Document of The World Bank Report No: ICR00001674 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-35560 IDA-35561 TF-53811) ON A CREDIT IN THE AMOUNT OF SDR 104.1 MILLION (US$ 140.3 MILLION EQUIVALENT) TO THE REPUBLIC OF NIGERIA FOR A HIV/AIDS PROGRAM DEVELOPMENT PROJECT Date 28 March 2011 Human Development Country Department AFCW2 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective March 2010) Currency Unit = Naira I Naira = US$0.0066 US$1 = 151.88 Naira FISCAL YEAR January -- December ABBREVIATIONS AND ACRONYMS AF Additional Financing MDAs (Nigerian Government) Ministries, Departments and Agencies ARV Antiretroviral M&E Monitoring and Evaluation CBO Community-based Organization MoH Ministry of Health CPS Country Partnership Strategy CSO Civil Society Organization NACA National Action Committee on AIDS/ National Agency for the Control of AIDS DALYs disability-adjusted life-years NARHS National AIDS and Reproductive Health Survey DFID Department for International Development NASCP National AIDS-STI Control Program IEC Information, Education and NDHS Nigerian Demographic and Health Survey Communication FCT Federal Capital Territory NGO Non-Governmental Organization (F)MoH (Federal) Ministry of Health NPT National Program Team FLHE Family Life and HIV/AIDS Education NSF National Strategic Framework OVCs Orphans and Vulnerable Children FSWs Female Sex Workers PEPFAR (the US) President’s Emergency Plan for AIDS Relief HAF HIV-AIDS Fund PAD Project Appraisal Document HEAP HIV-AIDS Emergency Action Plan PDO Project Development Objective HIV/AIDS Human Immunodeficiency Virus P(MTCT) (Prevention of) Mother to Child /Acquired Immunodeficiency Syndrome Transmission (of HIV infection) PLWHA People living with HIV and AIDS HPDP HIV/AIDS Program Development Project QER Quality Enhancement Review IBBSS Integrated Bio-Behavioural Surveillance SACA State Action Committee on AIDS/ Survey State Agency for the Control of AIDS IDA International Development Association STI Sexually Transmitted Infection ISR Implementation Status and Results UNAIDS United Nations Programme on HIV/AIDS MAP Multi-country AIDS Program USAID United States Agency for International Development MARPs Most at-risk populations VCT Voluntary Counseling and Testing Vice President: Obiageli Katryn Ezekwesili Country Director: Onno Ruhl Sector Manager: Eva Jarawan Project Team Leader: Francisca Ayodeji Akala ICR Team Leader: Michael O’Dwyer COUNTRY Project Name CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 6 3. Assessment of Outcomes .......................................................................................... 13 4. Assessment of Risk to Development Outcome......................................................... 23 5. Assessment of Bank and Borrower Performance ..................................................... 24 6. Lessons Learned ....................................................................................................... 26 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 27 Annex 1. Project Costs and Financing .......................................................................... 28 Annex 2. Outputs by Component ................................................................................. 29 Annex 3. Economic and Financial Analysis ................................................................. 37 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 39 Annex 5. Summary of Borrower's Report .................................................................... 40 Annex 6. List of Supporting Documents ...................................................................... 53 MAP A. Basic Information HIV/AIDS Program Country: Nigeria Project Name: Development Project IDA-35560,IDA- Project ID: P070291 L/C/TF Number(s): 35561,TF-53811 ICR Date: 03/30/2011 ICR Type: Core ICR Lending Instrument: APL Borrower: NIGERIA Original Total XDR 0.00M Disbursed Amount: XDR 92.70M Commitment: Revised Amount: XDR 92.70M Environmental Category: B Implementing Agencies: National Agency for the Control of AIDS Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 09/07/2000 Effectiveness: 04/26/2002 04/26/2002 10/02/2004 Appraisal: 01/29/2002 Restructuring(s): 05/22/2007 Approval: 07/06/2001 Mid-term Review: 05/22/2007 Closing: 03/31/2010 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory Implementing Quality of Supervision: Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Moderately Satisfactory Performance: Performance: i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes Moderately Satisfactory time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Agricultural extension and research 1 1 Central government administration 5 5 Health 91 91 Law and justice 1 1 Sub-national government administration 2 2 Theme Code (as % of total Bank financing) Child health 17 17 Gender 16 16 HIV/AIDS 33 33 Health system performance 17 17 Population and reproductive health 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Onno Ruhl Mark D. Tomlinson Sector Manager: Eva Jarawan Rosemary T. Bellew Project Team Leader: Francisca Ayodeji Akala Francois Decaillet ICR Team Leader: Michael O'Dwyer ICR Primary Author: Michael O'Dwyer ii F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) To assist Nigeria to reduce the spread, and mitigate the impact, of HIV infection by strengthening its multi-sectoral response to the epidemic through the implementation of a comprehensive program that includes the creation of an enabling environment for a large scale response, and laying the foundation for scaling up HIV/AIDS prevention, care, and treatment services at the federal, state, and local levels. Revised Project Development Objectives (as approved by original approving authority) Reducing the risk of HIV infections through behavior change. Improving access to HIV/AIDS counseling, testing and care services. (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Percentage of women (disaggregated by young people and adults) reporting the Indicator 1 : use of condom the last time they had sex with a non-marital, non-cohabiting sexual partner 6.5% (all ages) 33.4% (all ages) Value 9.8% (15-24) 35.5% (15-24) quantitative or 25% 78% 4.6% (25-49) 28.9% (25-49) Qualitative) [NDHS 1999] [NDHS 2008] Date achieved 12/01/2000 04/26/2002 05/22/2007 03/31/2010 Comments The original target was exceeded (134%). (incl. % There was 43% achievement of the highly ambitious revised target. achievement) Percentage of men (disaggregated by young people and adults) reporting the use Indicator 2 : of condom the last time they had sex with a non-marital, non-cohabiting sexual partner 14.8% (all ages) 54.4% (all ages) Value 32.4% (15-24) 49.4% (15-24) quantitative or 30% 78% 12.6% (25-49) 28.9% (25-49) Qualitative) [NDHS 1999] [NDHS 2008] Date achieved 12/01/2000 04/26/2002 05/22/2007 03/31/2010 Comments The original target was exceeded (49%). (incl. % There was 70% achievement of the highly ambitious revised target. achievement) Indicator 3 : Decrease in the percentage of young people aged 15 - 24 who are HIV infected Value 5.2% 4.1% quantitative or [Sentinel Site Survey None 3.2% [Sentinel Site Qualitative) 2003] Survey 2010] Date achieved 04/01/2004 04/26/2002 05/22/2007 03/31/2010 Comments Good progress. (This indicator is taken as a proxy for incidence of infections, (incl. % noting that overall prevalence is not an appropriate indicator of success.) iii achievement) Percentage of women and men aged 15-49 who have had sex with a non-marital, Indicator 4 : non co-habiting sexual partner in the last 12 months 18.9% (all) 17.9% (all) Value 14.2% (women) 13.1% (women) quantitative or None 3.6% 39.1% (men) 29.5% (men) Qualitative) [NDHS 2003] [NDHS 2008] Date achieved 04/01/2004 04/26/2002 05/22/2007 03/31/2010 Comments Significant progress against baseline, with 25% drop in numbers of men (incl. % reporting such high risk sex. achievement) Percentage of sex workers who in the past 12 months did not use a condom Indicator 5 : consistently during sexual intercourse with a client Value 19.4% 1% (Lagos State) quantitative or [IBBSS 2003 - selected None 5% [IBBSS 2007] Qualitative) states] Date achieved 12/31/2003 04/26/2002 06/30/2009 03/31/2010 Comments No nationally comparable IBSS data, but Lagos State data shows significant (incl. % progress and achievement of Original Credit end of project target. achievement) Indicator 6 : Median age at first sex Value 17.4 (women) 18.1 (women) 17.0 (women) quantitative or 20.1 (men) None 20.4 (men) 20.6 (men) Qualitative) [NDHS 2003] [NDHS 2008] Date achieved 04/01/2004 04/26/2002 05/22/2007 03/31/2010 Comments Additional financing target met for women and almost met for men. (It is not (incl. % clear why NACA set a lower AF target than that recorded as baseline). achievement) Percentage of orphans and vulnerable children whose households received free Indicator 7 : basic external support in caring for the child Value Increase by 20%, 1.7% 6.3% quantitative or in relation to the 30% [NDHS 2003] [NDHS 2008] Qualitative) baseline Date achieved 04/01/2004 04/26/2002 05/22/2007 03/31/2010 Comments Modest progress made when comparing the two NDHS results. (Project support (incl. % to provision of OVC services was through the HAF and very limited). achievement) Pregnant women living with HIV who receive a complete course of antiretroviral Indicator 8 : prophylaxis to reduce the risk of MTCT Value 5.25% 18.7% quantitative or (NNRIMS Data Base, None 80% [FMoH 2009] Qualitative) 2007) Date achieved 05/22/2007 04/26/2002 05/22/2007 03/31/2010 Comments Although signficant progress has been made on this indicator the highly (incl. % ambitious national target (largely dependent on broader health system inputs) achievement) has not yet been achieved. Persons aged 15 and older who received counseling and testing for HIV and Indicator 9 : received their test results iv Value 8.6% 14.5% quantitative or None 20% [NARHS 2005] [NDHS 2008] Qualitative) Date achieved 08/01/2006 04/26/2002 05/22/2007 03/31/2010 Comments Significant progress. Baseline data obtained from NARHS 2005 but no recent (incl. % NARHS survey to assess progress towards end of project target. achievement) Percentage of young people aged 15-24 who both can correctly identify ways of Indicator 10 : preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission By 2005, 80% of Value the population 21.1% 25.1% quantitative or knows how to 94% [NDHS 2003] [NDHS 2008] Qualitative) prevent HIV transmission. Date achieved 04/01/2004 04/26/2002 05/22/2007 03/31/2010 Original baseline and revised target were surprisingly high. UNAIDS report Comments <50% youth correctly answer 5 questions about HIV and transmission. NDHS (incl. % 2003 figure of 21% is taken as more appropriate baseline; NDHS 2008 figure of achievement) 25% indicates modest progres (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Indicator 1 : SACAs are set up and functional Value (quantitative 3 18 35 or Qualitative) Date achieved 06/18/2001 04/26/2002 03/31/2010 Comments (incl. % 100%achieved achievement) Indicator 2 : Action plans and contracts are signed with implementing partners Value (quantitative 0 None 100% 100% or Qualitative) Date achieved 06/18/2001 04/26/2002 05/22/2007 03/31/2010 Comments All participating agencies had developed and signed off Action plans by end of (incl. % project - 100% Achieved achievement) Indicator 3 : Increase in National AIDS Program Effort Index (API) Value (quantitative or Qualitative) Date achieved v Comments No data. The National Composite Policy Index was replaced by the National (incl. % Composite Policy Index in 2007. UNAIDS no longer provides a quantitative achievement) NCPI measure. National HIV/AIDS monitoring and evaluation framework finalized and NACA Indicator 4 : reports annually on at least 75% of indicators in the framework Value (quantitative 75% None 100% 80% or Qualitative) Date achieved 05/22/2007 04/26/2002 05/22/2007 03/31/2010 Comments Significant progress achieved and Original Credit End of Project target achieved (incl. % but formally revised target not met. achievement) NACA and SACAs will prepare a HIV/AIDS situation analysis and assessment Indicator 5 : of program performance annually Value (quantitative 0 0 100% or Qualitative) Date achieved 06/18/2001 04/26/2002 03/31/2010 Fully achieved. NACA Annual progress reports prepared. Analytical studies Comments prepared, including state level Epidemic Response and Policy Syntheses, and (incl. % Modes of Transmission studies. achievement) Percentage of Ministries, Departments and Agencies that are implementing Indicator 6 : HIV/AIDS workplace policy and programs in their regular work programs by June 2009 28/33 line Value 10 line ministries ministries (85%) (quantitative 0 85% by 2005 231/352 state or Qualitative) ministries (66%) Date achieved 06/18/2001 04/26/2002 05/22/2007 03/31/2010 Comments (incl. % 100% achieved at national level. 78% achieved at state level. achievement) Indicator 7 : CSOs present at least 30 proposals for financing per year Exceeded in all Value states (quantitative 0 30 grants per state [HAF Assessment or Qualitative) Abt Assoc 2008] Date achieved 06/18/2001 04/26/2002 10/10/2008 Comments (incl. % 100% achieved achievement) Indicator 8 : Proposals from CSOs are approved quickly and according to agreed criteria Achieved in all Value states (quantitative 0 None [HAF Assessment or Qualitative) Abt Assoc 2008] Date achieved 06/18/2001 04/26/2002 10/10/2008 vi Comments (incl. % 100% achieved achievement) Indicator 9 : Percentage of the approved proposals implemented as planned Value 90% (quantitative 0 None [HAF Assessment or Qualitative) Abt Assoc 2008] Date achieved 06/18/2001 04/26/2002 10/10/2008 Comments (incl. % 90% achieved achievement) Indicator 10 : State AIDS Program Effort Index Value (quantitative or Qualitative) Date achieved Comments No data. UNAIDS no longer provides a quantitative AIDS Program Effort (incl. % measure. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 09/04/2001 Satisfactory Satisfactory 0.00 2 12/12/2001 Satisfactory Satisfactory 0.00 3 05/16/2002 Satisfactory Satisfactory 0.00 4 11/11/2002 Unsatisfactory Unsatisfactory 1.74 5 05/23/2003 Satisfactory Satisfactory 2.87 6 11/17/2003 Unsatisfactory Unsatisfactory 5.37 7 06/03/2004 Unsatisfactory Unsatisfactory 9.62 8 11/04/2004 Unsatisfactory Unsatisfactory 13.80 Moderately 9 05/13/2005 Satisfactory 26.99 Unsatisfactory Moderately 10 12/14/2005 Satisfactory 48.95 Unsatisfactory 11 03/02/2006 Satisfactory Satisfactory 54.40 12 09/11/2006 Satisfactory Satisfactory 73.03 13 11/14/2006 Satisfactory Satisfactory 75.43 14 06/20/2007 Satisfactory Satisfactory 91.61 15 10/25/2007 Satisfactory Satisfactory 100.75 16 06/25/2008 Satisfactory Satisfactory 105.21 17 12/27/2008 Satisfactory Satisfactory 114.68 18 06/26/2009 Satisfactory Satisfactory 118.40 19 12/20/2009 Moderately Satisfactory Moderately Satisfactory 134.83 20 03/30/2010 Moderately Satisfactory Moderately Satisfactory 138.97 vii H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions Problem project for two years; low disbursement levels; state level activities slow to start; national/state level roles and responsibilities poorly understood. Changes: roles and 10/02/2004 N U U 13.41 responsibilities clarified; project opened to all states ; antiretrovirals added as eligible expenditure; additional funds available for high performing states and activities. 05/22/2007 Y S S 89.15 If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Satisfactory Against Formally Revised PDO/Targets Moderately Unsatisfactory Overall (weighted) rating Moderately Satisfactory viii I. Disbursement Profile ix 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Country and Sector Background: Nigeria is the most populous country in Sub- Saharan Africa. At the time of project appraisal it had a population of around 102 million. Since the country's first AIDS case was diagnosed in 1986, the epidemic had killed 1.7 million people and orphaned 1.5 million children. By 2001, 2.7 million Nigerians (including 120,000 children) were living with HIV/AIDS, the fourth largest total of any country. There was a growing realization that the epidemic posed a significant threat to Nigeria's development. AIDS was already eroding the country's modest health gains of the past generation. From 1980-1995, life expectancy at birth had risen from 47 to 53 years. AIDS reversed that trend and it was estimated that life expectancy would return to 47 years by 2004, erasing 25 years of progress1. 2. Economic and country context: AIDS was also seen as a threat to the future by impacts on economic growth and poverty. At the macro level, the epidemic was costing as much as 0.5% of annual growth. At the micro level, the vast majority of the infected were in their most productive years as workers and parents, jeopardizing the welfare of households and communities. The 972,000 AIDS orphans in Nigeria in 2001 were far less likely than other children to stay in school and far more likely to suffer from malnutrition, ill health, and social marginalization. Nigeria had only recently returned to democratic government, re-engaging with the bank in 1999. Institutional experience of working with the bank was seriously lacking, leading to a fragile operating environment. 3. Rationale for Bank assistance: In its 2001 Interim Country Strategy Update2, the Bank confirmed support to Nigeria in its fight against HIV/AIDS. This demonstrated strong and early leadership, and a willingness to take risks in a climate of considerable uncertainty: the Multi-country AIDS Program (MAP), launched in 2000, was the first major donor initiative in Africa to focus on HIV/AIDS. It responded to a perceived need for urgent action, in a context of weak policy development and management, pervasive gender imbalances and widespread poverty, but also an open and forward-looking government response. Following the return to civilian administration in 1999, President Obasanjo made HIV/AIDS one of the country’s primary concerns and the Government of Nigeria committed substantial resources of its own. It agreed a sensible and serious strategy, the HIV-AIDS Emergency Action Plan (HEAP). The Bank aimed to add value through: (i) significant additional funds for a wide scale response; (ii) a multi-sectoral response, drawing on wide experience of work with all development sectors in Nigeria; (iii) cross-country learning from other countries pursuing similar approaches with MAP support; and (iv) support to community-based activities, building on experience of social funds and targeted cash transfers. 1 An accurate prediction: by 2007 life expectancy was estimated at 46.5 (UNDP Human Development Report 2008) 2 Document number: IDA/R2001-81(IFC/R2001-100) Date of latest CAS discussion: June 14, 2001 1 1.2 Original Project Development Objective (PDO) 4. The original development objective was to assist Nigeria to reduce the spread, and mitigate the impact, of HIV infection by strengthening its multi-sectoral response to the epidemic through the implementation of a comprehensive program that included the creation of an enabling environment for a large scale response, and laying the foundation for scaling up HIV/AIDS prevention, care, and treatment services at the federal, state, and local levels. 1.3 Revised PDO (as approved by the Board) 5. The PDO was revised at the time of additional financing (AF) May 2007, in line with the recommendations made under the umbrella restructuring of projects under the Africa Region MAP, specifically: removal of overall HIV prevalence rate as a measure of project performance, reflecting increased understanding of the limitations of this measure, replaced by prevalence rate in the 15-24 year age group as a proxy for incidence of infection; and revision of key performance indicators to be realigned to the national strategy). The revised objectives were to: (i) reduce the risk of HIV infections through behavior change; and (ii) improve access to HIV/AIDS counseling, testing and care services. 