help in promoting behavior change (Appendix 5). Under GARFUND the communication process was not target-specific but related to the general population. The message content itself was to increase awareness and did not sell the kind of benefit that will provide skills and motivation for someone to want to change his/her behavior. (See Appendix 5: IEC Materials Produced Under GARFUND.) 2.6 Research Many relevant research activities were supported under the knowledge management component of GARFUND. Results of the researches have significantly improved the national response by providing useful insights into the specific aspects of the Ghanaian HIV/AIDS epidemic and providing evidence for the adoption of high-impact interventions. Through the research activities, quality of care for PLWHAs has improved and specific vulnerable groups sufficiently addressed with the prevention messages. Research and surveillance data will provide the basis for the development of the next generation of programs, while monitoring and evaluation will be used as tools to guide the implementation of programs and activities. (See Appendix 2: Research Activities Supported Under GARFUND). 3. Financial performance 3.1 Disbursement GARFUND overall budget was $27.8 million and it became effective on 8th May, 2002. By the end of 31 December, 2005, (i.e. 3 years and 7months) the budget had been fully disbursed. Total disbursement then was $26.5 million. Disbursement commenced late but was done in a record time. The process was decentralized with funds being disbursed to the source of operations in the districts through the entities' special Bank Accounts established for the purpose. Transfer of funds - 33 - from GAC Special Account to the entities Bank Accounts was aided by the rural Banking System which existed in the country. 3.2 Replenishment Replenishment from the credit to the GAC Special Account after disbursement was splendid. In all 48 withdrawal applications were submitted to the World Bank during the project period. All the applications were received in full except for some 2 applications which experienced some reduced amount due to wrong classification of cost. 3.3 Accounting At the commencement of the project GAC established a robust computerized accounting system aided by a comprehensive and user friendly accounting and administrative manual. This helped GAC to account for the project funds in a timely manner. Implementing entities were trained in fiduciary financial management and procurement and many manuals were developed for their use. These activities facilitated disbursement, procurement and accounting for grants and had salutary effect on the financial performance of the project. 3.4 Monitoring and supervision Funds disbursed to the Districts for NGO and CBO activities were supervised by the district assemblies. District teams monitored usage of the funds in the districts and reported to GAC. GAC financial consultants were also dispatched to the Districts, MDAs and Private Sector entities to monitor the operations and use of the funds in their respective organizations and report to GAC. At the end of each fiscal year independent Auditors were appointed to carry out external audit of all implementing entities and from time to time field investigations conducted on their operations. All these helped in meeting compliance with reporting and audit requirements. 4. Procurement 4.1 Objective, processes and guidelines The principles of fairness, transparency, equal opportunity, economy and efficiency guided procurement practices in implementation of the GARFUND. The overriding objective was the procurement of goods and services that were fit for purpose through the selection of the Most Economically Advantageous Tender. Procurement with IDA funds was mainly for goods and services; there were no civil works. Procurement was done at two levels, namely (i) the GAC Secretariat and (ii) subprojects (programs) level. At the GAC Secretariat, procurement consisted of: (i) goods and equipment for the Secretariat; (ii) technical services for the Secretariat; and (iii) small lump sum consultancy services for the Secretariat.. Procurement of goods and services was guided by IDA Guidelines and the Public Procurement Act of 2003, Act 663. At the sub-project level, Procurement was done to meet the requirements of proposals submitted by the implementing agencies. - 34 - Comprehensive guidelines and clearly defined criteria for selection and appraisal were documented in the GAC Operational Manual and disseminated through workshops. 