1.4 Original and revised key Indicators Original PDO Indicators3 Revised PDO Indicators Proportion of the population aged 15-to-49, who Percentage of women (disaggregated by young people and report using a condom in their last act of sexual adults) reporting the use of condom the last time they had sex intercourse with a non-regular partner with a non-marital, non-cohabiting sexual partner Percentage of men (disaggregated by young people and adults) reporting the use of condom the last time they had sex with a non-marital, non-cohabiting sexual partner HIV prevalence rate as measured among Decrease in the percentage of young people aged 15 - 24 who are pregnant women by the sentinel surveillance HIV infected system Proportion of men and women who have reduced Percentage of women and men aged 15-49 who have had sex the number of sexual partners in response to with a non-marital, non co-habiting sexual partner in the last 12 perceived risk months Percentage of sex workers who in the past 12 months did not use a condom consistently during sexual intercourse with a client Median age at first sex Number of households receiving help in caring Percentage of orphans and vulnerable children whose households for orphans and chronically ill household received free basic external support in caring for the child members Pregnant women living with HIV who receive a complete course of antiretroviral prophylaxis to reduce the risk of MTCT Persons aged 15 and older who received counseling and testing for HIV and received their test results Percentage of the population knowing how to Percentage of young people aged 15- 24 who both can correctly prevent HIV transmission identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission 3 These indicators have been re-ordered from the Project Appraisal Document (PAD) to show how they were updated at the time of restructuring 2 1.5 Main Beneficiaries 6. Specific groups were identified as needing special focus, and as such were the direct beneficiaries of the project: Sexually active population (reduced rate of new infections through behavior change, increased condom access, and reduced Sexually Transmitted Infection (STI) rate); New-born children (reducing mother to child transmission); People living with HIV/AIDS (extending their productive life through prevention and treatment of opportunistic infections, improved care and support, reduced stigma and enhanced legal and human rights); Orphans and affected households (support for health, education and social needs). It was noted that coverage was limited especially for those at higher risk (including commercial sex workers, men who have sex with men, and out of school youth), but the neglect of epidemiologic surveillance and lack of behavioral surveillance made it difficult to estimate levels of coverage and need. The project included the whole population as indirect beneficiaries: the epidemic was defined as generalized (prevalence over 1% in the general population) and there was widespread concern at the potential impact on economic growth, poverty, and health. 1.6 Original Components 7. Component 1: Capacity Development. (Appraisal estimate US$30.56 million /32% of estimated cost; actual cost US$70.30 million). With the return to democracy, the Government prioritized HIV and AIDS, establishing the multi-sectoral National Action Committee on AIDS 4 (NACA) to develop and coordinate implementation of a comprehensive HIV/AIDS strategy. State Action Committees on AIDS (SACAs) were also established. The project supported these bodies to carry out their responsibilities, inter alia by financing establishment and activities of National and State Program Teams (NPT/SPTs)5, which were later subsumed in NACA and SACAs. The project provided technical staff and support to NPT and SPTs; training and financial support to NACA and SACAs to develop and review policy, prepare and implement strategic plans, carry out coordination, and strengthen program management capacity; and consultancy support for the monitoring and evaluation program and knowledge management activities. The significant increase in cost over the appraisal estimate was the result of an increase in the number of eligible states from 14 to 35 and the need for a high level of capacity building support throughout the project. 8. Component 2: Expanding the Public Sector Response (Appraisal estimate US$31.25 million/33% of estimated cost; actual cost US$11.45 million). It was recognized that public sector agencies beyond the MoH needed to be involved, but few sectors had prepared integrated HIV/AIDS strategies. Support was provided to activities in the HEAP to be carried out by line Ministries to meet the needs of their own staff and their client groups by (i) financing plans approved by NACA and SACAs; and (ii) assisting with preparation of plans and programs of action. Resources were directed to the functional HIV/AIDS units established in target ministries to build high level 4 NACA became the National Agency for Control of AIDS in 2007 – the same acronym is used throughout this report 5 The PAD states that “The State Program Teams will be full-time units composed of contractual or seconded staff. They will include …: a Manager, a Procurement Specialist, an Accountant, an Internal Auditor, a Community Development Specialist, and a Monitoring and Evaluation Specialist. The National Program Team will also include .. a Partnership Coordinator and two additional financial management staff�. 3 commitment, disseminate prevention messages to staff, formulate HIV/AIDS workplace policies, and oversee sector-specific initiatives for client groups. However, with the exception of a few key ministries, line ministries focused on activities to meet the needs of their own staff line rather than on activities directed to their client groups; as a result, disbursements under this component were significantly lower than the appraisal estimate. 9. Component 3: The HIV/AIDS Fund (HAF) (Appraisal estimate US$33.87 million/35% of estimated cost; actual cost US$30.35 million). This component 6 encouraged Civil Society groups to focus on programs which public services could not easily deliver, targeting specific groups considered at higher risk (such as commercial sex workers, truck drivers, and youth) as well as strengthening care for the sick and orphans. HAF’s contribution was to provide funds for technical assistance, training and implementation support to Civil Society Organizations (CSOs), the private sector and communities to prepare and implement projects of their choosing, especially for targeted programs and providing care and support for the sick and orphans, areas which public services cannot easily or effectively reach. The fund financed: (i) proposals from civil society organizations (including Non-Government Organizations (NGOs), Community- Based Organizations (CBOs), trade and professional associations, and private companies) (ii) activities conducted by very small CBOs and communities (for a maximum of US$2,500 per proposal, with a community contribution in cash or in kind). 1.7 Revised Components 10. The components were not revised. Allocations to the individual components were increased through Additional Financing. 1.8 Other significant changes 11. Project restructuring (1). The project was first restructured in October 20047. It had been listed as a problem project for almost two years, and disbursement levels were low. State level activities had taken longer to start than expected, and roles and responsibilities between national and state levels were poorly understood. The main features of the restructuring were to: (i) clarify roles and responsibilities between federal and state teams, and between SACAs and State Program Teams; (ii) open the project to all states that met agreed financial management selection criteria (in response to demands from non-project states to be included)8; (iii) add Antiretrovirals (ARV) as an eligible expenditure9; and (iv) provide additional funds for high performing states and activities. 12. Additional Financing and project restructuring (2). Following the first project restructuring the number of participating states dramatically increased (from 14 to 35) and implementation in many states accelerated. As a result, the federal level and many states had insufficient funds to finance their 2007 workplans. This particularly affected the HAF component where NACA and states could not fund all eligible proposals. There was also a significant increase in capacity building needs as a result of the inclusion of 6 Including NGOs, CBOs, private sector and communities 7 This was an internal amendment of the Development Credit Agreement at the borrower’s request 8 Doubling the total population covered 9 The government subsequently obtained funds for ARVs from elsewhere; the project did not fund ARV procurement. 4 many new states. An additional credit of $50 million was thus made available in May 2007 for two years. This aimed to ensure: (i) continuity until the follow-on project was operational (noting that the extensive consultation process to prepare the follow-on project would require longer than anticipated, and the need to ensure that the institutional structures built-up under the current project would be sustained) ; (ii) maximal achievement of the development objective and outcomes; (iii) a strengthened national monitoring and evaluation system; (iv) more targeted civil society actions to be supported by the HAF (though the nature of this targeting was not specified reflecting the lack of consensus on the need to focus on specific groups); and (v) continued complementary support to treatment (the Global Fund was financing ARVs, the project was financing the necessary infrastructure and training). Project design and implementation modalities were unchanged. However, the PDO was modified in line with MAP recommendations (see above, #1.3) and key Performance Indicators were modified to reflect the increased geographic scope of the project and to align with Bank wide good practice related to HIV/AIDS monitoring frameworks. 13. Revised Financing Percentages and Cost Sharing. The ability of the Nigerian Government to provide counterpart funding, as required under the original Development Credit Agreement, had been a problem from the start. In response to a government request, this was reviewed in accordance with the Nigeria Country Financing Parameters. As a result it was agreed that all expenditure categories would be 100% project financed with effect from May 2005. 14. Project Schedule. The project closing date was extended three times. (i) for one year June 30, 2006 to June 30, 2007: to ensure completion of project activities (given the slow take off but rapid increase in disbursement following restructuring in October 2004). (ii) for two years June 30, 2007 to June 30, 2009: agreed at the time of AF to fund completion of additional project activities including support to scaled up project activities and financing of NGO activities underway and pending. (iii) for nine months to March 31, 2010, to allow additional time to implement ongoing activities and to prevent a funding gap between project closure and effectiveness of a follow-up project. The case for each extension was fully justified, building upon good project performance and contributing to sustainable project benefits. 15. Funding allocations. (i) In March 2006, unallocated funds of US$ 11.75 million were reallocated to 6 states, the Federal Capital Territory (FCT) and NACA all of which were recipients at project start up, and were demonstrating good implementation progress. (ii) In May 2007, US$ 32.5 million AF was allocated as supplementary amounts to participating states based on their needs, and US$17.5 million AF was allocated to NACA. (iii) In December 2009, at the request of the borrower, funds were reallocated within the 3 disbursement 10 categories of each State and Federal entity with each maintaining its current overall allocation. (iv) In May 2010 an amount equal to SDR 3,940,000 was cancelled from the Original Credit and returned to the Nigeria IDA pool for recommitment to support other 10 (i) Civil Works, Goods, and Consultants services, training study tours and audits; (ii) Sub-Projects; (ii) Incremental Operating Costs 5 activities that were consistent with the World Bank Nigeria Country Partnership Strategy (CPS) 11 . The three funding reallocations were fully justified as building upon good performance and ensuring maximal achievement of the project objectives. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 16. Detailed project preparation took place over a period of 15 months 12 . HIV prevalence had trebled over the previous 6 years (from 1.8% in 1993 to 5.4% in 1999) and all parties were agreed that a broad and ambitious emergency response was called for. There was a high level of political commitment to address the issue as seen by the constitution of a Presidential Council on AIDS and a multi-sectoral National Action Committee on AIDS. In view of the urgency of the need to respond, an interim plan (the HEAP) was developed by NACA with Technical Assistance provided by USAID, and NACA was preparing a longer term Strategic Plan. 17. A Quality Enhancement Review (QER) was carried out in January 2001 13. The review endorsed the overall approach and the (government) program content, stating that it “focused on all the critical factors for addressing the emerging HIV/AIDS epidemic�, but expressed concern that the program was too ambitious. It was recognized that the planning context was weak: there was little epidemiological information, institutions had only just been established and had limited capacity, and there were no policies or national strategic plans to guide project preparation. Of particular note was a lack of information to inform and guide interventions targeted to the specific groups most at risk as the source of new infections. The need for prioritization and sequencing of actions according to currently available epidemiological indicators was noted at the time of concept review. The QER stated that the Bank’s most significant contribution would be to build the capacity of implementing agencies to plan, deliver and evaluate specific services. 18. Lessons learnt and reflected in the project design. The project design reflected some key generic lessons learned from international experience with HIV/AIDS, and from implementation of other Bank-financed projects in Nigeria including the need to: maintain political commitment; promote advocacy and coordination across sectors; support capacity development (including for civil society) and community empowerment; develop an integrated approach to prevention and care (particularly for TB); target the highest risk most vulnerable groups; implement on a large and sustainable scale; carry out effective monitoring of the epidemic and risk behaviors and disseminate findings. 19. More specifically, the design: (i) responded to the need to develop an appropriate model of financing for the project: in developing the HAF, the project team drew on existing experience in Nigeria, including the Community-Based Poverty Reduction project; (ii) recognized the need to balance interventions such as mass communications aimed at the general population with targeting of interventions to so-called "high-risk" 11 This was in line with the Investment Lending Reform approved by the WB Board in February 2009 12 Identification mission March 2000, Project approval June 2001 13 This was an “abbreviated� review; there was no formal scoring of Quality at Entry. 6 groups – and the importance of sentinel surveillance (sero- and behavioral surveillance) as the basis for choosing priority groups and interventions (but also noted the major lack of information to guide such targeting); and (iii) because of implementation problems with previous Bank-financed projects in Nigeria, planned an extensive supervision program for the project. 20. Risks and their mitigation The Project Appraisal Document (PAD) identified important risks14, many of which materialized during implementation. While the risk mitigation measures were generally appropriate, some underestimated the level of inputs to meet the scale of the risk (eg advocacy and awareness-building campaigns to increase understanding and support among policy makers and the general public; information on country experiences and networking to maintain prevention emphasis) or overestimated capacity of key partners (eg supporting NGOs, private sector and line Ministries to specifically highest risk target groups; working through NGOs to build acceptance of controversial interventions). Project funds enabled NACA to devote considerable effort to increase SACA capacity to plan interventions; less support was given to other agencies, or to building consensus on more controversial interventions. NACA also used resources to ensure that procurement and financial management systems were developed and well managed. The PAD rated overall risk of the project as Substantial. The Implementation CR team agrees with this assessment. 21. Adequacy of government’s commitment, stakeholder involvement and/or participatory processes. The government had demonstrated a high level of commitment to the project objectives at the time of project preparation: it accorded HIV/AIDS the highest priority and moved quickly to establish NACA, raise the profile of the epidemic, ensure a multi-sectoral response, and harness the energies of civil society and the private sector. Government stakeholders participated actively in HEAP development and many were already implementing HEAP activities. Government had committed $40 million over three years to NACA for HEAP implementation. There was broad stakeholder consultation on project design, including UN and bilateral donors, NGOs and CSOs, who also participated in consultations on the HEAP. 2.2 Implementation 22. The return of democratic rule in 1999 brought a major change in government attitude to the epidemic. In 2000 a Presidential Advisory Committee on AIDS was established to oversee HEAP development, which adopted a multisectoral approach. NACA was established the same year to oversee HEAP implementation. This high level commitment was sustained with adoption of a revised HIV policy in 2003. Despite this high level commitment, the project was launched and implemented in a context of severe capacity constraints, low levels of understanding of the nature of the epidemic, and 14 The risks were: Output to Objective (i) Political commitment deteriorates; (ii) Preventive activities do not get scaled up rapidly; (iii) Coherent action plans (federal or state) are not developed; (iv) Financial mechanisms prove too complex and confusing to borrower; Component to Output (v) Pressure to shift emphasis to high-cost treatment; (vi) Rate of HIV transmission does not decrease rapidly; (vii) Inadequate management/implementation capacity (procurement and financial; all levels); (viii) Lack of acceptance of controversial interventions; (ix) Inability to ensure timely conracting and flow of funds to line ministries and NGOs. 7 variable, but often inadequate, state level support. The presence of multiple project implementation entities across the various levels of government added to the challenges. Project Development Objectives 23. The original development objective was broad and ambitious, addressing strengthening of the multi-sectoral response, and creation of an enabling environment. At the start of implementation there was little understanding of the need for, or nature of, a multisectoral response, and how to create such an enabling environment. The revised objective (May 2007, in line with umbrella MAP recommendations) was more realistic, focusing on reduced risk of infection through behavior change, and improved access to counseling, testing and care. Building institutions and developing capacity 24. Developing federal and state level capacity Capacity constraints were well recognized at the start of implementation, including: lack of robust institutions and structures; limited human resource capacity at both federal and (particularly) state levels; high rates of staff turnover; and limited understanding of the project. As a result disbursement was very slow and implementation was haphazard in the first two years. 