4.2 Key issues i. Successes - The introduction of the output-based contract for CBOs increased the speed of disbursement and project implementation. - The use of M & E Monitoring Focal Persons at the Districts to monitor/verify outputs of CBOs greatly enhanced their performance. ii. Challenges at the Subproject Level Matching contribution requirement of the grant financing agreements was in most cases not met, especially in the case of MDAs and even when it was later on revised to 5%. iii. Variation in Corporate Governance Expertise of Civil Society Organizations There were wide variations in the expertise of NGOs. This did not allow for the design of appropriate and user-friendly procurement manual for use. In the course of implementation of the GARFUND, steps were taken to improve the capacities of the relatively weaker NGOs. vi. Lengthy Disbursement Process The process whereby disbursement to implementing agencies had to go through many channels before getting to the final beneficiary was fraught with delays in project implementation. Disbursement had to be routed from the GAC Secretariat, to Ministry of Finance, the Controller and Accountant-General's Department and to the bank. Besides the long processing cycle, where a particular signatory was not at work, there were also delays. 5. Capacity building activities Capacity building activities focused on providing technical training on HIV/AIDS to GARFUND beneficiaries to help them prepare their HIV/AIDS plans. A substantial amount of capacity building activities were undertaken during the period 2002 to 2005. This contributed significantly towards scaling up national effort and strengthening the capacities of implementing agencies.. Capacity building activities under the GARFUND received complementary support from the DFID funded SIPAA project and other funding sources. A total of nearly 20,000 implementing agencies benefited from the capacity building activities which covered project design and management, financial management and technical issues on HIV prevention, care and support. (See Appendices 9 & 10). 6. Evaluation of the Bank's performance The support of the Bank in funding and implementation of the project has been enormous. The Bank has done an excellent job in providing technical support to spearhead the establishment of the Ghana AIDS Commission and in getting its operations off the ground through the GARFUND. The GAC Management has enjoyed a close and fruitful working relationship with - 35 - the Bank. The various missions undertaken by the Bank provided substantial guidance and assisted the Ghana AIDS Commission in re-strategizing and contributed to effective project implementation. The encouragement of the Bank for GAC to assume a bigger role in donor co-ordination to disabuse the perception of the development partners of the project as a World Bank activity is also commendable. GAC notes that the Bank collaborated well with other development partners, sharing information and coordinating activities to the extent possible. 7. Evaluation of Ghana Government's performance The Government of Ghana has throughout the project period provided a very conducive environment for implementation of the project. It has ensured that good governance policies existed and there was virtually no governmental interference. The availability and unimpeded access of GAC Management, development partners and other key stakeholders to the President's own Adviser on HIV/AIDS for consultation and assistance from the initiation and establishment of the project, and direct involvement in various project activities is seen as a substantial contribution on the part of government towards the success of the project. Among the key issues of concern, however, were the rather undue delays in release of government's funding contribution to the project. Government is taking appropriate measures to ensure that the next phase of the national response does not experience this setback. 