25. Establishment of Project Teams. At the time of project design in-country capacity to respond to the epidemic was limited to the MoH. A major project achievement was to encourage government to address this by developing the necessary institutions and capacity. This presented further challenges including: Unclear roles and responsibilities (of all project stakeholders, but particularly new institutions - NACA, SACAs and their project teams); limited leadership and coordination; duplication of roles and role conflicts (the NPT Project Manager was also NACA Chair; NPT and NACA had overlapping roles resolved by the far-seeing decision to merge the two); implementation of multiple donor funded activities, with separate personnel in NACA (NACA addressed this by assigning cross-cutting roles to staff); and poor NACA and MoH coordination (resulting from institutional competition and high staff turnover). 26. Financing Counterpart funding. Weak federal government and state governments systems to allocate and disburse timely counterpart funding was an issue for the whole Nigeria country portfolio until this requirement was waived in May 2005 as part of revision of the Country Financing Parameters. Fostering a multisectoral response 27. At the time of project design HIV and AIDS was seen as a health issue: there was limited understanding in the country of the wide range and significance of structural, socioeconomic, cultural and behavioral issues driving the epidemic. The HIV/AIDS Program Development Project (HPDP) was an innovative project: Nigeria had not borrowed for a multisectoral project before. The project helped government to realize the need for a multisectoral response. The result was the creation of NACA, broadening of the government response beyond the MoH (initially to the full range of line ministries), and government acceptance of the importance of civil society and community involvement. 28. Operationalizing the multisectoral concept raised additional challenges. FMoH officials seconded to the project unit saw HPDP as a health sector project, and were 8 reluctant to work with other sectors. Most line ministries focused efforts on their staff rather than on the needs of their client groups (the health, education and women’s affairs ministries, and the Nigeria Prison Service were notable exceptions). All federal line ministries were included, but NACA did not have capacity to coordinate their inputs or supervise implementation. This was addressed as part of AF: the number of participating ministries was reduced, (with selection of those ministries most critical to an effective response); and they were asked to develop more client-centered interventions. NACA’s capacity was significantly increased with establishment of program and partnership units. Strengthened Civil Society involvement 29. The PAD noted that “[p]ublic services rarely reach socially marginalized groups, such as commercial sex workers. … who are among the most important groups to protect in addressing the epidemic�. It also recognized the central role of communities in setting behavioral norms for their members, and the burden of care and support faced by households and surrounding communities. Their active involvement was pivotal to both prevention and care. Although civil society had begun to fill these gaps they needed greater financial and technical support to increase their scale and effectiveness. It was also anticipated that hundreds of new NGOs and community organizations might arise as the epidemic and the response grew, and that these would need similar support. Civil society involvement remains pivotal to an effective response: recent studies concluded that “community-based approaches are particularly relevant for interventions which involve behavior change at the household level� 15 and to promote access to and utilization of services16. 30. There were no available mechanisms to encourage non-public sector responses, channel funds to CSOs or encourage collective learning among them. The project established the HAF to disburse funds using competitive mechanisms. It also recognized the need to provide small scale support for activities conducted by very small CBOs and communities and developed a new community driven mechanism, the Rapid Response Fund, as part of the HAF. Other factors under government control 31. Bureaucratic delays. Procedures for approving community-based programmes involved rigorous vetting and approval of applicants, and extensive documentation. There were often delays of six to nine months as a result. There were also long delays in transferring funds to NGOs. Other factors outside government control 32. The epidemic raised issues that were difficult to discuss in a conservative society; as a result, it was difficult to deliver clear prevention messages, and to address issues of stigma and discrimination, and to get people to understand how infection is transmitted. 15 Community-based Maternal and Child Nutrition and Health Interventions to Enhance Productivity and Life Expectancy in Nigeria, World Bank Health Nutrition Population (AFTHE), Africa Region, December 2010 16 Community Response Evaluation, DFID, World Bank, Macro ICF, 2010 – personal communication of initial results 9 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E design. 33. A full set of performance indicators was included in the PAD. It was noted that it would be difficult to detect significant changes in impact on prevalence during the project implementation period, and intermediate outcome measures and proxy indicators were also included. At the time of Additional Financing the prevalence indicator was changed to “decrease in the percentage of young people aged 15 - 24 who are HIV infected�, as a proxy for incidence and recognizing the limitations of overall prevalence as a measure of impact. The QER undertaken shortly before project approval stressed the importance of monitoring indicators to highlight institutional outcomes. A broad and reasonable range of indicators was developed, to monitor changes in knowledge and behavior, capacity to plan and manage the national response, and support to civil society in addition to HIV prevalence 17 . However, in-country M&E capacity was very limited and the systems available for collecting data were uncoordinated and unsystematic. It was stated that baseline data for the chosen indicators would be collected during the first year of the project, following which more specific quantitative targets would be set. This did not happen. The Nigeria National Response Information Management System (NNRIMS) Operational Plan (see below, #36) set highly ambitious targets in 2007. These were based on overly optimistic assumptions, particularly for changes in sexual behavior relating to increases in knowledge and condom use. M&E implementation and utilization. 34. M&E implementation. The limited M&E capacity at project start up reflected the previous low priority given to addressing the epidemic, and the health sector focus of the response. The PAD emphasized the need for urgent initiation of prevention and care activities. Implementation of a strong M&E system was seen as part of longer-term institutional development. NACA, as implementing agency, did not have control over data collection by states and line ministries, who had, in turn, limited incentives to share the data they were collecting with NACA. Baseline data was lacking. Different development partners had different data needs, linked to indicators which were not aligned with the emerging national system. 35. Steps were taken to address these shortcomings during the first year of implementation, including recruitment of an M&E consultant to help the NPT design a comprehensive framework, support from GAMET18, and addition of an M&E specialist in the NPT. Baseline data was available by the end of 2003. NACA initiated development of a National multisectoral HIV/AIDS M&E framework in 2002, resulting in the launch of the NNRIMS in April 2004, and roll out of the NNRIMS Operational Plan 2007-2010 in June 2007. This system combines routine service information, periodic population based and sentinel surveys, and program and project reports. 36. The situation had improved somewhat by 2005, and the system was further improved following restructuring in 2007. There was increasing rationalization and 17 It should be noted that standard indicators were not widely available at the time of project design 18 The Global AIDS Monitoring and Evaluation Team, set up as part of the Bank’s Global HIV/AIDS Program to improve the quality of HIV/AIDS M&E and build national capacity to develop country-led and owned M&E systems. 10 alignment of the indicators used by development partners. Routine monitoring tools were developed at state level and M&E Technical Working Groups, which included development partners, formed in many of the states, further strengthening SACA M&E capacity. NACA increased its capacity to collect and synthesize data provided by the states, and national sentinel site and behavioral surveys were underway. However, despite considerable system strengthening inputs from the Bank, progress on implementation (depending on the consistent availability and performance of skilled staff, and was thus outside the Bank’s control) remained slow – the Mid-term Review of the National Strategic Framework (NSF), 2005-09 in December 2007 identified a wide range of shortcomings, including limited state level NNRIMS coverage, inadequate skills in NACA and SACAs, and lack of gender disaggregated information. A notable finding was the poor funding of M&E, with most government coordinating bodies allocating less than 3% of their budgets, despite a 10% NSF stipulation. 37. Given the above, it is not surprising that M&E utilization was limited in the early stages of project implementation, though this improved significantly later on. At federal level, national data was used to monitor HIV/AIDS trends, and justify funding ministries, NGOs and public sector components. M&E data was extensively used to develop the most recent National Strategic Framework (NSF 2010-15) and plans. However, the need for geographically and behaviorally disaggregated data remains including information on outputs and outcomes, to guide resource allocation and track the effectiveness of interventions, particularly at state and local government level. Lack of such data has limited the extent to which project inputs can be directly shown to have contributed to increases in HIV service delivery and thus to outcomes and impacts (see Section 3.2). 2.4 Safeguard and Fiduciary Compliance 38. Environment. The project did not trigger any concerns related to the Bank’s safeguards policy. No major wider social issues or negative impacts were identified by an initial social assessment, nor in the course of project implementation. Project activities were carried out at existing sites and structures and there was no land acquisition or resettlement. ISRs consistently rated the project as satisfactory for overall safeguards compliance and in respect of operational policy OP4.01 (Environmental Assessment). There were no significant deviations or waivers from Bank safeguards and fiduciary policies and procedures during the implementation of the project. 39. Financial management and procurement. Acceptable financial management arrangements were maintained during project implementation. However, a 2009 external audit report noted some internal control lapses resulting from inadequate internal audit functions. There were also some delays in delivery of quarterly Financial Monitoring Reports and retirement of advances, and cases of inadequate documentation for incurred eligible expenditures. Some Project Implementation Units failed to fully maintain fixed assets registers. All annual financial statements were submitted on time and received unqualified opinions, and there were no outstanding financial reports. 40. Although the initial Procurement Capacity Assessment rating was “high risk� procurement performance was satisfactory throughout implementation. There was effective dialogue with the implementing institution to address procurement issues 11 candidly. Involvement of country office procurement staff allowed for close monitoring and guidance. Thorough training of the NPT and SPTs contributed significantly to good procurement management. The same qualified and experienced procurement specialist in NACA was responsible for procurement for the duration of the project. This continuity contributed to sound performance, and procurement was rated “satisfactory� in all ISRs. 2.5 Post-completion Operation/Next Phase 41. The Board approved a follow-on project, HPDP2, on June 16, 2009. Transition arrangements incorporated into this US$ 225 million credit include: Technical. HPDP2 design draws on lessons learnt from both country experience and international best practice including the need for interventions to be more strategic and selective (with focus on areas with the greatest potential impact), and for a stronger local evidence base for decision-making. An external evaluation of the HAF and Public Sector components gave guidance on modifying their design19. A DFID-financed overall review of the HPDP made recommendations on institutional and capacity issues. State and National level Modes of Transmission studies and work to increase knowledge of Most At Risk Populations (MARPs) will guide implementation of the new project, which will also develop new approaches to contracting of Civil Society Organizations. Institutional. The institutional architecture of the next project will be largely unchanged: NACA will be the implementing agency and will coordinate federal level operations. SACAs will coordinate at state level. NACA will have greater say in approving requests for state level implementation, strengthening their authority and ownership of the project. The project will be implemented within the parameters of the NSF 2010-15, and the national and state-level strategic and operational plans derived from this framework. 42. Despite the best efforts of the Bank Task Team to ensure a seamless transition, there has been a delay in finalization of government approval for HPDP2, and a gap between the two projects. A major reason for this delay was the uncertain political environment caused by the illness and subsequent death of the Nigerian President. 43. Partnership arrangements. A wide range of technical and financial support is currently provided by the United States Government (particularly focused on expanding treatment provision), the Global Fund (scaled up treatment care and support), DFID (capacity building for NACA and selected states; condom social marketing), UNAIDS and the UN family co-sponsors (multisectoral interventions through the Joint UN Programme). A Joint Financing Arrangement is being developed to ensure greater harmonization and alignment of partner support. The project supported preparation of a National AIDS Spending Assessment, 2007-08, which has provided government with information on who is working where, coverage of end beneficiaries, types of programs and the strength and impact of support. The close working relationship with DFID, developed during HPDP1, will be maintained, including through continued secondment of a senior DFID adviser to the Task Team and collaboration based on complementary 19 Assessment of Effects of HIV/AIDS Fund and Evaluation of the Support for the Public Sector on the National Response to HIV/AIDS in Nigeria, 2002-June2007. Abt Associates Inc Oct 2008. 12 use of financial and technical resources from the DFID funded “Enhancing Nigeria’s Response� project. 44. Monitoring and evaluation. HPDP2 will build upon existing support to scale up M&E systems at state level and in line ministries. Systems established by NACA and SACAs during HPDP1 implementation will be strengthened to monitor performance and project achievements. The Bank will use a subset of data from this system to track progress of the program. The Bank will also work with NACA and other partners to develop and implement a framework for impact assessment throughout the project. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 45. Relevance of Objectives The initial PDO was developed in the context of a renewed priority given to HIV and AIDS as shown by the establishment of NACA and development of the HEAP. The focus on a multi-sectoral response, creation of an enabling environment and laying the foundation for scaling up was wholly consistent with these national actions. The revised PDO reflected the need for effective prevention through behavior change. It remains highly appropriate to Nigeria’s social and economic development and is in line with the CPS Results Framework, which identifies behavioral change, reduction in risky sexual practices and increased access to prevention, testing and care and support services as key results areas for DFID and the World Bank. On this basis relevance of objectives is rated high. 46. Relevance of Design and Implementation. Design incorporated current international experience on HIV and AIDS. It followed the MAP framework which the Board had earlier approved as a model for replication, and remains consistent with the Bank’s approach of support to national programs in line with national development priorities and circumstances. Project components and organization matched what the project set out to achieve. It was recognized that there were significant gaps in understanding of the drivers of the epidemic at state level, which the project aimed to address through high levels of capacity building support to SACAs (eg by strengthening their planning and M&E skills). The MAP design as an Adaptable Program Loan was appropriate as a flexible lending instrument able to support policy reform and institutional strengthening. Two alternative project designs were rejected as having more limited relevance (design exclusively targeting MARPs rejected since the epidemic was already generalized; design solely addressing the health sector rejected since it would be unable to deliver a multi-sectoral multi-partner response). On this basis he relevance of design and implementation would have been rated high. However, the project depended for its success on other agencies (Line Ministries and SACAs) whose capacity was very limited: the time needed to strengthen these agencies was underestimated, as were the time and levels of input needed to establish a robust M&E system. For this reason the relevance of design and implementation is rated substantial. 47. Based on high relevance of objectives and substantial relevance of design overall relevance is rated substantial. 13 3.2 Efficacy/Achievement of Project Development Objectives 48. The original development objective was to assist Nigeria to reduce the spread, and mitigate the impact, of HIV infection by strengthening its multi-sectoral response to the epidemic through the implementation of a comprehensive program that included the creation of an enabling environment for a large scale response, and laying the foundation for scaling up HIV/AIDS prevention, care, and treatment services at the federal, state, and local levels [section 1.2]. The revised PDO at the time of Additional Financing) involved two principal sub-objectives: (i) reducing infection risk; (ii) expanding access to counseling, testing and care services. While the revised PDO was a shorter and sharper statement the intent of both the original and revised PDO was the same: to reduce the infection rate by strengthening the multisectoral response and scaling up prevention, care and treatment services. This PDO is evaluated below. A reduction in the risk of HIV infections through prevention (primarily through increased awareness and behavior change, achieved through a multisectoral approach involving a broad range of line ministries and civil society organizations), reflected the shared understanding that this will have the greatest long-term impact on the epidemic. Public sector and civil society outputs delivered within a context of increasing national capacity worked synergistically to deliver a multisectoral response and achieve this objective. 49. Two things were noted in assessing project achievements: - End-of-project targets, particularly those set at the time of Additional Financing, were highly over-optimistic by epidemiological and operational standards. The task team discussed these aspirational targets extensively with government. Government set these in the context of an anticipated large and coordinated increase in donor support, and an expectation of pooled funding which did not materialize. The task team drew attention to the underlying programmatic and capacity constraints which made these targets unrealistic. Despite their best endeavors they were unable to influence the final choice of targets. - A comparison with the “no project intervention� can not be evaluated because of lack of knowledge of the natural history of individual HIV epidemics and the absence of any reasonable counterfactual. Reducing infection risk 50. The most significant outcome has been a “decrease in the percentage of young people aged 15 - 24 who are HIV infected� [Fig 1] since it provides a proxy measure of incidence of new infections (and was revised from the original indicator “HIV prevalence rate as measured among pregnant women by the sentinel surveillance system� for this reason) . By 2010 the prevalence in this group had fallen to 4.1% from a baseline of 5.8%. (It should be noted that this evidence of a fall in incidence occurred during a period of rapid expansion of access to treatment, increasing the duration of disease, which would be expected to have the effect of increasing prevalence overall. This strengthens the conclusion that the observed decrease in prevalence in young people must have been related to a significant decrease in incidence.) Supporting evidence of change in key risky behaviors is presented below (increase in condom use in casual and commercial sex; reduction in rates of casual sex; and delay in intiation of sexual activity by young people). 14 Fig 1 Decrease in the percentage of young people aged 15-24 who are HIV infected 7.0% 5.8% 6.0% 5.2% 5.0% 4.4%4.1% 4.0% 3.2% 3.0% 2.0% 1.0% 0.0% 51. Additional evidence to support progress on reduction in infection risk is provided by Indicators 1 and 2 “Percentages of women and men reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting sexual partner� [Fig 2]. Original targets for this indicator were exceeded. Good progress towards achievement of the highly ambitious revised target was observed for men (70% achieved). Amongst women (who find it much harder to negotiate condom use) progress was more limited (43% achieved) but it is noted that this is progress from a very low base (33.4% use in 2008 against 6.4% in 1999). It is also encouraging to see a higher level of use amongst young women, who might be expected to be most vulnerable to unprotected sex. Fig 2 Percentage of women and men (15-49 yrs) reporting the use of a condom the last time they had sex with a non-marital, non-cohabiting, sexual partner 15 52. Delaying in reducing initiation of sexual activity is recognized as an important factor in reducing infection risk in young adults. The target for Indicator 6: “Median age at first sex� was met for females (a rise from 17.3 to 18.1) and almost met for males. There was also a fall of nearly 10%, from 5.5% to 5.1%, in the numbers of younger (15- 24 year old) adults reporting a sexually transmitted infection or symptoms suggestive of an infection between 2003 and 2008 (NDHS 2003, NDHS 2008); and a 10% drop in the percentage of women aged 15-19 having sex with men more than ten years older than them (from 11.6% to 10.5%), providing further evidence of a reduction in risky sexual behavior in this key group. In the light of this, the findings for Indicator 10: “Percentage of young people aged 15- 24 who both can correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission� are puzzling. The baseline of 84% (NARHS 2005) is surprisingly high, and might account for the unrealistic formally revised project target of 94%. The recent UNAIDS Report on the global AIDS epidemic reported that less than half of young people living in 15 of the 25 countries with the highest HIV prevalence (which includes Nigeria) can correctly answer five basic questions about HIV and its transmission, and the NDHS 2003 figure of 21% is likely to be a more accurate baseline for the country. The NDHS 2008 measure of 25% can therefore be taken as indicative of modest progress. 53. High rates of casual sex are associated with higher infection risk. There was significant progress on Indicator 4: “Percentage of women and men aged 15-49 who have had sex with a non-marital, non co-habiting sexual partner in the last 12 months� (revised from initial indicator “Proportion of men and women who have reduced the number of sexual partners in response to perceived risk� in line with global best practice). The numbers of men reporting such high risk sex dropped 25% (39.1% to 29.5%) whilst the rate amongst women fell less markedly from 14.2% to 13.1%. During this period Nigeria felt the effects of the global economic crisis, with increased levels of poverty, and a likely increase in rates of transactional sex (an increase in risky sex related to economic shocks has been observed in Kenya20; a similar response in Nigeria could explain this finding). Messages on the importance of partner reduction were a core element of a wide range of public sector and civil society interventions supported by the project, and 63% of respondents were aware of this (NARHS 2007). However, the revised target for this indicator (3.6%) is considered unrealistically ambitious. 54. Promoting high rates and consistent use of condoms in commercial sex is an important prevention intervention. Trend data on Indicator 5: “Percentage of sex workers who in the past 12 months did not use a condom consistently during sexual intercourse with a client� (Fig 3) is only available for Lagos State, which showed an impressive fall from 10.7% to 1% (IBBSS 2003, 2007). However, this is a significant finding: Lagos is the largest state in Nigeria (approximately 10% of the population) and as the capital with a large mobile population it is also a major centre for sex work. The same surveys also recorded an overall fall in inconsistent condom use by sex workers, from 19.4% to 8% (but different states were used in the two surveys). This is the only indicator to measure risk related behavior in a high risk group: it is estimated that 11.5% of new infections are 20 Robinson, Jonathan, and Ethan Yeh. 2011. "Transactional Sex as a Response to Risk in Western Kenya." American Economic Journal: Applied Economics, 3(1): 35–64. 16 related to sex work21, and a reduction in sex-work related risk is a major achievement for the country. Fig 3 Percentage of sex workers who in the past 12 months did not use a condom consistently during sexual intercourse with a client 19.4% 20.0% 18.0% 16.0% 14.0% 10.7% 12.0% 10.0% 8.0% 5.0% 6.0% 4.0% 1.0% 2.0% 0.0% Baseline (BSS Lagos only (BSS Lagos only (BSS Target 2003) 2003) 2008) Expanding access to counseling, testing and care services 55. A wide range of CSOs were awarded grants under the project at the Federal and State levels in order to support strong civil society platforms able to address vulnerabilities surrounding HIV/AIDS in their communities. Recipient organizations and networks included those focused on people living with HIV/AIDS, youth, women and faith-based organizations providing high level advocacy and community-based services in hard-to-reach areas. Inputs accounted for more than 30% of all funds disbursed. Services were provided to both the general population and high risk groups, and included promotion of HIV testing and counseling; treatment of Sexually Transmitted Infections; and care for People living with HIV and AIDS (PLWHA) and Orphans and Vulnerable Children (OVCs). Initial household survey findings from an evaluation of community responses to the epidemic22 provide an indication of the extent to which HAF outputs contributed to improved intermediate outcomes at the community level: communities with high levels of CBO activity (“Study� communities) were much more likely to be aware of the availability of services to prevent HIV transmission, and much more likely to make use of such services than matched (“Comparison�) communities with lower CBO activity levels (Figs 4 and 5). [See Annex 2: Outputs by Component, for further information on the HIV/AIDS Fund]. 21 Modes of HIV transmission in Nigeria, Nnorom et al, 2010 22 Community Response Evaluation, DFID, World Bank, Macro ICF, 2010 – personal communication of initial results 17 Fig 4 Household knowledge of service availability by type Comparison Study 100.0% 90.0% 76.3% 80.0% 70.1% 70.0% 61.0% 59.8% 60.0% 49.3% 50.0% 42.7% 36.3% 34.2% 40.0% 28.3% 30.0% 20.0% 14.3% 14.6% 10.0% 3.7% 0.0% Treatment Care and Prevention Community Impact HIV/AIDS services support service mobilization alleviation services services service service available in the community Source: World Bank/DFID/Macro, January 2011 Fig 5 Service use by type 30.00% 26.50% 25.00% 20.10% 20.00% 15.00% 10.00% 7.30% 7.20% 6.00% 5.20% 4.80% 5.00% 2.70% 3.20% 1.70% 1.70% 0.80% 0.60% 0.80% 0.00% Any HIV Treatment ART Care and Prevention Programs Any services services services services support services that provided by services mobilize and CBO organize Source: World Bank/DFID/Macro, January 2011 18 56. Given the limited support to the public sector from other sources, and noting the fall in prevalence in the 15-24 year age group (taken as a proxy for incidence of new infections), it seems reasonable to attribute much of the success presented above to project inputs: the IDA sector credit was a major source of funding for prevention activities (approximately 1/3rd of all prevention funding was provided by the project), and for the associated institutional strengthening needed for a sustained response, across the country. The most recent UNAIDS Report on the global AIDS epidemic23 noted that the epidemic in Nigeria stabilized between 2001 to 2009 (the lifetime of the project). The other major financers of HIV and AIDS during this period were the Global Fund, the US Government and DFID. The contribution from public sources was minimal24. The US Government provided significant funding for prevention ($315 million) through PEPFAR (the US President’s Emergency Plan for AIDS Relief). Global Fund support for prevention was $6.8m for Prevention of Mother to Child Transmission (PMTCT) under Round 1 (2003). DFID provided £21 million (approx $35 million) of which less than £3 million ($5 million) was for prevention activities in 6 focal states. 57. A notable result was the development of a multisectoral institutional framework (skilled staff working within established institutions and supported by well designed policies, plans, systems and operational guidelines) which contributed to the effective use of resources provided by government and other partners, particularly from the US government (through PEPFAR, USAID and Centers for Disease Control (CDC) programs) and the Global Fund. Operational tools and guidelines were developed addressing state level planning (frameworks covering strategic and operational plans), M&E (particularly the NNRIMS), Behavior Change Communication and Prevention interventions. NACA provided ongoing support to states throughout the project. It might have been expected that capacity building needs would reduce as the project matured, but the expansion in the number of states and the need for continued inputs to maintain quality resulted in a high level of inputs throughout the project life (the reason for the increased allocation to the Capacity Building component over the appraisal estimate). Outcomes included establishment of functional NACA and SACAs in all states, production of state-level operational plans to guide the use of all available resources, and use of an agreed M&E framework to track achievement of program objectives (though implementation of this remained a challenge). 58. The project made a significant contribution to institutional development and strengthening and has substantially strengthened national and state-level capacity to deliver a strong response to the epidemic:  Fully functional and staffed NACA and SACAs were established with project support; National and State Strategic Plans have been agreed for 2010 to 2015 and are the basis for annual work plans to guide the response in the coming years. NACAs and SACAs played an important role in coordinating the activities of other agencies (Line Ministries, Civil Society Organizations, Local Government bodies). It should be noted that these institutions remain fragile, and continuing support will be needed to ensure that progress is sustained and built upon. 23 Report on the global AIDS epidemic, UNAIDS, 2010 24 National AIDS Spending Assessment, NACA, Nigeria, March 2010 19  Public Sector: The Public Sector component of the project helped line ministries at federal and state level to engage on HIV/AIDS activities related to their specific mandates and competencies, providing catalytic seed money for the creation of financing mechanisms and development of operational guides and procedures.  HAF: The HAF process, by funding a wide range of CSOs, was able to leverage existing capacity and create additional capacity for the multisectoral response to reach a wide range of target populations both at the national and state level. These organizations strengthened their skills in strategic and operational planning, proposal development, M&E and reporting as a result. There remains, however, a major need to further strengthen capacity in these areas. 59. Nearly 50% of project inputs to federal and state level line ministries went to a few key ministries who focused on activities to meet the needs of their client groups: Health (including extension of HIV counseling and Testing, PMTCT and STI Treatment Services); Education (design and implementation of the Family Life and HIV/AIDS Education Curriculum); and Women’s Affairs and Social Development (establishment of a National OVC Steering committee; development and dissemination of National guidelines and standards of practice on OVCs). The other line ministries focused on activities to meet the needs of their own staff, including establishment of functional HIV/AIDS units to build high level commitment, formulate HIV/AIDS workplace policies and deliver prevention messages to staff. This explains the lack of demand for project funds under this component (40% of the appraisal estimate). A key outcome was the implementation of HIV/AIDS workplace policy and programs by most line ministries, (28 of 33 (85%) federal level Ministries, Departments and Agencies and 231 of 352 at state level (66%) are now implementing such policies. An external assessment of project achievements concluded that “the HIV/AIDS response in the agenda of the public sector at all levels in the country is remarkable�25. Project achievements and attribution under the original objectives 60. Project achievements under the original sub-objectives (to reduce the spread of the HIV/AIDS infection; to reduce the impact of HIV/AIDS on those infected and their families) are rated Satisfactory. It facilitated a broad multisectoral response through engagement of a wide range of partners (including people living with HIV and AIDS, federal and state governments and MDAs, national and international NGOs, CBOs, UN and donor organizations). Institutional structures were established and strengthened to support the response: NACA was successfully transformed from a committee to an agency, led a coordinated multisectoral response, and developed and operationalized the national strategy, plan and M&E framework. It facilitated establishment of SACAs in all states, and their transformation into agencies; SACAs received direct project support and disbursed funding to both private and public institutions and organizations further expanding the response at state level; and standard procedures and manuals supported implementation across the country, allowing a wide range of stakeholders to contribute to the response within the framework of a single strategic plan. 25 Abt Associates ibid 20 61. Federal line ministries contributed to expansion of the response according to their mandates, creating “critical mass� teams and developing workplans. They coordinated with state line ministries to implement these plans, with project support. 28 federal government ministries and agencies developed and implemented HIV/AIDS action plans targeting staff (through HIV Workplace Policies). Key ministries (Health, Education, Women’s Affairs) supported interventions to their target clients. In each State, 7-8 ministries also developed and implemented action plans. In 2008 the National Executive Council mandated state governments to provide at least 1% of Ministries of Health, Agriculture, Education, Youth and Women’s Affairs budgets to HIV. Project achievements and attribution under the revised objectives/additional financing 62. Existing indicators were aligned to similar indicators in the NSF, which included some highly ambitious aspirational targets set by the government. While the most up to date evidence available suggests that some progress has been made in achieving the AF targets, most have not been fully met. Achievements under the revised objectives included strengthening of the M&E system, expansion of the HAF (with increased focus on higher risk groups), and continued support to capacity building (including the additional needs in more recently recruited states). The design did not change, and progress continued to be made on the project objectives. However, on the basis of the failure to meet targets, the achievements must be rated Moderately Unsatisfactory. Overview of Project Achievements 63. The project was substantially successful in achieving its original objectives. However, as the original objective was formally revised at the time of additional financing in May 2007, the project outcome has been assessed against both the original and revised project objectives. To assist in arriving at an overall outcome rating, separate outcome ratings (against original and revised project objectives) were weighted in proportion to the share of actual credit disbursements made in the periods before and after approval of the revision. Based on the two ratings as shown below (#63), the overall achievement of the project is rated as Moderately Satisfactory. Table 1 Ratings weighted in proportion to the share of actual credit disbursements before and after Additional Financing Against Original Against Revised Overall Comments PDOs PDOs Rating Satisfactory Moderately Less progress against Unsatisfactory ambitious targets set for revised PDOs Rating value 5 3 Weight (% disbursed 74 26 100 before/after PDO change) Weighted value (2 x 3) 3.70 0.78 4.48 Final rating (rounded) Moderately Satisfactory 21 3.3 Efficiency 64. The project recognized the scarce capacity which existed at start up, and took steps to expand this. Following implementation delays during the early phase of the project considerable support was provided to strengthen the implementation capacity of existing fiduciary institutions such as Project Support Teams and by outsourcing implementation to civil society organizations under the HAF. The project management team ensured recipients of project funds submitted physical progress reports and financial statements on a regular basis. This was facilitated by NACA and participating SACAs. 65. Highly cost-effective interventions were selected for implementation using project funds26, and were delivered as population-based programs to prevent HIV/AIDS in the highest-prevalence and most affected states (though it is noted that information is lacking on the extent to which these interventions reached specific groups responsible for the largest number of new infections in those states). Several key interventions had a cost-effectiveness of US$100 per HIV infection averted or less (a commonly-used threshold for cost-effectiveness), and addressed more than 3% of all deaths and disability-adjusted life-years (DALYs) lost. Interventions included: voluntary testing and counseling (US$34 to US$161 per DALY averted); peer-based programs to educate higher-risk groups, including truck drivers, commercial sex workers, and youth (US$11 to US$74 per DALY averted); and social marketing, promotion, and distribution of condoms (US$39 to US$305 per DALY averted). 