8. Lessons learnt and recommendations Among the lessons learnt in implementation of the GARFUND and recommendations made are the following: 8.1 More resources are required Scaling up the national response will require more resources. There are opportunities within existing sources of funds to mobilize more resources to support the national response. These include getting the District Assemblies to comply with government's directive to contribute 1% of their common fund to HIV/AIDS activities, technical resources and expertise in the areas of behavior change, management information systems and database development. 8.2 Enhanced targeted funding would be advantageous Implementation of a targeted funding mechanism is necessary to help determine which particular organizations should receive funding. Future funding decisions should be based in part on past performance, if the organization is reapplying for continued support. Also, decisions on who will receive funding will be determined by evidence-based research and solid contingency plans. 8.3 Disbursement ˇ Disbursing funds in tranches to implementers was a mechanism that made them diligent in planning their activities and also helped GAC to disburse funds prudently. ˇ Disbursing funds directly to implementers' Special Accounts reduced bureaucracy and costs of operation. ˇ Use of GAC's in-house capacity for procurement and financial management enhanced - 36 - disbursement and recording of funds disbursed. ˇ Existing rural banks through which funds were channeled facilitated prompt disbursement and thereby enhanced project performance. 8.4. Accounting ˇ Fiduciary financial management training that was given to implementing agencies prior to sub-project implementation resulted in proper accounting records being kept and disbursement of funds was expeditious. ˇ Financial manuals designed for each class of implementers enhanced disbursement and preparation of up-to-date financial information.. 8.5 Replenishment ˇ Monthly reporting on draw downs of the credit helped to reduce liquidity problems during implementation. This helped GAC to quickly disburse funds to implementing agencies in tranches. Regular monthly draw down on credit greatly enhanced project performance. 8.6 Financial Monitoring and Supervision ˇ Where many implementing agencies were undertaking several different activities, different methods of monitoring needed to be employed in order to maximize returns on the investments. (e.g. field investigation, consultants, audit teams etc). ˇ Monitoring and supervision must be continuous and stringent in a project where implementers are diverse and scattered all over the country. 8.7 Procurement ˇ Disbursements are necessary but insufficient conditions for successful NGO participation in the fight against HIV/AIDS. ˇ Factors that could undermine NGO contributions, even when funding is accessible include recognizing the wide variations in expertise of NGOs and consequently designing tailored, user-friendly procurement manuals and a capacity building strategy based on preliminary needs assessment. 8.8 Capacity Building ˇ The comprehensive capacity-building program for CSOs increased their competencies and absorption capacities. ˇ Most of the CSOs that implemented various interventions needed deeper knowledge of HIV/AIDS issues to ground their interventions. This was addressed through enhanced organizational development and provision of basic HIV/AIDS competencies, program design and management. ˇ The strategy of working through partnerships and training of trainers worked to enhance scaling up of capacity building within a short period. The comprehensive capacity building program in care and support contributed to the development of PLWHA networks that constituted a platform for PLWHAs to effectively engage with other stakeholders in the national response. - 37 - (b) Cofinanciers: Most development partners (DP) supporting HIV/AIDS in Ghana (UN system and bilaterals) felt that the GARFUND was solely a Bank project that isolated the GAC from most of them, except DfID and USAID at the early stages of implementation. USAID contributed to the multilateral collaboration with the GOG aimed at securing government commitment and provided support to equip GAC Secretariat's premises. DFID financed technical assistance to help line ministries develop their action plans for HIV/AIDS before credit effectiveness and assisted in the expansion of the District Response Initiatives to enable more districts to access funds at project start-up. Several DPs also think that the focus of the project was too much towards awareness