66. Allocative efficiency increased over time. During the initial years of the project there was limited epidemiological information available to participating states, and as a result no stated consensus on how resources should have been most efficiently allocated to maximize the number of infections averted. On the basis of the information available (showing a generalized epidemic) the government decided to direct resources to the general population. At that time, resource allocation between interventions could not be clearly related to the epidemic profiles because of the lack of availability of this data. As a result, the initial advertisements seeking proposals for HAF funding from CSOs were broad and open ended (reflecting this lack of detailed understanding of the epidemic) but they became more narrowly focused over time (i.e. for the second and third funding rounds) with increasing prioritization of interventions considered to be of higher effectiveness as the data became available and knowledge of the drivers of the epidemic increased. 67. Based on the emphasis placed on capacity-building, the choice of interventions of high cost-effectiveness, and increasing allocative efficiency (see Operations Evaluation Department 's analysis regarding the principal elements contributing to the efficiency of the MAPs27) project efficiency is rated as Substantial. 26 Disease Control Priorities in Developing Countries, Jamison et al, 2006 27 Operations Evaluation Department, Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (2005), see especially Table 4.1, p. 45. 22 3.4 Justification of Overall Outcome Rating 68. Based on the above, the overall rating for the project is Moderately Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 69. Poverty Impacts. The project was a major contributor to efforts to prevent the spread of the epidemic and to reduction in the number of new infections. This can be expected to have led to a reduced burden of AIDS-related illnesses, particularly in adults of working age. Although there is no socio-economic impact data currently available, it can be expected that this will have had a positive aspects on earning capacity and household wealth. 70. Gender Aspects. NGOs and CSOs financed under the project worked with targeted women’s groups such as commercial sex workers. There is no information on reduction of gender stereotyping as a result of the project, but some of the gender disparities in project indicators would suggest that there continues to be a major need for work to address this. 71. Social Development. The project impacted significantly on social development both through activities to address stigma and discrimination and through sensitization on HIV/AIDS issues. Support to civil society through the HAF also had broader impacts on Social Development. (b) Other Unintended Outcomes and Impacts (positive or negative) 72. A significant unintended positive outcome has been the strengthening of donor collaboration. The World Bank country office played an active part in the HIV/AIDS Development Partners Group, which provided a useful forum to discuss and develop policy and coordinate activities. DFID health advisers were seconded to the Task Team, and were based in the Country Office: the resulting close collaboration between the two agencies provided valuable synergies in the use of technical and financial resources and strengthened the quality of policy dialogue with the borrower.. 73. An important unexpected positive outcome followed the establishment of the private sector response through the formation of the Nigeria Business Coalition against AIDS (NIBUCAA), as a result of which the majority of major multinational companies are now providing significant support to HIV programs for their employees and host communities. 4. Assessment of Risk to Development Outcome 74. The project made considerable efforts to mitigate risks. Management and implementation capacity received particular attention (details above, #3.5). Federal and state action plans have been developed, and have emphasized prevention. NACA and SACAs are allocated budgets, and project teams have emphasized the importance of ensuring adequate financial allocations and budget releases at every possible opportunity. 75. Despite these risk mitigation measures, several of the risks identified at appraisal remain significant, in large part because of the scale of the challenge, including: 23  Failure to sustain initial high levels of political commitment, as shown by failure to provide adequate resources (the public sector share of funding declined from 14.6% in 2007 to 7.6% in 2008; SACA budget and fund releases are often low and late). There is also limited understanding amongst politicians of the need to direct resources to communities and NGOs.  Continued pressure to fund treatment rather than prevention. There has been a rapid expansion of treatment access in recent years, with USG and Global Fund support, but coverage remains less than 50%, resulting in major political pressure to further increase treatment spending. Approximately 50% of total resources were spent on Treatment and Care in 2007/08, whilst less than 15% was spent on prevention28.  Allocative inefficiencies: there is still lack of acceptance of controversial interventions (eg condom provision) and of effective interventions for key risk populations (eg sex workers, men who have sex with men, and injecting drug users).  Insufficient capacity remains a major risk, particularly at the most decentralized levels of the system (local governments and ward councils). 76. Overall, the risk to development outcome remains substantial. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 77. The project identification process focused on critical gaps and opportunities for interventions to address the epidemic. It was consistent with the CPS and government sectoral priorities. The Bank had a consistently good working relationship with the Borrower during preparation and appraisal. Project preparation and appraisal was supported by a broad mix of specialists who provided a full and appropriate range of skills and considered all major relevant aspects of the design (including technical, financial, economic, institutional, and procurement and financial management). Major risk factors and lessons learned from other earlier social sector projects were incorporated into the design. The Bank provided adequate resources in terms of staff time and dollar amount to ensure quality preparation and appraisal work. The ICR team views the above aspects as satisfactory. 78. Project design was guided by the MAP Template, developed to respond to a perceived emergency. Alternative designs were considered, and rejected for valid reasons (See #47). Epidemiological information was limited, and capacity constraints were widely recognized. In view of this the project objective was over ambitious. M&E design was one of the weaker aspects of the project, and the Bank team could have done more to ensure the timely availability of baseline data and a robust M&E framework. 79. The many positive project design features are noted. The project was overambitious (given the capacity constraints) and there were weaknesses in M&E, including the setting of unrealistic targets for Additional Financing. Quality at entry is 28 National AIDS Spending Assessment, NACA, March 2010 24 therefore rated Moderately Satisfactory for both the Original Project and Additional Financing. (b) Quality of Supervision 80. A Quality of Supervision Assessment in October 2006 noted that the Task Team: (i) was right to start by addressing institutional impediments to implementation while adopting a more deliberate approach to the scaling up of service delivery aspects; (ii) was proactive in recognizing and solving problems; and (iii) had experienced members and gained a solid knowledge of contextual issues. The main weakness identified was in the adequacy and operation of M&E framework. The Task Team rose to the challenge, supporting roll out of the NNRIMS Operational Plan 2007-2010, implementation and use of key national surveys (IBBSS, 2007; NARHS, 2007; Antenatal clinic sentinel surveillance, 2008; Nigerian DHS, 2008), and development of state level M&E Technical Working Groups and routine monitoring tools in order to strengthen their capacity to provide effective supervision. 81. The Bank’s country office had an expanded team (including a secondee from DFID, a dedicated M&E adviser and several Short-Term Consultants), and was well supported by other Bank departments (particularly GAMET), reflecting the challenges of supervising such a large project, which covered the national program, and (eventually) 34 out of 36 states plus the Federal Capital Territory. The task team undertook regular supervision missions, prepared and agreed Aides-Memoire, alerted government and NACA to problems with project execution, and facilitated remedies in a timely manner, in conformity with Bank procedures. The Implementation Status and Results reports (ISRs) realistically rated project performance both in terms of achievement of development objectives and project implementation. The task team also monitored safeguard and fiduciary compliance. They identified a considerable number of minor Financial Management issues, which did not lead to major compliance concerns and were resolved in discussion with the client. Audit reports were reviewed by the task team who notified the client of any issues raised by the auditors and ensured that these were resolved. 82. Rating: Satisfactory (c) Justification of Rating for Overall Bank Performance 83. Based on the moderately satisfactory rating for quality at entry and satisfactory rating for quality of supervision, overall Bank Performance is rated as Moderately Satisfactory. 5.2 Borrower Performance (a) Government Performance 84. Government showed strong commitment to the project at the time of preparation. In 2002, President Obasanjo declared HIV and AIDS a national emergency, established a Presidential Advisory Council, and demanded a national emergency response plan. Government also supported project implementation, establishing institutions, and providing adequate staff. Government officials collaborated and cooperated fully with the task team. Appropriate levels of review and approval were generally in place; 25 financial accountability and follow-up was observed; expenditures were duly authorized before they were incurred; and documentation was well maintained for periodic review. 85. There were, however, delays from federal government in contribution of counterpart funding and appropriate budget provisions, until this requirement was waived in May 2005. The reduction in the government budget allocation to HIV and AIDS (eg a 19% reduction in the budget allocation to HIV and AIDS between 2006 and 2007) occurred in the context of rapid increases in levels of external funding, particularly from the Global Fund and PEPFAR. Many of the challenges faced during implementation were due to bureaucratic bottlenecks that could have been resolved faster with a more proactive approach from the government, though this was balanced by the sustained commitment to the development of institutions in the form of NACA and the SACAs. 86. Rating: Moderately Satisfactory (b) Implementing Agency Performance 87. NACA was generally proactive and strong in implementation. In the initial stages, it faced some leadership challenges. Once these were resolved it was well managed, and provided the needed support to all states, especially on policy guidelines and technical support. NACA also did some impressive work in development of NNRIMS as the basis for M&E, though implementation remained a constant challenge, and in strengthening planning with development of national strategic framework and national strategic plan. The performance of SACAs was more variable, but was moderately satisfactory overall. 88. Financial Management. NACA complied with Financial Management covenant on submission of periodic reports (Interim Financial Reports, Annual Audit reports). There were no outstanding reports. NACA provided timely, accurate, reliable financial management. Instances of unretired advances, inadequate documentation for incurred expenditures and ineligible expenditures were observed, but were subsequently resolved. 89. Procurement Arrangements. Procurement of all works, goods and technical services under the project followed the Procurement Guidelines “Procurement under IBRD Loans and IDA Credits�. NACA had well trained procurement personnel. Overall, fiduciary performance was satisfactory. 90. Rating: Moderately Satisfactory (c) Justification of Rating for Overall Borrower Performance 91. In light of the Moderately Satisfactory Government performance and NACA’s Moderately Satisfactory performance as discussed above, the overall performance of the Borrower is rated Moderately Satisfactory 6. Lessons Learned 92. Institutional capacity development is the most critical component of an effective and sustained response. Training and skills upgrading alone will not be sufficient in the absence of such capacity strengthening, which must include clearly defined and well understood roles, responsibilities and management structures. These need to be kept under regular review to ensure that timely support can be provided whenever new capacity needs arise. 26 93. Development of a comprehensive M&E framework should be one of the first project interventions. This is important both to demonstrate progress against well defined baselines, and also to inform program development in order to choose the most effective interventions and target these to the areas where they would have greatest impact. It is critical to know where the next infections are likely to come from and to adjust the project accordingly. The framework should set out arrangements of impact evaluation, and lay the basis for reviews of efficiency of project implementation. The implementing agency (NACA) has an important role to play in ensuring that M&E implementation is well managed to ensure that key data is available and well used. 94. Civil Society organizations can be important agents of change, but their contributions must be well managed if they are to be maximally effective. Components of effective management include: selection of CSOs with capacity and skills to develop well targeted and effective interventions; agreement on the outputs to be delivered by funded organizations, and monitoring of performance to ensure delivery of these; and negotiation of longer, larger scale contracts to ensure coverage and impact on beneficiary populations. 95. Principles for maximizing the effectiveness of community mobilization should be implemented with project support. These should include: total community coverage through a cascading training model utilizing the skills of local volunteers; communities to take the lead in designing their own interventions; approval for funding based on very simple instruments; and building upon existing systems (including chiefs and traditional leaders) to mobilize communities. 96. Maximizing outcomes and impact depends on clear focus and prioritization, including selection of a limited number of key ministries and agencies, increased focus on those states which are experiencing the greatest number of new infections, and delivery of services at scale to the most at-risk and vulnerable groups and populations within those states. Regularly updated estimates of the size of vulnerable groups is essential to ensure that high coverage levels are reached and maintained, supported by specific service delivery targets for proven priority interventions set at state level. 97. There is a need for more targeted communication on the part of the Bank and NACA with other parts of government (at Federal and state level) and with beneficiaries. Well designed briefs should be prepared for advocacy, communication to mobilize support, and sensitization to ensure that successes are built upon. 7. Comments on Issues Raised by Borrower and Implementing Agency 98. The Borrower and Implementing Agency did not have any major issues with the content of this report, and have indicated that they are in agreement with the conclusions. The Borrower has prepared its own evaluation report of the project, a summary of which can be found in Annex 5. 27 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) for both Grant and Additional Financing Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) 50.05 Capacity Development 70.30 140 (28.05 P + 22.00 A) Expanding the Public Sector 39.01 11.45 29 Response (28.01 P + 11.00 A) HIV/AIDS Fund and Community 50.63 30.35 60 Mobilization (33.63 P + 17.00 A) PPF refinancing 0.60 0.60 100 Cancelled 27.61 Total Project Costs 140.3 140.3 *P = Principal and A = Additional Financing (b) Financing Appraisal Actual/Latest Type of Estimate Estimate Percentage of Source of Funds Cofinancing (USD (USD Appraisal millions) millions) Borrower 5.98 0.00 0.00 International Development 90.30 0.00 0.00 Association (IDA) International Development Association (IDA) – Additional 50.00 0.00 0.00 Financing 28 Annex 2. Outputs by Component Component 1. Capacity Development The project contributed to the institutional strengthening of NACA through procurement of office equipment and vehicles, funding of coordination activities, meetings, workshops and trainings. The number of staff members in NACA increased from four at baseline to 109 people at project closing, resulting in a major increase in capacity to develop policy, carry out operational research, monitor the national response, and provide technical assistance and policy advice to the states. NACA capacity was further strengthened following transition to agency status in 2007. The project supported an institutional assessment in collaboration with DFID. This resulted in a restructuring of the agency, with designated Directors appointed to supervise individual departments. The Federal Government took over all staff funding in 2009. The project provided office equipment and funded technical staff for each participating SACA. State project teams were set up with a project manager, accountant, procurement officer, community development specialist and monitoring and evaluation officer. A broad range of training and TA was provided to NACA and SACAs to build capacity in: project management, planning and budgeting; procurement management; and IDA Credit disbursement and financial management, including auditing. Technical skills were strengthened in: Gender Mainstreaming; Behavior Change Communication and other aspects of Prevention, PMTCT, Care and Support; and Information Technology, knowledge management, and monitoring and evaluation. The project helped to build capacity for strategic planning at national and state levels. A National HIV Policy and National HIV/AIDS Strategic Frameworks and Plans (2005- 2009; 2010-2014) were developed following which all states prepared State Strategic Plans (2010-2014). A project-funded Planning Adviser was embedded in NACA and played a key part in providing technical assistance to all SACAs and Federal Ministries, Departments and A MDAs in the preparation of annual action plans. NACA took over funding of this position in 2009. Project funds were used to support preparation and dissemination of a wide range of policy and operational guidelines, including the NNRIMS Operational plan (2007 – 2010); NNRIMS Facilitators and Participants manual; National HIV/AIDS Policy (2003; 2009); The National HIV/AIDS Behavior Change Communication Strategy 2009-2014; the National Prevention Plan (2007); and Guidelines for mainstreaming HIV & AIDS and Gender into Poverty reduction Programs. A framework to guide implementation of the BCC intervention program was developed and launched in 2004 targeting the general populace and vulnerable groups. Funds were also used to develop a Workplace Policy on HIV/AIDS for NACA. NACA focused considerable attention on development of research capacity, and used project resources to conduct Epidemiology and Policy Response and Synthesis studies in 18 States, to carry out a National AIDS spending assessment (2010 – covering 2007-08), and to undertake a baseline survey of Orphans, Vulnerable Children and in and out of school Youths. 