raising, and that it did not built on the important gains of the HIV/AIDS response in Ghana that had been led by NACP since 1986. While they agreed with the key lessons learnt described in the ICR, their main recommendation for implementation of the M-SHAP funding scheme is a more inclusive supervision of the Bank that should effectively participate in the joint reviews that will be conducted through the newly created Partnership Forum chaired by the GAC. DFID acted as a financing partner to the GAC leveraging GARFUND resources through the provision of institutional, technical and administrative resources for initiating and sustaining GARFUND activities. It aimed at strengthening GAC's leadership role and empowering its Secretariat to respond quickly to management of grant disbursement and work towards common donor arrangements. DFID's support has also helped to build a robust national HIV/AIDS surveillance system; ensure an adequate and reliable supply of condoms in the public sector and through social marketing efforts; support HIV/AIDS teacher training and curriculum development in all public schools; and fund the first provision of anti-retroviral treatment in the public and mission hospitals. (c) Other partners (NGOs/private sector): NGO partners reported great benefits of the project including: (i) implementation of outreach HIV awareness programs in remote and rural areas; (ii) some indication of behavior change among young people who report abstinence from early sex and greater condom use; (iii) reduction of stigma resulting in the fact that more and more PLWHAs are reaching out to populations to share their experience; and; (iv) empowerment of women who are becoming more vocal about partner's irresponsible behavior. Despite these achievements, some challenges were noted in the processes of project approval, funds disbursement, capacity and commitment of regional and district M&E focal persons, and accountability of NGOs to beneficiaries. 10. Additional Information Background (i)The epidemic The first official AIDS cases in Ghana were reported in 1986 and associated mainly with women - 38 - who had traveled abroad. By December 1999, 37, 298 cases had been reported. At project inception, the national prevalence rate for HIV had increased from an estimated 2.6% in 1994, to 4.6% in 1998. Prevalence among STD patients was 17%, while for blood donors it was 4%. There were also regional variations with the northern sector having the lowest rate of 1.2%. The primary mode of transmission of HIV in Ghana is heterosexual, accounting for about 80% of all cases. Vertical transmission accounts for 15%, and transmission through blood and blood products accounts for another 5%. Most of the people infected with HIV are young and in their most productive years. Peak ages for reported age cases are 25-29 for females, and 30-34 for males, with the male to female ratio decreasing form 4:1 in 1996, to 2:1 in 1998. Nearly 90% of all cases occurred among adults aged between 15-49 and no longer predominantly repatriated AIDS cases. In 1994, AIDS accounted for 3.5% of all adult deaths in the country was projected to rise to 18% by 2004, and 33% by 2014. The estimated number of AIDS orphans was expected to rise from 126,000 to 250, 000 by 2004. The dependency ratio of 1.9% is also expected to rise. (ii)The project The Ghana AIDS Response Fund (GARFUND) project was designed to finance the scaling up of implementation of a multi-sectoral response to HIV/AIDS epidemic. Before the implementation of GARFUND, the national response to the AIDS focused primarily on health sector interventions. Clinical response focused on prevention of sexually transmitted diseases, and promotion of safe blood supply and clinics for commercial sex workers. Community response in the form of support for home-based care and support for families affected by AIDS, was almost non-existent. Virtually no programs or activities existed to protect the rights of People Living With HIV/AIDS (PLWHA) and their families as well as the rights of the civil society. The Government of Ghana (GOG) in recognition of the inadequacies of the national response to AIDS requested, in 1999, The World Bank for support in the financing of a fund to complement the Ministry of Health's efforts to fight the epidemic. The fund was intended to finance activities, which did not fall within the MOH's mandate. Subsequently, the GOG and the World Bank agreed that the Bank would transfer into a special AIDS fund, portions of any World Bank credits that would otherwise be canceled. The fund is the Ghana HIV/AIDS response fund.- GARFUND. The project was approved by the Board on December 28, 2000, signed on November, 2001, and became effective on May 8, 2002. - 39 - Annex 1. Key Performance Indicators/Log Frame Matrix Project Indicator Baseline End of project Comments development Appraisal Objective (PDO) estimate Intensify Actual (source, year)\ Target multisectoral activities designed to combat the spread of HIV infection: Maintain prevalence of HIV 3.8%(2002, 2.7% (2005 Sentinel Below 6% Satisfactory. among Pregnant women Sentinel Surveillance Survey) HIV prevalence well below Surveillance Survey) target. Reduce the prevalence of 15% for 24% for roamers 75% Not rated. End of project HIV infections among roamers figure not known pending commercial sex workers in 39% for seaters completion of an ongoing survey Kumasi 54% for seaters in June 2006. (WAPCAS, 2002) (WAPCAS, 2002) Increase the proportion of 60% N/A 75% Not rated. BSS is currently men and women who have being conducted and the results reduced the number of sexual will be available in September partners in response to 2006. perceived risk Increase the median age at 17 years 18.3 for females and 20.2 18 years Satisfactory. Source: first intercourse for males. 2003 GDHS. Next GDHS to be conducted in 2008. Increase the proportion of 15% 45% 30% Satisfactory. Source: 2003 men in a union using GDHS. Next GDHS to be condoms during their last conducted in 2008. intercourse Increase the proportion of 6% 35% 20% Satisfactory. Source: 2003 women in a union using GDHS. Next GDHS to be condoms during their last conducted in 2008. intercourse. Increase the percentage of 40% of males 86% of males 75% of males 50% of females males/females who know Highly Satisfactory. Target they can avoid HIV by using 22% of females 77% of females exceeded. Source:2003 GDHS condoms: males(m)/females(f) Increase the percentage of 60% 95% of males 90%Satisfactory. Targets males/females who know attained. Source:2003 GDHS they can avoid HIV by 90% of females restricting to sex to one uninfected partner Overall Satisfactory - 40 - Output Indicators Baseline Target Actual/End Comments Appraisal of Project Estimate Increase the proportion of 0% 96% (2934/3026) of 20% Highly satisfactory. Target funds awarded to CBO institutions funded exceeded. submitted subprojects (through through window B Windows B and C) and C (NGOs and CBOs) Increase the proportion of 0% 100% in 2003 100% Satisfactory. Target initially districts that have prepared 80% in 2004 attained but dropped by 20% at plans to address HIV/AIDS and 80% in 2005 end of project, because the are implementing part of their number of districts increased plans from 110 to 138. Increase the proportion of all 0% in project 30% 45% Satisfactory. Target exceeded subprojects that develop IEC sites, for all calls materials designed specifically Not available for for rural population (in local the country dialects) Percentage of first and second Not available 50% 100% of Moderately satisfactory. Target cycle schools that are providing 7281 Junior achieved for second cycle HIV/AIDS education Secondary schools. Figures for first cycle Schools schools were unavailable. Percentage of line ministries 0% 100% Satisfactory. Target achieved that have trained trainers at the 100% for At least one trainer trained in district level on HIV/AIDS districts. every district. Percentage of districts that 0% 30% 35% Highly Satisfactory. Target have organized care of AIDS exceeded and districts carrying orphans out care for the OVCs activities. Percentage of districts that 0% 50% 50% Satisfactory. Target attained have organized and districts carrying out care community-based care for for the PLWHAs activities. PLWHAs Percentage of districts that 0% 40% Not available Not rated. No information on have established an adequate functional referral system and functional referral system between home based care and between home-based and institutional based care institution-based care Percentage of funds disbursed 0% 30% 1% Unsatisfactory. Target not by component 1 for affiliation achieved. There are no well (umbrellas) that are able to organized umbrellas manage smaller civil society associations organizations or affiliates to provide services Increase by 10% every year, 0% 30% 91% for the Moderately satisfactory. No the proportion of subprojects 1st call. analyses were made for that implemented effectively, subsequent calls(2nd, 3rd, and meeting their stated objectives. 