29 The issue of transportation was a key constraint impeding coordination, monitoring and evaluation at the local government levels by the SACAs. HPDP1 provided vehicles to states as requested. Computers and supporting hardware (printers, monitors and universal power supplies) were procured, as were standby generators to ensure that the frequent power cuts did not disrupt work. Component II. Expanding the Public Sector Response Line Ministries carried out activities to meet the needs of their own staff and their client groups by (i) financing plans approved by NACA and SACAs; and (ii) supporting preparation of plans and programs of action. Functional HIV/AIDS units were set up in target ministries to build high level commitment, deliver prevention messages to staff, formulate HIV/AIDS workplace policies, and oversee sector-specific initiatives for client groups. A total of 27 Ministries, Departments and Agencies were funded at Federal level, of which the largest recipients of project funds (receiving 41% of total) were the Ministries of Health, Education, Women’s Affairs and Social Development, Transport, Information and Communications, and Labour and Productivity, and the Nigeria Prisons Service. MDA Amount Disbursed By NACA % of total disbursed to 27 Naira (million) US$ (million) MDAs Federal Ministry of Health 94.90 0.63 16 Federal Ministry of Education 36.70 0.24 6 Federal Ministry of Women Affairs & 25.41 0.17 4.5 Social Development Federal Ministry of Information & 11.76 0.08 2 Communications Federal Ministry of Labor & Productivity 29.26 0.20 5 Nigeria Prisons Service 25.30 0.17 4 Federal Ministry of Transport. 21.45 0.14 3.5 Total Disbursed to the 7 Sample MDAs. 244.78 1.63 41 Total IDA Credit Disbursed To all the 598.35 3.99 100.00 27 MDAs Each line ministry established a fully functional unit with full time staff to coordinate HIV/AIDS Program activities. They engaged their management and workforce to mobilized a critical mass of focal officials who promoted implementation of the program, advocated for high level commitment; disseminated prevention messages among personnel; and developed Workplace policy. Prevention programs were also developed for the client base of each ministry. This was significant in the case of Health (addressing 30 PMTCT, PLWHA and extension of HIV counseling and Testing), Education (school- goers) and Women’s Affairs and Social Development (on gender issues and OVC). For other ministries the focus was mainly on their own staff. The Federal Ministry of Health – National AIDS-STI Control Program Throughout the period covered by the project, the National AIDS-STI Control Program (NASCP), a Division of the Department of Public Health of the FMoH, was responsible for the national HIV/AIDS program of the Ministry. A similar arrangement existed at state level with State AIDS-STI Control Programs (SASCPs) in each State MoH. Key outputs were: - Formulation of the National and State Strategic Frameworks and implementation plans: NASCP facilitated annual meetings to develop NASCP and SASCP’s Annual Implementation Plans for the health sector response to HIV/AIDS. - Training of Trainers (TOTs) on Monitoring and Evaluation (use of PMTCT Management Information System tools and other aspects of M&E). - NASCP sensitized and increased awareness among FMoH staff (including Medical Practitioners, Matrons, Nurses, Lab Scientists and M&E officers). - SACA and SASCP advocacy visits to the political and Executive leadership of LGAs and held meetings with LGA Health Departments. - Support to development and coordination of systems for Anti-Retroviral delivery (including development of guidelines for adult and pediatric ARV treatment). - TOTs for logistics management, Procurement Management and Distribution of Essential Supplies. - Assessment of sites for Global Fund activities. - Blood Safety policy review was undertaken. - Support to strengthening the HIV/AIDS Sero- surveillance system, and conduct of national surveys (NARHS, IBBSS). - NASCP and SASCPs hosted coordination meetings and quarterly task team meetings on PMTCT. - Support to scale up of Voluntary Counseling and Testing: needs assessment surveys; equipment and furniture for over 50% of VCT sites - Supervisory visits of NASCP and SASCPs to ARV treatment sites. NASCP and SASCPs also convened meetings of implementing partners working on HIV/AIDS in the sector, including (among others) divisions responsible for TB control, Malaria and Vector Control, Epidemiology, Blood Transfusion services, and the National Primary Health Care Development Agency (NPHCDA). Regular coordinating meetings were held with divisions to expand STI Treatment Services. STI syndromic management guidelines were financed by the Project. Particular attention was given to provision of strengthened integrated TB Services. A monthly coordinating Committee, headed by the Minister for Health, met from 2006. The project financed the operational costs of program monitoring at all levels of the health sector response. M&E data on health sector HIV activities in the states and FCT were collected by SASCPs and transmitted to NASCP and NACA in collaboration with SACAs. The list of sites/facilities where services were provided was regularly updated. 31 Ministry of Education The major output of the Ministry of Education was the design and implementation of the Family Life and HIV/AIDS Education (FLHE) Curriculum. At close of the project: - 10 states were teaching an adapted FLHE Curriculum - over 1,000 teachers had been trained in FLHE Curriculum implementation - over 500 students had been enlisted and trained as Peer Educators. The project supported development of a National Policy on HIV/AIDS for the Education Sector, and an accompanying National Guideline for the Policy. These were prepared in 2004/05 to ensure equal assess to education of Children with HIV and to protect the rights of HIV-positive teachers. The policy also committed to delivery of education to OVCs, including provision of scholarships A support group was established in Benue state for positive teachers. HIV and AIDS desks were established at the Nigeria University Commission and the National Commission on Colleges of Education to increase knowledge and understanding of the epidemic at the tertiary education level. By project closing, many Higher Institutions had established youth friendly HIV centers. Ministry of Women’s Affairs and Social Development The Ministry of Women Affairs and Social Development (MoWASD established a federal level HIV/AIDS Coordinating Unit in 2002. This unit led government initiatives on gender mainstreaming, ensuring that gender. gender equity issues and HIV/AIDS mainstreaming were established in the MoWASDs of all participating states (33 by project close). Advocacy visits were paid to community leaders in the most affected states (eg Benue and Kogi). A bill was prepared on legislation on the rights of Orphans, Widows and PLWHAs in 2006, in order to avoid Disinheritance and Discrimination, and to promote women’s HIV/AIDS Initiatives. Following this a national level workshop was conducted to train women leaders as HIV/AIDS Counselors in 2008; and a similar workshop was held for Female sex Workers in the Federal Capital Territory. The project supported the ministry to establish and run a National OVC Steering committee and HIV Steering Committees in 33 states, including: training for capacity building on management of OVC issues for committee members and OVC Desk Officers; steering committee meetings; and zonal meetings for OVC Desk Officers. National guidelines and standards of practice on OVCs were developed and disseminated to States and NGOs working with MoWASD. Ministry of Information and Communications The Ministry only undertook HIV/AIDS activities in 2007 and 2010. Trainings were conducted for top level management and staff on sensitization and awareness generation, and to mobilize commitment to implementation. The Ministry trained staff to develop Information, Education and Communication/Behavior Change Communication materials, and in monitoring and evaluation. BCC materials were disseminated, including jingles targeted to the general population. These provided information on prevention of transmission and on access to VCT Centers. Information on access to ARV sites was also targeted to people living with HIV and AIDS. 32 The Nigerian Prisons Service Project-supported HIV/AIDS interventions began in 2002, with formation of a Critical Mass Committee. Following this critical mass committees were formed in all 36 states and FCT; 8 were established in the 9 prison zonal commands and one in the Prisons Headquarters, Abuja. A NPS HIV/AIDS Steering committee was formed in 2005. The main outputs were: - Preparation of policy and operational documents (eg HIV/AIDS workplace policy, HIV/AIDS Technical Guidelines, HIV/AIDS manual for prison health workers) - IEC/BCC materials for sensitization and education of inmates and staff, used to guide regular sensitization and awareness campaigns on knowledge of major routes of HIV transmission, prevention and control. - Capacity enhancement programs: BCC workshops for health workers and inmates (75 prison officers were trained to deliver BCC); HIV Counseling & Testing (130 prison officers trained on counseling; 90 staff trained to carry out tests; test kits provided); 20 peer educators trained at Kaduna Borstal Institution. State HIV desk officers were trained to use NNRIMS and complete the Quarterly Report format - Treatment, Care and Support for 346 prisoners and staff living with HIV and AIDS. As of 2010, 4 prison support groups were registered with NEPHWAN (the Network of People Living with HIV and AIDS in Nigeria). Component III. The HIV/AIDS Fund The HIV/AIDS Fund (and Rapid Response Fund) supported over 1000 civil society- based projects at national and sub-national levels. A review of this support29 noted that whilst the results and impact of these projects have not yet been systematically tracked, the interventions have almost certainly made a substantial positive to Nigeria’s response to HIV/AIDS. In particular, HAF-supported projects appear to have contributed significantly to efforts at sensitization and prevention as well as care and support of persons affected by the epidemic. This conclusion is supported by the preliminary findings of an evaluation of the community response to HIV and AIDS in Nigeria 30 suggesting that CBO engagement is associated with higher service availability and awareness of HIV/AIDS-related prevention, treatment and care and support services and with higher utilization of these services. The HAF sub-projects were facilitated by some exemplary practices in implementation (Box 1). But the review also found mixed implementation performance: selection of thematic objectives and funding priorities was rarely guided by epidemiological data on 29 Assessment of Civil Society Response to HIV/AIDS in Nigeria: Report to National Agency for the Control of AIDS (NACA), Sam Unom, August 2010 30 Evaluating the Effects of the Community Response to HIV and AIDS in Nigeria, Summary of Preliminary Findings, Macro ICF, personal communication 33 BOX 1. SELECTED EXAMPLES OF GOOD PRACTICE IN HAF IMPLEMENTATION 1. Cross River State demonstrated exemplary standards and openness and transparency in its HAF administration. Proposals from NGOs promoted by politically powerful persons (e.g. First Lady) were not considered because they were submitted late. The procurement specialist and the community mobilization officer ensured the faithful application of the guidelines, no doubt helped along by the Executive Secretary’s personal reputation for probity. 2. Cross River used LACAs to augment a monitoring system that would otherwise depend on one M&E officer and one clapped-out car. 3. Lagos set the pace in evidence-led HAF implementation, using the epidemiological response and policy synthesis to set objectives and targets for its RRF call. The state also commissioned an AIDS Spending Analysis which was used to set HAF thematic and spending priorities. 4. Kaduna SACA supervision of the grants was diligent, with each grantee receiving more than two SACA supervisory and monitoring missions and the SACA chair (the Deputy Governor now Governor) himself calling to check on progress. External auditing was also rigorous, with grantees required to pass the audits before accessing their succeeding tranches. 5. Disbursement of grants was timely and consistent in Benue State and, with the RRF, in Lagos State. 6. Lagos explored the use of intermediaries for capacity building and monitoring of CSOs. In 2005 the state contracted a well established NGO to reach 900 organisations. Lagos SACA noted the challenge of ensuring the neutrality of such contracted intermediaries, and used its M&E Technical Working Group (comprising technical experts and stakeholder representatives) to supervise these intermediaries. 7. Lagos also developed a directory of CSOs and used it to target calls to cover underserved geographical and thematic areas and population groups (for example, persons with disability) without the need for the application of less objective secondary criteria in selection of proposals. 8. Implementation of the Rapid Response Fund was widely hailed as well conceived and smoothly implemented. Acclaimed features included: well HIV/AIDS; the proposal review process was not always fully insulated from subjective chosen thematic areas; provision for hard-to-reach constituencies (e.g. rural interpretations and political interference and proposal review results were not widely areas, persons with disability); prompt and adequate funding (although publicized; and SACAs lacked the requisite M&E capacity to monitor projects. on thematic areas funded was low and project from NACA (three rounds of Informationfunding ceiling was described as too obtained from duration too short); user- friendly 13 states31. The analysis tape; and effective (including the HAF funding) and reporting formats; minimal redcovered 885 grantssupervision and Rapid mentoring total of Response Fund) for a by SACA. Naira 3.29 billion or approximately US$ 25 million32 (82% of the total HAF disbursements of $30.35 million). Priority Intervention Areas were based on National priorities. The thematic areas chosen by NACA for the third round of HAF funding were: 3 Benue; Cross River; Edo; Ekiti; Enugu; Gombe; Kwara; Lagos; Nassarawa; Ondo; Plateau; Rivers; Sokoto 32 At US$1 = Naira 130 34 1. Behavior Change Communication (BCC) (including: Targeted Condom Social Marketing for MARPs; directed to MARPs (FSWs, MSMs, IDUs, Uniformed Services, Transport Workers, Incarcerated Populations Physically Challenged Groups, and the Youth- In & Out of School); HIV Counseling & Testing (HCT) – Demand Creation / Referrals and Service Provision by organizations with relevant capacity 2. Care & Support – based on the Continuum of Care (Peer Education, HCT, Home Based Care, Palliative Care, Psychosocial Support, Socioeconomic Support, Nutritional Support, etc.)/Impact Mitigation: directed to (i) Orphans and Vulnerable Children (OVC) (ii) People Living with HIV/AIDS PLHA (iii) Care Givers 3. Universal Precaution & Medical Waste Management (Capacity Building) 4. Syndromic Management of Sexually Transmitted Infections (Capacity Building). SACAs requests for proposals for funding used similar breakdowns of thematic areas. BCC included: basic prevention messages related to safe sex and partner reduction; advocacy directed to policy makers and politicians; and messages related to reduction in stigma and discrimination. Care and support included: Home Based Care; income generation; nutrition; material and psychosocial care and education for OVCs. Universal Precautions included safe disposal of wastes, and information on how to avoid nosocomial transmission of infection. Table 1: HAF and Rapid Response Fund allocations to Civil Society Organizations. Thematic Areas Funds allocated % (Naira, Billion) Behavior Change Communication for Prevention 2.2 66.9 Of which: Advocacy and awareness messages to 1.37 41.8 general population Targeted to Most at Risk Groups 0.47 14.2 Linked to promotion of testing 0.03 0.8 Combined with Care and Support 0.34 10.2 Care and Support 0.58 17.4 Of which: Community level impact mitigation 0.37 10.2 Targeted to People living with HIV 0.14 4.3 and AIDS Targeted to OVCs 0.10 2.9 Promotion of testing 0.37 10.2 STI treatment 0.06 2.0 Universal precautions for Health workers 0.11 3.4 Total 3.29 100 35 An example of specific outputs funded by the project is provided by Kaduna SACA: Sample of Kaduna HAF 2 (Tranche 1) Results 1. Kaduna Archdiocesan Catholic Action Committee on AIDS (DACA)  Provision of food supplements to 1,119 PLWHAs  Home visits to 628 PLWHAs in rural and urban areas  2551 persons given free pre- and post-test counseling, out of which 1,095 tested positive and were processed for free access to ART services 2. Millennium Hope Program  Vocational skills training for 62 PLWHAsProvision of food items to PLWHAs 3. Partnership for Life Project/Centre for Population and Development  Formation of peer facilitation committees in 7 sites 4. Akkral Consult Ltd  Establishment of 3 support groups for PLWHAs in  Increase in number of people willing to go for HIV tests and to identify with existing support groups  Training and start-up support for income generation programs for PLWHA 5. Ugare Women Cooperative Society  Increased turnout for free counseling, testing and drugs at General Hospital 6. Gateway to Health & Life  Increased access of adolescents to youth-friendly reproductive healthcare services (including provision of youth-friendly screening and treatment of STIs)  Resulting reduction in incidence of adolescent reproductive health problems and increase in correct and consistent use of male and female condoms. The community response evaluation provides an indication of the extent to which HAF outputs contributed to improved intermediate outcomes at the community level. The study was carried out in the state which had been identified as having the highest HIV prevalence rate in each zone. The total survey sample consisted of 5376 individuals. The study findings are summarized in table 2. Table 2: Effect of increased CBO engagement on community awareness and use of HIV and AIDS prevention, treatment and care services33. 