4th) Percentage of districts that 0% 100% 100% Satisfactory. Target achieved. regularly receive information Best practices information in on "best practices" examples of all districts. HIV/AIDS interventions. - 41 - Annex 2. Project Costs and Financing Component Appraisal Estimated (US$ Actual Estimates (US$ Percentage of Appraisal millions) millions) Prevention and care services 21.00 21.63 77.81% Strengthening Public/Private 1.37 4.93% institutions for HIV/AIDS2.40 Control (Capacity Building) Knowledge Management 1.40 0.46 1.65% Project Management and Monitoring and evaluation 3.00 1.42 5.11% Total Baseline cost 27.80 0.00 Physical Contingencies 0.00 0.00 Price Contingencies 0.00 0.00 Total Project Cost 27.80 24.90 89.57% Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ million equivalent) 1 Procurement Method Expenditure Category ICB NCB 2 N.B.F. Total Cost Other 1. Works 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 2. Goods 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 3. Services 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 4. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 5. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 6. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) Total 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) - 42 - Project Costs by Procurement Arrangements (Actual/Latest Estimate) (US$ million equivalent) 1 Procurement Method Expenditure Category ICB NCB 2 N.B.F. Total Cost Other 1. Works 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.03) (0.03) 2. Goods 0.00 0.00 0.00 0.00 0.00 (0.00) (0.15) (1.14) (1.04) (2.33) 3. Services 0.00 0.00 0.00 0.00 0.00 (0.00) (0.26) (1.80) (1.56) (3.62) 4. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (21.64) (0.38) (22.02) 5. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) 6. Miscellaneous 0.00 0.00 0.00 0.00 0.00 (0.00) (0.00) (0.00) (0.00) (0.00) Total 0.00 0.00 0.00 0.00 0.00 (0.00) (0.41) (24.58) (3.01) (28.00) 1/Figures in parenthesis are the amounts to be financed by the Bank Loan. All costs include contingencies. 2/Includes civil works and goods to be procured through national shopping, consulting services, services of contracted staff of the project management office, training, technical assistance services, and incremental operating costs related to (i) managing the project, and (ii) re-lending project funds to local government units. Project Financing by Component (in US$ million equivalent) Percentage of Appraisal Component Appraisal Estimate Actual/Latest Estimate Bank Govt. CoF. Bank Govt. CoF. Bank Govt. CoF. Prevention and care 18.90 2.10 0.60 21.60 0.34 0.41 114.3 16.2 68.3 Strengthening of PPI 2.40 0.00 0.64 1.37 0.33 0.57 57.1 0.0 89.1 Knowledge Management 1.00 0.40 0.54 0.56 0.35 0.41 56.0 87.5 75.9 Project mangement 2.70 0.30 0.10 1.42 0.63 0.30 52.6 210.0 300.0 - 43 - Annex 3. Economic Costs and Benefits Not applicable - 44 - Annex 4. Bank Inputs (a) Missions: Stage of Project Cycle No. of Persons and Specialty Performance Rating (e.g. 2 Economists, 1 FMS, etc.) Implementation Development Month/Year Count Specialty Progress Objective Identification/Preparation 11/27/2000 5 TASK TEAM LEADER (1); S S SR. COUNSEL (1); COUNSEL(1); LEAD FINANCIAL MANGEMENT SPECIALIST (1); HEALTH SPECIALIST (1); PROCUREMENT SPECIALIST (1); FINANCIAL MANAGEMENT SPECIALIST (1) Appraisal/Negotiation 10/22/2000 10 TASK TEAM LEADER (2); S S HEALTH SPECIALIST (1); CONSULTANT (2); FINANCIAL MANGEMENT SPECIALIST (1); SR. PROCUREMENT SPECIALIST (1); PROCUREMENT SPECIALIST (1); IMPLEMENTATION SPECIALIST (1); LANGUAGE PROGRAM ASSISTANT (1) Supervision 07/07/2001 2 TASK TEAM LEADER (1); S S HEALTH SPECIALIST (1) 03/01/2002 7 TTL (1); HEALTH SPECIALIST S S (1); SOCIAL PROTECTION (1); FINANCIAL MANAGEMENT (1); PROCUREMENT (1); COMMUNICATIONS (1); EDUCATION (1) 06/07/2002 5 TASK TEAM LEADER (1); S S HEALTH SPECIALIST (1); EDUCATION SPECIALIST (1); IMPLEMENTATION (1); HIV/AIDS STRAT. UNAIDS (1) 11/08/2002 7 TASK TEAM LEADER (1); S S HEALTH SPECIALIST (1); SENIOR OPERATIONS OFFI - 45 - (1); FINANCIAL MANAGEMENT (1); PROCUREMENT (1); TEAM ASSISTANT (1); M&E (1) 03/14/2003 6 TASK TEAM LEADER (1); S S PROCUREMENT SPECIALIST (1); OPERATIONS OFFICER (1); IMPLEMENTATION SPECIAL (1); FINANCIAL MANAGEMENT (1); HIV/ÁIDS PROGRAMS (1) 10/17/2003 7 TASK TEAM LEADER (1); S S OPERATIONS OFFICER (1); EDUCATION SPECIALIST(1); PROCUREMENT SPECIALIST (1); FINANCIAL MANAGEMENT SPECIALIST (1); M&E SPECIALIST (1); IEC SPECIALIST(1) 04/20/2004 7 TASK TEAM LEADER (1); S S HEALTH/HIV (1); FINANCIAL MANAGEMENT (1); PROCUREMENT (1); EDUCATION (1); M&E SPECIALIST (1); IMPLEMENTATION CONSULTANT (1) 11/11/2004 6 TASK TEAM LEADER (1); S S OPERATIONS OFFICER (1); LEAD HEALTH SPECIALIST ON HIV/AIDS (1); FINANCIAL MANAGEMENT SPECIALIST (1); PROCUREMENT SPECIALIST (1); EDUCATION SPECIALIST (1) 04/16/05 6 TASK TEAM LEADER (1); S S LEAD HEALTH SPECIALIST (1); OPERATIONS OFFICER (1); OPERATIONS ANALYST (1); FINANCIAL MANAGEMENT SPECIALIST (1); PROGRAM ASSISTANT (1) 12/14/05 7 TASK TEAM LEADER (1); S S LEAD HEALTH SPECIALIST ON HIV/AIDS (1); OPERATIONS OFFICER (1); SR. HEALTH ECONOMIST (1); SR. PROCUREMENT SPECIALIST (1) FINANCIAL MANAGEMENT SPECIALIST (1); PROGRAM ASSISTANT (1) - 46 - ICR 03/07/2006 6 TASK TEAM LEADER (1); LEAD HEALTH SPECIALIST (1); PROCUREMENT SPECIALIST (1); SENIOR FINANCIAL MANAGEMENT SPECIALIST(1); CONSULTANT; PROGRAM ASSISTANT(1) (b) Staff: Stage of Project Cycle Actual/Latest Estimate No. Staff weeks US$ ('000) Identification/Preparation 0.34 784.20 Appraisal/Negotiation 21.90 51,982.28 Supervision 62.02 146,098.71 ICR 8.23 17,826.19 Total 92.49 216,691.38 - 47 - Annex 5. Ratings for Achievement of Objectives/Outputs of Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating Macro policies H SU M N NA Sector Policies H SU M N NA Physical H SU M N NA Financial H SU M N NA Institutional Development H SU M N NA Environmental H SU M N NA Social Poverty Reduction H SU M N NA Gender H SU M N NA Other (Please specify) H SU M N NA Private sector development H SU M N NA Public sector management H SU M N NA Other (Please specify) H SU M N NA - 48 - Annex 6. Ratings of Bank and Borrower Performance (HS=Highly Satisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory) 6.1 Bank performance Rating Lending HS S U HU Supervision HS S U HU Overall HS S U HU 6.2 Borrower performance Rating Preparation HS S U HU Government implementation performance HS S U HU Implementation agency performance HS S U HU Overall HS S U HU - 49 - Annex 7. List of Supporting Documents Aide-memoires 1. Aide-memoire: final implementation support mission December 2005 2. Aide-memoire: implementation support mission, February- March 2005 3. Aide-memoire: implementation support mission September-October 2004 4. Aide-memoire: implementation support mission October 2003 5. Aide memoire : implementation support mission, March 2003 6. Aide-memoire : GARFUND site vite, November 2002 7. Aide-memoire : implementation support mission September 2002 8. Aide-memoire : implementation support mission, May- June 2002 9. Aide Memoire : GARFUND technical launch, February- March 2002 Reports 1. BTOR- Mid-term review, March 2004 2. BTOR- Supervision mission, October, 2003 3. BTOR- Project site visit, November, 2002 4. BTOR- Project launch workshop, February-March, 2002 5. Project Appraisal Document, Ghana Aids Response Fund (GARFUND), December 8, 2000 6. Country Assistance Strategy (CAS) of The World bank Group for the Republic of Ghana, June 29, 2000 7. Ghana AIDS Response FUND (GARFUND)- Draft Operational Manual, September, 2000 8. MAP interim Review Report 9. National IEC/BCC Strategic Framework 2006-2010 report 10. Mid-term Review Report on Ghana AIDS Response Project, March 2004 11. Draft national Response to HIV and AIDS, Five-year Program of Work, 2006-2010 12. Joint Review of Ghana's National HIV/AIDS Response, June 2004 13. Project Appraisal Document, Multi-Sectoral HIV/AIDS Project (M-SHARP), October 2005 14. PRS/ISRs all series- 2002-2005 15. Ghana Demographic and Health Survey 2003 (GDHS 2003), ORC Macro, September 2005 16. An In Depth Analysis of HIV Prevalence in Ghana: Further Analysis of DHS Data, April 2005 17. HIV/AIDS Surveillance Reports, NACP/MOH; 2002, 2003, 2004; 18. HIV AIDS Sentinel Survey Report 2005, National AIDS/STI Conrol Programme, Ghana Health Service, March 2006 19. Ernst and Young Fiduciary Analysis of CSO activities (title to be confirmed). - 50 - - 51 -