33 It should be noted that these findings are preliminary and are not informed at this stage by information obtained from other components of the evaluation: analyses are ongoing and will continue to be refined 36 Services Study Communities (High CBO Activity) compared to Comparison Communities (Low CBO Activity) Availability HIV/AIDS Services 5.41 times as likely to report availability Prevention Services 9.23 times as likely to report availability Treatment Services 4.19 times as likely to report availability Care Services 4.13 times as likely to report availability Community Mobilization Services 6.35 times as likely to report availability Service Use Prevention Services 16.23 times as likely to report use Treatment Services 4.19 times as likely to report use Annex 3. Economic and Financial Analysis (including assumptions in the analysis) Key components considered in conducting the cost-effectiveness analysis. General • definition of intervention • states and time period • perspective (provider/societal/patient/client) • discount rate for cost/consequences incurred in different time periods Costs • types of costs (capital/recurrent) • units and unit costs (including adjustments for non-market items) • costing methods (allocation of shared costs, amortization) Effectiveness • outcomes (e.g., disability-adjusted life years, quality-adjusted life years, other) • • clear description of assumptions • generalizability and replicability Methodology The following procedures were used to perform the cost-effectiveness analysis:  Establish the appropriate level of analysis. For example, establish whether the analysis is going to be conducted at a national level, and/or on state and local levels, 37 explaining the rationale for the chosen design and noting the advantages and disadvantages of the rejected and accepted scale of the proposed studies;  Define and select interventions to be included in the analysis;  Assess all the interventions included and their combinations assuming that they are implemented for a preset number of years, set to a specific start year (base year). Include all resources used for each intervention, or a combination of interventions, and assign them with values. This assessment is also based on a related assessment of the cost for each of the interventions or their combinations;  Classify and measure costs. Use a standardized approach to measure costs, requiring information on the quantities of physical inputs needed per intervention and their unit cost. Thereafter, total costs were derived based on the quantities of inputs multiplied by their respective unit costs. In addition, we made sure that costs were evaluated by assuming a percentage use of capacity for all interventions, which was based on epidemiological data. Moreover, standardized approaches for discounting future costs to the selected base year value were applied;  Establish plausible ranges for the epidemiological model parameters by reviewing relevant published studies and survey results for the Nigerian context. We use baseline prevalence projections from available sources (e.g. UNAIDS and WHO) to calibrate key parameter values for Nigeria;  Undertake a number of epidemiological simulations by sampling values from each of the ranges. Thereafter, compare each simulation against the baseline projection of prevalence by gender and fit the model accordingly;  Assess the impact of interventions and their combinations (incrementally) against a “no intervention� scenario (defined by considering what would happen to the assessed population’s health if they were put to zero today, i.e. setting the impact of all the key interventions to zero);  Subsequently, trace the implications for the population health of adding all possible interventions, singly and in various combinations, against the baseline scenario. The difference experienced was thereafter be measured as the gain in health due to the reduction in disease burden from the interventions (DALY gained);  Next, the cost of each scenario was compared with the gain to identify the most cost- effective set of interventions at different levels of resource availability. Moreover, the comparison of the current mix against the optimal set for the resources currently available shows areas of inefficiency. 38 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Lending Esther Susuyu Ali Consultant (Sociology; Rural AFCW2 Development) Bayo Awosemusi Procurement Specialist AFTPC Francois Decaillet Senior Health Specialist AFTHE Jean J. Delion Senior Rural Development Specialist Brigitte Duces Principal Education Specialist ACTafrica John Elder Senior Social Protection Specialist AFTHE Akintola Fatoyinbo Senior Communications Specialist Sundararajan Srinivasa Gopalan Senior HNP Specialist AFTHE Keith E. Hansen Senior Economist and Deputy Head, ACTafrica ACT Africa Karen Alexandra Hudes Senior Counsel LEGAF Daniele Jaekel Operations Analyst| ACTafrica Blanshard Marke Lead Financial Management LOA Specialist Mynna D. Mccullough Operations Analyst AFTHE Muraino Olaseni Ogunsanya Financial Management Specialist AFCW2 Anne U. Okigbo Health Specialist AFTHE Bachir Souhlal Lead Operations Specialist Esther Usman Walabai Senior Agriculturist AFCW2 Supervision/ICR Amos Abu Senior Environmental Specialist AFTEN Sunday Achile Acheneje Procurement Specialist AFTPC Adewunmi Cosmas Ameer Adekoya Financial Management Specialist AFTFM Francisca Ayodeji Akala Senior Health Specialist AFTHE Mary Asanato-Adiwu Senior Procurement Specialist AFTPC Bayo Awosemusi Lead Procurement Specialist AFTPC Leah Belsky Junior Professional Associate LCSHH Boubou Cisse Economist (Health) AFTHE John A. Elder Lead Social Protection Specialist HDNSP Abiodun Elufioye Program Assistant AFCW2 Ella Omomene Iklaga Team Assistant AFCW2 Rita Obioma Itoro-Godfrey Team Assistant AFCW2 Ogo-Oluwa Oluwatoyin Jagha Monitoring & Evaluation Specialist AFTRL Masahiro Matsumoto E T Consultant EASHD Jane Miller Senior Health Specialist AFTH3 - HIS Susan Joyce Elizabeth A. Mshana Consultant AFCW2 Joanna Lee Nicholls Senior HIV/AIDS Specialist AFTH3 - HIS Michael O'Dwyer Lead Health Specialist AFTHE 39 Ayodeji Odutolu Consultant AFTHE Chita Azuanuka Oje Team Assistant AFCW2 Augustine Olaniyi Okesola Consultant HDNSP Anne U. Okigbo Senior Operations Officer AFTHE Foluso Okunmadewa Lead Social Protection Specialist AFTSP Senior Financial Management Adenike Sherifat Oyeyiola AFTFM Specialist Terese Tshimanga E T Temporary AFTH3 - HIS Juliana Victor-Ahuchogu Consultant AFTRL 40 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY00 14 58.30 FY01 91 316.94 FY02 37 60.52 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 FY08 0.00 Total: 142 435.76 Supervision/ICR FY00 0.00 FY01 0.00 FY02 0.00 FY03 39 138.29 FY04 40 232.26 FY05 32 142.84 FY06 44 172.87 FY07 70 243.90 FY08 85 216.22 FY09 47 0.00 Total: 357 1146.38 41 Annex 5. Summary of Borrower's Report 1. Preamble, Overview of Methodology / Approach Partnership between Nigeria and the World Bank to address the unprecedented challenge posed by HIV/AIDS commenced in the late 1990s culminating in the signing of the first HIV/AIDS Program Development Project (HPDP 1) in 2001. Project implementation commenced in 2002 and the project closed on 31 March 2010. This evaluation, conducted by a Team of Consultants had the following objectives: 1) analyze and present borrower evaluation of the relevance of the project objective to the HIVAIDS response at the national state and local levels; 2) indicate the results of each component of the project; 3) examine implementation issues; 4) provide feedback for knowledge sharing by NACA (who commissioned the study), and all agencies that were involved in project preparation and implementation including the funding organization. This summary presents the main findings, assessment of the roles of key stakeholders, measures for sustainability of achievements, and lessons learned. The full report details the methodology employed in conducting the evaluation including the process, database, other inputs; key findings, challenges and recommended next-steps. The evaluation focused on Implementation Agencies and stakeholders in the three tiers of HPDP 1 governance, which corresponded with the nation’s administrative structure: 1) NACA, MDAs at the Federal level; 2) SACAs of the 34 States, the Federal Capital Territory (FCT) and MDAs at the States level; and 3) LACAs. NACA, 10 states34 and their LACAs were selected for close study. The findings are considered adequate for generalization. Seven of the 27 Federal MDAs supported by NACA were selected for their strategic importance. The financial performance of all 35 SACAs and 27 Federal MDAs was assessed. 2. HPDP 1 Objective, Its Relevance and Achievements The original project objective was to assist Nigeria to reduce the spread, and mitigate the impact, of HIV infection by strengthening its multisectoral response to the epidemic through the implementation of a comprehensive program that includes the creation of an enabling environment for a large scale response, and laying the foundation for scaling up HIV/AIDS prevention, care, and treatment services at the federal, state and local levels. The three components were: 1 Capacity Development; 2 Expanding Public Sector Response; and 3The HIVAIDS Fund. Relevance of Project Objective - the project objective and components succinctly encapsulated the sixteen priority interventions adopted by Nigeria for the HIV/AIDS National Strategic Framework (NSF) For Action (2005 - 2009). Also reflected were priorities earlier defined by the HIV Emergency Action Plan, 2001 – 2004. The Project contributed to achievement of Millennium Development Goal 6 Combating HIV/AIDS 34 Benue, Cross River, Ekiti, Gombe, Rivers, Abia, Katsina, Jigawa, Lagos and FCT 42 and other communicable diseases by 2015; and is consistent with Nigeria’s commitment to the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS (scaling up prevention, care and support for universal access). Key implementers confirmed that the objective was relevant in addressing the epidemic at national, state and local levels and that the project objective has been largely achieved. The Project design was also considered appropriate after it was restructured in 2004, following when the rate of disbursement improved. 3. Brief on Socio-Economic and Epidemiological Factors Nigeria, the most populous country in Africa (estimated population 158.3 million) grapples with a high communicable disease burden. Life expectancy at birth is estimated at 48.4 in 2010 (UNDP). There has been a declining trend in HIV sero-prevalence across the country between 2001 and 2008. Prevalence rose from 1.8% in 1991, through 5.8% in 2001, dropping to 4.4% in 2005. It increased slightly to 4.6% in 2008. Wide variations exist between states (1% - 10.6%) and between urban and rural sites. Over 3 million people are currently living with HIV/AIDS in the country, with approximately 340,000 new infections a year, of which 55% are in women. There were 180,000 HIVAIDS related deaths in the same period. There are currently 2.2 million children below 15 years orphaned by AIDS (FMoH, 2008). 4. Project Financing HPDP 1 provided predictable and flexible funding for implementation of the national response. By project close, March 2010, GoN had received US$138 million. NACA received 63% (US$27 million) of its share of the IDA Credit (US$43 million). All the 34 states and FCT expended US$93 million (96 %. of total allocation to states - US$ 96 million). Records on expenses incurred on thematic areas by each implementation Agency were not available for the assessment. Relative percentages expended by the 34 states and FCT varied significantly. The analysis pointed to the need for further financial capacity enhancement ahead of and under HPDP 2. Federal Government’s contribution to financing of the project, through NACA, totaled approximately N 144.00 million (US$ 0.966). Of the 34 States and FCT, only 12 paid counterpart contributions, totalling approx US$4 million. The project also leveraged significant financing for the national response from other Development Partners (see Section 5.11). 5. Component 1: Capacity Development The first Component of HPDP 1 had several sub-components including: Policy Development and Strategic Planning; Coordination of the response at National, State and Local level; Project Management including staffing and capacity building; Procurement and Financial management; Behavioral Change communication; Partnership; Gender Mainstreaming; Monitoring and Evaluation of implementation of the project and of the entire national response; Research in relation to knowledge generation on HIVAIDS and Knowledge Sharing. 43 Project Achievements 5.1. Coordination and Governance Coordination and Governance at National Level: From the return of democracy in 1999, through creation of NACA in Jan 2000 to date, the level of Federal level commitment to the multilateral response has been high. NACA constantly engaged high level policy makers, both executive and legislative arms of governance to advocate for the response and commitment through financial provision. Government commitment resulted in the emergence and growth of NACA to lead the national effort. Government convened and hosted African Heads of States in April 2001, resulting in the Abuja Declaration and Framework for Action, and the meeting which led to the African Union Abuja declaration of 2006 for Accelerated Action. As a direct result of aggressive advocacy and mobilization by NACA, as of 2010 35 SACAs, (in 34 States and FCT) had been established by the end of the project, from a base line of 6 SACAs and 4 MDAs supporting the response in 2002 (Kano and Niger States are the exceptions). 27 Federal MDAs have mainstreamed HIVAIDS activities in their sector programs. Considerable increase in GoN funding of NACA has enabled it to fund 100% of its wage bill from the Agency’s line budget, as compared to 2008 when HPDP1 paid 40% of the wage bill. In May 2007, NACA became the National Agency for the Control of AIDS. Coordination at the Sub-national Level: SACAs and LACAs: Twenty-two SACAs have now transformed to Agencies. The rest have Bills on the Agency structure already presented to their various Houses of Assemblies. However, it is noted that the high level of commitment at the national level progressively dwindles at the level of states and LGAs, reflected in correspondingly lower financial inputs by states. LACAs remain the weakest among the three tiers of coordination of the HIV/AIDS response. Even in spite of HAF, Component 3 of HPDP 1, (which also ought to have been administered by SACAs in collaboration with LACAs), the operational and financial weakness of LACAs has created a gap at the grassroots level, in the mobilization and coordination of local responses of stakeholders. 5.2. Strategic Development and Project Management The performance of SACAs’ and especially NACA’s has been impressive: the Agencies effectively mobilized stakeholders in policy reviews, policy formulation and preparation of strategic frameworks. All States and FCT (with the exception of Kano State) have produced State Strategic Plans (SSP) 2010 – 2014. Of the SSPs, only 3 were not HPDP1 funded (Taraba, Niger and Borno SSPs). 5.3. Planning From 2002 to 2009, NACA provided IDA funded Technical Assistance (TA) for all SACAs, and all Federal MDAs in the preparation of Action plans, at interactive sessions, during the 3rd to the 4th quarter annually. Similar TA was provided by NACA for CSOs in 2008 and 2009. 44 5.4. Capacity Enhancement The project provided the following staff for each SACA: manager, procurement officer, accountant, community development specialist, and M&E officer. HPDP1 funded training and TA were provided by NACA for NACA officials, SACAs, Federal MDAs and CSOs. SACAs also utilized project funds for capacity enhancement for States MDAs. The range of training and TA provided included project management, planning and budgeting; Gender Mainstreaming; SBCC and other aspects of Prevention including PMTCT; Care and Support; Information Technology, knowledge management, M&E with emphasis on utilization of the NNRIMS Guidelines. 5.5. Procurement Management A procurement management system was established by NACA and SACAs. NACA and the World Bank provided procurement and financial management TA to States through trainings, seminars, workshops and reviews. Main themes included procurement planning, documentation, methodology for Procurement of goods and equipment, and contract monitoring. Procurement management followed the HPDP1 Procurement Manual, the World Bank Guidelines as stipulated in the Development Credit Agreement and the Procurement Act, Federal Government, 2007. 5.6. Financial Management Financial Management arrangements in NACA and participating states followed the HPDP 1 Financial Management manual, agreed with the Bank. Arrangements were adequate for Federal and State level project implementation. Computerized accounting systems were introduced and used in NACA and SACAs. 5.7 Communications and Partnership with the Media Following NACA structural reorganization in 2009, the Communications Dept. was split: the Behavior Change Communication (BCC) Unit is now part of Prevention Planning and Implementation, under Program Coordination Department; the Corporate Communication Unit is managed as a Specialist Unit. BCC - Key Achievements: NACA and implementation entities (SACAs, MDAs, CSOs and implementing partners) produced and aired BCC messages all year round to target audiences. Messages largely focused on HIV prevention including PMTCT, HCT and Testing and prevention of Stigma and discrimination. Target audiences were the general population, priority audience especially policy makers, PLWHAs, MARP (FSW, MSM, Transport Workers, the Uniformed Services). The project contributed to financing of: National Social and Behavior Change communication training manual, 2010; Review of National HIV/AIDS BCC Strategy (2004–08); National Prevention plan, 2007 (updated 2010) National HIV&AIDS BCC Strategy (2009 – 2014); and Assessment of HIV/AIDS communication initiatives in Nigeria (J 2008). As a result of BCC interventions, among other measures, the percentage of people aged 15 to 49 years knowledgeable about correct ways pf preventing sexual transmission of HIV increased from 25% in 1999 to 59% in 2003, and 67% in 2008 (NDHS, 2008). The 2008 achievement was 11.5% above the 2010 target of 55.5%. Corporate Communications, NACA: Focused on media publicity, campaign rallies, awareness creation, advocacy visits, workshops and conferences. The Unit provided capacity building for the media and sponsored BCC activities providing the link between 45 the BCC Unit and the media. A Media advisory committee was established in 2004 and reconstituted in 2010. The Corporate Communication Unit has produced 3 editions of a NACA quarterly news magazine in 2010. 5.8. Mainstreaming Gender Into HIV/AIDS Response The National Gender Technical Committee (GTC) was set up as a NACA standing Committee. Several States also set up GTCs. NACA in collaboration with UNIFEM organized gender mainstreaming training programs for key program implementors: NACA directors and deputy directors, program officers, managers,; Federal MDA officials; SACAs; State level MDAs; some LACAs; and CSOs. A Gender Division was created in NACA in 2009, as one of three Divisions of the Program Coordination Department. The National Women’s Coalition on AIDS (NAWOCA) was inaugurated in 2007, as an advocacy platform to address the disproportionate vulnerability of women and girls to HIV infection in Nigeria, and to protect the rights of women and girls living with HIV and AIDS. State chapters were launched in Nasarawa and Katsina States. A national work- plan had been formulated and agreed but yet to be implemented due to the need for NACA and SACAs to provide financial resources and engage gender experts. 5.9. Partnership With Stakeholders NACA mobilized and coordinated key Civil Society stakeholder groups including: Network for People living with HIV/AIDS in Nigeria (NEPWHAN); Civil Society for HIV/AIDS in Nigeria (CiSHAN); Society on Women and AIDS in Africa, Nigeria (SWAAN); National Youth Network in HIV/AIDS (NYNETHA); National Faith-based Advisory Committee on AIDS (NFACA); the National AIDS Research Network (NARN); the Nigerian Business Coalition Against AIDS (NiBUCAA); and The National Association of Nigerian Traders (NANT). 5.10. Promoting Private Sector Participation NACA engaged with the private sector through NiBUCAA, established in 2003 and including mainly multinational and large national companies. Private sector expenditure on HIVAIDS program totaled over NGN 3 billion (US$ 20 million) from inception of the multilateral response to 2010. 5.11. Knowledge Management, Monitoring and Evaluation NACA developed the Nigerian National Response Information Management System (NNRIMS), a comprehensive M&E framework, including process, outcome, and impact indicators; and produced NNRIMS Participant’s Manual and NNRIMS Operational Plan (2007 – 2010). These are used by all implementing partners, donors and the research community. M&E system development efforts received substantial project support and direct TA. NACA provided technical and administrative coordination for six major implementation reviews between 2005 and 2009, including National HIVAIDS Response Review (2005 – 2009) (Dec 2009), and Assessment of Effectiveness of HIV/AIDS Fund (HAF) and Evaluation of the Support for the Public Sector (MAP) on the National Response to HIV/AIDS in Nigeria, 2002 – June 2007 (Oct 2008). Other key studies supported by the project included: Measurement of HIV/AIDS Service delivery resource gaps, for the period 2010 to 2015 (jointly conducted by NACA and Health System 20/20 Project); National AIDS Spending Assessment. 2007 and 2008 (NACA/ UNAIDS, 2010); and HIV/STI Integrated Biological and Behavioral Surveillance Survey (IBBSS) 2007. 46 6. Component 2: Expanding Public Sector Response From a baseline of 3 MDAs at project inception, NACA posted a very impressive performance, recruiting 27 MDAs by project closure. The MDAs actively mobilized their personnel, the executive / political leadership and their clients bases. 6.1. MDA Financing NACA disbursed approximately US$4 million to 27 MDAs, for execution of planned activities. FMoH received the main share (16% of the total). The Ministries of Education, Women’s Affairs and Social Development and the Nigerian Prison Service (NPS) received 6%, 4.5% and 4.0% respectively; 2.0 % was disbursed to the Ministry of Information and Communications. Implementation was considerably lower than targets, largely due to constraints with plan approval and delayed disbursement. Of 7 Federal MDAs studied, only two (Ministry of Transport and NPS) reported having received subventions from their line budgets. Evaluation data from States did not include records of SACA MDAs financing; and only one state, Lagos out of the 35 SACAs reported on financial support to LGAs. 6.2. Brief on Performance of sample MDAs HIV/AIDS program was mainstreamed into the sectoral investments of 6 of 7 MDAs assessed. Each MDA had a functional unit coordinating Program activities. A two-pronged approach was adopted: i) focusing on management and workforce (to mobilize a critical mass of officials to implement the program; launch advocacy campaigns for high level commitment; and disseminate prevention messages to staff); and ii) delivering awareness generation, BCC and sector specific initiatives to the sectors for which each MDA had responsibilities. All seven MDAs formulated HIV/AIDS Workplace Policy to guide its HIV plans and activities. 6.2.1. The Federal Ministry of Health (FMoH): AIDS-STI Control Programs. The FMoH NASCP and State MoHs SASCPs played primary and central roles by strengthening elements of health system for HIV/AIDS service delivery nation wide including health sector strategy development, development of guidelines, capacity building, annual planning, monitoring and evaluation. With funding from HPDP1, key accomplishments of NASCP included: TA to develop NASCP and SASCPs Annual implementation Plans; Training of Trainers for Health Workers on PMTCT M&E; ARV administration (systems development support, financed NASCP coordination ; Development of adult and paediatric ARV guidelines; Essential Supplies Logistics, Procurement Management and Distribution ToT; Assessment of sites for Global Fund activities (2007); NASCP and SASCPs-convened meetings of implementing partners includin divisions responsible for Tuberculosis control, Malaria and Vector Control, Epidemiology, Blood services Division of the Hospital Services Dept., and the National Primary Health Care Development Agency (NPHCDA); STI Treatment Services expansion coordinating meetings; Guidelines for standard operation procedure for STI Syndromic management. The project financed the program monitoring operational costs at all levels of the health sector. 6.2.2 Ministry of Education (MoE) The main thrust of the Federal FMoE was the Family Life HIV&AIDS Education (FLHE) Curriculum, developed for primary and 47 secondary levels for use in all states. Ten states are delivering the adapted Curriculum, over 1,000 teachers have been trained in curriculum implementation and over 500 students as Peer Educators. Many Higher Institutions have established youth friendly Centers eg University of Nigeria, Nsukka and the University of Ibadan. Education policy documents, guidelines and strategic documents were developed including: National Policy on HIV/AIDS for the Education Sector; National Guideline for the Policy; National Education Sector Strategic Plan (NESP); National Monitoring and Evaluation Plan / Indicators; National Family Life and HIV/AIDS Education Curriculum; Instructional Materials Development Guideline; and Printed and Produced Reports on FLHE & peer Education Trainings. 6.2.3. Ministry of Womens’ Affairs and Social Development The project supported the Federal MoWASD to ensure that Gender and equity issues and HIV/AIDS mainstreaming were established for 33 State ministries. A Bill has been presented to the National Assembly, to make provision for the prevention of HIV and AIDS based Stigmatization, Discrimination and to protect the human rights and Dignity of People Living With and People Affected by HIV and AIDS. 6.2.4. The Federal Ministry of Transport The Ministry’s main clientele include important risk populations. In the provision of prevention services to its main clientele, FMoT mounted BCC messages. In 2005 and 2006, eight Bill Boards with HIV/AIDS Messages were constructed and erected at Strategic Places at Seaports, Jetty, and Rail Stations in order to disseminate information to transporters and their passengers. Fliers, posters, hand bills were also printed and distributed. 6.2.5. The Nigerian Prisons Service (NPS) Capacity enhancement was provided to health workers and inmates on HIV Counseling & Testing, BCC, and M&E. Test kits were supplied. NPS also provided Treatment, Care and Support for 346 PLWHA in the prison (inmates & staff). 7. Component 3:- The HIVAIDS Fund (HAF) The main objective of the third component of HPDP 1 was to expand investment in the HIV/AIDS national response to the non-public sector, consisting of: CSOs, Private Sector Organizations (PSOs), NGOs and Community Based Organizations. That had been largely achieved, as civil society organizations have become more active in the response to HIV/AIDS. The mechanism established for assistance by the Public Sector to the Civil Society covered all the states of the country, through NACA HAF and the 35 SACAs. 48 Project Achievements 7.1. Sub-Project Financing: Out of a total allocation of US$13 million for the National HAF only 67% (US$ 8.7 million) was expended. For the 35 SACAs, 122% was utilized (US$ 38.6 of a total allocation of US$ 31.6 million). Expenditure ranged from a low of 1% (Ebonyi State) to a high of 149% (Oyo State). (It is noted that project level documentation is incomplete. 7.2. HAF End-beneficiaries In line with targeting of MARP, the review found that the population cluster groups that benefited directly from the sub-projects included: Youth (in-school and out-of-school; Students in tertiary institutions; Women; People Living With HIV/AIDS; Orphans and vulnerable children; Sex Workers and clients; Hotel and pub house managers; Long distance drivers and passengers; Network groups and associations, including workplace groups; Faith based groups and religious adherents; Health workers etc.; Motor vehicle mechanics, Hair dressers and barbers. 165 grantees were funded by the National HAF covering all thematic areas. Of these 26 CSOs addressed prevention; 34 focused on care and support; 57 BCC; 19 impact mitigation; 15 advocacy; 27 capacity building; 26 HCT/VCCT; 4 condom social marketing; 5 OVC; and 6 universal precautions and medical waste. Similar enumeration in regard to State HAF would require more complete records, but it appears that state level administered HAFs addressed similar thematic areas. 7.3. HAF in general supported Capacity Enhancement and Institutional development of grantees’ organizations in: Proposal Development; workplan formulation; improved knowledge of transmission, prevention, care and support for PLWHA; how to address stigma and prevent discrimination; home based care for PLHIV; other forms of technical assistance, training on implementation of a wide range of HIV/AIDS services; and project monitoring. VCT services were increased leading to increase in VCT uptake including by MARPs. Through HAF, the project succeeded in increasing support from community leaders, religious leaders and political leaders. An innovation under HAF3 was support for the emerging trend of ICT based social networking for psychosocial support to vulnerable populations (text messaging, phone-in/Q & A sessions on toll free hotlines). Organizations that focused on HIV and persons with disabilities formed a network for better synergy and effective resource mobilization. Key challenges included the need for better targeting of OVCs and MARPs; weak technical skills in financial and procurement management; delayed releases of funds; the need for good documentation and for regular quarterly monitoring. 8. Prospects for sustainability of activities after project closure The study reviewed measures instituted by Implementation Agencies and stakeholders to ensure sustainability of project achievements, including: i) governance and institutional factors; ii) further technical skills development in program, project and procurement management and monitoring; iii) further financial management and audit system building. Implementation Agencies are also seeking resource mobilization from endogenous sources through: advocacy for political commitment targeted at he Federal and State level policy makers; and LGA political leadership; increased annual budgetary process 49 efficiency; increased allocation by the three tiers of Government; more active engagement with the Private Sector, through NIBICAA, to widen and deepen the scope for Public Private Partnership; and proposals for increase in Value Added Tax. 9. Assessment of Performance of Key Stakeholders 9.1. Performance of Government: Federal Government of Nigeria performance to present has been quite satisfactory. The country has demonstrated leadership in mobilizing governments’ commitments to the response in Africa. FGN commitment resulted in establishment of NACA to lead the national level efforts. In April 2001, the FGN convened and hosted African Heads of States, which forum produced the Abuja Declaration and Framework for Action, for the fight against HIV, TB and related Diseases in Africa. Also relevant in terms of continental appeal, is the African Union Abuja declaration of 2006 for Accelerated Action. Regarding total spending on HIV/AIDS in Nigeria, GoN (Federal and States) contributed 14.65% and 7.6% in 2007 and 2008 respectively (Nigeria National AIDS Spending Assessment, March 2010). 9.2. Performance of The National Agency for the Control of AIDS (NACA) NACA enacted its roles satisfactorily. Assessment of NACA’s coordination role in the context of higher level FGN commitment revealed that country ownership has been high. The Agency played significant role in mobilizing MDAs to mainstream HIVAIDS program and for states to establish SACAs and move from a health-centered to a multisectoral response. Stakeholders were mobilized; training and TA were provided for NACA, SACAs, MDAs and CSOs in all technical aspects of the response, in collaboration with Development Partners. NACA mobilized stakeholders in policy formulation and review, and preparation of strategic framework. However, NACA noted the unclear roles and relationships between NACA, SACAs and the Bank in regard to oversight of SACAs; clarification would enhance effectiveness of future implementation. NACA has had a functional Board since it transformed to an Agency in May 2007. Its staff strength has considerably increased (4 in 2001 to 109 by 2010). NACA now finances 100% of its wage bill from its line budget (up to 2008 HPDP 1 financed 40%). 9.3. Performance of States’ Agencies for the Control of AIDS (SACAs) Performance of SACAs is estimated as moderately satisfactory. SACAs effectively mobilized state level stakeholders in state policy reviews and formulation and preparation of State Strategic Plans. By 2010, twenty-two SACAs had transformed to Agencies. SACAs provided Technical Support to state level MDAs and LACAs but the rate of success was mixed. The transition period between closure of HPDP 1 and start of HPDP2 should allow for reflection on measures for strengthening SACA’s technical capacity for monitoring and reporting; mobilization and coordination roles in regard to states MDAs, LACA, CSOs, CBOs; and productive engagement with the private sector. (See more recommendations in the full report). The project was restructured at mid-term 50 review in 2004, removing the counterpart fund requirement, following which Credit disbursement rate progressively rose . 9.4. Performance of Local Agencies for the Control of AIDS (LACAs) LACAs remained the weakest among the three tiers of coordination of the Nigeria HIV/AIDS response. Little has been reported on their performance. In terms of inputs, only one out of the 35 SACAs (Lagos) reported providing financial support to LGAs using the IDA Credit. For LGAs to be empowered to meet their role will urgently require: planned and consistent attention advocacy to mobilize LGA Political Leadership; training and TA for capacity building; provision of funds through LGA budget line; participation in National Council on AIDS and other relevant fora; regular reporting; close and joint monitoring of implementation (LGAs / SACAs /NACA). 9.5. Performance of The World Bank In addition to the flexible financial investment, through HPDP 1, the country benefited from high quality TA, which has been the hallmark of the World Bank. Commitment to meeting client needs and responsiveness to changing requirements facilitated: HPDP1 adjustment at a midterm review in 2004; additional financing in 2007; and preparation and Board Approval of HPDP2 in 2009. Implementation Agencies reported periods of implementation delays as a result of delayed communication of “no objection� and disbursement of IDA Credit from the Bank. With increase in Bank Country Office Staff the flow of communication improved. On the whole, aggregate performance of the World Bank was quite satisfactory. 10 Key Lessons Learned Continuing political commitment at the highest level of all tiers of Government is critical for an effective national response. With the general election scheduled for 2011, a comprehensive advocacy program will be required to ensure renewed commitment to the response, especially at LGA and State levels. Commitment at the highest level of private sector corporate governance is fundamental to responsive Public Private Partnership (PPP) in combating the epidemic, both at work and in the community at large. The response should not be allowed to remain largely public sector centered. If henceforth, the public sector could engage more proactively with Captains of Industries (for-profit private sector) that would actively mobilize more of the latter’s contributions. Otherwise, the response would continue to be external dependent. Given the vastness of micro and small enterprises in Africa and in Nigeria in particular, engagement with the recently established National Association of Nigerian Traders (NANT) has the potential of extending community responses to more rural areas, hard to reach areas and MARPs, since NANT members constantly commute and transact businesses between and in major urban and rural markets. With well targeted capacity building, technical support and regular monitoring, Civil Society (i.e. NGOs, FBOs, CSOs) should remain one of the most vibrant sectors of the response. 51 Formation and nurturing of a CSO network focused on HIV and persons with disabilities will increase synergy and effective resource mobilization from other investors. Strategic and sustained capacity enhancement, financial investment and active monitoring of SACAs, LACAs and CBOs are fundamental for effective decentralization; this depends on skilled and empowered sub-national governments,. An innovation under Component 3, which has a ready appeal to the youths-in-school and youths out-of-school is support towards the emerging trend of ICT based social networking, for psychosocial support to vulnerable populations (young person) e.g. text messaging, phone-in/Q & A sessions on toll free hotlines. Subsequent funding cycles should consider the integration of poverty reduction sub- components into HIV/AIDS programming. That is given the recognition that poverty has been one of the main driving forces for the spread of the epidemic; and that most of those that are infected and affected, even if they were economically comfortable before, ended up being pauperized by the scourge. For categories of ss such as prisoners, male and female sex workers, youths in correction homes, etc the possibility of project success is higher when provisions are made (linkage to BCC) for re-orientation of the end beneficiaries towards acquisition of sustainable alternative skills e.g. in areas such as hairdressing, weaving, tie-and-dye, barbing, carpentry. Alternatively, end-beneficiaries that required skills in such income generating activities should be formally and simultaneously (during implementation of BCC activities), linked to vocational institutions offering economic empowerment programs in the area. Active and effective monitoring of the epidemic in Nigeria, through various surveys, studies and reviews; including Advocacy, BCC/IEC which placed the subject upfront constantly have contributed to awareness generation. 52 Annex 6. List of Supporting Documents Project Appraisal Document, June 2001 Additional Financing Project Paper, P105097 April, 2007 Interim Country Strategy Update Document number: IDA/R2001-81(IFC/R2001-100) June 2001 Aides Memoires (numbers 1-12) Quality Enhancement Review January 2001 Implementation Status Reports (numbers 1-20) Quality of Supervision Assessment October 2006 Revised Country Financing Parameters. May 2005 Interim Financial Reports and Annual Audit reports HIV-AIDS Emergency Action Plan (HEAP), NACA, Federal Government of Nigeria, National multisectoral HIV/AIDS M&E framework, 2002 Nigeria National Response Information Management System (NNRIMS) April 2004 NNRIMS Operational Plan 2007-2010, June 2007 Midterm Review of the National Strategic Framework (NSF), 2005-09 December 2007 DFID-financed overall review of the HPDP, National AIDS and Reproductive Health Surveys (2003, 2005, 2007) Integrated Bio-Behavioural Surveillance Survey (2003, 2005, 2007) Antenatal clinic sentinel surveillance (2003, 2005, 2008) Nigerian Demographic and Health Surveys (1999, 2003, 2008) Report on the global AIDS epidemic, UNAIDS, 2010 Community Response Evaluation (draft), Macro ICF, February 2010 Modes of HIV transmission in Nigeria, Nnorom et al, 2010 National Strategic Framework for Action (2005-2009), NACA, 2005 National Strategic Framework (NSF 2010-15) and plans. UNDP Human Development Report 2008 National AIDS Spending Assessment, 2007-08 NACA, Nigeria, March 2010 Community-based Maternal and Child Nutrition and Health Interventions to Enhance Productivity and Life Expectancy in Nigeria, World Bank Health Nutrition Population (AFTHE), Africa Region, December 2010 Assessment of Effects of HIV/AIDS Fund and Evaluation of the Support for the Public Sector on the National Response to HIV/AIDS in Nigeria, 2002-June2007. Abt Associates Inc Oct 2008. Robinson, Jonathan, and Ethan Yeh. 2011. "Transactional Sex as a Response to Risk in Western Kenya." American Economic Journal: Applied Economics, 3(1): 35–64. Operations Evaluation Department, Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (2005), see especially Table 4.1, p. 45. 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Mt Abeokuta Chappal Waddi ONDO Udi Hills (2,419 m ) OGUN Go EDO th ENUGU To Enugu LAGOS ANA Lomé Benin Abakaliki Lagos City A AMB Asaba Awka EBONYI NIG ERIA RA RA RA Sapete CAMEROON r Nige CROSS SELECTED CITIES AND TOWNS D E LTA Owerri Umuahia Warri RIVER STATE CAPITALS IMO ABIA NATIONAL CAPITAL 5°N RIVERS Aba Uyo 5°N Yenogoa AKWA- Calabar To Port RIVERS Gulf of Guinea BAYELSA Harcourt IBOM Doula N MAIN ROADS ig er 0 50 100 150 200 Kilometers Delta RAILROADS SEPTEMBER 2004 IBRD 33458 This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information STATE BOUNDARIES shown on this map do not imply, on the part of The World Bank 0 50 100 150 Miles Group, any judgment on the legal status of any territory, or any Bioko I. INTERNATIONAL BOUNDARIES endorsement or acceptance of such boundaries. 5°E (EQ. GUINEA) 10°E